European Society of Cardiology: Cardiovascular Disease Statistics 2019 (Executive Summary)

For the full version of this paper go To: Timmis A, Townsend N, Gale CP, et al. European Society of Cardiology: Cardiovascular Disease Statistics 2019 [published online ahead of print, 2019 Dec 10]. Eur Heart J. 2019;ehz859. doi:10.1093/eurheartj/ehz859 This is the second report on cardiovascular disease (CVD) statistics for the member countries of the European Society of Cardiology (ESC). It updates and expands upon the widely cited 2017 report1 and now includes data from 56 of the 57 member countries (Uzbekistan’s data contribution was unavailable at the time of writing). Contributing member countries are: All European countries except Andorra, Liechtenstein, Monaco, and Vatican City Non-European countries Asia: Kazakhstan and Kyrgyzstan East Mediterranean: Israel, Lebanon, and Syrian Arab Republic North Africa: Algeria, Egypt, Libya, Morocco, and Tunisia define international inequalities in CVD burden across ESC member countries; drive policy initiatives to help reduce inequalities in CVD burden; map European CVD healthcare delivery; and provide a one-stop source of CVD statistics for academics, clinicians, and other interested parties. 2. Data sources and presentation: The ESC Atlas is a repository of CVD data collected by groups such as the World Health Organization (WHO), the Institute for Health Metrics and Evaluation (IHME), and the World Bank (WB). It also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Throughout the 2019 report, ESC member countries are categorized according to 2018 WB definitions as high-income and middle-income (a composite of lower- and upper-middle-income) to permit stratified presentations of CVD statistics by national income status.3 The data sources come with important limitations that include: adjustments applied by all data providers to account for missing data; differences in reporting practices causing variable precision of national data estimates; misclassification bias due to miscoding of diagnostic groups and death certificates; and hidden within-country inequalities in disease burden and healthcare delivery. The limitations as they apply to the quality, precision, and availability of the data emphasize the need for cautious interpretation of the CVD statistics presented in this report. 3. Financial and economic burden of cardiovascular disease: The ESC Atlas provides a potential platform for collecting economic data relevant to CVD in ESC member countries. In a European Heart Network study, CVD was estimated to cost the European Union economy €210 billion a year in 2015, of which 53% (€111 billion) was due to healthcare costs, 26% (€54 billion) to productivity losses and 21% (€45 billion) to the informal care of people with CVD.4 The study highlighted substantial variation in CVD economic burden with direct healthcare cost per capita ranging from €48 in Bulgaria to €365 in Finland. In Germany, the cost of CVD comprised 13% of national health expenditure and is projected to surpass €40 billion by 2020.5 The data presented in this report show that the burden of CVD disease is not only a health issue, but an economic challenge to the healthcare systems of ESC member countries that is expected to grow exponentially in future years.6 4. Risk factors and health behaviours: Nine risk factors and health behaviours, accounting for >90% of the population attributable risk of acute myocardial infarction, were identified in the INTERHEART study.7 National statistics relevant to eight of these risk factors and health behaviours are available in the ESC Atlas as follows: Blood pressure: Across ESC member countries, almost one in four people had elevated blood pressure (≥140/90 mmHg) in 2015. Systolic blood pressure was higher in males compared with females and in middle-income compared with high-income countries. The median age-standardized prevalence of elevated blood pressure trended downwards between 1980 and 2015 from 35.3% to 24.8%. Cholesterol: Across ESC member countries, about one in seven people had hypercholesterolaemia (≥6.2 mmol/L) in 2009. Rates were similar in females and males but were substantially lower in middle-income compared with high-income countries. Median age-standardized blood cholesterol concentrations declined from 5.5 to 5.1 mmol/L between 1980 and 2009. Diabetes: Across ESC member countries, more than one in 20 adults had diabetes with prevalence higher in middle-income compared with high-income countries. Prevalence has increased three-fold during the last 25 years. Obesity: Across ESC member countries, age-standardized data showed that one in five adults was obese in 2016, as defined by a body mass index of ≥30 kg/m2 with prevalence similar in high-income and middle-income countries. Prevalence across ESC member countries increased sharply between 1980 and 2016 from 9.6% to 22.6%. Smoking: Across ESC member countries, more than one in five adults smoked tobacco according to 2014 estimates. Smoking was less common in females than males, particularly in middle-income countries. Between 1995 and 2014, the prevalence of smoking across ESC member countries declined from 28.0% to 21.0%. Alcohol: Across ESC member countries alcohol consumption was more than three times higher in males compared with females, and almost twice as high in high-income compared with middle-income countries. Since 2010 consumption has declined by nearly 9% in middle-income countries but in high-income countries little change has occurred. Vegetable and fruit consumption: Across ESC member countries just over half of all adults consumed at least one portion of both vegetables and fruit, with consumption greater in females than males. Physical activity: Across ESC member countries, physical activity was graded insufficient in one in three adults. Rates of inactivity were somewhat higher in females compared with males, and in high-income compared with middle-income countries. The WHO has set non-communicable disease targets relevant to global cardiovascular health to be achieved by 2025 (with reference to 2010).8 If current trends recorded in the ESC Atlas continue, the target for a 30% relative reduction in tobacco use appears feasible for ESC member countries and also the target for a 10% relative reduction in harmful use of alcohol for middle-income (not high-income) countries. Trends documented in the ESC Atlas make targets for a 25% relative reduction in the prevalence of elevated blood pressure and for a halt in the rise of diabetes and obesity unlikely to be achieved. 5. Cardiovascular disease morbidity: During the last 27 years, declines in the age-standardized incidence of CVD across ESC member countries have been small and in 11 countries non-existent. The incidence of CVD’s major components, ischaemic heart disease (IHD), and stroke, have both shown a downward trend but changes in prevalence have been small. The age-standardized incidence and prevalence of IHD and stroke were lower in females than males and in high-income compared with middle-income ESC member countries. Ischaemic heart disease and stroke accounted for 82% of disability-adjusted life years (DALYs) due to CVD in ESC member countries. Age-standardized DALYs due to CVD have been in steep decline the last 27 years, with just two middle-income countries recording an increase. Disability-adjusted life years due to CVD were almost twice as high in males compared with females and three times as high in middle-income compared with high-income ESC member countries. The morbidity statistics recorded in the ESC Atlas confirm persisting inequalities in disease burden by gender and national income status. The statistics emphasize the need for concerted application of CVD prevention policies, particularly in middle-income countries where the need is greatest. 6. Cardiovascular disease mortality: Cardiovascular disease remains the most common cause of death across ESC member countries with age-standardized rates greater for males than females. It accounts for more than one in three of all potential years of life lost. Cardiovascular disease is also the most common cause of premature (age <70 years) death in males but in females cancer is now more common. In both sexes, premature CVD death is more common in middle-income countries where it accounts for a greater proportion of potential years of life lost compared with high-income countries. Inequalities in CVD mortality recorded in the ESC Atlas largely mirror those for morbidity with the CVD burden falling hardest on middle-income countries that are less able to meet the costs of contemporary healthcare compared with high-income countries. Cardiovascular disease prevention is less affected by resource constraints and the potential reversibility of risk factors and unhealthy behaviours provides a huge opportunity to address the health inequalities documented in this report. Meanwhile, the WHO target for a 25% relative reduction in mortality from CVD, cancer, diabetes, and chronic respiratory disease by 20258 is unlikely to be achieved with the downward CVD trends documented in this report concealing alarming increases in mortality in some member countries. 7. Cardiovascular healthcare delivery: The 2018/19 survey data recorded in the ESC Atlas shows a 15-fold variation in cardiologists per million people across ESC member countries, with females comprising just 28% of all cardiologists. Middle-income member countries are severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation, and cardiac surgical procedures. Despite this, outliers can often be identified emphasizing that national income status is not the only driver for cardiological healthcare delivery. The 15-fold variation in cardiologists per million people across ESC member countries suggests that under-provision may be common. Under-representation of females is also common and is now recognized as a particular problem for cardiology.9,10 Contemporary CVD investigation and treatment represents a substantial challenge to national economies and this no doubt contributes to the under-provision of capital resource, manpower, and interventional technologies in many middle-income ESC member countries. Technological costs are predicted to increase steeply in coming years, and this will exacerbate the challenge to middle-income economies. Cardiovascular disease prevention is surely the solution, being less dependent on financial muscle and providing a more effective means of managing the CVD epidemic and reducing disease burden. 8. Conclusion: This report gives much attention to the inequalities that persist between high-income and middle-income ESC member countries. Inequalities impact upon healthcare delivery and disease prevalence, the availability of good cardiological care tending to vary inversely with national needs. The paradox of greater cardiological provision in those high-income ESC member countries where need is manifestly less must contribute to the continued imbalance in cardiovascular mortality between high- and middle-income member countries. Resolution of this paradox is now a major goal of the ESC in its global mission to reduce the burden of CVD. Conflict of interest: none declared.