Epidemiology of cardiovascular diseases in women in Europe

Nutrition, Metabolism & Cardiovascular Diseases (2010) 20, 379e385

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REVIEW

Epidemiology of cardiovascular diseases in women in Europe S. Panico*, A. Mattiello Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy Received 12 July 2009; accepted 2 February 2010

KEYWORDS Europe; Cardiovascular disease; Risk factors; Mortality; Morbidity

Abstract Cardiovascular diseases, defined as diseases of the heart and circulatory system are the main cause of mortality, morbidity and hospitalisation in women all over Europe. Evaluation of descriptive epidemiology of cardiovascular disease and its risk factors in the European women cannot ignore the extraordinary changes in the economic and political profile of the continent that occurred in the past 20 years. A keynote is requested by the knowledge that the Eastern female populations currently appear to be the less protected from cardiovascular disease (CVD; both coronary heart disease (CHD) and stroke) and its risk factors and require major efforts in public health for both primary prevention and risk factors and events treatment. Another important piece of information is that the traditional geographical differences in CHD indicating an advantage of Southern European women in comparison with other European ones is less evident than in the past, owing to the levelling off regarding the differences in risk factors associated lifestyles. The figures for prevalence of epidemic risk factors, such as smoking, physical inactivity, overweight and obesity, high blood pressure and cholesterol levels indicate an urgent need to implement public health interest as well as investments on the whole spectrum of CVD manifestations in terms of risk factors and events. ª 2010 Elsevier B.V. All rights reserved.

Cardiovascular disease (CVD) is the leading cause of mortality, morbidity and hospitalisation in both genders in all countries of Europe [1,2]. The public health burden of CVD events is substantial, and is the valid reason to implement programmes of prevention of first and recurrent events all over the European countries [2,3]. Moreover, in most countries, due to the demographic

* Corresponding author. Tel.: þ39 817 463687; fax: þ39 815466152. E-mail address: [email protected] (S. Panico).

structure and the overall improvement in treatment, although the clinical onset is mainly acute, CVD often evolves gradually and may interfere with quality of life, physical disability and lifelong dependence on health services and medications. Premature deaths are concurrent with adverse outcomes in elderly people, including decreased physical performance, cognitive impairment and dementia. The costs for this burden are huge and are related to health care and social services, illness benefits and retirement, impact on families and caregivers and loss of years of productive life.

0939-4753/$ - see front matter ª 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.numecd.2010.02.004

380 In the past 20 years, the political and economic profile of Europe has undergone extraordinary changes. When describing the epidemiology of cardiovascular disease and its risk factors in the European women, this profound evolution cannot be neglected. Today, the European region, as defined by the World Health Organization (WHO), comprises 53 countries. Each of these countries has a quite specific political, economic and cultural history that has had specific influence on cardiovascular epidemiology, with differences, which often appear more pronounced for women. In the European Union (EU), 27 countries are now state-members, although the differences, mainly economic and cultural, among them e and particularly between the early and the late members e were and are still conspicuous. To observe and evaluate the data of the female populations across Europe, it is relevant to take into account the diversity of their historical background. A reasonable approach is to describe and comment on data e when available e comparing the aggregate of the 53 countries of the WHO European region, the aggregate of the 27 countries, which are state-members of the EU and the aggregate of countries composed on the basis of a sort of geo-socio-political indicator as are those definable as Northern, Southern, Western, Eastern and Central. The crucial role played by social, economic and cultural factors in determining such a frequent disease in populations is more evident when evaluating the data on women; for them the societal evolution has led to impressive changes. To estimate the burden of CVD in European women e as well as in men e mortality represents the most reliable indicator at a large level; this allows a number of comparative comments on the several aggregates of European countries, which are quite insightful to contextualise the epidemiology of CVD in the European women. Rigorous data on morbidity (prevalence, incidence and attack rates) are limited to some geographical areas, for some periods covered by CVD events registries [3,4]. Distribution and prevalence of risk factors and, in general, risk conditions for CVD are available in a dozen European countries where health interviews or examination surveys have been made available, mostly for very defined periods, rarely in different periods over time [5]. For some other European areas, the size of these phenomena can be estimated on the basis of some local observations [1]. An orientation for the use of databases for health indicators in European countries is available as a basis for further information on health status [6].

Mortality CVDs, defined as diseases of the heart and circulatory system, are the main cause of death all over Europe. When summing up the latest available year data (on average in the first part of the year 2000) for each country, the figures are as described below. The number of women of all age who died of CVD was 2.35 million, that is, 54% of total deaths, a proportion higher than for men (43%). Coronary heart disease (CHD) and stroke are the main forms of CVD. CHD is the single most common cause of death in Europe: 1.92 million deaths, of which about 960 000 in men and 963 000 in women; no significant difference in proportional

S. Panico, A. Mattiello mortality is detectable between men and women since about one CHD death occurs in five women (22%) and in five men (21%). Stroke is the second single most common cause of death in Europe: 1.24 million deaths, of which about 744 000 are in women and 494 000 are in men; there is a difference between genders with one death in six women (17%) and one in 10 men (11%). Although CVD is the main cause of death for women in all the 27 EU countries, the figures for the EU are a little different and are to be interpreted taking into account three features: (a) the demographic structure of the single populations (older than the other European ones); (b) the modification of risk conditions associated to lifestyle and the medical attention to their potential treatment; (c) the outcomes of the clinical management of the CVD events. The number of women of all ages who died of CVD was 1.09 million making up 45% of total deaths, a proportion higher than for men (38%). In women in the EU, CHD and stroke are also the main forms of CVD, accounting for about 350 000 and 300 000 deaths, respectively. In comparison with the other European countries, CHD appears relatively less frequent: around one death in six men (16%) and in seven women (15%). The competitive cause of death due to cancer, especially breast, may be an important part of this occurrence. Nevertheless, it is still the single most common cause of death. Stroke is the second and accounts for almost one-fourth of all CVD deaths. Stroke deaths appear more common in women in the EU than in men; a difference between genders is detectable with 1 death in 10 men (9%) and 1 in eight women (12%). Fig. 1 compares the proportional mortality in Europe as a whole and the EU for CHD, stroke and other CVDs. The overall burden appears smaller in the EU at all ages: it is not reasonable to attribute this finding to differences in deathcertificate coding modalities; the age structures of populations indicate that the EU has an older population with a higher life expectancy at birth (78.1 against 74.6 years for all European countries in 2005), suggesting a better natural history for CVD, possibly influenced by better care for both risk conditions and events, and the concomitant role of competitive cancer deaths [1,2,7]. There are countries such as Italy, France and Germany experiencing 81.1, 80.7 and 80.2 years of life expectancy, respectively, and others such as the Russian Federation, Hungary and Slovakia experiencing 66.4, 73.1 and 74.3 years, respectively. The life expectancy figure for women across selected European countries, representative of different parts of the continent and different socioeconomical historical background, is consistently higher than for men but lower in the Eastern countries; the range of life expectancy, an indicator of the quality of life and health care, varies from 83.8, 82.3 and 82.0 years of Italy, Austria and Germany, respectively, to 74.2, 78.1 and 79.9 years of the Russian Federation, Hungary and Slovakia, respectively (Fig. 2). The figures are consistently lower for all other Eastern countries, where CVD appears to be a greater public health issue for women than elsewhere in Europe, indirectly confirmed by the fact that CVD causes more than 50% of deaths in women in most of these countries [1]. These data indicate the dramatic differences between the Eastern and the other European populations, attributable to the societal evolution along an economic transition where inequalities in health have been

CVD epidemiology in European women

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described and where women have been one of the weak links of the social chain [8e10]; a recent report from Romania has described low rates of reperfusion in patients with myocardial infarction, high case fatality rates, with an excess in-hospital deaths in women of 30% compared with men [11]. The mortality secular trends for CHD and stroke are in line with the previous comments. In economically more stable countries, both CHD and stroke mortality are declining, whereas in less economically stable ones, the

finding has two important aspects: (a) the standardised rates are higher; and (b) the secular trends show an upand-down fluctuation with an early increase and a recent tendency to a small decrease, an indicator of the influence of the disordered and rapid change of living conditions of these populations. When looking at some representative female populations of different geo-sociopolitical parts of Europe before age 65 years (which includes the potential working life span), a four- to sixfold difference between countries of different economic

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Figure 2 Life expectancy in years at birth for women in selected countries. (http://epp.eurostat.ec.europa.eu/portal/page/ portal/eurostat/home) 2005.

382 conditions for CHD and stroke mortality rates can be detected in the recent years.

Morbidity The descriptive epidemiology of CVD morbidity in European countries is not easy since there is no routinely updated source for Europe-wide morbidity. The only collaborative experience among centres located in several European countries has been made in the MONICA Project (MONICA, Multinational MONItoring of trends and determinants in Cardiovascular disease), which promoted the detection of incidence and attack rates for cardiovascular events using standardised procedures allowing a reliable comparison between units of observation [12,13]. However, the involved units did not necessarily represent the general population of the country in which they were located. Nevertheless, a unique insight has been provided to estimate the burden of the disease’s acute events and chronic complications across Europe. Incidence, fatality and disability-adjusted life years (DALY) appear of great interest when comparing women and men. The comparable data indicate that there is a gradient from North to South of Europe for CHD incidence in women [12]. These range from Southern Mediterranean (Italy and Spain) with around 40 events per 100 000 to Northern (Ireland and Finland) with over 140 events per 100 000 in women aged 35e64 years. The data refer to the mid-1990s, but it seems likely that this gradient is still persistent; in more recent years, hospital discharge statistics for CHD are consistent with this finding, although they indicate an attenuation of the geographical variation [1]. The data for attack rates are consistent with those on incidence of first event. Unfortunately, previous data, describing CHD morbidity in several parts of Europe, were available only for men; however, it is reasonable to say that e consistently with men and also for women e the attenuation of the variation between Northern and Southern European countries has started between the 1970s and the 1980s. For women living in centres located in the Russian Federation, Poland or Czech Republic, the available incidence data indicate a two- to three-fold higher rate than those in Southern Europe and from one-and-half to two-fold higher than those in Central-Western Europe. The data from MONICA taken over time indicate that a small decrease in incidence is detectable for many centres, mainly located in non-Eastern countries, whereas in Eastern ones, in some cases, the annual incidence rate is increasing, thus confirming the urge for a public health action. It is interesting to note that rates are not significantly falling in some Southern and Central European populations, especially in women; the change in some lifestyles appears to be crucial for this phenomenon. When comparing CHD incidence rates in the latest years, it should be noted that the new more sensitive diagnostic tools, which affected the recent changes in the diagnostic criteria of coronary events and the diffusion of coronary revascularisation make it difficult to compare past and recent trends in CHD. Data from many countries have indicated a potential increase in diagnosis that may differ in different settings [14,15]; however, this fact does not seem to interfere with the interpretation of the

S. Panico, A. Mattiello overall picture, since it has become relevant only in the recent years. The fatality rates within 28 days from a CHD acute event among women are a little higher than those in men in all centres. The range in the mid-90s was reported from an impressive 45e50% in centres of Spain, Italy and Germany to a dramatic 60e70% in the Russian Federation and Poland. The reasons for this gender difference, still detected, are quite debated and vary from the role of risk factors (more severe in women in which the disease occurs than in men), to the delay in event diagnosis and treatment. The incidence of stroke increases with age: in European women, it ranges from 1 to 2 per 1000 person years at age 65 years up to about 50 per 1000 at age 85 years or older. The incidence of first stroke before the age of 85 years is slightly higher in men than in women. In the MONICA collaborative project, a geographic pattern is recognised, with very high attack and incidence rates in the Finnish populations studied, but overall with higher attack and incidence among the populations of Eastern Europe than among those in Western Europe [13]. These results are in line with mortality statistics for stroke, and appear similar to those detectable for CHD. The range of variation for incidence rates between populations and geographical distribution are not substantially different from that of stroke attack rates. The findings are consistent between genders; however, the case fatality rates are higher in women than in men. A comprehensive review of several observational studies finds less geographical variation for the incidence of stroke [16]. The heterogeneity of aetiology and clinical manifestation of stroke makes different observational findings possible; interestingly, the gender difference is comparable: more men than women suffer from stroke before the age of 85 years, but case fatality is higher in women [16]. Again, the picture for Eastern countries is impressive: the incidence of stroke in the Russian Federation and Ukraine is high. It is reasonable that this finding may be attributed to well-known social and economic changes that have occurred in these countries over the past 2 decades, including changes in medical care, access to vascular prevention strategies among those at high risk and the exposure to risk factors. Europe as a whole recognises, as for mortality, a greater public health problem for CVD morbidity (CHD and stroke) in comparison with the EU; this is due to the high social impact of CVD in Eastern European, whatever disease frequency indicator is used and independently from gender. The data for DALY, derived from morbidity rates are clear: in the EU, over 12 million DALYs are lost each year for CVD (19% of total), whereas in Europe as a whole, 34 million DALYs are lost (23%) [17]. The worst figure is for the former Soviet Union countries: Ukraine, the Russian Federation and Belarus have a three-fold higher rates than Spain, Italy or France.

Epidemic risk factors Smoking: The epidemiology of smoking in European women is characterised by the socio-cultural changes for the female gender that occurred in the past decades. Currently, 200 000 women are estimated to die from

CVD epidemiology in European women smoking each year in Europe, of whom about 80 000 die from CVD, but the figures are rapidly evolving. The prevalence of smoking has always been lower in females than in males in all countries since the diffusion of cigarette consumption as a social habit, definitely after World War II. Northern and Central European women have been more familiar with cigarettes than Southern and Eastern European women. Over the years, the trend has been changing in parallel with economic growth and the promotion of the social image that smoking is a sign of social emancipation: Southern European women e markedly the young generations e are currently on the ascending part of the curve of prevalence, whereas the prevalence in Eastern countries remains at low levels and is much lower than in men. However, an international survey carried out in 30 European countries on boys and girls aged 15 years in 2001/ 2002, gathering also information on previous time periods starting (for some countries) since the early the 1990s, has shown that in many Western and Southern European populations 15-year-old girls have an equal or even greater prevalence of smokers than boys [18]. In the Eastern European countries, boys still have a higher prevalence but the gap has been narrowing over time; moreover, the gender difference in adults in some of those countries is less marked than in the youth: in the Russian Federation, the adult prevalence in the same years is 60% versus 16% in adults and 27% versus 19% in youth. Within this framework, the CVD mortality attributable to smoking in European women is smaller than in men, but is expected to increase in Southern, Western and Eastern European countries. Concomitantly, a further increase is also expected for the influence on incidence and mortality rates due to passive smoking. A smoke-free society campaign with women (especially young) as the main target appears a public health priority almost everywhere in Europe. We know that smoking cessation can be achieved and is effective in reducing CVD risk in both disease-free individuals and cardiovascular patients. The information that women suffering from heart attack in Europe have the worst performance in quitting smoking [19] and that young women start smoking more and more implies that there is a long way to go. Legislation to protect individuals from passive smoking has been shown to be effective in public health and is strongly suggested by the European governing authorities [20,21]. Diet: A descriptive figure of some dietary components, which may be relevant for CVD aetiology all over Europe, is available from a questionnaire-based survey proposed by the WHO Regional Office for Europe; however, the surveys in each of the countries have been conducted using different methods, in different times and interviewing population groups not necessarily comparable with the general populations [22]. Moreover, the Food and Agricultural Organization (FAO) data on food availability are a source of data for comparison in Europe; however, due to their nature, they may imply different interpretation according to the wealthy class of the single countries [23]. According to these figures, we know that: (a) the consumption of fruit and vegetables, which in most countries is lower than the recommended daily amount, has a decreasing gradient from Northern to Southern Europe and from Northern Central to Eastern Europe; (b) the

383 consumption of fat of animal origin has an opposite pattern; (c) the trends for these consumptions over the past years have not changed much but for a narrowing distance between North and South Europe. Observational data from a European-wide study on diet and cancer (over 500 000 individuals, of which almost 350 000 women, in 10 countries, from North to South) confirm these data [24]; in over 74 000 elderly individuals in the same study, including about 50 000 women, it appears clear that a Mediterranean pattern improves survival, mainly attributable to less chronic disease frequency, with CVD on top [25]. Women are known to be the deciders in buying and preparing food for the families all over Europe; therefore, it is reasonable to say that the data described earlier for the whole populations apply to women and that campaign for CVD prevention dietary measures should have women as a crucial target. Physical activity: Physical inactivity has been estimated to affect about 3% of the total disease burden in economically developed countries, and specifically over 20% for CHD and 10% for stroke [26]. Comparable data on the prevalence of physical activity levels at the European level are available only for the early 15 state-members of the EU. In 2002, a survey was conducted indicating that (a) about 50% of adult European citizens are physically inactive; (b) less than 20% have minimal activity after the age of 60 years; (c) the Central and Northern European countries are below the European average for physical inactivity, and are the places where citizens recognise structural opportunities in their living area; (d) Southern (Mediterranean) countries are above this average (the only exception being Ireland); (e) only one European citizen over six reports a level of physical activity to be considered useful for CVD prevention (a little less women than men); and (f) women have higher levels of physical inactivity all over Europe [27]. Some national data confirm this figure, which appears particularly worrisome in Mediterranean countries where the increasing levels of physical inactivity over time is the main cause for the increase in overweight and obesity, especially in women [28e31]. We may speculate that in Eastern European countries, this phenomenon is very likely to occur in a few years, since populations under transitional economies recognise a consistent trend in increase of overweight and obesity all over the world. The message for public health all over Europe is clear: the future of prevention of CVD mostly depends on the promotion of physical activity, especially in women. Overweight and obesity: As reported in the previous section, the increase of prevalence of overweight and obesity has become an epidemiological emergency in Mediterranean countries [28e31]. This phenomenon is being seen as the key feature, which may undermine the Mediterranean advantage with regard to cardiovascular disease [32]. In addition, it appears to be a key public health issue in Eastern European countries for the very near future, worsening the cardiovascular risk of these populations. As observed, women are mostly affected by this phenomenon. According to the WHO World Health Report, 7% of all disease burden is due to increase in body mass index (BMI) at the population level, with an estimate of 30% of CHD and ischaemic stroke attributable to BMI exceeding 21 kg m2 (considered a theoretical minimum) [26]. Survey

384 data in 34 European countries, carried out using reported information, indicate for women a prevalence of obesity (BMI > 30 kg m2) ranging from 7% in Norway to 25% in Turkey, with 25 countries with more than 10% of obese women and 10 with more than 20%. In a recent WHO report, attempting an estimation of trends for some chronic disease risk factors over the 53 European countries, in 2010, only 17 will have a mean BMI in the female population lower than 25 kg m2, with 16 countries exceeding 26 kg m2 [33]. Recent analytical studies on CVD risk indicate that overweight and obesity play a greater than-expected role in determining CVD (especially coronary), and report a specific role of abdominal obesity: the case-control INTERHEART estimates that 63% of heart attacks in Western Europe and 28% in Central and Eastern Europe are due to abdominal obesity; two large cohorts (one from Denmark and the other from Italy), part of the collaborative European Prospective Investigation into Cancer and Nutrition (EPIC) study on cancer, have recently produced data on the risk of adiposity on CVD, confirming that body mass and central adiposity are independent contributors. For women, central adiposity appears as a very strong determinant of CVD [34e36]. Blood pressure: The prevalence of high blood pressure levels in European women has a substantially similar figure of that in men. No specific geographical pattern may be detected; however, it is interesting to note in the MONICA project, comparable data on adult women and men indicate that the highest sex ratio is consistently detected in the Russian population samples (more prevalent hypertensives e systolic blood pressure greater than 160 mmHg e among women), where morbidity and mortality for CVD are quite high and life expectancy is among the lowest [4]. Unfortunately, little comparable data are available for all the Eastern European countries. Nevertheless, some estimation based on national data indicates that a blood pressure mean greater than 127 mmHg in women aged 15 years and older is expected to be detected in 2010 in Bosnia, Lithuania, Serbia and Montenegro, Russian Federation, Moldova, Georgia, Belarus and Germany; with the exception of Germany, all of them being Eastern countries [37]. Again, both the lack of prevention programmes for countrywide risk factors and the poor compliance to good clinical practice in detecting and treating high blood pressure levels may have played a role in this; conversely, countrywide attention to blood pressure determinants and hypertension treatment seems to have played a role in some Western countries such as UK and Finland [37]. Blood cholesterol: The prevalence of undesirable blood cholesterol levels (3.8 mmol l1) varies widely among European women, following trends and value similar to those of men [26,38]. The INTERHEART estimation of heart attacks due to abnormal blood lipids indicates a higher attributable risk in Western than in Central and Eastern European countries, with Southern European estimates as the lowest [34]. The efforts in both primary and secondary prevention programmes are visible in some Western and Central European countries and a generalised decrease in blood cholesterol, both in men and in women, is reported in the MONICA observations between the mid-1980s and mid1990s, while Eastern and Southern countries have not experienced such a decrease; with some of them revealing

S. Panico, A. Mattiello a tendency to an increase [38]. Eastern and Southern European female populations still need a more intensive attention through campaigns to reduce blood cholesterol.

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