Coronary heart disease mortality trends in the Netherlands 1972-2007

Performance of the SCORE and Globorisk cardiovascular risk prediction models: a prospective cohort study in Dutch general practice

BACKGROUND

GPs frequently use 10-year-risk estimations of cardiovascular disease (CVD) to identify high- risk patients.

AIM

To assess the performance of four models for predicting the 10-year risk of CVD in Dutch general practice.

DESIGN AND SETTING

Prospective cohort study. Routine data (2009- 2019) was used from 46 Dutch general practices linked to cause of death statistics.

METHOD

The outcome measures were fatal CVD for SCORE and first diagnosis of fatal or non- fatal CVD for SCORE fatal and non-fatal (SCORE- FNF), Globorisk-laboratory, and Globorisk-office. Model performance was assessed by examining discrimination and calibration.

RESULTS

The final number of patients for risk prediction was 1981 for SCORE and SCORE-FNF, 3588 for Globorisk-laboratory, and 4399 for Globorisk- office. The observed percentage of events was 18.6% (n = 353) for SCORE- FNF, 6.9% (n = 230) for Globorisk-laboratory, 7.9% (n = 323) for Globorisk-office, and 0.3% (n = 5) for SCORE. The models showed poor discrimination and calibration. The performance of SCORE could not be examined because of the limited number of fatal CVD events. SCORE-FNF, the model that is currently used for risk prediction of fatal plus non-fatal CVD in Dutch general practice, was found to underestimate the risk in all deciles of predicted risks.

CONCLUSION

Wide eligibility criteria and a broad outcome measure contribute to the model applicability in daily practice. The restriction to fatal CVD outcomes of SCORE renders it less usable in routine Dutch general practice. The models seriously underestimate the 10-year risk of fatal plus non-fatal CVD in Dutch general practice. The poor model performance is possibly because of differences between patients that are eligible for risk prediction and the population that was used for model development. In addition, selection of higher-risk patients for CVD risk assessment by GPs may also contribute to the poor model performance.

Coronary heart disease and stroke mortality trends in Brazil 2000-2018

OBJECTIVE

To analyse the mortality rate trend due to coronary heart disease (CHD) and stroke in the adult population in Brazil.

METHODS

From 2000 to 2018, a time trend study with joinpoint regression was conducted among Brazilian men and women aged 35 years and over. Age-adjusted and age, sex specific CHD and stroke trend rate mortality were measured.

RESULTS

Crude mortality rates from CHD decreased in both sexes and in all age groups, except for males over 85 years old with an increase of 1.78%. The most accentuated declining occurred for age range 35 to 44 years for both men (52.1%) and women (53.2%) due to stroke and in men (33%) due to CHD, and among women (32%) aged 65 to 74 years due to CHD. Age-adjusted mortality rates for CHD and stroke decreased in both sexes, in the period from 2000 to 2018. The average annual rate for CHD went from 97.09 during 2000-2008 to 78.75 during 2016-2018, whereas the highest percentage of change was observed during 2008 to 2013 (APC -2.5%; 95% CI). The average annual rate for stroke decreased from 104.96 to 69.93, between 2000-2008 and 2016-2018, and the highest percentage of change occurred during the periods from 2008 to 2013 and 2016 to 2018 (APC 4.7%; 95% CI).

CONCLUSION

The downward trend CHD and stroke mortality rates is continuing. Policy intervention directed to strengthen care provision and improve population diets and lifestyles might explain the continued progress, but there is no room for complacency.

Time Trends in Survival Following First Hemorrhagic or Ischemic Stroke Between 1991 and 2015 in the Rotterdam Study

Background and Purpose—

The introduction of stroke units and the implementation of evidence-based interventions have been a breakthrough in the management of patients with stroke over the past decade. Survival following stroke is an important indicator in monitoring stroke burden. Recent data on survival by stroke subtype in the general population is scarce. We assessed (1) recent temporal time trends in survival; (2) age-standardized death rates; (3) survival probabilities at 6 months, 1, 2, and 3 years following first hemorrhagic or ischemic stroke.

Methods—

Within the population-based Rotterdam Study between 1991 and 2015, we assessed time trends in survival among 162 with first-ever hemorrhagic and 988 patients with first-ever ischemic stroke across 3 time periods (1991–1998; 1999–2007; 2008–2015) using time-varying Cox regression model and calculated age-standardized death rates according to the European 2010 census population.

Results—

In the hemorrhagic stroke group, a total of 144 deaths occurred during 386 person-years. Following a hemorrhagic stroke, we observed similar mortality rates over the years with 30 per 100 person-years in 2015 compared with 25/100 person-years in 1991. Similarly, compared with the earliest study period (1991–1998), mortality rates remained unchanged in the latest study period (2008–2015; hazard ratio, 0.97 [95% CI, 0.61–1.57]; P =0.93). In the ischemic stroke group, a total of 711 deaths occurred during 4897 person-years. We observed a decline in mortality rates in 2015 (11 per 100 person-years) compared with 1991 (29/100 person-years). This translated to favorable trends in the latest study period 2008 to 2015 (hazard ratio, 0.71 [95% CI, 0.56–0.90]; P <0.01).

Conclusions—

Survival following ischemic stroke has improved over the past decade, while no change was observed in survival following hemorrhagic stroke.

Coronary heart disease mortality is decreasing in Argentina, and Colombia, but keeps increasing in Mexico: a time trend study

Background

Mortality rates due to coronary heart disease (CHD) have decreased in most countries, but increased in low and middle-income countries. Few studies have analyzed the trends of coronary heart disease mortality in Latin America, specifically the trends in young-adults and the effect of correcting these comparisons for nonspecific causes of death (garbage codes). The objective of this study was to describe and compare standardized, age-specific, and garbage-code corrected mortality trends for coronary heart disease from 1985 to 2015 in Argentina, Colombia, and Mexico.

Methods

Deaths from coronary heart disease were grouped by country, year of registration, sex, and 10-year age bands to calculate age-adjusted and age and sex-specific rates for adults aged ≥25. We corrected for garbage-codes using the methodology proposed by the Global Burden of Disease. Finally, we fitted Joinpoint regression models.

Results

In 1985, age-standardized mortality rates per 100,000 population were 136.6 in Argentina, 160.6 in Colombia, and 87.51 in Mexico; by 2015 rates decreased 51% in Argentina and 6.5% in Colombia, yet increased by 61% in Mexico, where an upward trend in mortality was observed in young adults. Garbage-code corrections produced increases in mortality rates, particularly in Argentina with approximately 80 additional deaths per 100,000, 14 in Colombia and 13 in Mexico.

Conclusions

Latin American countries are at different stages of the cardiovascular disease epidemic. Garbage code correction produce large changes in the mortality rates in Argentina, yet smaller in Mexico and Colombia, suggesting garbage code corrections may be needed for specific countries. While coronary heart disease (CHD) mortality is falling in Argentina, modest falls in Colombia and substantial increases in Mexico highlight the need for the region to propose and implement population-wide prevention policies.

Thermodilution vs estimated Fick cardiac output measurement in an elderly cohort of patients: A single-centre experience

Aims

Patients referred to the cath-lab are an increasingly elderly population. Thermodilution (TD, gold standard) and the estimated Fick method (eFM) are interchangeably used in the clinical routine to measure cardiac output (CO). However, their correlation in an elderly cohort of cardiac patients has not been tested so far.

Methods

A single, clinically-indicated right heart catheterization was performed on each patient with CO estimated by eFM and TD in 155 consecutive patients (75.1±6.8 years, 57.7% male) between April 2015 and August 2017. Whole Body Oxygen Consumption (VO2) was assumed by applying the formulas of LaFarge (LaF), Dehmer (De) and Bergstra (Be). CO was indexed to body surface area (Cardiac Index, CI).

Results

CI-TD showed an overall moderate correlation to CI-eFM as assessed by LaF, De or Be (r² = 0.53, r² = 0.54, r² = 0.57, all p < .001, respectively) with large limits of agreement (-0.64 to 1.09, -1.07 to 0.77, -1.38 to 0.53 l/m²/min, respectively). The mean difference of CI between methods was 0.22, -0.15 and -0.42 (all p<0.001 for difference to TD), respectively. A rate of error ≥20% occurred with the equations by LaF, De or Be in 40.6%, 26.5% and 36.1% of patients, respectively. A CI <2.2 l/m²min was present in 42.6% of patients according to TD and in 60.0%, 31.0% and in 16.1% of patients according to eFM by the formulas of LaF, De or Be.

Conclusion

Although CI-eFM shows an overall reasonable correlation with CI-TD, the predictive value in a single patient is low. CI-eFM cannot replace CI-TD in elderly patients.

Endurance training restores spatially distinct cardiac mitochondrial function and myocardial contractility in ovariectomized rats

We previously demonstrated that the loss of female hormones induces cardiac and mitochondrial dysfunction in the female heart. Here, we show the impact of endurance training for twelve weeks, a nonpharmacological therapy against cardiovascular disease caused by ovariectomy and its contribution to cardiac contractility, mitochondrial quality control, bioenergetics and oxidative damage. We found that ovariectomy induced cardiac hypertrophy and dysfunction by decreasing SERCA2 and increasing phospholamban protein expression. Endurance training restored myocardial contractility, SERCA2 levels, increased calcium transient in ovariectomized rats but did not change phospholamban protein expression or cardiac hypertrophy. Additionally, ovariectomy decreased the amount of intermyofibrillar mitochondria and induced mitochondrial fragmentation that were accompanied by decreased levels of mitofusin 1, PGC-1α, NRF-1, total AMPK-α and mitochondrial Tfam. Endurance training prevented all these features except for mitofusin 1. Ovariectomy reduced O₂ consumption, elevated O₂^.- release and increased Ca²⁺-induced mitochondrial permeability transition pore opening in both mitochondrial subpopulations. Ovariectomy also increased NOX-4 protein expression in the heart, reduced mitochondrial Mn-SOD, catalase protein expression and increased protein carbonylation in both mitochondrial subpopulations, which were prevented by endurance training. Taken together, our findings show that endurance training prevented cardiac contractile dysfunction and mitochondrial quality control in ovariectomized rats.

Secular trends in excess mortality of late-life depression

BACKGROUND

Late-life depression is associated with premature mortality, however, little is known whether excess mortality rates of depression have changed over time. This study aims to identify and explain secular trends in excess mortality of major depressive disorder (MDD) and subthreshold depression (SUBD).

METHODS

Cohort-sequential-longitudinal study of 4084 community-dwelling older adults in the Netherlands based on data from the Longitudinal Aging Study Amsterdam (LASA). Six measurement cycles were included from 1992/93 until 2008/09, each linked to the overall 5-year mortality, covering a 16-year time span. MDD and SUBD were identified using a two-stage screening procedure with the Center for Epidemiological Studies Depression Scale and the Diagnostic Interview Schedule. Age and sex were covariates. Education, health and lifestyle factors, and use of antidepressants were included as putative explanatory factors. Generalized Estimating Equations was used to investigate the association between the interaction 'Depression × Time' and 5-year mortality, and to find explanatory factors for the trend.

RESULTS

A downward trend in excess mortality of MDD was found (OR = .92, 95%-CI:.85-.99, P = .04), adjusted for age and sex, which could not be explained by education, health and lifestyle factors, nor antidepressants use. Sex differences in the trend were not found (P = .77). No trend in excess mortality of SUBD was found (OR = 1.01, 95%-CI: .97-1.04, P = .65).

LIMITATIONS

The findings do not imply a similar trend for other countries.

CONCLUSIONS

The results indicate a favorable development in excess mortality of community-dwelling older adults with MDD, while those with SUBD do not show a clear trend in excess mortality.

Differences in declining mortality rates due to coronary heart disease by neighbourhood deprivation

BACKGROUND

Cardiovascular disease (CVD) is the main cause of death in most industrialised countries, including those in Europe. The mortality rates due to coronary heart disease (CHD), one of the most serious CVD conditions, have been decreasing in most European countries during the last decades. However, whether the trends over time in CHD mortality rates differ depending on neighbourhood deprivation has rarely been investigated.

METHODS

For each year of the study period, 1988-2012, in Sweden, age-standardised mortality rates were calculated for three different types of neighbourhoods, characterised by a Neighbourhood Deprivation Index. Joinpoint regression was used to investigate potential changes in age-standardised mortality rates by neighbourhood deprivation and over time.

RESULTS

Over the study period, age-standardised mortality rates due to CHD were consistently the highest in the deprived neighbourhoods and the lowest in the affluent neighbourhoods. We observed a statistically significant overall decline, ranging from 67% to 59%, in the age-standardised CHD mortality rates for each level of neighbourhood deprivation. Furthermore, the decline for the affluent neighbourhoods was significantly higher compared with the decline in the deprived neighbourhoods.

CONCLUSION

Age-standardised CHD mortality rates decreased significantly in Sweden between 1988 and 2012. This decline was more pronounced in the affluent neighbourhoods, which indicates that the improvements in prevention and treatment of CHD have not benefited individuals residing in deprived neighbourhoods to an equal extent. Knowledge of time trends in CHD mortality by level of neighbourhood deprivation may help guide decision-makers in the development of appropriate healthcare policies for deprived neighbourhoods.

Comparing trends in mortality from cardiovascular disease and cancer in the United Kingdom, 1983-2013: joinpoint regression analysis

BACKGROUND

We aimed to study the time trends underlying a change from cardiovascular disease (CVD) to cancer as the most common cause of age-standardized mortality in the UK between 1983 and 2013.

METHODS

A retrospective trend analysis of the World Health Organization mortality database for mortality from all cancers, all CVDs, and their three most common types, by sex and age. Age-standardized mortality rates were adjusted to the 2013 European Standard Population and analyzed using joinpoint regression analysis for annual percent changes.

RESULTS

The difference in mortality rate between total CVD and cancer narrowed over the study period as age-standardized mortality from CVD decreased more steeply than cancer in both sexes. We observed higher overall rates for both diseases in men compared to women, with high mortality rates from ischemic heart disease and lung cancer in men. Joinpoint regression analysis indicated that trends of decreasing rates of CVD have increased over time while decreasing trends in cancer mortality rates have slowed down since the 1990s. The lowest improvements in mortality rates were for cancer in those over 75 years of age and lung cancer in women.

CONCLUSIONS

In 2011, the age-standardized mortality rate for cancer exceeded that of CVD in both sexes in the UK. These changing trends in mortality may support evidence for changes in policy and resource allocation in the UK.

Decline in Cardiovascular Mortality: Possible Causes and Implications

If the control of infectious diseases was the public health success story of the first half of the 20th century, then the decline in mortality from coronary heart disease and stroke has been the success story of the century's past 4 decades. The early phase of this decline in coronary heart disease and stroke was unexpected and controversial when first reported in the mid-1970s, having followed 60 years of gradual increase as the US population aged. However, in 1978, the participants in a conference convened by the National Heart, Lung, and Blood Institute concluded that a significant recent downtick in coronary heart disease and stroke mortality rates had definitely occurred, at least in the US Since 1978, a sharp decline in mortality rates from coronary heart disease and stroke has become unmistakable throughout the industrialized world, with age-adjusted mortality rates having declined to about one third of their 1960s baseline by 2000. Models have shown that this remarkable decline has been fueled by rapid progress in both prevention and treatment, including precipitous declines in cigarette smoking, improvements in hypertension treatment and control, widespread use of statins to lower circulating cholesterol levels, and the development and timely use of thrombolysis and stents in acute coronary syndrome to limit or prevent infarction. However, despite the huge growth in knowledge and advances in prevention and treatment, there remain many questions about this decline. In fact, there is evidence that the rate of decline may have abated and may even be showing early signs of reversal in some population groups. The National Heart, Lung, and Blood Institute, through a request for information, is soliciting input that could inform a follow-up conference on or near the 40th anniversary of the original landmark conference to further explore these trends in cardiovascular mortality in the context of what has come before and what may lie ahead.

Trends in risk factors for coronary heart disease in the Netherlands

BACKGROUND

Favourable trends in risk factor levels in the general population may partly explain the decline in coronary heart disease (CHD) morbidity and mortality. Our aim was to present long-term national trends in established risk factors for CHD.

METHODS

Data were obtained from five data sources including several large scale population based surveys, cohort studies and general practitioner registers between 1988 and 2012. We applied linear regression models to age-standardized time trends to test for statistical significant trends. Analyses were stratified by sex and age (younger <65 and older ≥65 years adults).

RESULTS

The results demonstrated favourable trends in smoking (except in older women) and physical activity (except in older men). Unfavourable trends were found for body mass index (BMI) and diabetes mellitus prevalence. Although systolic blood pressure (SBP) and total cholesterol trends were favourable for older persons, SBP and total cholesterol remained stable in younger persons.

CONCLUSIONS

Four out of six risk factors for CHD showed a favourable or stable trend. The rise in diabetes mellitus and BMI is worrying with respect to CHD morbidity and mortality.

Future trends and inequalities in premature coronary deaths in England: Modelling study

BACKGROUND

Coronary heart disease (CHD) is a major cause of premature mortality, particularly in deprived groups. Might recent declines in overall mortality obscure different rates of decline among social strata, creating potentially misleading views on inequalities?

METHODS

We used a Bayesian analysis of an age-period-cohort model for the English population. We projected age-specific premature CHD mortality (ages 35-74) by gender and area-based deprivation status for the period 2007-2035, using 1982-2006 as the input. Deprivation status was measured by Index of Multiple Deprivation quintiles, which aggregate seven types of deprivation, including health and income. We analysed inequality in premature CHD mortality. We investigated the annual changes in inequality and the contributions of changes in each IMDQ to the overall annual changes, using both absolute (probability) and relative (logit) scales. We quantified inequality using the statistical variance in the probability of premature death among deprivation quintiles.

RESULTS

The overall premature CHD mortality trends conceal marked heterogeneities. Our models predict more rapid declines in premature CHD mortality for the most affluent quintiles than for the most deprived (annualized rate of decline 2006-2025, 7.5% [95% Credible Interval 4.3-10.5%] versus 5.4% [2.2-8.7%] for men, and 6.3% [3.0-9.9%] versus 5.9% [1.5-10.8%] for women). For men, the posterior probability that the rate of decline is greater for the most affluent was 82%. Variance in premature CHD mortality across deprivation quintiles was projected to decrease by approximately 81% [28-95%] among men and by 89% [30-99%] among women. This decrease was particularly driven by the most deprived groups due to their higher premature death rates. However, relative inequality was projected to rise by 93% among men [81-125%] and rise by 13% [-25-58%] among women. These increases are also mostly influenced by the most deprived, reflecting their slower declines in premature deaths.

CONCLUSIONS

Overall, premature coronary death rates in England continue to decline steeply. Absolute inequalities are decreasing, reflecting declines in the high premature mortality in deprived groups. However, relative inequalities are projected to widen further, reflecting slower mortality declines in the most deprived groups. More aggressive and progressive prevention policies are urgently needed.

Variation in causes of death in patients with non-small cell lung cancer according to stage and time since diagnosis

BACKGROUND

Many patients with non-small cell lung cancer (NSCLC) die within the first few years of diagnosis, and considerable excess mortality remains even after 5 years. We investigated the death rate and the distribution of causes of death for NSCLC patients by age and stage at diagnosis during long-term follow-up.

PATIENTS AND METHODS

All 72 021 patients aged 45-89 years diagnosed with stage I-III NSCLC between 1989 and 2008 in the Netherlands and who died up till 2011 were derived from the Netherlands Cancer Registry and linked with the database of Statistics Netherlands for underlying causes of death. Mortality ratios and proportional distribution of causes of death were calculated during 5 time periods after diagnosis of NSCLC (up to 15 years).

RESULTS

Median follow-up was 9.6 years (range: 0-23 years). Lung cancer was the predominant cause of death in the first 6 years after diagnosis (being 80%-85% and ∼90% up to 3 years for localized and locally advanced disease, respectively, and ∼60%-75% and ∼75%-85% during years 4-6 for both stage groups, respectively). Thereafter, lung cancer as cause of death proportionally decreased with time since diagnosis, but remained over 30%. Hence, cardiovascular diseases and chronic obstructive pulmonary diseases (COPD) became more important causes of death, especially for patients aged >60 years at diagnosis (up to 34% for cardiovascular diseases and up to 19% for COPD).

CONCLUSIONS

With time, the relative contribution of cardiovascular and COPD causes of death increased, although the absolute contribution of lung cancer remained high in non-metastatic NSCLC. Therefore, managing morbidity of these diseases remains relevant.

Pediatric lipid management: an earlier approach

The National Heart, Lung and Blood Institute Expert Panel Integrated Guidelines promote the prevention of cardiovascular disease (CVD) events by encouraging healthy behaviors in all children, screening and treatment of children with genetic dyslipidemias, usage of specific lifestyle modifications, and limited administration of lipid pharmacotherapy in children with the highest CVD risk. These recommendations place children in the center of the fight against future CVD. Pediatric providers may be in a position to shift the focus of CVD prevention from trimming multiple risk factors to cutting out the causes CVD.

Shifts in the age distribution and from acute to chronic coronary heart disease hospitalizations

BACKGROUND

Shifts in the burden of coronary heart disease (CHD) from an acute to chronic illness have important public health consequences.

OBJECTIVE

To assess age-sex-specific time trends in rates and characteristics of acute and chronic forms of CHD hospital admissions in the Netherlands.

METHODS

Using nationwide Dutch registers, we assessed time trends between 1998 and 2007 in hospitalization rates of 188,266 acute myocardial infarction (AMI, ICD-9 410), 294,374 unstable angina (ICD-9 411, 413) and 205,649 chronic forms of CHD (ICD-9 412, 414) admissions.

RESULTS

Between 1998 and 2007, the age-standardized CHD hospitalization rate declined from 688 to 545 per 100,000 in men and from 281 to 229 per 100,000 in women. Overall, hospitalization rates decreased at younger age (<75 years) but increased in very old age (≥85 years). The annual percentage change in hospitalization rates was larger for AMI (men:-5.1%, women:-4.4%) than for unstable angina patients (men:-2.0%, women:-2.0%). For chronic CHD, the average annual percentage change was +0.7% in men and +2.1% in women. The proportion of chronic CHD in the total of CHD admissions increased between 1998 and 2007 from 29% to 36% in men and from 23% to 30% in women. The proportion of AMI decreased from 30% to 24% in men and from 27% to 22% in women.

CONCLUSIONS

An increasing proportion of Dutch CHD hospital admissions was for chronic forms of CHD. The age at hospitalization was pushed towards older age: premature CHD admission declined over time and admission rates at very old age increased.

Future declines of coronary heart disease mortality in England and Wales could counter the burden of population ageing

Background

Coronary Heart Disease (CHD) remains a major cause of mortality in the United Kingdom. Yet predictions of future CHD mortality are potentially problematic due to population ageing and increase in obesity and diabetes. Here we explore future projections of CHD mortality in England & Wales under two contrasting future trend assumptions.

Methods

In scenario A, we used the conventional counterfactual scenario that the last-observed CHD mortality rates from 2011 would persist unchanged to 2030. The future number of deaths was calculated by applying those rates to the 2012–2030 population estimates. In scenario B, we assumed that the recent falling trend in CHD mortality rates would continue. Using Lee-Carter and Bayesian Age Period Cohort (BAPC) models, we projected the linear trends up to 2030. We validate our methods using past data to predict mortality from 2002–2011. Then, we computed the error between observed and projected values.

Results

In scenario A, assuming that 2011 mortality rates stayed constant by 2030, the number of CHD deaths would increase 62% or approximately 39,600 additional deaths. In scenario B, assuming recent declines continued, the BAPC model (the model with lowest error) suggests the number of deaths will decrease by 56%, representing approximately 36,200 fewer deaths by 2030.

Conclusions

The decline in CHD mortality has been reasonably continuous since 1979, and there is little reason to believe it will soon halt. The commonly used assumption that mortality will remain constant from 2011 therefore appears slightly dubious. By contrast, using the BAPC model and assuming continuing mortality falls offers a more plausible prediction of future trends. Thus, despite population ageing, the number of CHD deaths might halve again between 2011 and 2030. This has implications for how the potential benefits of future cardiovascular strategies might best be calculated and presented.

Time-dependent changes in atherosclerotic plaque composition in patients undergoing carotid surgery

BACKGROUND

Time-dependent trends in the incidence of cardiovascular disease have been reported in high-income countries. Because atherosclerosis underlies the majority of cardiovascular diseases, we investigated temporal changes in the composition of atherosclerotic plaques removed from patients undergoing carotid endarterectomy.

METHODS AND RESULTS

The Athero-Express study is an ongoing, longitudinal, vascular biobank study that includes the collection of atherosclerotic plaques of patients undergoing primary carotid endarterectomy in the province of Utrecht from 2002 to 2011. Histopathologic features of plaques of 1583 patients were analyzed in intervals of 2 years. The analysis included quantification of collagen, calcifications, lipid cores, plaque thrombosis, macrophages, smooth muscle cells, and microvessels. Large atheroma, plaque thrombosis, macrophages, and calcifications were less frequently observed over time, with adjusted odds ratios of 0.72 (95% confidence interval, 0.650-0.789), 0.62 (95% confidence interval, 0.569-0.679), 0.87 (95% confidence interval, 0.800-0.940), and 0.75 (95% confidence interval, 0.692-0.816) per 2-year increase in time, respectively. These changes in plaque characteristics were consistently observed in patient subgroups presenting with stroke, transient ischemic attack, ocular symptoms, and asymptomatic patients. Concomitantly, risk factor management and secondary prevention strategies among vascular patients scheduled for carotid endarterectomy significantly improved over the past decade.

CONCLUSIONS

In conclusion, over the past decade, atherosclerotic plaques harvested during carotid endarterectomy show a time-dependent change in plaque composition characterized by a decrease in features currently believed to be causal for plaque instability. This appears to go hand in hand with improvements in risk factor management.

Continuing decrease in coronary heart disease mortality in Sweden

Background

Deaths from coronary heart disease (CHD) have been decreasing in most Western countries over the last few decades. In contrast, a flattening of the decrease in mortality has been recently reported among younger age groups in some countries. We aimed to determine whether the decrease in CHD mortality is flattening among Swedish young adults.

Methods

We examined trends in CHD mortality in Sweden between 1987 and 2009 among persons aged 35 to 84 years using CHD mortality data from the Swedish National Register on Cause of Death. Annual percent changes in rates were examined using Joinpoint software.

Results

Overall, CHD mortality rates decreased by 67.4% in men and 65.1% in women. Among men aged 35–54 years, there was a modest early attenuation from a marked initial decrease. In the oldest women aged 75–84 years, an attenuation in the mortality decrease was observed from 1989 to 1992, followed by a decrease, as in all other age groups.

Conclusions

In Sweden, coronary heart disease deaths are still falling. We were unable to confirm a flattening of the decline in young people. Death rates continue to decline in men and women across all age groups, albeit at a slower pace in younger men since 1991. Continued careful monitoring of CHD mortality trends in Sweden is required, particularly among young adults.

Trends in mortality rates from coronary heart disease in Belgrade (Serbia) during the period 1990-2010: a joinpoint regression analysis

Background

Coronary heart disease (CHD) causes an estimated 7 million deaths worldwide each year. In the last few decades, mortality from CHD has been decreasing in many countries. The aim of this study was to analyze the trends of mortality from CHD and myocardial infarction (MI) in the population of Belgrade during the period 1990–2010.

Methods

Mortality data for CHD and MI were obtained from the Municipal Institute of Statistics in Belgrade and used to calculate age- and sex-specific and age-adjusted mortality rates. Joinpoint regression analysis was used to estimate annual percent changes (APCs) in mortality and to identify points in time where significant changes in trend occur.

Results

Trends in CHD mortality rates showed significant decline in men during the period studied (APC -0.5%, no joinpoints detected), but no significant change among women (APC +0.4%, no joinpoints detected). While we observed significant declines in CHD mortality in men aged 35–44, 55–64 and 65–74 and women aged 55–64, there was a significant increase in mortality in men aged ≥85 and women aged 75–84 and ≥85. Trends in MI mortality rates showed similar patterns in both genders, with a significant decline from the mid-1990s. Significant decline in MI mortality was observed in almost all age groups, except the two oldest (75–84 and ≥85) in women population.

Conclusions

Given that CHD and MI mortality trends showed different patterns during the period studied, especially in women, our results imply that further observation of trend is needed.

Decreasing trends in cardiovascular mortality in Turkey between 1988 and 2008

BACKGROUND

Cardiovascular disease (CVD) mortality increased in developed countries until the 1970s then started to decline. Turkey is about to complete its demographic transition, which may also influence mortality trends. This study evaluated trends in coronary heart disease (CHD) and stroke mortality between 1988 and 2008.

METHODS

The number of deaths by cause (ICD-8), age and sex were obtained from the Turkish Statistical Institute (TurkStat) annually between 1988 and 2008. Population statistics were based on census data (1990 and 2000) and Turkstat projections. European population standardised mortality rates for CHD and stroke were calculated for men and women over 35 years old. Joinpoint Regression was used to identify the points at which a statistically significant (p < 0.05) change of the trend occurred.

RESULTS

The CHD mortality rate increased by 2.9% in men and 2.0% in women annually from 1988 to 1994, then started to decline. The annual rate of decline for men was 1.7% between 1994-2008, whilst in women it was 2.8% between 1994-2000 and 6.7% between 2005-2008 (p < 0.05 for all periods).Stroke mortality declined between 1990-1994 (annual fall of 3.8% in both sexes), followed by a slight increase between 1994-2004 (0.6% in men, 1.1% in women), then a further decline until 2008 (annual reduction of 4.4% in men, 7.9% in women) (p < 0.05 for all periods).

CONCLUSIONS

A decrease in CVD mortality was observed from 1995 onwards in Turkey. The causes need to be explored in detail to inform future policy priorities in noncommunicable disease control.

Trends in age-adjusted coronary heart disease mortality rates in Slovakia between 1993 and 2009

Cardiovascular diseases (CVD) and especially coronary heart disease (CHD) are the main causes of death in the Slovak Republic (SR). The aim of this study is to explore trends in age-adjusted coronary heart disease mortality rates in the whole Slovak population and in the population of working age between the years 1993 and 2009. A related indicator - potential years of life lost (PYLL) due to CHD--was calculated in the same period for males and females. Crude CHD mortality rates were age-adjusted using European standard population. The joinpoint Poisson regression was performed in order to find out the annual percentage change in trends. The age-adjusted CHD mortality rates decreased in the Slovak population and also in the population of working age. The change was significant only within the working-age sub-group. We found that partial diagnoses (myocardial infarction and chronic ischaemic heart disease) developed in the mirror-like manner. PYLL per 100,000 decreased during the observed period and the decline was more prominent in males. For further research we recommend to focus on several other issues, namely, to examine the validity of cause of death codes, to examine the development of mortality rates in selected age groups, to find out the cause of differential development of mortality rates in the Slovak Republic in comparison with the Czech Republic and Poland, and to explain the causes of decrease of the age-adjusted CHD mortality rates in younger age groups in Slovakia.

Trends in cardiovascular diseases and cancer mortality in 45 countries from five continents (1980-2010)

BACKGROUND

Cardiovascular diseases (CVD) and cancer are worldwide main causes of death with mortality trends varying across countries with different levels of economic development.

DESIGN AND METHODS

We analysed trends in CVD and cancer mortality for 37 European countries, five high-income non-European countries and four leading emerging economies (BRICS) using data from the World Health Organization database for the period 1980-2010.

RESULTS

In high-income countries, CVD mortality trends are characterized by steep declines over the last decades, while a downward trend in cancer mortality started more recently and was less pronounced. This resulted in the gradual convergence of the CVD and cancer mortality rates, and the latter are already higher in some countries. The absolute number of CVD deaths decreased in most settings, while cancer deaths increased in nearly all countries. Among the BRICS, China and South Africa share a similar pattern of no meaningful variation in both CVD and cancer age-standardized mortality rates and an increase in the overall number of deaths by these causes. Brazil presents trends similar to those of high-income countries, except for the still increasing number of CVD deaths.

CONCLUSIONS

The substantial decreases in CVD mortality over the last decades have overcome the impact of the growth and ageing of populations in the overall number of deaths, while stabilization in the number of cancer deaths was observed only in some of the high-income countries.

NHLBI integrated pediatric guidelines: battle for a future free of cardiovascular disease

The report of the National Heart, Lung and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents collects into one document atherosclerotic disease prevention in pediatric age groups. The guidelines summarize the evidence base and make recommendations that encourage universal adoption of healthier lifestyles, identification of children with cardiovascular disease risk factors, and treatment of those risk factors using targeted lifestyle modification and rarely pharmacotherapy. These recommendations highlight childhood as a frontier for cardiovascular disease prevention. The guideline recommendations are controversial and not universally embraced, but at the very least, they suggest directions for important research. This article explores key facets of the guidelines, controversies and future directions in preventive cardiology for children.

Trends in age-specific coronary heart disease mortality in the European Union over three decades: 1980-2009

AIMS

Recent decades have seen very large declines in coronary heart disease (CHD) mortality across most of Europe, partly due to declines in risk factors such as smoking. Cardiovascular diseases (predominantly CHD and stroke), remain, however, the main cause of death in most European countries, and many risk factors for CHD, particularly obesity, have been increasing substantially over the same period. It is hypothesized that observed reductions in CHD mortality have occurred largely within older age groups, and that rates in younger groups may be plateauing or increasing as the gains from reduced smoking rates are increasingly cancelled out by increasing rates of obesity and diabetes. The aim of this study was to examine sex-specific trends in CHD mortality between 1980 and 2009 in the European Union (EU) and compare trends between adult age groups.

METHODS

Sex-specific data from the WHO global mortality database were analysed using the joinpoint software to examine trends and significant changes in trends in age-standardized mortality rates. Specific age groups analysed were: under 45, 45-54, 55-64, and 65 years and over. The number and location of significant joinpoints for each country by sex and age group was determined (maximum of 3) using a log-linear model, and the annual percentage change within each segment calculated. Average annual percentage change overall (1980-2009) and separately for each decade were calculated with respect to the underlying joinpoint model.

RESULTS

Recent CHD rates are now less than half what they were in the early 1980s in many countries, in younger adult age groups as well as in the population overall. Trends in mortality rates vary markedly between EU countries, but less so between age groups and sexes within countries. Fifteen countries showed evidence of a recent plateauing of trends in at least one age group for men, as did 12 countries for women. This did not, however, appear to be any more common in younger age groups compared with older adults. There was little evidence to support the hypothesis that mortality rates have recently begun to plateau in younger age groups in the EU as a whole, although such plateaus and even a small number of increases in CHD mortality in younger subpopulations were observed in a minority of countries.

CONCLUSION

There is limited evidence to support the hypothesis that CHD mortality rates in younger age groups in the member states of the EU have been more likely to plateau than in older age groups. There are, however, substantial and persistent inequalities between countries. It remains vitally important for the whole EU to monitor and work towards reducing preventable risk factors for CHD and other chronic conditions to promote wellbeing and equity across the region.

Age-specific trends in morbidity, mortality and case-fatality from cardiovascular disease, myocardial infarction and stroke in advanced age: evaluation in the Swedish population

Background

It is not clear if the downward trend in cardiovascular disease (CVD) observed for ages up to 85 years can be extended to the oldest old, those 85 years and above.

Methods and Findings

This nationwide cohort study presents age specific trends of CVD as well as for myocardial infarction (MI) and stroke separately for the period 1994 to 2010 for individuals 85 to 99 years old in Sweden. Data were extracted from national registries. All analyses were based on one-year age- and sex- specific figures. The risk for CVD increased with every age above 85 years although the rate of increase leveled off with age. Over time, the risk for CVD and MI decreased for all ages, and for stroke for ages up to 89 years. However, the risk of MI increased until around 2001 in all age groups and both sexes but decreased after that. The overall mortality improved for all outcomes over the period 1994 to 2010, so did the survival within 28 days from an event. The average annual decline in mortality over all ages, 85 and above was 3% for MI, 2% for stroke and for 2% CVD. Corresponding figures for ages 60–84 was 4% for each of MI, stroke and CVD. The results were similar for men and women.

Conclusions

Improvements in CVD risks observed among ages up to 85 years appear to have extended also to ages above 85 years, even if the rate of improvement plateaued with age. The improvements in survival for all ages up to 99 years give no support to the hypothesis that more fragile individuals reach higher ages. Additional research is needed to find out if improvement in survival can be seen also for the second and third event of CVD, stroke and MI.

Pharmacological primary and secondary cardiovascular prevention among diabetic patients in a multiethnic general practice population: still room for improvements

BACKGROUND

Ethnic minority groups have higher prevalence of cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). We assessed general practitioners' (GPs') performance with respect to the pharmacological prevention of CVD in patients with T2DM from different ethnic backgrounds in Oslo.

METHODS

Of 1653 T2DM patients cared for by 49 GPs in 2005, 380 had a diagnosis of CVD. Ethnicity was categorized as Norwegian, South Asian and other. Risk factor levels, medication use, achievement of treatment targets (HbA1c ≤ 7.5%, systolic blood pressure (SBP) ≤ 140 mmHg, total cholesterol/HDL-cholesterol < 4) and therapeutic intensity (number of drugs targeting each risk factor) were recorded. Chi-square, Wald tests and multiple linear regression analyses were used.

RESULTS

Of the 1273 patients receiving primary prevention, 1.5% had their Hb1Ac, 4.8% SBP and 12.7% lipids levels above treatment thresholds without relevant prescriptions. Among patients on pharmacological therapy, 66% reached the HbA1c, 62% SBP and 62% lipid target. Proportions not achieving the HbA1c target were 26% in Norwegians, 38% in South Asians and 29% in others (p = 0.008). Proportions not achieving the SBP target were 42% in Norwegians, 22% in South Asians and 25% in others (p ≤ 0.001). Of those not achieving the HbA1c and SBP targets, 43% and 35% respectively, used only one agent.

CONCLUSIONS

Norwegian GPs comply reasonably well with guidelines for pharmacological prevention of CVD in T2DM patients across ethnic groups. However, lipid-lowering therapy was generally underused, and the achievement of treatment targets for HbA1c in ethnic minorities and for BP in Norwegians could be improved.

Sex differences in age-related cardiovascular mortality

Introduction

Sex-related physiological differences result in different expressions of diseases for men and women. Data are contradicting regarding the increase in the female risk for cardiovascular disease (CVD) at mid-life. Thus, we studied possible sex differences in age-adjusted mortality for CVD and non-vascular diseases stratifying our findings by specific age groups.

Methods

Over one million deaths (1 080 910) reported to the Finnish nationwide Causes of Death Register in 1986–2009 were analyzed. A total of 247 942 male deaths and 278 752 female deaths were of CVD origin, the remaining deaths were non-vascular. The annual mortality rates were calculated per 100 000 mid-year population, separately for men and women in 5-year age categories.

Results

The age-standardized risk of death from CVD was 80% higher for men (442/100 000) than for women (246/100 000). After age 45–54 the male CVD mortality rate elevated parallel to the non-vascular mortality, whereas in women the CVD mortality elevated considerably more rapidly than the non-vascular mortality from age 60 years onwards.

Conclusions

Heart disease mortality in men accelerates at a relatively young age, but in women the risk shows a steep increase at approximately 60 years of age. These data emphasize the need to identify and prevent risk factors for CVD, especially in women in their mid-life years.

Unequal trends in coronary heart disease mortality by socioeconomic circumstances, England 1982-2006: an analytical study

Background

Coronary heart disease (CHD) remains a major public health burden, causing 80,000 deaths annually in England and Wales, with major inequalities. However, there are no recent analyses of age-specific socioeconomic trends in mortality. We analysed annual trends in inequalities in age-specific CHD mortality rates in small areas in England, grouped into deprivation quintiles.

Methods

We calculated CHD mortality rates for 10-year age groups (from 35 to ≥85 years) using three year moving averages between 1982 and 2006. We used Joinpoint regression to identify significant turning points in age- sex- and deprivation-specific time trends. We also analysed trends in absolute and relative inequalities in age-standardised rates between the least and most deprived areas.

Results

Between 1982 and 2006, CHD mortality fell by 62.2% in men and 59.7% in women. Falls were largest for the most deprived areas with the highest initial level of CHD mortality. However, a social gradient in the pace of fall was apparent, being steepest in the least deprived quintile. Thus, while absolute inequalities narrowed over the period, relative inequalities increased. From 2000, declines in mortality rates slowed or levelled off in the youngest groups, notably in women aged 45–54 in the least deprived groups. In contrast, from age 55 years and older, rates of fall in CHD mortality accelerated in the 2000s, likewise falling fastest in the least deprived quintile.

Conclusions

Age-standardised CHD mortality rates have declined substantially in England, with the steepest falls in the most affluent quintiles. However, this concealed contrasting patterns in underlying age-specific rates. From 2000, mortality rates levelled off in the youngest groups but accelerated in middle aged and older groups. Mortality analyses by small areas could provide potentially valuable insights into possible drivers of inequalities, and thus inform future strategies to reduce CHD mortality across all social groups.

Remarkable decline in ischemic stroke mortality is not matched by changes in incidence

BACKGROUND AND PURPOSE

In Western Europe, mortality from ischemic stroke (IS) has declined over several decades. Age-sex-specific IS mortality, IS incidence, 30-day case fatality, and 1-year mortality after hospital admission are essential for explaining recent trends in IS mortality in the new millennium.

METHODS

Data for all IS deaths (1980-2010) in the Netherlands were grouped by year, sex, and age. A joinpoint regression was fitted to detect points in time at which significant changes in the trends occur. By linking nationwide registers, a cohort of patients first admitted for IS between 1997 and 2005 was constructed and age-sex-specific 30-day case fatality and 1-year mortality were computed. IS incidence (admitted IS patients and out-of-hospital IS deaths) was computed by age and sex. Mann-Kendall tests were used for trend evaluation.

RESULTS

IS mortality declined continuously between 1980 and 2000 with an attenuation of decline in the 1990s in some of the age-sex groups. A remarkable decline in IS mortality after 2000 was observed in all age-sex groups, except for young men. An improved decline in 30-day case fatality and in 1-year mortality was also observed in almost all age-sex groups. In contrast, IS incidence remained stable between 1997 and 2005 or even increased slightly.

CONCLUSIONS

The recent remarkable decline in IS mortality was not matched by a decline in the number of incident nonfatal IS events. This is worrying, because IS is already a leading cause of adult disability, claiming a heavy human and economic burden. Prevention of IS is therefore now of the greatest importance.

Searching for ways to switch on brown fat: are we getting warmer?

Obesity rates are increasing alongside those of its co-morbidities, placing a huge strain on health systems across the globe. Evidence points to inappropriate levels of ectopic lipid accumulation outside of adipose tissue being a major factor in the progression of many of these diseases. Brown adipose tissue (BAT) has a huge capacity to remove lipids from the circulatory system to fuel thermogenesis. Multiple studies have now confirmed the existence of active BAT in adult humans, making strategies aimed at activating it a potential therapeutic option in obese subjects. In recent years, researchers working in murine models have found a wide range of endogenous molecules with specific roles regulating BAT. These findings place BAT firmly within the wider network of physiological regulation covering global metabolism. They also highlight the possibility of targeting thermogenesis in a safe and specific manner to remove potentially harmful lipids released from stressed or failing white adipose tissue in obese states.

Gender- and age-specific trends in coronary heart disease mortality in France from 2000 to 2007: results from the MONICA registers

BACKGROUND

Several recent studies in the USA, the UK and Australia have raised concern about a possible plateau or even reverse trend in coronary heart disease (CHD) mortality in younger populations. We aimed to assess the recent gender- and age-specific trends in CHD mortality among inhabitants aged 35-74 years from the three geographical areas covered by the French MONICA population registers.

METHODS

Registered events were fatal myocardial infarctions and coronary deaths selected after a thorough investigation by the physician who signed the death certificate, general practitioners and cardiologists, and by public and private hospitals for in-hospital deaths.

RESULTS

From 2000 to 2007 age-standardized CHD mortality rates decreased significantly by 24% in men and 38% in women. In the age group 55-74, the estimated annual percentage change (EAPC) in mortality was -5.2 (95% confidence interval: -6.6 to -3.7; p < 10(-4)) among men and -9.0 (-11.6 to -6.4; p < 10(-4)) among women. In the 35-54 age group, the EAPC in mortality was -4.1 (-7.2 to -1.1; p < 10(-2)) among men and -2.5 (-8.7 to 3.7; p = 0.43) among women. These trends remained similar when possible coronary deaths were also accounted for, except in young men where the decline was no longer significant.

CONCLUSIONS

A clear decline in recent CHD mortality rates was observed among subjects above 54 years, but not among younger subjects, particularly in women. These results may be due to unfavourable trends in some risk factors in the latter age group and call for a strengthening of primary prevention.

The relation between socioeconomic status and short-term mortality after acute myocardial infarction persists in the elderly: results from a nationwide study

We assessed whether the previously observed relationship between socioeconomic status (SES) and short-term mortality (pre-hospital mortality and 28-day case-fatality) after a first acute myocardial infarction (AMI) in persons <75 years, are also observed in the elderly (i.e. ≥75 years), and whether these relationships vary by sex. A nationwide register based cohort study was conducted. Between January 1st 1998 and December 31st 2007, 76,351 first AMI patients were identified, of whom 60,498 (79.2 %) were hospitalized. Logistic regression analyses were performed to measure SES differences in pre-hospital mortality after a first AMI and 28-day case-fatality after a first AMI hospitalization. All analyses were stratified by sex and age group (<55, 55–64, 65–74, 75–84, ≥85), and adjusted for age, ethnic origin, marital status, and degree of urbanization. There was an inverse relation between SES and pre-hospital mortality in both sexes. There was also an inverse relation between SES and 28-day case-fatality after hospitalization, but only in men. Compared to elderly men with the highest SES, elderly men with the lowest SES had a higher pre-hospital mortality in both 75–84 year-olds (OR = 1.26; 95 % CI 1.09–1.47) and ≥85 year-olds (OR = 1.26; 1.00–1.58), and a higher 28-day case-fatality in both 75–84 year-olds (OR = 1.26; 1.06–1.50) and ≥85 year-olds (OR = 1.36; 0.99–1.85). Compared to elderly women with the highest SES, elderly women with the lowest SES had a higher pre-hospital mortality in ≥85 year-olds (OR = 1.20; 0.99–1.46). To conclude, in men there are SES inequalities in both pre-hospital mortality and case-fatality after a first AMI, in women these SES inequalities are only shown in pre-hospital mortality. The inequalities persist in the elderly (≥75 years of age). Clinicians and policymakers need to be more vigilant on the population with a low SES background, including the elderly.

Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study

OBJECTIVE

To report trends in event and case fatality rates for acute myocardial infarction and examine the relative contributions of changes in these rates to changes in total mortality from acute myocardial infarction by sex, age, and geographical region between 2002 and 2010.

DESIGN

Population based study using person linked routine hospital and mortality data.

SETTING

England.

PARTICIPANTS

840,175 people of all ages who were admitted to hospital for acute myocardial infarction or died suddenly from acute myocardial infarction.

MAIN OUTCOME MEASURES

Acute myocardial infarction event, 30 day case fatality, and total mortality rates.

RESULTS

From 2002 to 2010 in England, the age standardised total mortality rate fell by about half, whereas the age standardised event and case fatality rates both declined by about one third. In men, the acute myocardial infarction event, case fatality, and total mortality rates declined at an average annual rate of, respectively, 4.8% (95% confidence interval 3.0% to 6.5%), 3.6% (3.4% to 3.7%), and 8.6% (5.4% to 11.6%). In women, the corresponding figures were 4.5% (1.7% to 7.1%), 4.2% (4.0% to 4.3%), and 9.1% (4.5% to 13.6%). Overall, the relative contributions of the reductions in event and case fatality rates to the decline in acute myocardial infarction mortality rate were, respectively, 57% and 43% in men and 52% and 48% in women; however, the relative contributions differed by age, sex, and geographical region.

CONCLUSIONS

Just over half of the decline in deaths from acute myocardial infarction during the 2000s in England can be attributed to a decline in event rate and just less than half to improved survival at 30 days. Both prevention of acute myocardial infarction and acute medical treatment have contributed to the decline in deaths from acute myocardial infarction over the past decade.