Prof. Renata Cífková, MD, CSc.
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1 Prof. Renata Cífková, MD, CSc. Head of the Department of Preventive Cardiology, Thomayer Teaching Hospital, Prague Focuses on arterial hypertension epidemiology, clinical trials, target organ damage prevention and regression, epidemiology of atherosclerosis, preventive cardiology, angiology Vice President of the WG Hypertension and the Heart, European Society of Hypertension
2 Epidemiology of CV disease in Europe A focus on Central and Eastern Europe Renata Cífková Center for CV Prevention, Charles University Medical School & Thomayer University Hospital Department of Medicine II, Charles University Medical School Department of Preventive Cardiology, IKEM Prague, Czech Republic
3 1. To which age category indicated below do you belong? a. < 35 years b years c years d years e. 65 years
4 2. Please indicate your gender a. Male b. Female
5 3. What is your specialty? a. internal medicine b. cardiology c. nephrology d. endocrinology e. general practitioner (family physician) f. other
6 Russian Fed. Bulgaria Romania Hungary Poland Argentina Czech Republic China-Rural Colombia China-Urban Scotland Ireland Finland N. Ireland Greece England/Wales Belgium USA Denmark N. Zealand Mexico Germany Portugal Sweden Korea Austria Netherlands Italy Norway Canada Spain Australia France Switzerland Israel Japan Death Rates for CVD and Stroke Men, yrs Circulation 2009;119:e21-e181
7 Russian Fed. Bulgaria Romania Hungary Colombia China-Rural China-Urban Argentina Poland Czech Republic Mexico Puerto Rico Scotland N.Ireland USA England/Wales New Zealand Greece Korea Ireland Denmark Belgium Portugal Germany Sweden Finland Netherlands Canada Italy Austria Norway Australia Israel Spain Switzerland Japan France Death Rates for CVD and Stroke Women, yrs Circulation 2009;119:e21-e181
8 Standardized mortality Czech Republic, 2009 Males Females 26.8% 45.3% 22.5% 51.4% 27.9% 26.1% CVD Malignancies Other
9 Age-adjusted death rates/100,000 Czech Republic, Males - Total - CVD - CHD - Stroke % p < < < < Females - Total - CVD - CHD - Stroke < < < < 0.001
10 Number of deaths/100,000 Number of deaths/100,000 Age-stand. total, CVD, IHD, and stroke mortality (age group yrs) Czech Republic Males Females Total mortality CVD mortality IHD mortality Stroke mortality J Hypertens 2010;28:
11 Number of deaths/100,000 Number of deaths/100,000 Number of deaths/100,000 Number of deaths/100,000 Total mortality, age years Males vs Females: p = 0,001 CVD mortality, age years Males vs Females: p = 0, y = -37x R 2 = 0, y = -17x R 2 = 0, y = -12x R 2 = 0,98 y = -25x R 2 = 0, year year CAD mortality, age years Males vs Females: p = 0,001 Males Females Stroke mortality, age years Males vs Females: p = 0, y = -17x R 2 = 0, y = -8x R 2 = 0, y = -6x R 2 = 0, year 100 y = -5x R 2 = 0, year J Hypertens 2010;28:
12 Factors affecting CHD mortality Risk factors Treatment CHD incidence Case fatality CHD mortality
13 Litoměřice WHO MONICA projekt Nové okresy Cheb Praha východ Pardubice Plzeň Benešov Chrudim Kroměříž Jindřichův Hradec
14 Sample sizes and response rates /8 2000/1 2007/8 Total Males Resp *** Females Resp *** *** p < for trend
15 Methods / / /08 Physician-completed questionnaire (CVD history) Body weight, height, BP Total cholesterol, HDL-cholesterol Physician-completed questionnaire (CVD history incl. family history) Body weight, height, BP, waist/hip ratio Total cholesterol, HDL-cholesterol Triglycerides Fasting glycemia
16 Systolic BP mmhg Males mmhg Females p < p < Atherosclerosis 2010;211:676-81
17 Diastolic BP mmhg Males mmhg Females p < p < Atherosclerosis 2010;211:676-81
18 Prevalence of hypertension Males Females % % p for linear trend: ns p < Atherosclerosis 2010;211:676-81
19 BMI Males Females kg/m 2 kg/m 2 p < p pro trend: NS Atherosclerosis 2010;211:676-81
20 Awareness of hypertension Males % % p for linear trend: Females p for linear trend: Atherosclerosis 2010;211:676-81
21 Antihypertensive medication Males % % p for linear trend: Females p for linear trend: Atherosclerosis 2010;211:676-81
22 Hypertension control BP < 140/90 mmhg of all hypertensives Males % % p for linear trend: Females p for linear trend: Atherosclerosis 2010;211:676-81
23 Hypertension control BP< 140/90 mmhg of all drug-treated hypertensives Males % % p for linear trend: < Females p for linear trend: < Atherosclerosis 2010;211:676-81
24 Antihypertensive medication Czech Republic 1997/ / /08* 17.3% 51.2% 17.6% 46.7% 27.1% 40.6% 33.6% 35.4% n = 512 n = % n = 573 monotherapy combination of 2 drugs combination of > 3 drugs * Only 6 districts
25 Total cholesterol mmol/l Males mmol/l Females p < p < Atherosclerosis 2010;211:676-81
26 HDL-cholesterol mmol/l Males p < mmol/l Females p for linear trend: n.s Atherosclerosis 2010;211:676-81
27 Non-HDL-cholesterol / / / /08 p for trend Males 4.85 ± ± ± ± ± ± 1.10 < Females 4.61 ± ± ± ± ± ± 1.12 < Atherosclerosis 2010;211:676-81
28 Lipid-lowering drugs 1997/98 n = 130 (3.95%) 2000/01 n = 171 (5.1%) 2007/08 n = 386 (10.7%) 13% 3% 3% 27.5% 4% 1.6% 4.7% 15.5% 81% 68.5% fibrates statins other combinations 78.0% Atherosclerosis 2010;211:676-81
29 Smoking Males % % p < Females p for trend: n.s. Atherosclerosis 2010;211:676-81
30 BMI Males Females kg/m 2 kg/m 2 p < p for trend: NS Atherosclerosis 2010;211:676-81
31 BMI in the Czech Republic Males p for trend in obesity: < Females p for trend in obesity: n.s BMI > 30.0 kg/m 2 BMI kg/m 2 BMI < 25.0 kg/m 2 Atherosclerosis 2010;211:676-81
32 Conclusions Total and CV mortality is decreasing in the Czech Republic. The decrease is due to decreasing stroke and CHD mortality rates.
33 Conclusions (2) In a random Czech population sample mean SBP and DBP decreased the prevalence of hypertension in females decreased the number of individuals using antihypertensive agents increased hypertension control improved over a period of years
34 Conclusions (3) In a random Czech population sample the proportion of male smokers decreased (by a third), with no change in the prevalence of female smokers (25%) total and non-hdl-cholesterol decreased in both genders; there was a rise in individuals using lipid-lowering drugs there was an increase in male BMI over a period of years
35 10-year risk of death from CVD in the Czech population
36 10-year risk of death from CVD in the Czech population
37
38 mmhg Systolic BP German CV Prevention Study Males Females ns * * Preventive Medicine 1994;23:
39 mmhg Diastolic BP German CV Prevention Study Males Females * Preventive Medicine 1994;23:
40 BMI German CV Prevention Study Males Females * * kg/m Preventive Medicine 1994;23:
41 Smoking German CV Prevention Study Males % % Females Preventive Medicine 1994;23:
42 Total Cholesterol German CV Prevention Study mmol/l Males mmol/l Females * * * 7 Preventive Medicine 1994;23:
43 HDL-cholesterol German CV Prevention Study Males mmol/l 2 1,8 1,6 1,4 1,2 1 0,8 0, ,4 0, mmol/l Females 2 1,8 1,6 1,4 1,2 1 0,8 0, ,4 0, Preventive Medicine 1994;23:
44 Kaunas Population, Lithuania Age range, yrs 1983/ / / /02 Total Resp Medicina 2003;39:
45 mmhg Systolic BP Kaunas, Lithuania Males Females p < ** ** / / / / / / / /02 Medicina 2003;39:
46 mmhg Diastolic BP Kaunas, Lithuania Males Females *** *** / / / / / / / /02 Medicina 2003;39:
47 BMI Kaunas, Lithuania Males Females kg/m * 29 *** *** / / / / / / / /02 Medicina 2003;39:
48 Total Cholesterol Kaunas, Lithuania mmol/l Males mmol/l Females * 8 7 *** * *** / / / / / / / /02 p < Medicina 2003;39:
49
50 WHO MONICA Age-standardized SBP Men, years BEL-GHE CAN-HAL CZE-CZE GER-AUR GER-AUU GER-BRE GER-EGE ITA-BRI NEZ-AUC POL-TAR POL-WAR RUS-MOC RUS-MOI RUS-NOC RUS-NOI UNK-BEL UNK-GLA USA-STA YUG-NOS MEAN Lancet 2000; 355:675-87
51 BEL-GHE CAN-HAL CZE-CZE GER-AUR GER-AUU GER-BRE GER-EGE ITA-BRI NEZ-AUC POL-TAR POL-WAR RUS-MOC RUS-MOI RUS-NOC RUS-NOI UNK-BEL UNK-GLA USA-STA YUG-NOS MEAN WHO MONICA Age-standardized SBP Women, years Lancet 2000; 355:675-87
52 Patients with controlled BP (%) Manage it well! program: blood pressure control rates 120 baseline end of follow-up n = overall control systolic control diastolic control responders overall control: <140/90 mmhg, systolic control: <140 mmhg, diastolic control: <90 mmhg responders: <140 or <90 mmhg L. Szirmai, J Hypertens 2005;23:
53 Limitations of hypertension studies in primary care Not dealing with population random samples (involving mostly individuals with a disease), predominantly elderly populations Most of the studies are based on a questionnaire completed by GPs with no review of source data No review of patient selection according to the protocol
54 CV RISK ASSESSMENT IN POLAND IN 2002 DESIGN AND METHODS: BP, BMI, laboratory tests Representative sample of 3051 adults in Poland Age range18-94 years 304 territorial clusters, three-stage stratified sampling procedure The diagnosis of hypertension was based on three separate visits (BP>=140/90 mmhg or medication) Response rate for BP and anthropometric measurements 78%, for laboratory tests 62% 95% confidence interval ± 2% T. Zdrojewski et al.,j Hum Hypertens 2004;18:557-62
55 Prevalence and control of arterial hypertension in Poland (age range 30-70) 31% 14% 44% 19% 18% 33% 11% 31% Optimal Normal High normal Hypertension Treated sufficiently Treated insufficiently Detected, not treated Not detected T. Zdrojewski et al., J Hum Hypertens 2004;18:557-62
56
57 Age- and sex-adjusted prevalence Gypsies Non-Gypsies p Number Response, % Hypertension ns Undiagnosed hypertension ns Obesity Central obesity Metabolic syndrome CVD
58 WHO MONICA Smokers Men, years BEL-GHE CAN-HAL CZE-CZE GER-AUR GER-AUU GER-BRE GER-EGE ITA-BRI NEZ-AUC POL-TAR POL-WAR RUS-MOC RUS-MOI RUS-NOC RUS-NOI UNK-BEL UNK-GLA USA-STA YUG-NOS MEAN Lancet 2000; 355:675-87
59 WHO MONICA Smokers Women, years BEL-GHE CAN-HAL CZE-CZE GER-AUR GER-AUU GER-BRE GER-EGE ITA-BRI NEZ-AUC POL-TAR POL-WAR RUS-MOC RUS-MOI RUS-NOC RUS-NOI UNK-BEL UNK-GLA USA-STA YUG-NOS MEAN Lancet 2000; 355:675-87
60 WHO MONICA Total cholesterol Men, years BEL-GHE CAN-HAL CZE-CZE GER-AUR GER-AUU GER-BRE GER-EGE ITA-BRI NEZ-AUC POL-TAR POL-WAR RUS-MOC RUS-MOI RUS-NOC RUS-NOI UNK-BEL UNK-GLA USA-STA YUG-NOS MEAN 5 6,2 5,6 6,1 6,2 6,2 6,2 5,8 5,7 5,9 5,6 5,7 5,3 5,4 5,4 5,4 5,9 6,1 5,8 6, Lancet 2000; 355:675-87
61 WHO MONICA Total cholesterol Women, years BEL-GHE CAN-HAL CZE-CZE GER-AUR GER-AUU GER-BRE GER-EGE ITA-BRI NEZ-AUC POL-TAR POL-WAR RUS-MOC RUS-MOI RUS-NOC RUS-NOI UNK-BEL UNK-GLA USA-STA YUG-NOS MEAN 6 5,8 5,9 6,1 5,9 6,2 5,8 5,6 5,9 5,5 5,6 5,5 5,6 5,3 5,4 5,9 6,1 5,3 6,2 5, Lancet 2000; 355:675-87
62 WHO MONICA BMI Men, years BEL-GHE CAN-HAL CZE-CZE GER-AUR GER-AUU GER-BRE GER-EGE ITA-BRI NEZ-AUC POL-TAR POL-WAR RUS-MOC RUS-MOI RUS-NOC RUS-NOI UNK-BEL UNK-GLA USA-STA YUG-NOS 25,2 25,6 25,9 25,9 26,1 26,3 26,4 26,7 26,8 26,9 26,8 26,9 27,1 27,1 27,1 27,3 27,5 27,6 27,8 MEAN 26, , , ,5 28 Lancet 2000; 355:675-87
63 WHO MONICA BMI Women, years BEL-GHE CAN-HAL CZE-CZE GER-AUR GER-AUU GER-BRE GER-EGE ITA-BRI NEZ-AUC POL-TAR POL-WAR RUS-MOC RUS-MOI RUS-NOC RUS-NOI UNK-BEL UNK-GLA USA-STA YUG-NOS 25,5 25,6 25,6 26,1 26,8 26,3 26,5 26,4 26,3 26,5 27,5 26,6 26,9 27,6 27,8 27,8 28,5 28,5 29,3 MEAN 26, , , , , ,5 30 Lancet 2000; 355:675-87
64 4. What is the major cause of CHD mortality decline in developed countries? a. interventional cardiology and cardiac surgery b. drug treatment of CHD (beta-blockers, ACE-inhibitors, ASA-statins), hypertension and dyslipidemia c. decline in major CV risk factors
65 Percentage of the Decrease in Death from CHD Attributed to Treatment and Risk Factor Changes NEJM 2007;356:
66 Conclusions CVD mortality in all European post-communist countries is the highest in Europe. In fact, CVD mortality rates continue to rise in most post-communist countries in Europe except for the Czech Republic, Poland, and Slovenia.
67 Conclusions, cont d In most of the countries, there is a lack of recent CVD risk factor data on representative populations. Longitudinal trends are available only for the Czech Republic, Germany and Lithuania. Improvement in the CV risk profile was seen in the Czech Republic (BP, lipids, smoking in males); a smaller improvement was found in Kaunas, mostly in females (BP, BMI). Most of the major risk factors increased slightly in Germany over the study period.
68 Conclusions, cont d Therefore, the best comparable data are still provided by the WHO-coordinated MONICA study confirming a poor CV risk profile in most of the European post-communist countries (particularly for smoking, BP, and BMI).
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