The challenge of cardiovascular disease in Russia

Transcription

1 The challenge of cardiovascular disease in Russia David Leon The 21st Norwegian Conference on Epidemiology Tromsø, October 30 November 1, 2013

2 Major changes in society. Brehznev Era of stagnation Yelstin Putin Putin Medvedev Gorbachev Perestroika and Glasnost

3 Life expectancy at birth Males 85 Females EU members (pre-2005) Russia

4 Life expectancy at birth Males 85 Females 80 Russia 64 (2011) Norway 79 (2011) Russia 76 (2011) Norway 84 (2011)

5 Russia has the highest cardiovascular mortality rate in the world 5

6 Russia highest out of all 33 countries for men and women 6

7 Cardiovascular disease mortality in Russia is atypical 7

8 Age-standardised rate per 100, Massive fluctuations over time in ischaemic heart disease, (age <65 years) Men Norway UK Russia Women UK Norway Russia Source : WHO HFA database 8

9 Ratio of mortality : Russian Federation / Norway Particularly high mortality at working ages compared to other countries : Russia / Norway, Male <65 Male 65+ Female <65 Female 65+ Source : WHO HFA database

10 Smoking Important but does not explain fluctuations 10

11 Trends of adult smoking rates in Russia, Source : Lunze K &Migliorini L. BMC Public Health 2013;13:64 11

12 Paradoxical lipid profile relative to other countries Prevalence of raised total cholesterol not high Levels of LDL ( bad ) cholesterol tend to be average or below average Levels of HDL ( good )cholesterol above average NB : national data available NB : statin use very low 12

13 Hypertension High rates in Russia compared to other European countries Poor rates of control Likely to be an important factor NB : comprehensive national data poorly documented and of questionable quality 13

14 Classic risk factors do not explain international differences 14

15 Alcohol A key driver of fluctuations

16 Strong evidence that alcohol drives fluctuations in male life expectancy in Russia Males Life expectancy at birth 66 SDR per 100, SDR for alcohol poisonings, ages Life expectancy at birth (years) Source : V. Shkolnikov and E. Andreev Year 16

17 Mortality from circulatory disease and acute alcohol poisoning among men aged years, Russia, Total circulatory disease mortality per 100, Total circulatory disease Acute alcohol poisoning Acute alcohol poisoning mortality per 100, Source : Data provided by Evgueny Andreev

18 Individual-level evidence on alcohol Izhevsk Family Study (men aged years) and

19 Hazardous drinking and mortality from various types of circulatory disease Men aged years, Izhevsk, Underlying cause of death Alcoholic cardiomyopathy Number of deaths Hazardous drinking (proxy report) OR* (95% CI) (9.5,25.94) Other cardiomyopathy (2.05,7.18) Cerebrovascular disease Other circulatory disease Ischaemic heart disease (1.24,3.40) (1.51,7.81) (2.17,4.24) 19 * OR adjusted for age, smoking and education Source : Leon, Shkolnikov, McKee, Kiryanov, Andreev, IJE, 2010

20 Doubts about the diagnosis... 20

21 A new international project University of Tromsø, Norway Ministry of Health and Care Services, Norway 21

22 Institute of Internal Medicine SBRAMS, Novosibirsk, Russia Cardiovascular disease in Russia: strengthening evidence about causes, mechanisms, prevention and treatment Finland Max Planck Institute for Demographic Research 22

23 Location of study sites and collaborators Tromso London Rostock Oulu Arkhangelsk Moscow Kazan Novosibirsk 23

24 Four themes Theme A: Levels and trends in cardiovascular disease and associated risk factors Theme B: Understanding the nature and causes of cardiovascular disease in Russia (including cause of death study) Theme C: Barriers, opportunities and capacity for improved prevention and treatment (role of health service) Theme D: Capacity development and training 24

25 Theme B : Cross-sectional studies Two locations Arkhangelsk and Novosibirsk Population-based random sample men and women aged years attention given to reducing selection bias N=2750 in each city Additional sample heavy alcohol drinkers from medical facility (N=250 in each city) Main field work starts

26 Cardiovascular phenotypes Type Source Biomarker/proxy measure Atherosclerosis Cardiac remodelling Arrhythmia Vascular dysfunction Questionnaire ECG Carotid ultrasound Blood Echocardiography ECG, Actiwave Cardio Vicorder Previous MI Evidence previous MI Carotid IMT, plaque NT-pro BNP, HsTnI, hstnt Myocardial function and size Baseline rhythm, heart rate variability Pulse-wave velocity 26

27 Cutting edge scientific approaches 27

28 Serum NMR metabolomics Highly standardised and reproducible platform for 117 primary and 99 derived measures of specific molecular entities (now >100,000 individuals assayed) Nature Genetics 44, 269, 2012 How are alcohol and CVD phenotypes related to 14 lipoprotein subclasses? Identifying markers of intermediate metabolism associated with CVD phenotypes 28

29 The microbiome Key expertise : Vadim Govorun, Moscow 29

30 Associations : Analytic framework Endogenous exposures : a priori CVD risk biomarkers (including lipoprotein NMR profile) Socio-demographic + exogenous exposures CVD phenotypes Studies in other countries eg Tromsø 7 Metabolic profile Microbiome

31 Thank you 31

32 Alcohol control : policy developments since : Federal law No.171 on production and sale of alcohol; 2009: Elaboration of the Russian anti-alcohol policy framework (the Conceptual Framework on anti-alcohol policy implementation); 2009: Strengthening of institutional policy control (Establishment of the Federal Alcohol Service) 2011: Introduction of greater controls and restrictions on production and sale of alcohol (Federal law No.218).

33 Tobacco control : policy developments since : the Federal law No.87 of 2001 On limitations of smoking tobacco is in effect; 2008: Ratification of the WHO Framework Convention on Tobacco Control by the Russian Federation; 2009: Defining the magnitude of the problem: 40% smoking prevalence (GATS report on Russia); 2010: Development of the anti-tobacco policy (the Conceptual framework on anti-tobacco policy for ; 2013: Introduction of restrictions on tobacco sale and smoking in public (Federal law No. 15 on Health protection of citizens from exposure to tobacco smoke and consequences from tobacco consumption )

34 Mortality from selected causes Women, aged 45-59, Russia Age-standardised mortality rate per 100, Cancer oesophagus Cancer stomach Cancer breast Ischaemic heart disease Injuries, poisoning, violence Source : WHO HFA database 34

35 Index of CVD risk - 1 Ratio of apolipoprotein B to apolipoprotein A1 Atherogenic index

36 Index of CVD risk - 2 B-type natriuretic peptide Index of stress on ventricles of heart Marker of non-atherosclerotic cardiac damage

37 Association of pattern of drinking with cardiovascular risk factors OR (95% CI) Pattern of drinking OR top 20% ApoB/A1 ratio OR top 20% B-type natriuretic peptide (BNP) Abstains 1.00 [ref] 1.00 [ref] Non-hazardous 0.34 (0.21, 0.54) 2.35 (1.20, 4.58) Hazardous 0.31 (0.16, 0.59) 4.31 (2.14, 9.52) P-value trend <0.001 <0.001 Adjusted for age, BMI and waist-hip ratio Source : Leon DA et al, Eur.J Epidemiol, 28 (5): , 2013