Summary
Variations in cardiovascular disease (CVD) burden between West and South European countries are rarely reported. To address this knowledge gap, The Lancet Regional Health-Europe convened experts from a broad range of countries to assess the current state of knowledge of cardiovascular disease inequalities across Europe. This Review is specifically focused on West and South European countries. Mortality, risk factor and economic data for nine West European and six South European countries were sourced from the World Health Organisation, the Global Burden of Disease study and the World Bank. Healthcare data were collected by survey of participating countries. A key finding was of declines in age-standardised mortality rates (ASMRs) across all countries since 1990. In 2019 rates per 100,000 were lower in West European countries in males (279.7 (264.1–335.9) vs 337.2 (323.7–367.2)) and females (196.2 (183.3–228.8) vs 247.3 (232.2–268.3)). Differences in risk factor exposures were small, with the exception of physical activity and dietary factors, but across all countries the prevalence of obesity has increased, affecting >20% of adults in 2019. Healthcare delivery in 2019 showed inequalities with cardiovascular procedure rates lower in South compared with West European countries. Further declines in ASMRs in West and South European countries will require population strategies to reduce obesity and address inequalities in physical activity and dietary factors. Reducing the gap in procedure rates is unlikely to match the beneficial effects of population strategies for reducing CVD burden in South European countries.
Keywords: Cardiovascular care Europe, Cardiovascular outcomes Europe, Cardiovascular disease Europe, Cardiovascular procedures Europe
Introduction
International comparisons of cardiovascular disease (CVD) burden, the healthcare applied in its treatment and mortality outcomes are rarely reported. Yet the value of such studies is considerable for policy makers in the development of strategies for prevention and treatment of CVD. Existing studies often lack population coverage because they are based on selected samples of hospital patients reported in voluntary registries or trials that differ from national populations in treatments and outcomes.1, 2, 3, 4 The present study takes a population approach in examining national inequalities in cardiovascular healthcare and outcomes between West and South European countries as contextualised by healthcare systems, socioeconomic factors, human and capital resource, and determinants of cardiovascular risk. Variations in CVD across Europe are well documented5 but while recent reductions in disease manifestations have been greatest in the high income countries of Western Europe5,6 focus on Southern Europe has been more limited.7 This review seeks to resolve this limitation by defining inequalities between West and South European countries in terms of the incidence and mortality of CVD, risk factors and healthcare delivery with the rationale of identifying potential targets for reducing disease burden at regional and national level.
Methods
Data sources
This review focuses on adult (age > 16 years) CVD in the West and South European countries listed in Table 1,8 all of which are classified as high-income by World Bank (WB) criteria.9 The review utilises mortality and risk factor data from the World Health Organisation (WHO) and the Global Burden of Disease (GBD) study with additional WB economic data.10, 11, 12, 13 Information about national healthcare systems and health expenditure was obtained from on-line sources.14,15 The WHO database collates data on the absolute number of medically certified deaths from national authorities based on their vital registration systems. All participating countries are rated high quality by the WHO with 100% completeness of mortality data.16 From the primary data, mortality rates are calculated using country-level data on population size, obtained from the same database, as denominators. Age-standardized rates are estimated using the direct method with the 2013 European Standard Population to control for cross-national differences in population age structures.17 Estimates of CVD incidence come from the GBD study,11 The estimates are derived using modelling software and data from health surveys, prospective cohorts, health system administrative data and registries. Their accuracy is heavily dependent on the original data used. Cardiovascular healthcare data for 2019 were collected by The European Society of Cardiology (ESC) Atlas survey of member countries that included the West and South European countries that are the subject of this report.6 The data were subjected to quality control procedures, including comparison with other data sources to identify abnormal values. These values were discussed with the provider national cardiac society and corrected where necessary. The data were reviewed by independent experts before final approval.
Table 1.
CVD: Economic data for 2019 sourced from World Bank.
| GDP per capita (current international US$) | CHE per capita (current international US$) | CHE (% of GDP) | |
|---|---|---|---|
| West Europe | |||
| Austria | 58,076 | 6134 | 10.4 |
| Belgium | 54,278 | 5847 | 10.7 |
| France | 48,971 | 5493 | 11.1 |
| Germany | 55,653 | 6739 | 11.7 |
| Ireland | 87,380 | 6010 | 6.7 |
| Luxembourg | 117,341 | 6757 | 5.4 |
| Netherlands | 59,004 | 6248 | 10.1 |
| Switzerland | 72,034 | 8532 | 11.3 |
| United Kingdom | 49,041 | 5087 | 10.2 |
| Median (IQR) | 58,076 (54,278–72,034) | 6134 (5847–6739) | 10.4 (10.1–11.1) |
| South Europe | |||
| Cyprus | 42,711 | 3017 | 7.1 |
| Greece | 30,356 | 2419 | 7.8 |
| Italy | 44,376 | 3998 | 8.7 |
| Malta | 47,271 | 4040 | 8.2 |
| Portugal | 36,172 | 3518 | 9.5 |
| Spain | 41,695 | 3984 | 9.1 |
| Median (IQR) | 42,203 (37,552–43,960) | 3751 (3142–3994) | 8.4 (7.9–9.0) |
GDP = gross domestic product. CHE = current healthcare expenditure. IQR = interquartile range.
Data presentation
All analyses, interpretations and conclusions are those of the authors. Data presentation is descriptive, and no attempt is made to attach statistical significance to differences observed in stratified analyses. For consistency, measures of central tendency across groups of countries are presented as medians with interquartile ranges in parentheses. Values > 1000 are not decimalised. Rates per million people are computed from WB population estimates with age-standardization.17 Time series data are illustrated using locally weighted scatter plot smoothing (LOWESS).18 Box plots are used for comparison of CVD procedure rates between West and South European countries. The plots display a box representing the median value and first and third quartile values, with whiskers positioned at the furthest data points within 1.5 times the interquartile range. Any countries outside this range are defined as outliers and are plotted individually.
Results
Healthcare systems
In most South European countries including Italy, Spain, Greece, Portugal and Malta healthcare funding is by tax-based ‘Beveridge-type’ systems, that focus on ensuring universal coverage and equity of access. In the majority of Western European countries, including Germany, France, Austria, Netherlands and Switzerland healthcare funding is by “Bismarck-type” systems, financed primarily through compulsory health insurance contributions. However, in Belgium, Ireland and Luxembourg funding is mainly by taxation with the option available of private insurance. In the UK funding is almost exclusively by taxation.
Healthcare expenditure
Data for 2019 showed that after adjustment for local purchasing power, West European countries spent on average almost twice as much on healthcare as those in the South (Table 1). Annual expenditure per capita exceeded USD 6000 per capita in all West European countries with the exception of Belgium, France and UK where it was greater than USD 5000 per capita. Among South European countries only Malta spent more than USD 4000 per capita on healthcare. In terms of national capacity to finance the healthcare sector, West European countries made a median allocation of 10.4% (10.1%–11.1%) of GDP to healthcare, ranging from 5.4% in Luxembourg to 11.3% in Switzerland. In South European countries the median allocation was 8.4% (7.9%–9.0%) of GDP ranging from 7.1% in Cyprus to 9.5% in Portugal.
Incident CVD and mortality
Age standardised rates of incident CVD in West and South European countries remained consistently higher in men compared with women during the period 1990–2019 (Table 2). During the same period substantial declines in disease incidence occurred in both West and South European countries (Fig. 1) with similar impact on ischaemic heart disease (IHD) and stroke. Minor heterogeneity was observed in the declining incidence of CVD which ranged from 17% in Italy to 42% in Germany in males and from 17% in Austria to 39% in Spain in females. Declines in age-standardised mortality rates (ASMRs) for CVD during the period 1990–2019 were also substantial with only small differences between West and South Europe at a regional and national level (Fig. 2). Similar changes occurred in premature (age <70 years) mortality and contributed towards marked reductions in disability adjusted life years (Table 2). The declines in ASMRs during the period 1990–2019 showed minor heterogeneity in males and females, and were lowest in Cyprus (35% and 42%, respectively) and highest in Luxembourg (68% and 70%, respectively). In 2019 median ASMRs per 100,000 were lower in West compared with South European countries in males (279.7 (264.1–335.9) vs 337.2 (323.7–367.2)) and in females (196.2 (183.3–228.8) vs 247.3 (232.2–268.3)) (Table 3).
Table 2.
Cardiovascular disease (CVD): incidence, prevalence and mortality.
| Male | West Europe |
South Europe |
||
|---|---|---|---|---|
| 1990 | 2019 | 1990 | 2019 | |
| CVD | ||||
| Incidence | 897.4 (821.1–984.5) | 636.8 (589.2–715.4) | 812.7 (776.6–850.2) | 601.0 (571.1–631.8) |
| Prevalence | 7234 (6815–7288) | 5894 (5819–6141) | 6473 (6381–6566) | 5363 (5339–5567) |
| DALYs | 7301 (5864–7707) | 2514 (2298–3024) | 6791 (5816–7404) | 2972 (2602–3500) |
| IHD | ||||
| Incidence | 410.8 (385.6–500.8) | 288.0 (251.8–300.7) | 344.8 (265.8–375.3) | 249.2 (209.5–268.8) |
| Prevalence | 3023 (2853–3433) | 2548 (2304–2676) | 2643 (2334–2731) | 2327 (2189–2355) |
| DALYS | 4239 (3599–5149) | 1291 (1147–1674) | 3214 (2919–4373) | 1632 (1148–2157) |
| Stroke | ||||
| Incidence | 114.0 (110.5–127.7) | 62.6 (60.5–70.1) | 129.7 (116.9–141.2) | 70.6 (68.3–76.6) |
| Prevalence | 893.3 (887.6–1004.1) | 615.3 (595.7–662.4) | 936.0 (853.5–999.1) | 630.3 (610.2–702.2) |
| DALYs | 1439 (1270–1681) | 575.8 (517.2–598.5) | 1641 (1598–2011) | 637.9 (612.6–939.0) |
| CVD mortality | ||||
| Crude rate | 425.1 (350.6–480.8) | 214.3 (202.3–236.0) | 376.0 (331.0–423.5) | 282.6 (241.6–333.9) |
| Premature rate | 139.8 (124.3–159.6) | 54.0 (43.4–66.1) | 124.8 (108.5–136.2) | 69.4 (62.6–74.7) |
| ASMR | 728.4 (622.6–953.9) | 279.7 (264.1–335.9) | 762.1 (669.9–868.7) | 337.2 (323.7–367.2) |
| Female | West Europe |
South Europe |
||
|---|---|---|---|---|
| 1990 | 2019 | 1990 | 2019 | |
| CVD | ||||
| Incidence | 666.4 (608.2–685.7) | 469.0 (459.9–480.4) | 642.4 (602.1–658.3) | 445.1 (439.5–474.8) |
| Prevalence | 6496 (6083–6657) | 5249 (5006–5391) | 5966 (5853–6022) | 4855 (4769–4917) |
| DALYs | 4110 (3193–4203) | 1580 (1499–1751) | 4508 (3643–4871) | 1764 (1591–2167) |
| IHD | ||||
| Incidence | 190.5 (164.9–199.2) | 116.1 (102.7–139.4) | 136.7 (102.1–175.6) | 93.3 (71.7–116.5) |
| Prevalence | 1395 (1300–1529) | 1136 (1045–1175) | 1169 (1034–1299) | 1018 (962.2–1095) |
| DALYs | 1715 (1560–2273) | 570.7 (493.6–703.9) | 1556 (1323–2367) | 722.9 (489.1–946.3) |
| Stroke | ||||
| Incidence | 115.1 (114.3–127.0) | 63.9 (60.9–75.5) | 123.7 (119.7–148.9) | 70.8 (68.5–73.6) |
| Prevalence | 972.7 (951.8–1111) | 708.3 (684.4–792.3) | 1015 (965.7–1143) | 725.3 (710.4–814.3) |
| DALYs | 1251 (1027–1304) | 475.4 (436.6–533.5) | 1688 (1335–2131) | 587.8 (509.2–736.2) |
| CVD mortality | ||||
| Crude rate | 420.8 (380.2–520.4) | 226.6 (205.5–266.2) | 415.9 (382.8–462.8) | 303.6 (262.7–394.4) |
| Premature rate | 67.1 (47.8–76.1) | 21.5 (19.1–25.8) | 61.7 (48.0–72.9) | 26.0 (23.8–31.9) |
| ASMR | 467.2 (412.3–641.1) | 196.2 (183.3–228.8) | 610.4 (525.9–698.9) | 247.3 (232.2–268.3) |
Data from the Global Burden of Disease study are age standardised rates (interquartile range) per 100,000.
DALYS = disability adjusted life years; IHD = ischaemic heart disease; ASMR = age standardised mortality rate.
Fig. 1.
Incidence of cardiovascular disease in males and females (1990–2019). Data are age standardized rates per 100,000.
Fig. 2.
CVD age-standardized mortality rate in males and females (1990–2019). Data are age standardized rates per 100,000.
Table 3.
National mortality statistics.
| Crude CVD mortality |
Premature CVD mortality |
ASMR |
||||
|---|---|---|---|---|---|---|
| Male | Female | Male | Female | Male | Female | |
| West Europe | ||||||
| Austria | 328.2 | 394.9 | 66.1 | 25.8 | 407.9 | 311.0 |
| Belgium | 234.9 | 266.2 | 54.0 | 25.3 | 282.1 | 203.3 |
| France | 206.3 | 226.6 | 48.2 | 17.5 | 236.7 | 155.0 |
| Germany | 372.2 | 424.3 | 82.0 | 32.0 | 394.7 | 292.8 |
| Ireland | 199.9 | 174.4 | 55.9 | 20.6 | 335.9 | 228.8 |
| Luxembourg | 171.9 | 184.0 | 37.2 | 19.1 | 279.7 | 190.7 |
| Netherlands | 202.3 | 212.4 | 43.4 | 21.5 | 239.0 | 173.7 |
| Switzerland | 214.3 | 249.6 | 38.0 | 13.8 | 264.1 | 196.2 |
| UK | 236.0 | 205.5 | 66.2 | 29.0 | 279.3 | 183.3 |
| Median (IQR) | 214.3 (202.3–236.0) | 226.6 (205.5–266.2) | 54.0 (43.4–66.1) | 21.5 (19.1–25.8) | 279.7 (264.1–335.9) | 196.2 (183.3–228.8) |
| South Europe | ||||||
| Cyprus | 222.3 | 185.9 | 65.8 | 23.8 | 322.1 | 231.4 |
| Greece | 409.8 | 415.2 | 110.4 | 34.3 | 374.4 | 281.0 |
| Italy | 342.9 | 424.6 | 61.5 | 24.0 | 345.6 | 260.2 |
| Malta | 258.3 | 275.1 | 73.0 | 33.2 | 383.9 | 271.0 |
| Portugal | 306.9 | 332.1 | 75.2 | 28.0 | 328.8 | 234.4 |
| Spain | 236.1 | 258.6 | 57.1 | 19.7 | 257.3 | 178.0 |
| Median (IQR) | 282.6 (241.6–333.9) | 303.6 (262.7–394.4) | 69.4 (62.6–74.7) | 26.0 (23.8–31.9) | 337.2 (323.7–367.2) | 247.3 (232.2–268.3) |
Data are from the WHO and are rates per 10,000 in 2019 or latest available year.
CVD = cardiovascular disease ASMR = age standardised mortality rate UK = United Kingdom. IQR = interquartile range.
CVD risk factors
GBD data showed that between 1990 and 2019, annual population-weighted exposure to small particulate matter (PM2.5) declined by nearly 40% in West European countries and by nearly 20% in South European countries. In all countries, exposure levels declined below the European Union (EU) air quality standard of 25 μg/m3 but remained somewhat higher in South compared with West European countries (Table 4). Among socioeconomic factors, unemployment as a percentage of the 2019 labour force was lower in West compared with South European countries (4.7% (3.9%–5.4%) vs 8.6% (6.6%–12.9%), with wide national variation, ranging from 3.0% in Germany to 17.2% in Greece. Crime, violence and vandalism characterised neighbourhoods of similar proportions of the populations of West and South European countries (12.2% (8.7%–13.7%) vs 12.2% (10.0%–13.4%)) but again there was significant national heterogeneity with proportions ranging from 6.7% in Portugal to >20% in the UK.
Table 4.
Risk factors: environment, diet.
| W Europe, 2019 or latest year | S Europe 2019, 2019 or latest year | |
|---|---|---|
| Environment | ||
| Air pollution | ||
| PM2.5 (μg/m3) | 11.4 (10.1–12.0) | 13.7 (10.5–15.3) |
| Ozone (ppb) | 42.1 (39.2–43.1) | 49.9 (46.9–53.5) |
| Urban noise exposure >55 dB (% of population) | ||
| Road | 19.3 (14.4–24.2) | 18.1 (9.4–24.2) |
| Rail | 1.9 (1.3–3.6) | 1.1 (0.9–1.3) |
| Diet | ||
| Trans fatty acids (% daily energy) | 0.57 (0.43–0.62) | 0.43 (0.29–0.44) |
| Sugar (kcals/capita/day) | 429 (348–452) | 300 (266–316) |
| Sugar sweet beverages (g/day) | 138.5 (115.4–156.1) | 99.2 (87.6–140.3) |
| Fruit (g/day) | 144.9 (136.9–152.2) | 207.0 (167.1–242.6) |
| Vegetables (g/day) | 160.6 (153.5–187.7) | 248.4 (217.1–281.7) |
Data are median values (interquartile range) from the GBD study. Sex-specific data unavailable.
There were only small regional differences in the proportions of adults who were regular smokers with West European countries having a slightly higher percentage of female smokers and lower percentage of male smokers compared with South European countries (Table 5). At a national level, however, there were greater differences with 38.2% of adult males in Cyprus smoking regularly, more than in any other of the countries included in this report and over twice the proportion of UK smokers (Table 5).
Table 5.
Risk factors: lifestyle, clinical.
| W Europe 2019 or latest year |
S Europe 2019 or latest year |
|||
|---|---|---|---|---|
| Female | Male | Female | Male | |
| Lifestyle | ||||
| Daily smokers (%) | 16.2 (15.3–20.0) | 21.5 (19.0–23.0) | 15.9 (14.3–18.3) | 24.5 (23.4–31.7) |
| Annual alcohol (L pure alcohol) | 5.8 (5.4–6.2) | 18.5 (17.7–19.5) | 4.7 (3.8–5.4) | 16.6 (13.4–18.8) |
| Insufficient physical exercise (%) | 34.0 (30.4–40.0) | 26.4 (25.3–30.6) | 46.7 (42.4–48.2) | 36.2 (34.5–37.2) |
| Clinical risk factors | ||||
| Raised blood pressure (%) | 15.5 (13.7–16.4) | 23.1 (22.4–25.2) | 15.5 (14.9–16.7) | 24.1 (23.6–25.0) |
| Total cholesterol (mmol/L) | 4.9 (4.8–4.9) | 4.8 (4.7–4.8) | 5.0 (4.9–5.0) | 4.8 (4.8–4.9) |
| Non-HDL cholesterol | 3.2 (3.2–3.3) | 3.4 (3.4–3.5) | 3.4 (3.4–3.5) | 3.6 (3.5–3.6) |
| Obesity (%) | 20.7 (20.0–21.1) | 23.1 (22.0–24.5) | 22.2 (21.3–24.8) | 23.1 (20.7–24.5) |
| Diabetes (%) | 5.2 (4.8–5.9) | 7.6 (5.5–8.8) | ||
Data are median values (interquartile range) from the WHO.
There were substantial regional differences in physical activity which was more commonly rated insufficient (<150 min of moderate-intensity or <75 min of vigorous-intensity physical activity per week) in males and females living in South compared with West European countries (Table 5). More than a third of males and nearly half of females in South European countries took insufficient physical activity in 2016 compared with a quarter of males and a third of females in West European countries.
Regional differences in alcohol consumption between West and South European countries were small. However, dietary fat and sugar consumption were higher in West European countries (Table 5) while fruit and vegetable consumption was lower (Table 4).
WHO data showed that between 1990 and 2015, the prevalence of raised blood pressure (≥140/90 mmHg) across West and South European countries declined in both males and females by an estimated 30% and 42%, respectively. During this period rates were consistently higher in males compared with females but in 2015 showed only small differences at regional level. At national level differences were greater with rates for males ranging from 17.9% in UK to 29.3% in Portugal and for females from 12.4% in UK to 19.6% in Portugal. Non-HDL cholesterol levels across West and South European countries also declined between 1990 and 2018 by an estimated 22.2% in males and 21.4% in females but again 2018 data showed only small differences at regional and national level, ranging in males from 3.13 mmol/L in Belgium to 3.76 mmol/L in Malta and in females from 3.00 mmol/L in Belgium to 3.63 in Portugal.
Across West and South European countries the prevalence of obesity (BMI ≥30 kg/m2) has increased steeply since 1990 and 2019 WHO data showed that >20% of adults in every West and South European country were obese, exceeding 25% in Ireland, Malta and UK. Associated with the high and increasing prevalence of obesity across West and South European countries is a parallel epidemic of diabetes with a 2019 population prevalence for males and females ranging from <5% in Belgium, France, Ireland and Greece to 10.4% in Germany.
Healthcare delivery
The ESC Atlas survey showed that in terms of human capacity, West European countries were no better resourced than South European countries where there were approximately 20% more cardiologists but fewer interventional cardiologists and an approximately even distribution of cardiac surgeons (Table 6). Capital resource per million people in terms of hospitals with cardiac catheterisation laboratories and hospitals with cardiac surgical facilities was also similar between West and South Europe although these aggregate data conceal national differences, with cardiac surgery, for example, available in <1 hospital per million people in Austria, France, Netherlands, UK and Germany and >2 per million in Belgium, Cyprus and Greece.
Table 6.
CVD healthcare.
| W Europe | S Europe | All | |
|---|---|---|---|
| Human resource (per million) | |||
| Cardiologists | 96.6 (45.3–107.1) | 115.9 (90.6–196.3) | 98.9 (54.1–116.4) |
| Female cardiologists (%) | 23.8 (21.6–27.6) | 32.3 (22.6–36.7) | 26.2 (21.1–30.9) |
| Interventional cardiologists | 10.8 (10.2–18.0) | 19.3 (12.4–21.7) | 14.4 (10.3–21.2) |
| Cardiac surgeons | 6.6 (4.7–10.2) | 8.0 (7.6–10.0) | 7.8 (5.3–10.0) |
| Capital resource (per million) | |||
| Hospitals with catheter laboratories | 3.4 (2.6–4.1) | 3.7 (2.6–5.2) | 3.4 (2.6–4.3) |
| Hospitals implanting pacemakers | 5.8 (3.7–8.7) | 4.6 (2.7–5.8) | 5.0 (3.5–7.0) |
| Hospitals implanting cardiac defibrillators | 2.2 (1.9–3.7) | 3.4 (3.2–4.8) | 3.2 (2.0–4.5) |
| Hospitals with cardiac surgery | 0.9 (0.9–1.7) | 1.9 (1.8–2.3) | 1.7 (0.9–1.9) |
| Cardiac procedures (per million) | |||
| Coronary angiograms | 4438 (3993–6136) | 3508 (3278–4554) | 4261 (3335–4994) |
| Percutaneous coronary intervention | 2589 (1501–3132) | 1611 (1438–1866) | 2106 (1454–2913) |
| Primary percutaneous coronary intervention | 390.3 (371.3–530.7) | 538.9 (478.6–632.1) | 478.6 (371.3–563.2) |
| Transcatheter aortic valve implantation | 170.7 (103.9–207.6) | 87.5 (62.2–90.9) | 109.7 (86.6–180.4) |
| Catheter ablation | 685.0 (341.8–885.9) | 394.0 (372.3–395.3) | 395.3 (348.4–851.2) |
| Pacemaker implantation | 851.6 (611.7–928.9) | 895.8 (832.3–949.0) | 886.3 (722.2–949.0) |
| Implantable cardiac defibrillator | 155.1 (133.2–172.8) | 134.8 (121.9–148.8) | 148.8 (121.9–163.6) |
| Coronary artery bypass graft surgery | 363.3 (260.4–493.0) | 240.7 (219.3–314.3) | 300.9 (245.5–397.2) |
| Heart transplantation | 4.0 (2.4–5.9) | 2.8 (2.0–4.1) | 3.5 (2.2–5.6) |
ESC Atlas Data for 2019. Data are median values (interquartile range).
Although the human and capital resources available for cardiovascular healthcare were similar in West and South European countries the ESC Atlas survey showed important differences in cardiovascular procedure rates which, with the exception of primary percutaneous coronary interventions (PCI) and pacemaker implantation, were consistently higher in West European countries (Table 6). The difference was not trivial, as exemplified by 2019 rates of diagnostic and therapeutic procedures for IHD which showed 27% more diagnostic coronary arteriograms, 61% more PCIs and 51% more coronary artery bypass graft operations performed in West compared with South European countries (Fig. 3).
Fig. 3.
Cardiovascular procedure rates West Europe (blue) vs South Europe (orange). Data from the ESC Atlas Project. PCI = percutaneous coronary intervention; TAVI = transcatheter aortic valve implantation; CABG = coronary artery bypass grafting; ICD = implantable cardioverter defibrillator.
It was not only for IHD that there was the gap in diagnostic and therapeutic procedure rates between West and South European countries. Similar gaps were found for catheter ablation transcatheter aortic valve implantation, implantable cardiac defibrillator implantation and heart transplantation. Only for primary PCI and pacemaker implantation did regional procedure rates showed more equality.
Discussion
This report has compared CVD mortality, risk factors and procedure rates between West and South European countries. Key messages are summarised in the box above. We have shown that across these European regions there have been substantial declines in ASMRs during the last 29 years, with averaged rates now somewhat higher in South European countries. Declines in ASMRs have been associated with heterogenous declines in many environmental, socioeconomic and clinical risk factors although the increasing prevalence of obesity and type II diabetes provides real cause for concern. West European countries spent almost twice as much on healthcare in 2019 and had higher procedure rates for the investigation and treatment of CVD. The heterogeneity in spending, prevalence of risk factors and procedure rates across West and South European countries provides policy makers with potential targets for intervention to help resolve international inequalities in CVD healthcare.
It was an important observation of this study that males and females in West and South European countries have seen similar declines in age-adjusted CVD mortality as those reported internationally in other high income economies.19,20 The observational data we present do not permit inference of causation although it is widely recognised that reductions in CVD mortality in Europe and elsewhere have been largely driven by a combination of risk factor modification and treatment effects.21,22 The reductions in recent years of major risk factors, including air pollution and raised blood pressure and non-HDL cholesterol, has likely been important in this respect although the current epidemic of obesity and type II diabetes may already be causing mortality rates to plateau.19 Also important have been population strategies to modify lifestyle as exemplified by the success of smoking legislation for reducing population risk of CVD.23 All the countries included in this report have a raft of anti-smoking measures but implementation is likely more variable and the exceptionally high smoking rate in Cyprus, where declines in ASMRs the last 29 years have been relatively modest, provides a clear target for national action.24 Other lifestyle risk factors include insufficient physical activity which was more common in South compared with West European countries and associates with an increased risk of mortality and CVD events across high-, middle- and low-income countries.25 Even light-intensity physical activity has been shown to be beneficial.26 Measures to increase physical activity in South European countries represent a simple, widely applicable, low cost strategy for reducing CVD deaths. Also needed are policies to encourage healthy eating in West European countries where consumption of dietary fat and sugar was higher and consumption of fruit and vegetables lower compared with South European countries.27,28
The countries that are the subject of this report were all classified as high-income by World Bank criteria.9 Yet GDP per capita was variable and on average over 40% higher in West compared with South European countries. Add to this the variations in healthcare systems, and institutional contexts and it is not surprising that levels of healthcare funding vary considerably across West and South European countries. Contemporary data on how national healthcare expenditure is distributed are unavailable but in 2013 the Health Expenditures by Diseases and Conditions (HEDIC) project reported that CVD consumed 16% of the total spend in a basket of 11 European countries, more than any other diagnostic group.15 Despite the paucity of granular economic data, it is likely that CVD continues to consume a large proportion of national healthcare expenditure in European countries, given its high prevalence and the associated capital and technological costs of contemporary disease management.29
The financial costs of CVD likely contributed to the differences in CVD procedure rates between West and South European countries that were a major finding of this report. Procedure rates were generally higher in West compared with South European countries, with the exception of primary PCI and pacemaker implantation, perhaps because there are unambiguous indications for these life-saving procedures. In the case of primary PCI, for example, the procedure is mandated in international guidelines for all people presenting with ST elevation myocardial infarction (STEMI) in order to restore coronary perfusion and limit infarct size.30,31 Incidence data for STEMI across West and South European countries are unavailable but the 2019 data in Table 2 shows that differences in the incidence of IHD, the usual cause of STEMI, were small and were likely reflected in only small differences in STEMI yielding comparable primary PCI procedure rates.
Regional differences in procedure rates do not necessarily imply under-provision but cannot be explained by differences in the age-adjusted incidence of IHD which was similar in West and South European countries as discussed above. However, health technology is expensive29 and a potential explanation for the lower procedure rates in South European countries is the gap in prosperity that allowed Belgium, Germany and Switzerland to perform >6000 diagnostic coronary arteriograms per million people in 2019 with only Italy, the most prosperous of the South European countries, performing >5000. Similar national differences saw France, Germany and Switzerland among West European countries performing >3000 PCIs per million people in 2019 but again Italy was an outlier among South European countries performing >2000 PCIs per million people. For coronary artery bypass grafting too, more procedures were undertaken in prosperous West European countries with Austria, Belgium, Germany, Netherlands and Switzerland each reporting >300 procedures per million people in 2019, a procedure rate matched only by Greece and Malta among South European countries.
While inequalities in national procedure rates likely reflect, at least in part, variations in healthcare funding, other factors also merit consideration. Table 1 shows that Italy spent no more on healthcare than other South European countries yet was an outlier in Fig. 3 by performing more PCIs and TAVIs and implanting more ICDs than other countries in that region. This may reflect differences in guideline adherence and other metrics of quality of care. National comparisons of management and outcomes of CVD have mostly involved a limited number of countries32, 33, 34 but guideline groups are now developing a range of cardiovascular quality indicators to enable identification of country specific opportunities for improved healthcare delivery.35, 36, 37, 38, 39
Limitations
The WB, WHO and GBD study together constitute the most credible sources of national estimates of CVD and its associated risk factors. General limitations of the data include the adjustment applied by all the main providers to account for missing data, and differences in reporting practices such that precision of the estimates they provide often varies by country. Misclassification bias due to miscoding of diagnostic groups and death certificates is another potential limitation. Data completeness also varies by country and there is no information about within-country inequalities. A more detailed account of the data, particularly its sources, analytic methodology and limitations has been provided elsewhere.6
Conclusion
This comparative study is reassuring in showing substantial declines over the last 30 years in the incidence of CVD and ASMRs in West and South European countries. There seems little doubt that risk factor modification, including the improvements in air pollution and reductions in blood pressure and non-HDL cholesterol identified in this report, have played an important role in delivering these mortality reductions, with premature (age < 70 years) deaths now caused more commonly by cancer than CVD in all West European and many South European countries.5 Less reassuring were the surging rates of obesity and type II diabetes that have reached epidemic proportions in Europe and elsewhere in the world.40 However, differences between West and South European countries in exposure to CVD risk factors were, with the exception of physical activity and dietary factors, quite small and although there was some heterogeneity at national level in population rates of smoking and elevated blood pressure the impact on disease incidence and mortality cannot be quantified. Nevertheless, these risk factors are potentially reversible and their association with CVD makes them targets for intervention. Treatment effects also merit consideration and the ESC Atlas survey showed substantial differences in cardiovascular diagnostic and therapeutic procedure rates between West European and South European countries. Correcting inequalities in investigational and therapeutic technology would require substantial financial resource that might challenge the spending power of many countries.29 Current health expenditure per capita in South European countries was on average less than half the expenditure in West European countries and population strategies including tobacco control,24 minimum pricing of alcohol,41,42 sugar and calorie reduction43 and diabetes screening programmes44 may be no less effective for delivering further reductions in CVD mortality than increased technological spending.
Key messages.
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•
Spending on healthcare is lower in South compared with West European countries.
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In both West and South European countries age-standardised mortality rates for cardiovascular disease have been in steep decline the last 20 years.
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•
Differences in exposure to risk factors for CVD were generally small between West and South European countries. An exception was physical activity which was more commonly rated insufficient in South European countries.
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•
Dietary fat and sugar consumption was higher in West compared with South European countries where fruit and vegetable consumption was higher.
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Cardiovascular procedure rates were higher in West compared with South European countries, with only primary PCI and pacemaker implantation rates similar across both regions.
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Prevention strategies should be prioritised in addressing national inequalities in CVD mortality between West and South European countries.
Contributors
Timmis, Huculeci, and Vardas designed the study. Timmis and Torbica drafted the manuscript. Huculeci, Kazakiewicz, and Vardas were responsible for data collection. Kazakiewicz, Huculeci, and Vardas directly accessed and verified the underlying data which were managed and analysed by Kazakiewicz. Timmis, Townsend, Aboyans, and Vardas interpreted the data and together with Kazakiewicz, Torbica, and Huculeci assisted in revising the manuscript following peer review.
Data sharing statement
The excel work files for data presented in this manuscript are available on request from the authors.
Declaration of interests
Timmis owns stock in HD Clinical (Electronic health record systems) and RE-COGNITION Health (Dementia care). Torbica has a consulting contract with the European Society of Cardiology. Aboyans has an unpaid leadership role in the European Heart Health Institute and has received consulting fees from Bayer, Amarin, Boehringer-Ingelheim and NovoNordisk. Vardas has received consulting fees from Hygeia Hospital Group.
References
- 1.Fox K.A.A., Accetta G., Pieper K.S., et al. Why are outcomes different for registry patients enrolled prospectively and retrospectively? Insights from the global anticoagulant registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) Eur Heart J Qual Care Clin Outcomes. 2018;4(1):27–35. doi: 10.1093/ehjqcco/qcx030. [DOI] [PubMed] [Google Scholar]
- 2.Arulmurugananthavadivel A., Holt A., Parveen S., et al. Importance of diagnostic setting in determining mortality in patients with new-onset heart failure: temporal trends in Denmark from 1997 to 2017. Eur Heart J Qual Care Clin Outcomes. 2022;8(7):750–760. doi: 10.1093/ehjqcco/qcab073. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Nakano A., Vinter N., Egstrup K., Svendsen M.L., Schjødt I., Johnsen S.P. Association between process performance measures and 1-year mortality among patients with incident heart failure: a Danish nationwide study. Eur Heart J Qual Care Clin Outcomes. 2019;5(1):28–34. doi: 10.1093/ehjqcco/qcy041. [DOI] [PubMed] [Google Scholar]
- 4.Earle N.J., Kerr A.J., Legget M., Wu B.P., Doughty R.N., Poppe K.K. Acute coronary syndrome registry enrolment status: differences in patient characteristics and outcomes and implications for registry data use (ANZACS-QI 36) Eur Heart J Qual Care Clin Outcomes. 2019 doi: 10.1093/ehjqcco/qcz046. qcz046. [Epub ahead of print] [DOI] [PubMed] [Google Scholar]
- 5.Townsend N., Kazakiewicz D., Lucy Wright F., et al. Epidemiology of cardiovascular disease in Europe. Nat Rev Cardiol. 2022;19(2):133–143. doi: 10.1038/s41569-021-00607-3. [DOI] [PubMed] [Google Scholar]
- 6.Timmis A., Vardas P., Townsend N., et al. European society of Cardiology: cardiovascular disease statistics 2021. Eur Heart J. 2022;43(8):716–799. doi: 10.1093/eurheartj/ehab892. [DOI] [PubMed] [Google Scholar]
- 7.Menotti A., Puddu P.E., Tolonen H., Kafatos A. Cardiovascular mortality in Northern and Southern European cohorts of the Seven countries study at 60-year follow-up. J Cardiovasc Med (Hagerstown) 2023;24(2):96–104. doi: 10.2459/JCM.0000000000001425. [DOI] [PubMed] [Google Scholar]
- 8.EuroVoc publications office of the European Union. https://eur-lex.europa.eu/browse/eurovoc.html?params=72,7206#arrow_7206
- 9.Serajuddin U., Hamadeh N. New World Bank country classifications by income level: 2020-2021. https://blogs.worldbank.org/opendata/new-world-bank-country-classifications-income-level-2020-2021
- 10.WHO mortality database. https://www.who.int/data/data-collection-tools/who-mortality-database
- 11.IHME—measuring what matters. http://www.healthdata.org
- 12.World Bank—Data Bank https://databank.worldbank.org/home.aspx
- 13.Current health expenditure (% of GDP), the World Bank. 2021. https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS Available at:
- 14.Schengen Visa Health insurance and healthcare system in Europe. https://www.schengenvisainfo.com/europe-health-insurance/
- 15.Eurostat HEDIC: health expenditures by diseases and conditions. 2016. https://ec.europa.eu/eurostat/documents/3888793/7605571/KS-TC-16-008-EN-N.pdf/6cb33aa4-2e65-4df7-9b2b-1ff171eb1fba?t=1473156921000
- 16.WHO methods and data sources for country-level causes of death 2000-2019. https://www.who.int/docs/default-source/gho-documents/global-health-estimates/ghe2019_cod_methods.pdf
- 17.Office for National Statistics Revised European standard population. 2013. https://ec.europa.eu/eurostat/documents/3859598/5926869/KS-RA-13-028-EN.PDF/e713fa79-1add-44e8-b23d-5e8fa09b3f8f
- 18.Cleveland W.S. Robust locally weighted regression and smoothing scatter-plots. J Am Stat Assoc. 1979;74:829–883. [Google Scholar]
- 19.Lopez A.D., Adair T. Is the long-term decline in cardiovascular-disease mortality in high-income countries over? Evidence from national vital statistics. Int J Epidemiol. 2019;48(6):1815–1823. doi: 10.1093/ije/dyz143. [DOI] [PubMed] [Google Scholar]
- 20.GBD Mortality Collaborators Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390:1084–1150. doi: 10.1016/S0140-6736(17)31833-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Smolina K., Wright F.L., Rayner M., Goldacre M.J. Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study. BMJ. 2012;344 doi: 10.1136/bmj.d8059. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.O'Flaherty M., Buchan I., Capewell S. Contributions of treatment and lifestyle to declining CVD mortality: why have CVD mortality rates declined so much since the 1960s? Heart. 2013;99(3):159–162. doi: 10.1136/heartjnl-2012-302300. [DOI] [PubMed] [Google Scholar]
- 23.Pell J.P., Haw S., Cobbe S., et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N Engl J Med. 2008;359(5):482–491. doi: 10.1056/NEJMsa0706740. [DOI] [PubMed] [Google Scholar]
- 24.European Commission Status on the various smoke-free regulations in EU. https://health.ec.europa.eu/tobacco/smoke-free-environments_en#:∼:text=Protecting%20EU%20citizens%20from%20second%2Dhand%20tobacco%20smoke,-The%202009%20Council&text=Among%20these%2C%20Ireland%2C%20Greece%2C,with%20only%20limited%20exceptions%20allowed
- 25.Lear S.A., Hu W., Rangarajan S., et al. The effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 high-income, middle-income, and low-income countries: the PURE study. Lancet. 2017;390(10113):2643–2654. doi: 10.1016/S0140-6736(17)31634-3. [DOI] [PubMed] [Google Scholar]
- 26.Qiu S., Cai X., Jia L., et al. Does objectively measured light-intensity physical activity reduce the risk of cardiovascular mortality? A meta-analysis. Eur Heart J Qual Care Clin Outcomes. 2021;7(5):496–504. doi: 10.1093/ehjqcco/qcaa051. [DOI] [PubMed] [Google Scholar]
- 27.Estruch R., Ros E., Salas-Salvadó J., et al. Primary prevention of cardiovascular disease with a Mediterranean Diet Supplemented with extra-virgin olive oil or Nuts. N Engl J Med. 2018;378(25):e34. doi: 10.1056/NEJMoa1800389. [DOI] [PubMed] [Google Scholar]
- 28.Meier T., Gräfe K., Senn F., et al. Cardiovascular mortality attributable to dietary risk factors in 51 countries in the WHO European Region from 1990 to 2016: a systematic analysis of the Global Burden of Disease Study. Eur J Epidemiol. 2019;34(1):37–55. doi: 10.1007/s10654-018-0473-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Jayawardana S., Cylus J., Mossialos E. It's not ageing, stupid: why population ageing won't bankrupt health systems. Eur Heart J Qual Care Clin Outcomes. 2019;5:195–201. doi: 10.1093/ehjqcco/qcz022. [DOI] [PubMed] [Google Scholar]
- 30.Ibanez B., James S., Agewall S., et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC) Eur Heart J. 2018;39(2):119–177. doi: 10.1093/eurheartj/ehx393. [DOI] [PubMed] [Google Scholar]
- 31.Rossello X., Lobo-Gonzalez M., Ibanez B. Editor's Choice- Pathophysiology and therapy of myocardial ischaemia/reperfusion syndrome. Eur Heart J Acute Cardiovasc Care. 2019;8(5):443–456. doi: 10.1177/2048872619845283. [DOI] [PubMed] [Google Scholar]
- 32.Blöndal M., Ainla T., Eha J., et al. Comparison of management and outcomes of ST-segment elevation myocardial infarction patients in Estonia, Hungary, Norway, and Sweden according to national ongoing registries. Eur Heart J Qual Care Clin Outcomes. 2022;8(3):307–314. doi: 10.1093/ehjqcco/qcaa098. [DOI] [PubMed] [Google Scholar]
- 33.Rapsomaniki E., Thuresson M., Yang E., et al. Using big data from health records from four countries to evaluate chronic disease outcomes: a study in 114 364 survivors of myocardial infarction. Eur Heart J Qual Care Clin Outcomes. 2016;2(3):172–183. doi: 10.1093/ehjqcco/qcw004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.McNamara R.L., Chung S.C., Jernberg T., et al. International comparisons of the management of patients with NSTEMI in the United Kingdom, Sweden, and the United States: the MINAP/NICOR, SWEDEHEART/RIKS-HIA, and ACTION registry-GWTG/NCDR registries. Int J Cardiol. 2014;175(2):240–247. doi: 10.1016/j.ijcard.2014.04.270. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.NICE quality and outcomes framework indicator. https://www.nice.org.uk/standards-and-indicators/qofindicators
- 36.Aktaa S., Polovina M., Rosano G., et al. European society of Cardiology quality indicators for the care and outcomes of adults with heart failure. Developed by the working group for heart failure quality indicators in collaboration with the heart failure association of the European society of Cardiology. Eur J Heart Fail. 2022;24(1):132–142. doi: 10.1002/ejhf.2371. [DOI] [PubMed] [Google Scholar]
- 37.Schiele F., Aktaa S., Rossello X., et al. 2020 Update of the quality indicators for acute myocardial infarction: a position paper of the Association for Acute Cardiovascular Care: the study group for quality indicators from the ACVC and the NSTE-ACS guideline group. Eur Heart J Acute Cardiovasc Care. 2021;10(2):224–233. doi: 10.1093/ehjacc/zuaa037. [DOI] [PubMed] [Google Scholar]
- 38.Zusman O., Bebb O., Hall M., et al. International comparison of acute myocardial infarction care and outcomes using quality indicators. Heart. 2019;105(11):820–825. doi: 10.1136/heartjnl-2018-314197. [DOI] [PubMed] [Google Scholar]
- 39.Rossello X., Medina J., Pocock S., et al. Assessment of quality indicators for acute myocardial infarction management in 28 countries and use of composite quality indicators for benchmarking. Eur Heart J Acute Cardiovasc Care. 2020;9(8):911–922. doi: 10.1177/2048872620911853. [DOI] [PubMed] [Google Scholar]
- 40.Chan M. Obesity and diabetes: the slow-motion disaster. Milbank Q. 2017;95:11–14. doi: 10.1111/1468-0009.12238. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.O'Donnell A., Anderson P., Jané-Llopis E., Manthey J., Kaner E., Rehm J. Immediate impact of minimum unit pricing on alcohol purchases in Scotland: controlled interrupted time series analysis for 2015-18. BMJ. 2019;366:l5274. doi: 10.1136/bmj.l5274. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Wyper G.M.A., Mackay D.F., Fraser C., et al. Evaluating the impact of alcohol minimum unit pricing on deaths and hospitalisations in Scotland: a controlled interrupted time series study. Lancet. 2023;401:1361–1370. doi: 10.1016/S0140-6736(23)00497-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.WHO/Europe to launch new sugar and calorie reduction initiative. 2022. https://www.who.int/europe/news/item/20-01-2022-who-europe-to-launch-new-sugar-and-calorie-reduction-initiative-led-by-the-united-kingdom
- 44.Cardiovascular disease and diabetes: policies for better health and quality of care. 2015. https://www.oecd.org/spain/Cardiovascular-Disease-and-Diabetes-Policies-for-Better-Health-and-Quality-of-Care-Spain.pd