Large differences in cardiovascular mortality and prevention policies across EU

21 September 2009

New research from the EuroHeart mapping project shows huge inequalities in both national prevention policies and levels of cardiovascular mortality seen across the EU.

While heart disease remains the leading cause of death in Europe, mortality rates are falling in most (but not all) countries, according to new findings released by the project [1]. However, this detailed research, part of a three-year programme to analyse cardiovascular health and prevention policies in 16 European countries, also reveals huge inequalities among countries both in the rate of cardiovascular mortality and in national prevention programmes.

  • highest rates of mortality from coronary heart disease (CHD) in men under 65 were found in Hungary (105 per 100,000 population), Estonia (104), Slovakia (74), Greece (50), Finland (48) and UK (44).
  • highest rates for women under 65 were found in Hungary (28), Estonia (20), Slovakia (19), UK (11), Greece (10) and Belgium (9);
  • lowest rates for men under 65 were found in France (17), Netherlands (22), Italy (25) and Norway (27); and
  • lowest rates for women under 65 were found in Iceland (3), France (3), Slovenia (5) and Italy (5).

This pattern was also reflected (though not exactly mirrored) in risk factor prevalence, where, for example, Greece (46%), Estonia (42%), Slovakia (41%), Germany (37%) and Hungary (37%) had the highest rates of cigarette smoking.

There are also noticeable differences in trends in CHD mortality; in Finland mortality rates from CHD declined by 76% from 1972 to 2005; in the same period in Greece, mortality rates for CHD increased by 11%. In nine of the 16 EuroHeart countries, the trends in CHD death rates in women show that they have declined less than in men.

The research also found striking inequalities among the 16 countries in terms of CHD prevention policies and legislation:

  • all countries reported some type of legislation covering public health, tobacco control and food. However, Denmark and Greece do not have national policies relating specifically to coronary heart disease;
  •  Belgium, Estonia, Finland, France, Iceland, Italy and Slovenia have five policies in place related to cardiovascular health promotion, CHD, hypertension, stroke and hyperlipidaemia; Greece had just one;
  • two countries reported no national guidelines within the broad context of cardiovascular disease (Denmark and Greece). All other countries reported national guidelines on CHD and hypertension, with a minority (Belgium, Finland, Ireland) reporting official government endorsement of existing European guidelines. Most countries had national guidelines on the management of hyperlipidaemia (except Denmark and Greece), diabetes and stroke prevention. Twelve countries (excepting Denmark, Greece and Slovenia) had obesity guidelines; and
  • only three countries (France, Germany and Ireland) reported recommendations for emergency first-aid (cardio-pulmonary resuscitation (CPR) and access to and training in the use of external defibrillators).

“What these findings show us,” says Susanne Logstrup, director of the European Heart Network, a joint co-ordinator with the European Society of Cardiology of the EuroHeart project, “is that most countries have taken legislative action and have policy measures in place for public health, coronary heart disease, tobacco, food and physical activity.

“Although most countries have some sort of prevention targets, the links between these targets and monitoring, public reporting of progress and national evaluation are much less clear. Only in about half the participating countries could we identify budgets allocated to policy and programme implementation.

“We cannot conclude that there is a clear association between prevention policies and cardiovascular mortality in all countries, but in some countries — such as Greece — the association is striking.”

Nowhere is this association more evident than in the effect of smoking bans on acute coronary events.

  • in February last year the French authorities announced a 15% decrease in emergency admissions for heart attack just one year the public ban on smoking came into effect;
  • similar results were reported from Italy when researchers in Rome found an 11.2% reduction of acute coronary events since a January 2005 smoking ban [2];
  • researchers from Ireland, where a public smoking ban was introduced in 2004, found a reduction of 11% in admissions with acute coronary events in the year following the ban, which was sustained through the following year [3];
  • the number of people admitted to hospital for heart attacks fell by 17% in the year after Scotland's smoking ban took effect in March 2006 [4];
  • a recent meta-analysis of eight studies on the effects of smoke-free legislations concluded that they yielded “an immediate 19% reduction” in acute heart attack events [5].

Total bans on smoking in all enclosed public places and workplaces, including bars and restaurants, are so far in place in Ireland and UK. Legislation in Italy, Malta, Sweden, Latvia, Finland, Slovenia, France and the Netherlands allows for special enclosed smoking rooms.

Commenting on the findings for the European Society of Cardiology, Professor Lars Rydén, Chair of the ESC committee for cardiovascular prevention, said: “The EuroHeart project reflects ESC policy on cardiovascular prevention in Europe. It is important to speak with a unified professional voice alongside other organisations and to have a simple, consistent message. This has been our policy since 1994, when development of the first prevention guidelines began in collaboration with other professional societies.

"Those guidelines are now in their fourth edition, and many other organisations now support them. However, studies tell us there is still an enormous gap between recommendation and reality, and a lot of work for their implementation is still left to be done. We need to speak with a unified voice to make the strong recommendations which are necessary.”

Professor Rydén adds that the European Heart Health Charter, devised with the support of the ESC, European Heart Network, European Commission and WHO, was developed as such an alliance to provide a European-wide approach to the prevention of CVD and fulfil an EU treaty commitment “to protect health and improve the quality of life in the European population by reducing the impact of cardiovascular disease”.

“The broader WHO’s Europe presents even greater gaps between its 53 countries, which have been increasing over the past 20 years. We are observing a difference up to 10 times in death rates from ischemic hearth diseases in men below 65 years of age. On the other side of the coin, we see that some countries have been able to put in place successful policies to reduce this burden,” concludes Dr Nata Menabde, Deputy Regional Director for Europe.

“WHO/Europe and the European Commission are working with all their Member States to strengthen the capacity of health systems in Europe to address the root causes of cardiovascular and non-communicable diseases, including smoke, obesity, alcohol and lack of physical activity”.

1. Cowburn G, Bhatnagar P, Logstrup S. National plans, policies and measures impacting on cardiovascular health promotion and cardiovascular disease prevention. European Heart Network, European Society of Cardiology 2009.

2. Cesaroni GF, Forastiere N, Agabiti P, et al. Effect of the Italian smoking ban on population rates of acute coronary events. Circulation 2008; 117: 1183-1188.

3. Cronin E, et al. ESC Congress 2007.

4. Pell JP, Haw S, Cobbe S, et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N Engl J Med 2008; 359: 482-491.

5. Glantz S. Meta-analysis of the effects of smokefree laws on acute myocardial infarction: an update. Prevent Med 2009; in press.

6. WHO Regional Office for Europe. The Tallinn Charter: Health Systems for Health and Wealth. 2008;

7. WHO Regional Office for Europe. Gaining Health: The European Strategy for the prevention and control of NCDs. 2006

About EuroHeart

EuroHeart is a joint project of the European Heart Network and European Society of Cardiology to strengthen cross-sector cooperation; obtain comprehensive comparable information on policies and actions on cardiovascular health promotion and disease prevention; improve awareness, diagnosis and treatment of women with CVD across Europe; and create a level playing field by introducing national versions of CVD guidelines.

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