Cardiovascular Mortality and Structural Inequalities in Europe

Background: Cardiovascular Diseases (CVD) remain the leading cause of mortality in Europe despite substantial improvements in prevention and treatment. Persistent inequalities across the continent suggest that cardiovascular mortality may be influenced not only by individual behavioral risk factors, but also by broader structural, socioeconomic, infectious-disease, and psychosocial conditions. This study examined long-term associations between circulatory-system mortality and selected epidemiological and structural indicators across European countries between 1990 and 2019. Methods: A longitudinal ecological study was conducted using country-level data from European countries for 1990, 2000, 2010, and 2019. The dependent variable was age-standardized mortality from diseases of the circulatory system (SDR per 100,000 population). Independent variables included tuberculosis incidence, alcohol poisoning mortality, suicide mortality, smoking prevalence, and Gross National Income (GNI) per capita. Multivariable linear regression models were constructed for each study year to identify independent predictors of circulatory-system mortality. Comparative East-West analyses were additionally performed to assess regional inequalities across Europe. Results: The multivariable regression models demonstrated high explanatory power across all study years (adjusted R2 approximately 0.71-0.82). Tuberculosis incidence consistently remained the strongest positive independent predictor of circulatory-system mortality, while GNI per capita demonstrated a stable inverse association. Alcohol poisoning mortality was positively associated with cardiovascular mortality in most study years. Smoking prevalence showed positive but statistically unstable associations after multivariable adjustment, whereas suicide mortality did not remain independently associated with circulatory-system mortality. Comparative analyses demonstrated persistent East-West disparities throughout the study period. Eastern and post-socialist European countries generally exhibited substantially higher cardiovascular mortality, higher tuberculosis incidence, higher alcohol-related mortality, and lower national income compared with Western European countries. These patterns persisted despite overall declines in circulatory-system mortality across Europe between 1990 and 2019. Conclusions: Cardiovascular mortality in Europe appears to be strongly associated with broader structural, infectious, socioeconomic, and psychosocial conditions rather than solely with individual behavioral risk factors. The coexistence of elevated circulatory-system mortality, tuberculosis burden, alcohol-related mortality, and socioeconomic disadvantage in Eastern Europe supports structural and syndemic interpretations of cardiovascular inequalities. Reducing cardiovascular mortality inequalities in Europe may therefore require not only conventional risk-factor prevention, but also broader policies addressing social inequality, psychosocial stress, healthcare-system resilience, and structural vulnerability.