Unequal access to cardiovascular care: learning from European experience

Despite Europe’s commitment to universal healthcare, cardiovascular outcomes remain deeply unequal across countries, regions, and social groups. Learning from national reforms and shared data initiatives offers a path towards a fairer future for all Europeans. Europe’s health systems are founded on the principle of universal access. Yet across the continent, inequalities in cardiovascular disease (CVD) prevention and care persist. Differences in income, education, geography, sex, and ethnicity continue to determine who lives and who dies from heart disease. Data from The Lancet Regional Health—Europe Series on Inequalities and Disparities in Cardiovascular Health reveal that premature deaths from ischaemic heart disease remain up to three times higher in some Central and Eastern European countries compared with Western Europe.1 Women, too, continue to face disproportionate risks even in nations with advanced healthcare systems.2 ‘Universal coverage is not synonymous with universal access,’ notes recent discussions. ‘It is not enough to offer care free at the point of delivery if structural, cultural, and social barriers prevent timely use’.3 The European map of cardiovascular mortality shows persistent north–south and east–west divides (Figure 1). South-Western European countries such as France and Portugal have achieved steady declines in mortality through strong prevention, early diagnosis, and integrated primary care.2 Geographic variations in cardiovascular mortality across Europe. The figure displays mortality-prevalence ratios for ischaemic heart disease per 100 000 inhabitants, stratified by country and sex (women and men), using data from the year 2021. The metric shown is the mortality/prevalence ratio per 100 000 population in women and in men. Data sources: Global Burden of Disease Study (GBD), 2021 Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2021. Available from https://vizhub.healthdata.org/gbd-results/. In contrast, several Central and South-Eastern European nations, such as Austria and Greece, continue to struggle with higher premature death rates, reflecting a structural failure to address region-specific risk factors such as delayed presentation, limited emergency capacity, and incomplete uptake of evidence-based therapies.2 In Romania, Bulgaria, and parts of the Balkans, infrastructure gaps persist: catheterization laboratories are concentrated in capital cities, leaving rural populations without access to emergency care.4 Yet, as data from the European Society of Cardiology (ESC) Atlas of Cardiology demonstrate, ‘building Cath labs is not enough.’ Greece has more Cath labs per capita than France (6.2 vs 5.0 per million), yet ischaemic heart disease mortality is threefold higher, especially in women (men 5.3% vs 1.8%; women 9.4% vs 2.3%). The difference lies in prevention, networks for timely percutaneous coronary intervention (PCI) or fibrinolysis, and equity of access.5 Even within high-income countries, rural communities often face longer travel times to PCI hospitals, fewer rehabilitation options, and weaker follow-up networks. Access disparities overlap with rural regions in Romania, Poland, and Croatia, where more than 40% of people live outside cities, and Cath labs are concentrated in urban centres. The consequence for ST-segment elevation myocardial infarction (STEMI) patients is clear: every 1-h delay in reperfusion increases acute heart failure and mortality, particularly in women.6 The first priority must be to shift the disease burden away from STEMI towards less severe ischaemic heart disease presentations through stronger prevention. Statin use in primary prevention appears to be a promising approach.7 Sex-based differences remain a defining feature of cardiovascular inequity. Women are less likely to receive timely reperfusion for acute myocardial infarction and are under-represented in rehabilitation programmes and nutritional counselling. Recent Global Burden of Disease data underscore the disproportionate impact of modifiable metabolic risks, particularly poor diet, elevated blood pressure, and hyperglycaemia, on outcomes in women newly diagnosed with CVD.3 Dietary improvement is therefore central. Replacing saturated fats with omega-3 fatty acids and increasing the intake of nuts, seeds, and vegetables may provide significant cardioprotective benefits. Omega-3 polyunsaturated fatty acids supplementation may also serve as a reasonable adjunct to guideline-directed care.8 Socioeconomic status compounds this gap. Lower-income women often face multiple disadvantages: limited health literacy, competing family responsibilities, and lower trust in healthcare systems. In summary, these disparities cannot be explained solely by biology but reflect systemic under-recognition and gender bias in research and practice. Amid persistent disparities, Europe also offers success stories. Scandinavian cardiac networks integrating general practitioners, emergency services, and tertiary centres have reduced delays and improved outcomes. The European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart) project of the ESC is another landmark defining common data standards and promoting transparent benchmarking across nations.9 Reforms in Poland, Lithuania, and Slovenia, focusing on emergency transport and national quality registries, have already narrowed survival gaps after acute coronary syndromes. These examples demonstrate that well-targeted, system-level reforms can deliver measurable equity even with limited resources. Europe’s diversity is both a challenge and strength. While health systems differ in structure and financing, the road to equity follows shared principles: strengthen prevention, ensure timely access, and guarantee continuity of care. Policies must also extend beyond the health sector. Education, employment, housing, and urban design all contribute to cardiovascular risk. Addressing these upstream determinants is essential to meet the United Nations goal of reducing premature non-communicable disease mortality by one-third by 2030. The forthcoming Lancet Regional Health—Europe Commission report10 urges governments to: Develop national plans to monitor and reduce cardiovascular inequalities. Invest in workforce distribution through training and incentives for underserved areas. Invest in digital infrastructure to link registries and improve transparency. Require sex- and socioeconomic-disaggregated data in all audits and studies. Europe has the data and expertise. What is needed now is coordinated, sustained action. Professional societies, European Union institutions, and national ministries must align efforts to translate evidence into equitable care delivery. ‘We cannot abolish vulnerability,’ say recent discussions. ‘But we must not allow vulnerability to become disparity. The promise of European healthcare will be fulfilled only when every citizen, regardless of birthplace, income, or gender, has equal opportunity for a healthy heart.’3 The authors acknowledge the contributions of The Lancet Regional Health—Europe Commission on Inequalities and Disparities in Cardiovascular Health and its collaborating institutions. All authors declare no disclosure of interest for this contribution.