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Mortality rates and number of deaths from cardiovascular diseases in Italy from 1982 to 1993.
International Journal of Cardiology 75 (2000) 37–42 www.elsevier.com / locate / ijcard
Mortality rates and number of deaths from cardiovascular diseases in Italy from 1982 to 1993. A comparison with total and tumour data a, a b a a G. Massarelli *, A. Muscari , C. Hanau , U. Paradossi , P. Puddu a
Department of Internal Medicine, Cardioangiology, Hepatology, University of Bologna, Bologna, Italy b Department of Statistical Science, University of Bologna, Bologna, Italy Received 8 June 1999; received in revised form 1 February 2000; accepted 11 February 2000
Abstract In this study the recent Italian trends in cardiovascular deaths and mortality are described and compared with the trends regarding total and tumour deaths and mortality. The data, collected from the National Institute of Statistics, are presented as total (T), tumour (TU), cardiovascular (CV), cerebrovascular (CVD), ischemic heart disease (IHD) standardized mortality (sm), non-standardized mortality (nsm) and absolute number of deaths (d), according to sex, age, and geographical area. Data on sm were available only for the age group ,75 years old. In males, from 1982 to 1993, T-sm fell by 18%, TU-sm by 4%, CV-sm by 30%, CVD-sm by 38% and IHD-sm by 24%. In females, the decrements were generally greater: T-sm 20%, TU-sm 4%, CV-sm 35%, CVD-sm 39% and IHD-sm 28%. Since 1985 / 87, tumours have been the leading cause of mortality, in both sexes. By 1991 / 93, the highest rates of CV, CVD, IHD-sm were reported mostly in the South of Italy. Non-standardized mortality rates for tumours increased, and for cardiovascular diseases decreased, in both sexes and age groups (,75 and $75 years old). As for sm, in the group ,75 years, old tumours have been the leading cause of mortality since 1985 / 87, but in the older age group CV-nsm has been more than twice TU-nsm. By 1991 / 93 in comparison with 1982 / 84, CV deaths have fallen by 6% (228% in the age group ,75 years, 13% in the age group $75 years), while TU deaths have grown by 17% (13% in the age group ,75 years, 145% in the age group $75 years). Considering all age groups, by 1991 / 93 the absolute number of CV-d (239.241) was much greater than the number of TU-d (151.908); overall, almost 70% of CV-d and 40% of TU-d took place in the older age group. For the near future, the rapid aging of the Italian population (from 1982 / 84 to 1991 / 93 there was a 40% increment in the population older than 75 years) is a relevant variable to take into account. Thus, despite the ‘reassuring’ fall in CV-sm and nsm, cardiovascular diseases are expected to remain the major cause of death and physical disability in adults. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Cardiovascular mortality; Cardiovascular deaths; Total mortality; Tumour mortality
1. Introduction Since the 1960s age-specific cardiovascular mortality has been falling, first in the United States and afterwards in the other Western countries [1–3]. By 1993, cardiovascular mortality in Europe was ac*Corresponding author. Isituto di Ricovero e Cura a Carattere Scientifico, Via Pinidolo 23 25064 Gussago, Brescia, Italy. Fax: 139-1162875-792.
countable for about 40% of all cause mortality before the age of 75 years, with large international and subnational (regional) differences [4]. In spite of decreasing age-specific cardiovascular mortality, in Western Europe there has been no major decrement in the total number of deaths from cardiovascular diseases. In fact the number of cardiovascular deaths and chronically ill patients may even be increasing [5]. On the other hand, during the same period,
0167-5273 / 00 / $ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 00 )00236-9
38
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42
cardiovascular mortality in Eastern Europe has increased, likely due to changing nutritional and social habits [4]. In Italy age-specific cardiovascular disease mortality has been falling since the late 1970s [6–8], but still cardiovascular diseases are the major cause of death and physical disability in adults [9,10]. This study presents the recent Italian trends in cardiovascular deaths and in standardized and non-standardized mortality rates. For comparison, total and tumour mortality has also been reported. In Italy, there are no registries on the incidence and prevalence of cardiovascular diseases. However, these data on mortality may provide, although indirectly, an estimation of the trends, changes and impact of cardiovascular disease morbidity.
2. Materials and methods Mortality and population data were collected from the National Institute of Statistics (ISTAT). The causes of death were coded according to the IX Revised International Classification of Diseases. The
following codes were considered: 001–999 for total mortality, 140–239 for tumour mortality, 390–459 for cardiovascular mortality, 410–414 for ischemic heart disease mortality, and 430–438 for cerebrovascular disease mortality. The period 1982 to 1993 was considered, and all data were averaged in three year sub-periods in order to reduce random variations in annual mortality rates. The collected data are presented in three different modalities. In the first, data are shown as total standardized mortality (T-sm), tumour-sm (TU-sm), cardiovascular-sm (CV-sm), cerebrovascular-sm (CVD-sm) and ischemic heart diseases-sm (IHD-sm) in relation to sex and geographical area (north5N, centre5C, and south5S). Mortality data were standardized310 000 to the 1971 population, according to direct method, by ISTAT. This analysis, which allows comparison with previous literature data [6–8] was restricted to the subjects younger than 75, because standardized mortality data for older age groups were not available. In the second modality, to evaluate the actual contribution of the different age groups to mortality,
Fig. 1. Per cent variations in standardized mortality rates in males and females, aged ,75 years, from 1982 / 84 to 1991 / 93. TU-sm5tumour standardized mortality, T-sm5total standardized mortality, IHD-sm5ischemic heart disease standardized mortality, CV-sm5cardiovascular disease standardized mortality, CVD-sm5cerebrovascular disease standardized mortality.
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42 Table 1 Total, tumour, cardiovascular, cerebrovascular, ischemic heart disease standardized mortality rates310 000 population and mean annual per cent variation from 1982 / 84 to 1991 / 93 in the population ,75 years old a 1982 / 84
1985 / 87
1988 / 90
1991 / 93
Annual per cent variation
Males T-sm TU-sm CV-sm CVD-sm IHD-sm
59.2 19.2 19.9 4.9 9.0
54.6 19.1 17.3 4.2 8.0
50.7 19.0 14.9 3.4 7.2
48.5 18.3 13.9 3.0 6.7
21.5 20.3 22.5 22.2 22.0
Females T-sm TU-sm CV-sm CVD-sm IHD-sm
32.8 11.2 11.2 3.7 3.2
30.0 11.0 9.5 3.2 2.8
27.5 11.0 8.0 2.6 2.5
26.3 10.8 7.2 2.3 2.3
21.7 20.3 23.0 23.2 22.3
a
T-sm5total standardized mortality, TU-sm5tumour standardized mortality, CV-sm5cardiovascular standardized mortality, CVD-sm5 cerebrovascular standardized mortality, IHD-sm5ischemic heart disease standardized mortality.
data are presented as non-standardized mortality (nsm)310 000 population. Total-nsm (T-nsm), tumour-nsm (TU-nsm) and cardiovascular-nsm (CVnsm) are reported according to age (,75 vs. $75 years old) and sex. Finally, data are shown as absolute number of deaths (d), not referred to the population. Total-d (T-d), tumour-d (TU-d) and cardiovascular deaths (CV-d) are reported according to age (,75 vs. $75 years old) and sex.
39
3. Results Fig. 1 shows the course of the per cent variations in total, tumour, cardiovascular, cerebrovascular and ischemic heart disease standardized mortality in Italy from 1982 to 1993 for the population younger than 75 years. The absolute values for the same standardized mortalities are reported in Table 1, together with the mean per cent annual variation during the whole period. By 1985 / 87 tumours have become the leading cause of mortality. The per cent annual variations for CV-sm, CVD-sm and IHD-sm are greater than those observed in the previous decade [6–8] and much greater than those for T-sm and TU-sm. Table 2 shows the standardized mortality rates and the per cent changes from 1982 / 84 to 1991 / 93 according to sex and geographical area. By 1991 / 93 in males, CV-sm and CVD-sm were highest in the south, while IHD-sm was greatest in the north. Since 1982 / 84 up to 1991 / 93, in females, CV-sm, IHD-sm, and CVD-sm have been highest in the S. Almost without exception, in both sexes, and for all pathologies considered, the greatest per cent reductions occurred in the N and the lowest in the S, while the C remained the area with the lowest mortality rates. In Fig. 2 the data on T-nsm, TU-nsm and CV-nsm according to age (,75 vs. $75 years old) and sex are shown. In both age groups and sexes, T-nsm and CV-nsm are falling while TU-nsm is increasing. Also in this analysis, since 1985 / 87, tumours have become
Table 2 Standardized cardiovascular, cerebrovascular, and ischemic heart disease mortality rates310 000 population and per cent variations from 1982 / 84 to 1991 / 93, according to geographical area and sex for the population ,75 years old Years
Males 1982 / 84
Females 1991 / 93
% difference
1982 / 84
1991 / 93
% diff
Cardiovascular disease mortality North 21.1 a Centre 17.9 South 19.3
14.1 12.9 14.5
233 228 225
10.6 9.5 13.3
6.6 6.4 8.8
238 233 234
Cerebrovascular disease mortality North 5.0 Centre 4.4 South 5.1
2.9 2.7 3.6
242 239 229
3.4 3.2 4.5
2.0 1.9 2.9
241 240 236
Ischemic heart disease mortality North 9.9 Centre 8.2 South 8.1
7.0 6.5 6.6
229 221 219
3.3 2.7 3.4
2.2 2.1 2.5
233 222 226
a
Italics are the highest mortality rates and the greatest per cent reduction values amongst the three geographical areas.
40
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42
the leading cause of death in the population younger than 75 years. On the contrary, in the subjects older than 75 years CV diseases are by large the leading cause of mortality, with rates more than twice TU-nsm. Fig. 3 shows the absolute values, not related to the population, of T-d, TU-d and CV-d for the period 1991 / 93, together with their per cent variations from the period 1982 / 84. Data are presented separately according to sex and age. In the whole population,
during the period 1991 / 93 with respect to 1982 / 84, total deaths have increased by 1% (214% in the subjects younger than 75, and 115% in the subjects older than 75), CV deaths have fallen by 6% (228% in the population younger than 75, 13% in the older group), while TU deaths have increased by 17% (13% in the younger age group and 145% in the older) with no relevant differences in relation to sex. In females CV-d fell by 4% (233% in the younger
Fig. 2. Non-standardized mortality rates according to age and sex from 1982 / 84 to 1991 / 93. T-nsm5total non-standardized mortality, TU-nsm5tumour non-standardized mortality, CV-nsm5cardiovascular non-standardized mortality.
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42
41
Fig. 3. Absolute values for total deaths, cardiovascular deaths and tumour deaths in the period 1991 / 93, together with the per cent variations from the period 1982 / 84.
age group and 11% in the older); in males CV-d decreased by 9% (225% in the younger age group and 17% in the older). Furthermore almost 70% of CV-d and only 40% of TU-d took place in the older age group. Considering all ages, by 1991 / 93 the absolute number of CV-d (239 241) has been much greater than the number of TU-d (151 908).
4. Discussion In Italy since 1982 / 84 the per cent fall in cardiovascular, cerebrovascular and ischemic heart disease standardized mortality has been much greater than in total and tumour mortality in the population younger than 75 years (Fig. 1). As a result, since
42
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42
1985 / 87, tumours have become the commonest cause of death. As in other countries [4,11,12], the annual per cent fall in CV-sm has been greater than in the previous decade, and in females it has been more pronounced than in males (Table 1). These trends are in agreement with epidemiological data showing a general decrement in CV risk factors, mainly smoking and arterial hypertension, across the population [13– 16]. By 1991 / 93 CV-sm was maximal in the south of Italy in both sexes and the per cent annual decrement in the same area was lower than in the rest of the country (Table 2). TU-nsm has increased in both sexes and age groups, although it has overcome CV-nsm only in the population less than 75 years old (Fig. 2). Since CV non-standardized mortality has fallen across the whole population, the increment in the absolute number of all CV deaths in the subjects older than 75 (Fig. 3) has to be related only to the aging of the population: in fact the proportion of population older than 75 has grown from 5% in 1982 / 84 to 7% in 1991 / 93 (a 40% increment). Considering all ages, by 1991 / 93 the absolute number of CV-d was much greater than the number of TU-d. Still, in the population older than 75 years there has been a large increment in TU-d, which in part could be explained by a greater commitment to reach a definite diagnosis in the elderly. Within the next decades, a further decrease in CV mortality has to be expected in Italy, as in the other Western countries, in relation to better control of risk factors and improvement in medical intervention. Still, in spite of the rapid and ‘reassuring’ fall in CV standardized and non-standardized mortality rates, the aging of the population will determine an increment in cardiovascular patients and, possibly, deaths. As a result, in the near future cardiovascular diseases are expected to remain the leading cause of death and disability in the Western world, and many efforts have to be spent not only in further decreasing mortality, but in preventing disabilities and enhancing the quality of life particularly of the elderly. A closer cooperation between geriatricians and cardiologists, and a greater number of trials concerning the elderly are needed. In the meantime Italian medical and preventive resources for cardiovascular diseases have
to prepare to tackle the expected increased needs of the elderly population.
References [1] Higgins M, Thom T. Trends in CHD in United States. Int J Epidemiol 1989;18(Suppl 1):S58–S65. [2] Uemura K, Pisa Z. Recent trends in cardiovascular disease mortality in 27 industrialized countries. Wld Hlth Stat Quart 1985;38:142–62. [3] Cooper R, Ueshima H, Stamler J, Yu C, Tatara K, Asakura S. Age-specific mortality trends in the USA from 1960 to 1980: divergent age–sex color patterns. J Chron Dis 1984;37:425–39. [4] on behalf of the Task Force of the European Society of Cardiology on cardiovascular disease mortality and morbidity statistics in Europe, Sans S, Kesteloot H, Kromhout D. The burden of cardiovascular diseases mortality in Europe. Eur Heart J 1997;18:1231–48. [5] Kelly DT. Our future society. A global challenge. Circulation 1997;95:2459–64. [6] Nicolosi A, Casati S, Taioli E, Polli E. Death from cardiovascular disease in Italy, 1972–1981: Decline in mortality rates and possible causes. Int J Epidemiol 1988;17:766–72. [7] Cecchi F, Montereggi A, Dolara A, Barchielli A. Trend di mortalita` per cardiopatia ischemica e altre malattie cardiovascolari in Italia nel periodo 1970–86. Loro suddivisione per sesso e area geografica. G Ital Cardiol 1991;21:415–21. [8] Capocaccia R, Farchi G, Mariotti S et al. In: La mortalita` in Italia nel periodo 1970–79, Istituto Superiore di Sanita` Roma, 1984, pp. 90–110. [9] Capocaccia R, Farchi G, Mariotti S, et al. Rapporti Istisan per gli ` anni 1982–1993. Istituto Superiore di Sanita. ` In: Stili di vita e condizione di salute, [10] Istituto Superiore di Sanita. ` indagine multiscopo 1993 / 94, vol. 2, Istituto Superiore di Sanita, Roma, 1996, pp. 69–85. [11] Zhang XH, Sasaki S, Kesteloot H. The sex ratio of mortality and its secular trends. Int J Epidemiol 1995;24:720–9. [12] Sytkowski PA, D’Agostino RB, Belanger A, Kannel WB. Sex and time trends in cardiovascular disease incidence and mortality: the Framingham Heart Study, 1950–1989. Am J Epidemiol 1996;143:338–50. [13] The Research Group ATS-RF2 of the Italian National Research Council. Distribution of some risk factors for atherosclerosis in nine italian population samples. Am J Epidemiol 1981;113:338–46. [14] The Research Group ATS–RF2 of the Italian National Research Council. Time trends of some cardiovascular risk factors in Italy, results from the nine communities study. Am J Epidemiol 1987;126:95–103. [15] the RIFLE Project Research Group, Menotti A, Seccareccia F, Lanti M. Mean levels and distributions of some cardiovascular risk factors in Italy in the 1970’s and 1980’s. The Italian rifle pooling project, risk factors and life expectancy. G Ital Cardiol 1995;25:1539–72. [16] the Responsible Investigators of the RF2, 0B43 and MICOL Research Groups, Menotti A, Scanga M. Trends in coronary risk factors in Italy. Int J Epidemiol 1992;21:883–91.
Mortality rates and number of deaths from cardiovascular diseases in Italy from 1982 to 1993. A comparison with total and tumour data a, a b a a G. Massarelli *, A. Muscari , C. Hanau , U. Paradossi , P. Puddu a
Department of Internal Medicine, Cardioangiology, Hepatology, University of Bologna, Bologna, Italy b Department of Statistical Science, University of Bologna, Bologna, Italy Received 8 June 1999; received in revised form 1 February 2000; accepted 11 February 2000
Abstract In this study the recent Italian trends in cardiovascular deaths and mortality are described and compared with the trends regarding total and tumour deaths and mortality. The data, collected from the National Institute of Statistics, are presented as total (T), tumour (TU), cardiovascular (CV), cerebrovascular (CVD), ischemic heart disease (IHD) standardized mortality (sm), non-standardized mortality (nsm) and absolute number of deaths (d), according to sex, age, and geographical area. Data on sm were available only for the age group ,75 years old. In males, from 1982 to 1993, T-sm fell by 18%, TU-sm by 4%, CV-sm by 30%, CVD-sm by 38% and IHD-sm by 24%. In females, the decrements were generally greater: T-sm 20%, TU-sm 4%, CV-sm 35%, CVD-sm 39% and IHD-sm 28%. Since 1985 / 87, tumours have been the leading cause of mortality, in both sexes. By 1991 / 93, the highest rates of CV, CVD, IHD-sm were reported mostly in the South of Italy. Non-standardized mortality rates for tumours increased, and for cardiovascular diseases decreased, in both sexes and age groups (,75 and $75 years old). As for sm, in the group ,75 years, old tumours have been the leading cause of mortality since 1985 / 87, but in the older age group CV-nsm has been more than twice TU-nsm. By 1991 / 93 in comparison with 1982 / 84, CV deaths have fallen by 6% (228% in the age group ,75 years, 13% in the age group $75 years), while TU deaths have grown by 17% (13% in the age group ,75 years, 145% in the age group $75 years). Considering all age groups, by 1991 / 93 the absolute number of CV-d (239.241) was much greater than the number of TU-d (151.908); overall, almost 70% of CV-d and 40% of TU-d took place in the older age group. For the near future, the rapid aging of the Italian population (from 1982 / 84 to 1991 / 93 there was a 40% increment in the population older than 75 years) is a relevant variable to take into account. Thus, despite the ‘reassuring’ fall in CV-sm and nsm, cardiovascular diseases are expected to remain the major cause of death and physical disability in adults. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Cardiovascular mortality; Cardiovascular deaths; Total mortality; Tumour mortality
1. Introduction Since the 1960s age-specific cardiovascular mortality has been falling, first in the United States and afterwards in the other Western countries [1–3]. By 1993, cardiovascular mortality in Europe was ac*Corresponding author. Isituto di Ricovero e Cura a Carattere Scientifico, Via Pinidolo 23 25064 Gussago, Brescia, Italy. Fax: 139-1162875-792.
countable for about 40% of all cause mortality before the age of 75 years, with large international and subnational (regional) differences [4]. In spite of decreasing age-specific cardiovascular mortality, in Western Europe there has been no major decrement in the total number of deaths from cardiovascular diseases. In fact the number of cardiovascular deaths and chronically ill patients may even be increasing [5]. On the other hand, during the same period,
0167-5273 / 00 / $ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 00 )00236-9
38
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42
cardiovascular mortality in Eastern Europe has increased, likely due to changing nutritional and social habits [4]. In Italy age-specific cardiovascular disease mortality has been falling since the late 1970s [6–8], but still cardiovascular diseases are the major cause of death and physical disability in adults [9,10]. This study presents the recent Italian trends in cardiovascular deaths and in standardized and non-standardized mortality rates. For comparison, total and tumour mortality has also been reported. In Italy, there are no registries on the incidence and prevalence of cardiovascular diseases. However, these data on mortality may provide, although indirectly, an estimation of the trends, changes and impact of cardiovascular disease morbidity.
2. Materials and methods Mortality and population data were collected from the National Institute of Statistics (ISTAT). The causes of death were coded according to the IX Revised International Classification of Diseases. The
following codes were considered: 001–999 for total mortality, 140–239 for tumour mortality, 390–459 for cardiovascular mortality, 410–414 for ischemic heart disease mortality, and 430–438 for cerebrovascular disease mortality. The period 1982 to 1993 was considered, and all data were averaged in three year sub-periods in order to reduce random variations in annual mortality rates. The collected data are presented in three different modalities. In the first, data are shown as total standardized mortality (T-sm), tumour-sm (TU-sm), cardiovascular-sm (CV-sm), cerebrovascular-sm (CVD-sm) and ischemic heart diseases-sm (IHD-sm) in relation to sex and geographical area (north5N, centre5C, and south5S). Mortality data were standardized310 000 to the 1971 population, according to direct method, by ISTAT. This analysis, which allows comparison with previous literature data [6–8] was restricted to the subjects younger than 75, because standardized mortality data for older age groups were not available. In the second modality, to evaluate the actual contribution of the different age groups to mortality,
Fig. 1. Per cent variations in standardized mortality rates in males and females, aged ,75 years, from 1982 / 84 to 1991 / 93. TU-sm5tumour standardized mortality, T-sm5total standardized mortality, IHD-sm5ischemic heart disease standardized mortality, CV-sm5cardiovascular disease standardized mortality, CVD-sm5cerebrovascular disease standardized mortality.
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42 Table 1 Total, tumour, cardiovascular, cerebrovascular, ischemic heart disease standardized mortality rates310 000 population and mean annual per cent variation from 1982 / 84 to 1991 / 93 in the population ,75 years old a 1982 / 84
1985 / 87
1988 / 90
1991 / 93
Annual per cent variation
Males T-sm TU-sm CV-sm CVD-sm IHD-sm
59.2 19.2 19.9 4.9 9.0
54.6 19.1 17.3 4.2 8.0
50.7 19.0 14.9 3.4 7.2
48.5 18.3 13.9 3.0 6.7
21.5 20.3 22.5 22.2 22.0
Females T-sm TU-sm CV-sm CVD-sm IHD-sm
32.8 11.2 11.2 3.7 3.2
30.0 11.0 9.5 3.2 2.8
27.5 11.0 8.0 2.6 2.5
26.3 10.8 7.2 2.3 2.3
21.7 20.3 23.0 23.2 22.3
a
T-sm5total standardized mortality, TU-sm5tumour standardized mortality, CV-sm5cardiovascular standardized mortality, CVD-sm5 cerebrovascular standardized mortality, IHD-sm5ischemic heart disease standardized mortality.
data are presented as non-standardized mortality (nsm)310 000 population. Total-nsm (T-nsm), tumour-nsm (TU-nsm) and cardiovascular-nsm (CVnsm) are reported according to age (,75 vs. $75 years old) and sex. Finally, data are shown as absolute number of deaths (d), not referred to the population. Total-d (T-d), tumour-d (TU-d) and cardiovascular deaths (CV-d) are reported according to age (,75 vs. $75 years old) and sex.
39
3. Results Fig. 1 shows the course of the per cent variations in total, tumour, cardiovascular, cerebrovascular and ischemic heart disease standardized mortality in Italy from 1982 to 1993 for the population younger than 75 years. The absolute values for the same standardized mortalities are reported in Table 1, together with the mean per cent annual variation during the whole period. By 1985 / 87 tumours have become the leading cause of mortality. The per cent annual variations for CV-sm, CVD-sm and IHD-sm are greater than those observed in the previous decade [6–8] and much greater than those for T-sm and TU-sm. Table 2 shows the standardized mortality rates and the per cent changes from 1982 / 84 to 1991 / 93 according to sex and geographical area. By 1991 / 93 in males, CV-sm and CVD-sm were highest in the south, while IHD-sm was greatest in the north. Since 1982 / 84 up to 1991 / 93, in females, CV-sm, IHD-sm, and CVD-sm have been highest in the S. Almost without exception, in both sexes, and for all pathologies considered, the greatest per cent reductions occurred in the N and the lowest in the S, while the C remained the area with the lowest mortality rates. In Fig. 2 the data on T-nsm, TU-nsm and CV-nsm according to age (,75 vs. $75 years old) and sex are shown. In both age groups and sexes, T-nsm and CV-nsm are falling while TU-nsm is increasing. Also in this analysis, since 1985 / 87, tumours have become
Table 2 Standardized cardiovascular, cerebrovascular, and ischemic heart disease mortality rates310 000 population and per cent variations from 1982 / 84 to 1991 / 93, according to geographical area and sex for the population ,75 years old Years
Males 1982 / 84
Females 1991 / 93
% difference
1982 / 84
1991 / 93
% diff
Cardiovascular disease mortality North 21.1 a Centre 17.9 South 19.3
14.1 12.9 14.5
233 228 225
10.6 9.5 13.3
6.6 6.4 8.8
238 233 234
Cerebrovascular disease mortality North 5.0 Centre 4.4 South 5.1
2.9 2.7 3.6
242 239 229
3.4 3.2 4.5
2.0 1.9 2.9
241 240 236
Ischemic heart disease mortality North 9.9 Centre 8.2 South 8.1
7.0 6.5 6.6
229 221 219
3.3 2.7 3.4
2.2 2.1 2.5
233 222 226
a
Italics are the highest mortality rates and the greatest per cent reduction values amongst the three geographical areas.
40
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42
the leading cause of death in the population younger than 75 years. On the contrary, in the subjects older than 75 years CV diseases are by large the leading cause of mortality, with rates more than twice TU-nsm. Fig. 3 shows the absolute values, not related to the population, of T-d, TU-d and CV-d for the period 1991 / 93, together with their per cent variations from the period 1982 / 84. Data are presented separately according to sex and age. In the whole population,
during the period 1991 / 93 with respect to 1982 / 84, total deaths have increased by 1% (214% in the subjects younger than 75, and 115% in the subjects older than 75), CV deaths have fallen by 6% (228% in the population younger than 75, 13% in the older group), while TU deaths have increased by 17% (13% in the younger age group and 145% in the older) with no relevant differences in relation to sex. In females CV-d fell by 4% (233% in the younger
Fig. 2. Non-standardized mortality rates according to age and sex from 1982 / 84 to 1991 / 93. T-nsm5total non-standardized mortality, TU-nsm5tumour non-standardized mortality, CV-nsm5cardiovascular non-standardized mortality.
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42
41
Fig. 3. Absolute values for total deaths, cardiovascular deaths and tumour deaths in the period 1991 / 93, together with the per cent variations from the period 1982 / 84.
age group and 11% in the older); in males CV-d decreased by 9% (225% in the younger age group and 17% in the older). Furthermore almost 70% of CV-d and only 40% of TU-d took place in the older age group. Considering all ages, by 1991 / 93 the absolute number of CV-d (239 241) has been much greater than the number of TU-d (151 908).
4. Discussion In Italy since 1982 / 84 the per cent fall in cardiovascular, cerebrovascular and ischemic heart disease standardized mortality has been much greater than in total and tumour mortality in the population younger than 75 years (Fig. 1). As a result, since
42
G. Massarelli et al. / International Journal of Cardiology 75 (2000) 37 – 42
1985 / 87, tumours have become the commonest cause of death. As in other countries [4,11,12], the annual per cent fall in CV-sm has been greater than in the previous decade, and in females it has been more pronounced than in males (Table 1). These trends are in agreement with epidemiological data showing a general decrement in CV risk factors, mainly smoking and arterial hypertension, across the population [13– 16]. By 1991 / 93 CV-sm was maximal in the south of Italy in both sexes and the per cent annual decrement in the same area was lower than in the rest of the country (Table 2). TU-nsm has increased in both sexes and age groups, although it has overcome CV-nsm only in the population less than 75 years old (Fig. 2). Since CV non-standardized mortality has fallen across the whole population, the increment in the absolute number of all CV deaths in the subjects older than 75 (Fig. 3) has to be related only to the aging of the population: in fact the proportion of population older than 75 has grown from 5% in 1982 / 84 to 7% in 1991 / 93 (a 40% increment). Considering all ages, by 1991 / 93 the absolute number of CV-d was much greater than the number of TU-d. Still, in the population older than 75 years there has been a large increment in TU-d, which in part could be explained by a greater commitment to reach a definite diagnosis in the elderly. Within the next decades, a further decrease in CV mortality has to be expected in Italy, as in the other Western countries, in relation to better control of risk factors and improvement in medical intervention. Still, in spite of the rapid and ‘reassuring’ fall in CV standardized and non-standardized mortality rates, the aging of the population will determine an increment in cardiovascular patients and, possibly, deaths. As a result, in the near future cardiovascular diseases are expected to remain the leading cause of death and disability in the Western world, and many efforts have to be spent not only in further decreasing mortality, but in preventing disabilities and enhancing the quality of life particularly of the elderly. A closer cooperation between geriatricians and cardiologists, and a greater number of trials concerning the elderly are needed. In the meantime Italian medical and preventive resources for cardiovascular diseases have
to prepare to tackle the expected increased needs of the elderly population.
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