Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments

BACKGROUND

Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey.

METHODS

Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model.

RESULTS

Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m(2) and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder.

DISCUSSION

CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically.

Explaining the decline in coronary heart disease mortality in Turkey between 1995 and 2008

Background

Coronary heart disease (CHD) mortality rates have been decreasing in Turkey since the early 1990s. Our study aimed to determine how much of the CHD mortality decrease in Turkey between 1995 and 2008 could be attributed to temporal trends in major risk factors and how much to advances in medical and surgical treatments.

Methods

The validated IMPACT CHD mortality model was used to combine and analyse data on uptake and effectiveness of CHD treatments and risk factor trends in Turkey in adults aged 35–84 years between 1995 and 2008.

Data sources were identified, searched and appraised on population, mortality and major CHD risk factors for adults those aged 35–84 years. Official statistics, electronic databases, national registers, surveys and published trials were screened from 1995 onwards.

Results

Between 1995 and 2008, coronary heart disease mortality rates in Turkey decreased by 34% in men and 28% in women 35 years and over. This resulted in 35,720 fewer deaths in 2008.

Approximately 47% of this mortality decrease was attributed to treatments in individuals (including approximately 16% to secondary prevention, 3% angina treatments, 9% to heart failure treatments, 5% to initial treatments of acute myocardial infarction, and 5% to hypertension treatments) and approximately 42% was attributable to population risk factor reductions (notably blood pressure 29%; smoking 27%; and cholesterol 1%). Adverse trends were seen for obesity and diabetes (potentially increasing mortality by approximately 11% and 14% respectively). The model explained almost 90% of the mortality fall.

Conclusion

Reduction in major cardiovascular risk factors explained approximately 42% and improvements in medical and surgical treatments explained some 47% of the CHD mortality fall. These findings emphasize the complimentary value of primary prevention and evidence-based medical treatments in controlling coronary heart disease.

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.

High prevalence of cardiovascular risk factors in a Western urban Turkish population: a community-based study

OBJECTIVE

Cardiovascular diseases (CVD) are the largest cause of morbidity and mortality in Turkey and in the World. Heart of Balçova Project is a community- based health promotion project that aims to reduce CVD incidence and prevalence through risk factor modification in the individual and population level. This paper presents results of the baseline survey that aimed to define CVD risk factors and risk of developing coronary heart disease (CHD) in the Balçova population.

METHODS

The study population included 36,187 people over 30 years of age residing in Balçova in 2007. Individuals were interviewed at their homes. Anthropometrics and blood pressure were measured and in total 12914 fasting blood samples were collected for lipid and glucose analyses. CHD risk was estimated using Framingham risk equation. Student's t test, Chi-square for trend test and ANOVA were used to compare mean levels and percentages of risk factors between age groups and gender.

RESULTS

In total 5552 men and 10528 women participated in the study. Smoking prevalence was 38.6% in men and 26.8% in women. The prevalence of obesity was 29.4% among men and 44.2% among women and obesity prevalence increased until the age group 75 years old. While 14.6% of men and 12.6% of women had diabetes, 39.8% of men and 41.8% of women had hypertension. The prevalence of high total cholesterol was 56.0% in men and 50.6% in women. Men had a higher risk of developing CHD compared to women in the following 10 years (13.4% vs 2.5%).

CONCLUSION

The prevalence of preventable risk factors for CHD is very high in Balçova population. Community-based interventions should be planned and implemented targeting both the high-risk individuals and whole population.