1. Cardiovascular disease mortality: Key evidence

Abstract

Cardiovascular mortality today is about half the level in 1995, but improvements have slowed significantly since 2010. Cardiovascular disease made the largest contribution to gains in life expectancy both before and after 2010, but its contribution to life expectancy gains in some OECD countries fell after 2010. There is a strong need to improve national and international data and monitoring to support more timely and effective policy responses for preventing, managing and treating cardiovascular disease and associated risk factors, and for tackling socio-economic and gender inequalities.

    

There is a strong need for international collaboration to support policy action given emerging evidence of the slowdown in improvements in life expectancy at birth in several OECD countries since 2010 (Raleigh, 2019[1]), and the need for better understanding of the contribution of CVD to this slowdown (Public Health England, 2018[2]; American Heart Association, 2018[3]). Available evidence to date suggests there are some common trends and drivers across countries and therefore collaborative international investigations can facilitate improved understanding of common drivers and inform appropriate policy action.

Mark Pearson, Deputy Director of the OECD Directorate of Employment of Labour and Social Affairs emphasised how the trend towards decelerating improvements in CVD mortality rates calls for a global response in terms of better and more timely evidence to inform decision-making in this area. This includes a better understanding of: (i) CVD risk factors and the drivers of the slowdown; (ii) cost-effective interventions for both prevention and treatment; (iii) attainable life expectancy gains from current medical technology; and, (iv) models of care delivery in different health systems. One of the main drivers of CVD – being overweight – is expected to result in an enormous economic burden: 3.3% of GDP on average in both OECD countries and EU member states between 2020 and 2050 (OECD, 2019[4]).

Richard Murray, Chief Executive of The King’s Fund, described the increasing concerns about the slowdown in life expectancy improvements in the United Kingdom since 2011. International collaboration, including among countries and between institutions such as The King’s Fund and OECD can help inform the national policy debate regarding best practice for timely monitoring of population-level mortality trends, and understanding of common trends and disease drivers of this phenomenon, including CVD mortality. The economic consequences of these trends, including on long-term forecasts of social care spending and pension expenditure, have been flagged in the United Kingdom.

Reductions in CVD mortality have driven significant increases in life expectancy globally since the 1970s. However, CVD remains one of the leading causes of death in most high-income countries, and evidence shows many of these deaths are potentially preventable. For example, although being overweight is a major risk factor for CVD, 58% of adults were overweight or obese in 2017 on average across 23 OECD countries with comparable data, and the prevalence of obesity is rising globally (Figure 1.1) (OECD, 2019[5]). Given the substantial potential for further reductions in CVD mortality in most countries, the recent slowdown in CVD mortality improvements in several countries is an unwelcome development that needs to be addressed.

Figure 1.1. Overweight including obesity among adults by sex, measured and self-reported, 2017 (or nearest year)

Note: Left- and right-hand side estimates utilise measured and self-reported data, respectively. OECD36 average includes both data types.

Source: OECD (2019[4]) The Heavy Burden of Obesity, https://doi.org/10.1787/67450d67-en.

Improvements in life expectancy are slowing in many high-income countries

Dr Veena Raleigh provided an overview of why current trends in CVD mortality in some countries are a cause for concern. Life expectancy at birth varies significantly in EU countries, although differences have narrowed somewhat over the years. In 2016, life expectancy at birth varied by 11.5 years in males and by 7.8 years among females, with levels generally being lower among the Eastern European countries. Although male life expectancy exceeds female life expectancy in all countries, the gender divide is wider among Eastern European countries. Life expectancy in the United States is below the EU average, whereas in Australia, Canada and Japan it is higher than the EU average. Japan has the highest female life expectancy globally (Raleigh, 2019[1]).

In several EU countries, the pace of improvement in life expectancy has slowed over the past decade (Figure 1.2). Improvements slowed also in Australia and Canada. Japan showed the reverse pattern, with little improvement in longevity in the 5 years prior to 2011, and a marked acceleration thereafter. Overall, the slowdown has been greatest in the United States, where life expectancy has fallen in recent years, but other countries such as the United Kingdom, France, Germany, Sweden and the Netherlands have also experienced significant slowdowns.

Figure 1.2. Slowdown in life expectancy gains, 2012-17 and 2002-07

1. Three-year average.

Source: OECD (2019[5]), Health at a Glance 2019, https://doi.org/10.1787/4dd50c09-en.

In some countries, CVD has been a significant contributor to the slowdown

Diseases of older ages are the main contributors to the slowdown in improvements in life expectancy. Improvements in CVD mortality have slowed in many countries, respiratory diseases (including influenza and pneumonia) claim excess lives in some winters, and deaths from dementia and Alzheimer’s disease are rising. Although the impact on overall mortality is less than some of these other drivers, it is noteworthy that in some countries (notably the United Kingdom and the United States) mortality improvements have slowed or even reversed among working age adults, largely due to accidental deaths including drug-related deaths (Raleigh, 2019[1]; Public Health England, 2018[2]; Ho and Hendi, 2018[6]; Office for National Statistics, 2018[7]).

The focus of the workshop was to discuss the existing evidence about the contribution of CVD to the slowdown in life expectancy gains. Despite very significant falls in CVD mortality over the past 50 or so years, CVD remains a major killer in many high-income countries, and is the leading cause of death in the EU. CVD mortality rates vary significantly among the EU countries, with rates in Eastern European countries being over four times higher than in some other EU countries. In the United Kingdom, CVD is responsible for 1 in 4 premature deaths, and CVD is among the largest contributors to socio-economic inequalities in life expectancy.

An analysis by Public Heath England (PHE) concluded that the slowdown in CVD mortality improvements was a significant contributor to the slowdown in improvements in life expectancy in England since 2011 (2018[2]). CVD mortality improvements are slowing or plateauing also in some other European countries and the United States (Shah et al., 2019[8]; Shah et al., 2019[9]).

The risk factors driving CVD mortality are potentially avoidable

A significant proportion of the morbidity and mortality associated with CVD is preventable. A large body of evidence shows that there is significant potential for reducing CVD deaths further through primary and secondary prevention measures aimed, for example, at reducing the prevalence of smoking, obesity, diabetes, undiagnosed / untreated high levels of blood pressure, blood sugar and cholesterol.

OECD’s 2015 report titled Cardiovascular Disease and Diabetes (2015[10]) outlines the remarkable decrease of more than 60% in CVD mortality rates achieved since 1960 across OECD countries. While describing the advances attained in the prevention and treatment of CVD, the report notes that CVD remains the leading cause of death in most OECD countries and that prospects for further CVD improvements are slowing. It points to several significant challenges faced by health systems in reducing the burden of CVD in coming decades. The report also assesses OECD health system performance along the care pathway by which CVD and diabetes are prevented, managed and treated, and draws key policy implications to reduce the burden of both diseases.

Also relevant to this topic is an OECD report which analyses the economic, social and health costs of the rising number of people who are obese or overweight in up to 52 countries, including the OECD, the EU and the Group of 20 (G20) countries (2019[4]). More than half the population is now overweight in 34 out of 36 OECD countries and almost one in four people is obese. The report estimates a reduction in life expectancy in OECD countries of 2.7 years caused by excessive weight. It makes an urgent economic case for scaling up investments in policies for tackling a mounting health problem across the world, since being overweight will account for over 8% of total health expenditure in OECD and EU countries between 2020 and 2050 (OECD, 2019[4]).

Overview of CVD mortality in Europe

The burden of CVD mortality is high and variable

Ms Susanne Løgstrup provided some background on the CVD statistics compiled by the European Heart Network (EHN). She described the health burden and economic costs associated with CVD in Europe. CVD is the leading cause of death in Europe, accounting for 3.9 million deaths in 2017, over 45% of all deaths, and 37% in EU countries. It is also the leading cause of premature mortality (i.e. deaths under age 65 years).

CVD has major economic costs as well as human costs for Europe. Overall CVD is estimated to cost the EU economy EUR 210 billion a year, of which 53% (EUR 111 billion) is due to direct health care costs, 26% (EUR 54 billion) to productivity losses and 21% (EUR 45 billion) to the informal care of people with CVD (Wilkins et al., 2017[11]).

However, there is significant variation in the burden of CVD across European countries. Age-standardised death rates for both ischaemic heart disease (IHD) and stroke (i.e. the major components of overall CVD mortality) are several times higher in Eastern Europe than in Western and Southern Europe.

CVD mortality is plateauing in some countries

Over the past five decades, mortality rates from CVD have fallen significantly in Northern and Western European countries in both males and females. Long-term mortality trends in Central and Eastern European countries have been less consistent, with early decreases followed by sharp increases in the 1990s, and a falling trend thereafter.

Box 1.1. Cardiovascular disease mortality trends in France

Evidence of slowdown in myocardial infarction mortality improvements amongst women

In France, between 1975 and 2010, population-wide myocardial infarction (MI) mortality rates decreased by 70%. Rates fell by almost one-quarter in both sexes, placing France among western countries with the lowest MI mortality rates. Almost half of the decrease in MI mortality was related to improved treatments of acute conditions, and the other half to reduced prevalence of cardiovascular risk factors (Gabet et al., 2016[12]). Similar findings were observed in the FAST-MI surveys, observational cohorts including patients with acute ST-elevation myocardial infarction (STEMI) or Non-ST-elevation myocardial infarction (NSTEMI) over one month every five years since 1995; six-month mortality decreased from 17.2% in 1995 to 5.3% in 2015 for STEMI patients, and from 17.2% in 1995 to 6.3% in 2015 in NSTEMI patients (Puymirat et al., 2017[13]).

However, the decline in MI mortality rates was less notable among the cohort born after World War II, particularly in women. This finding is consistent with data from the French MONICA registries, which reported no clear decline in CHD mortality rates between 2000 and 2007 in individuals aged under 54 years, especially women. These results may be due to unfavourable trends in some risk factors in the latter age group and call for a strengthening of primary prevention, targeting particularly younger women (Wagner et al., 2014[14]; Gabet et al., 2016[12]).

In fact, recent trends in the incidence of women hospitalised for MI showed a significant increase between 35 and 64 years mainly due to tobacco. The prevalence of daily smoking among women aged 45-54 increased from 21.5% in 2000 to 30.8% in 2017. Among women aged 55-64, the decrease observed in 2017 occurred after prevalence had doubled between 2000 (11.0%) and 2016 (21.1%). This increase relates to the women born after the Second World War, who were among the first generations widely adopting the smoking habit in the 1970s (Olié et al., 2019[15]; Gabet et al., 2017[16]).

The differences in stroke mortality trends

Stroke and MI mortalities showed some similar patterns, although no slowdown in stroke mortality rate reductions in recent birth cohorts was found, nor any clear difference between sexes. Stroke and MI share some risk factors such as hypertension, smoking and obesity. Thus, the greater slowdown in MI mortality rate reductions in women in recent birth cohorts may suggest either gender differences in MI management compared with stroke, or gender-differential profile changes of certain risk factors, which contributed more to MI than stroke incidence (Lecoffre et al., 2017[17]).

Source: Santé Publique France. Mortality data were obtained from the French Epidemiology Center on medical causes of death (CépiDc, Inserm). CépiDc collects and codes the two-part medical certificates for all deaths occurring in France.

However, there is evidence that, over the past two decades, IHD mortality rates are beginning to plateau in younger age groups in some countries – England, Wales, Scotland, the United States and Australia. This is also the case for AMI mortality rates in France (see Box 1.1). An analysis by EHN of data to 2009 did not find evidence of such a pattern occurring consistently across EU countries (Nichols et al., 2013[18]). However, more recent data for Greece, Spain and Portugal (Southern European countries with traditionally low CVD mortality) shows a plateauing of IHD and stroke mortality in the under 65s since 2010 (see Box 1.2 for Portugal). A slowdown or plateauing in IHD and/or stroke mortality at ages under 65 since 2010 is also observed for some Nordic and Western European countries. In the United Kingdom, CVD mortality improvements have slowed, especially at ages under 75, and CVD is a significant contributor to the slowdown in life expectancy improvement overall (see Box 1.3).

Box 1.2. Evidence of increase in CVD mortality amongst young Portuguese men

In Portugal, age-standardised mortality rates for AMI and stroke have plateaued in recent years. At ages under 65 years there are signs of rising mortality from AMI among men, and a flat-lining of AMI and stroke mortality among women.

Figure 1.3. Age-standardised AMI and stroke mortality rates per 100 000 population aged <65 years

Source: Statistics Portugal. Directorate-General of Health, Quality Department and Health System Central Administration.

Moreover, the incidence of coronary events among young adults has shown little or no change in several countries (France, Finland, Australia, United States) (Salomaa, 2020[19]). The fact that the incidence of coronary events in some countries is declining more slowly than mortality rates in recent years suggests that while declines in mortality are being driven by improvements in acute coronary care, the impact of preventive measures is more modest.

Ms Løgstrup warned against complacency about CVD mortality trends and that behavioural risk factors remain a major, preventable contributor to deaths, including premature mortality. She argued for stronger prevention measures and continued investment in the treatment of cardiovascular patients. Finally, she recommended that, given recent trends, the incidence of and mortality from CVD (overall and premature) should be closely monitored and the underlying causes identified.

Ms Løgstrup has documented these facts in a brief paper located in Chapter 3. Ms Løgstrup’s presentation can be found in https://www.oecd.org/health/is-cardiovascular-disease-slowing-improvements-in-life-expectancy-47a04a11-en.htm.

Box 1.3. Evidence of CVD mortality improvement slowdown in the United Kingdom

The rate of improvement in CVD mortality in the United Kingdom has been slowing since 2011 (Figure 1.4). (Public Health England, 2019[20]; Northern Ireland Department of Health, n.d.[21]; National Records of Scotland, n.d.[22])

Figure 1.4. Age-standardised death rate from CVD per 100 000 world standard population, United Kingdom, 1979-2015

Source: World Health Organization, Mortality Database.

The rapid decline in heart disease since the 1980s can be attributed to two key factors (Unal, Critchley and Capewell, 2004[23]; Bajekal et al., 2012[24]):

• improved treatment uptake and medical therapies

• reduction in major risk factors, notably reduced smoking prevalence, but also reduced prevalence of high cholesterol and high blood pressure.

However, the increasing prevalence of diabetes, obesity and physical inactivity may be offsetting some of these gains. Some commentators also note that, following the concerted efforts over decades to identify and treat those at risk of CVD, the gains from these approaches may now be diminishing because of the smaller proportion of the population not yet identified and treated.

Public Health England notes that the reasons for the current slowdown are complex and due to factors operating across a wide range of areas. Further, that work is needed to understand the relative contribution of different drivers, requiring not only surveillance of mortality but also how this links to the disease burden and its many drivers. Further work to identify variation across the United Kingdom in diagnosis practices and optimal treatment rates for risk factors, (e.g. atrial fibrillation, hypertension and cholesterol) may be warranted. An increased focus on understanding the reasons for the persistent inequality gap and how it could be reduced is also required.

Source: Public Health England (2018[2]), A review of recent trends in mortality in England.

The contribution to life expectancy gains of CVD relative to other causes of death: past and present

Mortality patterns have changed significantly in recent years

Professor Jessica Ho analysed changes in life expectancy in OECD countries between 2000-10 and 2010-most recent year available, differences between countries in the rates of change, and the age groups and causes of death contributing most to these changes. The analysis covered 32 OECD countries for which recent mortality data by cause of death were available.

In most countries, the pace of life expectancy gains slowed significantly after 2010. The eight Central and Eastern European countries where baseline levels of life expectancy were considerably lower did not experience a slowdown. Hence, the analysis focused on the remaining 24 OECD countries, which were classified into three groups of eight based on their life expectancy gains during the most recent period: High, Medium and Low for countries experiencing high, medium and low gains in life expectancy respectively (see Table 1.1 for the countries in each group).

The key findings from Professor Ho’s data analysis for this workshop were:

• Life expectancy gains by age are changing. Since 2010, in all three groups of countries the greatest contribution to life expectancy gains in both sexes came from ages 65-84, followed by ages 45-64. However, the lower life expectancy gains in the Low and Medium groups since 2010 were largely driven by smaller mortality reductions at ages 45-84 after 2010 than pre-2010.

• Patterns of cause-specific mortality since 2010 are changing. Since 2010, while mortality from most causes continued to fall, mortality from mental and nervous system diseases (including Alzheimer’s disease) increased in 23 of the 24 countries, from accidental poisoning in 14 countries for males and 17 for females, and from respiratory disease in 15 countries for women. CVD mortality today is about half the level in 1995, but improvements have slowed significantly since 2010. In all three groups of countries, CVD made the largest contribution to gains in life expectancy both before and after 2010, but its contribution to life expectancy gains in Low and Medium group countries fell after 2010.

• The drivers for the slowdown in life expectancy differ between the Low and High groups, and before and after 2010. The three causes contributing most to differences between the Low and High groups were CVD, cancer, and external causes in men and CVD, cancer, and mental and nervous system disorders in women. The causes that contributed most to smaller life expectancy gains in the most recent period compared with pre-2010 were the same for the Medium and Low groups. For men they were smaller improvements in mortality from CVD and external causes, combined with increased mortality from mental and nervous system disorders. For women, they were smaller improvements in CVD mortality, combined with life expectancy losses from influenza and pneumonia, and mental and nervous system disorders, especially in the Low group.

Table 1.1. Countries with high/medium/low gains in life expectancy since 2010
		Average Annualised Gain in Life Expectancy (years)			Average Annualised Gain in Life Expectancy (years)
		Men			Women
		2000-10	2010-Present		2000-10	2010-Present
High	Belgium	0.30	0.30	Belgium	0.21	0.20
	Denmark			Denmark
	Finland			Finland
	Japan			Japan
	Luxembourg			Luxembourg
	Norway			Norway
	Switzerland			Switzerland
	Ireland			Portugal
Medium	Australia	0.28	0.20	Australia	0.22	0.12
	Austria			Austria
	Spain			Spain
	France			Canada
	Iceland			Germany
	Netherlands			Greece
	Portugal			Ireland
	Sweden			Israel
Low	Italy	0.27	0.12	Italy	0.19	0.07
	New Zealand			New Zealand
	United Kingdom			United Kingdom
	United States			United States
	Canada			France
	Germany			Iceland
	Greece			Netherlands
	Israel			Sweden
Note: Countries where men and women are not in the same group are shaded.
Source: Data from the Human Mortality Database and World Health Organization Mortality Database.

The quality and timeliness of available data needs to improve

In conclusion, Professor Ho cautioned that international comparisons can be impacted by differences in diagnostic practices, death certification and cause of death coding across countries and over time. For example, many deaths now coded to dementia, Alzheimer’s disease and other mental and nervous system disorders would previously have been coded to CVD or other causes. There can also be associations between different causes of death – for example, people with CVD are more susceptible to influenza and pneumonia, likewise, the latter conditions increase the risk of a coronary event. In some recent years, there have been widespread outbreaks of influenza across many European countries. Likewise, the use of illicit drugs and opioids increases the risk of dying from CVD. Use of prescription opioids and illicit drugs is increasing in several high-income countries (including the United States but also Australia, Canada, the United Kingdom, and the Nordic countries), with death rates among young and middle-aged adults rising in some countries (Ho, 2019[25]). Interpreting trends in CVD mortality is therefore made more complex when there are interactions with other causes of death, and which may have varying trends.

Finally, Professor Ho stressed the importance of improving the quality and timeliness of vital registration systems and data releases used for monitoring contemporary trends in CVD mortality, and the broader drivers underlying these trends.

During the discussion participants queried the potential reasons why most Nordic countries (Norway, Finland, Denmark) “bucked the trend” of a slowdown in life expectancy gains in recent years. A slowdown in CVD mortality improvements was reported by participants from several countries, and especially among young adults in some countries (for example, Australia and Portugal). Potential reasons advanced for the slowdown in CVD mortality improvements among French women include an increase in the prevalence of some cardiovascular risk factors (tobacco, physical inactivity) and a decrease in treatment of other risk factors (hypertension and cholesterol particularly).

Professor Ho has documented these facts in a brief paper located in Chapter 4. Professor Ho’s presentation can be found in https://www.oecd.org/health/is-cardiovascular-disease-slowing-improvements-in-life-expectancy-47a04a11-en.htm.

Trends in CVD mortality and risk factors – the Global Burden of Disease study

Dr Catherine Johnson described the aims, coverage and methods of the Global Burden of Disease (GBD) study in monitoring levels and trends in disease risk factors, incidence, prevalence and mortality. She noted that the decrease in CVD mortality seen in most high-income countries over the past few decades is levelling off, and mortality may be increasing in certain countries among the OECD, including Latvia, Estonia, Greece, and Portugal (Roth et al., 2018[26]).

The top risk factors for CVD are: dietary risk, high systolic blood pressure, high low-density lipoprotein cholesterol and high fasting plasma glucose. Overall, the top 11 major risk factors for CVD have remained unchanged in order of rank importance since 1990, with the exception of tobacco, which has dropped in rank because of the impact of public health policies in reducing smoking prevalence. However, GBD’s assessments show rising prevalence of several common risk factors for CVD, including elevated low-density lipoprotein cholesterol, systolic blood pressure, fasting plasma glucose and BMI, and low physical activity in most, but not all, of the OECD countries. Results indicate that these risk factors are increasing across all quintiles of the socio-demographic index, a summary measure of development (http://ihmeuw.org/526l) (IHME, 2017[27]). For example, being overweight causes 9 to 27% of the CVD deaths in the OECD, depending on the country (http://ihmeuw.org/526m) (IHME, 2017[27]). These trends in key risk factors could contribute to decelerating improvements in CVD mortality, with the risk of mortality increasing if these trends continue.

Policies and interventions aimed at reducing the risk factors for and mortality from CVD need to be tailored locally to the target populations if they are to be effective.

The GBD can be used to monitor trends in both CVD mortality and common CVD risk factors over time.

During the discussion, participants raised various technical and methodological queries about the GBD methodology, relating to e.g. coding, data sources used for risk factors, and how changes in clinical guidelines over time are handled in interpreting the data.

Dr Johnson has documented these facts in a brief paper located in Chapter 5. Dr Johnson’s presentation can be found in https://www.oecd.org/health/is-cardiovascular-disease-slowing-improvements-in-life-expectancy-47a04a11-en.htm.

Socio-economic inequalities in CVD mortality in Europe

Inequalities in CVD mortality in Europe are wide

Like other speakers, Professor Anton Kunst noted the dramatic falls in CVD mortality since the 1970s, but also the decelerating improvements in recent years. He highlighted the need to distinguish between the two key determinants of CVD mortality trends: incidence i.e. the numbers of people who develop CVD (driven by exposure to biological and lifestyle risk factors) and case-fatality i.e. the numbers who die from it (the outcome of access to health care, medical technology and treatment).

Inequalities in CVD mortality in Europe are wide and strongly associated with behavioural and lifestyle factors. Risk factors such as smoking, physical inactivity and a poor diet show a socio-economic gradient in many countries. Professor Kunst noted that such biological and lifestyle factors are influenced by environmental conditions including physical exposures, socio-cultural influences, social networks and social status as determined by education, employment, wealth and attributes such as prestige and power. Dahlgren and Whitehead’s rainbow model (2007[28]) illustrates how the wider societal and environmental context influences individual lifestyles and behaviours, and the mediating factors.

Professor Kunst noted that in Europe and the United States, IHD had changed over time from being a “manager’s disease” to becoming a “disease of poverty”. Wide socio-economic inequalities in CVD mortality are now characteristic of many European countries, including those with generous social welfare schemes (e.g. Finland, Denmark). For example, avoidable cardiovascular mortality at ages <75 years in England varies approximately four-fold between the most and least deprived groups (Figure 1.5). A recent study (Lewer et al., 2020[29]) found that if everyone in England had the same mortality rate as people living in the least deprived areas, there would have been almost 900 000 fewer premature (i.e. under 75 years) deaths between 2003 and 2018; IHD was among the largest contributors to inequalities in premature mortality.

Figure 1.5. Under 75 mortality rates from all cardiovascular disease considered ‘avoidable’ for deprivation deciles in England 2016

Source: Public Health England (reference). Data from Office for National Statistics.

Some trends in inequalities are not favourable

A recent study of trends in socio-economic inequalities in CVD mortality (Di Girolamo et al., 2019[30]) between the 1990s and the early 2010s in 12 European populations found that CVD mortality declined rapidly among all socio-economic groups. Relative declines (%) were faster among higher socio-economic groups; absolute declines (deaths per 100 000 person-years) were greater among lower socio-economic groups. Therefore, although relative inequalities widened over time, absolute inequalities often declined substantially. In the early 2010s, inequalities in CVD mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries. The authors conclude that lower socio-economic groups have experienced remarkable declines in CVD mortality over the last 25 years, and trends in inequalities are favourable. The evidence suggests that equitable access and the quality of medical care and treatments have contributed to these trends. Nevertheless, inequalities in CVD mortality remain wide and an important challenge for European health systems and policies.

Prevention policies can exacerbate inequalities and need to address also the broader determinants of ill health

Professor Kunst noted (as others have, for example Lewer and colleagues (2020[29]) and Lorenc and colleagues (Lorenc et al., 2013[31]; Brown, Platt and Amos, 2014[32]), that public health interventions such as smoking cessation that aim to change individual behaviour, although effective, can increase inequalities because of higher adoption among more affluent groups. Like Professor O’Flaherty, Professor Kunst argued that universal population-level measures to tackle the underlying causes, such as smoking bans in public places and structural interventions like taxation and minimum unit pricing, are likely to have a more progressive effect.

Policies and structural measures need to give consideration to social constructs beyond individual lifestyle and health-related behaviours, and also to extend beyond the health sector to address the “upstream” determinants of ill health. This approach to addressing health inequalities aligns with the landmark Marmot reviews of health inequalities in England in 2010 and the recently published ten year update (The Marmot Review, 2010[33]; The Marmot Review, 2020[34]).

Professor Kunst has documented these facts in a brief paper located in Chapter 6. Professor Kunst’s presentation can be found in https://www.oecd.org/health/is-cardiovascular-disease-slowing-improvements-in-life-expectancy-47a04a11-en.htm.

Drivers of cardiovascular disease mortality and the cost of inaction

CVD mortality can change rapidly

While noting the unprecedented decline in CVD mortality in high-income countries since the 1970s, Professor Martin O’Flaherty also noted that some other parts of the world (for example Eastern European countries) are still in an earlier phase of the CVD mortality transition (Capewell and O’Flaherty, 2011[35]).

Key themes of Professor O’Flaherty’s presentation were that CVD mortality trends can change rapidly in both directions, most such deaths are preventable, and their key drivers are largely concentrated in lifestyle risks. Most CVD events manifest at older ages; hence, the perception is of a process that develops slowly and that will reverse slowly, if at all. But O’Flaherty and colleagues note that this perception is incorrect, pointing to extensive evidence from clinical trials, natural experiments and policy interventions showing that changes in diet and lifestyle across entire populations can be quickly followed by dramatic declines in mortality (Capewell and O’Flaherty, 2011[36]; Capewell and O’Flaherty, 2011[35]). Trials on, for example, hypertension and blood lipid treatment can show effects within months. Population-wide policy interventions for CVD prevention aimed at changing lifestyles and diets (such as smoke-free legislation or reductions in dietary salt, transfats, or saturated fat) can be effective, cost-saving, and can achieve substantial and rapid reductions in disease, hospital admissions and mortality. Conversely, mortality can also increase rapidly after adverse changes in diet, lifestyle and other risk factors. The referenced publications provide several examples of rapid changes (declines and increases) in CVD mortality seen in various countries, in response to changes in lifestyle factors such as diet and smoking. Soft drinks manufacturers in the United Kingdom have reduced the sugar content of soft drinks following the introduction of the government’s sugar levy in April 2018 (Scarborough et al., 2020[37]).

Modelling the impact of drivers of CVD mortality

O’ Flaherty and colleagues have been studying the determinants of CVD mortality associated with lifestyle and treatment factors. The IMPACT family of models developed internationally uses epidemiological tools and mathematical models to analyse data on demographics, risk factors, and treatment trends to estimate the relative contributions of lifestyle risk factors and medical treatments to changes in the incidence of and mortality from CVD overall, and specific CVD conditions. The model can also estimate the future consequences of altering treatment strategies and changing population risk.

The IMPACT model consistently found that about 40 to 72% of the fall in deaths is attributable to risk factors changes and 23 to 55% to treatments (Mensah et al., 2017[38]). Particularly powerful drivers were population-wide declines in smoking, blood pressure and cholesterol levels, and provision of secondary prevention and acute care. Where CHD rates were increasing, it was primarily due to adverse population-level trends in behavioural risk factors. A consistent finding in most populations studied with IMPACT is that the almost universally observed increases in obesity and diabetes offset a significant proportion (10-14%) of the mortality reductions attributed to favourable changes in other risk factors.

Professor O’Flaherty speculates that population drivers of incidence (i.e. risk factors such as poor diet, smoking, low physical activity and increasing trends in obesity and diabetes) rather than worsening case-fatality rates are likely causes of the current slowdown in CVD mortality improvements in many countries. Key drivers of non-communicable diseases in the United Kingdom between 1990-2016 were diet (40%), smoking (19%), alcohol (9%) and lack of physical activity (2%) (Steel et al., 2018[39]). In their analysis of GDB data for the United Kingdom, Steele and colleagues (2018[39]) note that the continued dominance of CVD mortality argues for renewed efforts to deliver systematic programmes to reduce risk factors, such as high body-mass index, high fasting glucose, high blood pressure, and high cholesterol.

The costs of inaction can be high

As CVD remains a major killer, and is contributing to the slowdown in overall mortality improvements in many countries, it needs to be addressed urgently. Professor O’Flaherty noted that the key priorities should be to: reduce the burden of CVD, reduce inequalities, and reduce pressures on the health care system. Like Professor Kunst, he argued that this requires a combination of targeted policies in deprived communities alongside structural, population-level policies to, for example, improve diets and reduce smoking and alcohol intake – including by the use of fiscal and regulatory measures, although regulations and fiscal policies that impact on consumer choice can be politically controversial and face public resistance. Other policy instruments used in various countries include public information, food labelling, marketing and advertising control, and food reformulation.

In conclusion, CVD mortality trends can change rapidly in both directions, most such deaths are preventable, and their key drivers are largely concentrated in lifestyle risks. Evidence shows that population level policies, including fiscal and regulatory measures to stimulate lifestyle changes, can deliver large and rapid health and economic gains in terms of reducing CVD. Such policies have several advantages: they can be cost-effective, have a rapid impact, reduce inequalities, and reduce pressures on the health care system (e.g. fiscal and regulatory measures do not require health care resources).

The economic costs of inaction are high. For example, the cumulative health, social care and informal care costs of the future burden of dementia and disability in the CVD slowdown era in England and Wales over 2020-29 is estimated to total GBP 47.6 billion (Kypridemos et al., 2018[40]).

During the discussion participants queried the possibility of current trends being affected by cohort effects, and of newly emerging risk factors, such as pollution and climate change, in addition to the classical ones. In this context, illicit drug use and influenza outbreaks were also mentioned. In response, Professor O’Flaherty noted the WHO’s view that 80% of CVD is associated with the classic risk factors. Other points noted were the importance of analysing not just mortality but also quality of life, and the importance of improved access to and timeliness of care in the context of acute events in some countries.

Professor O’Flaherty has documented these facts in a brief paper located in Chapter 7. Professor O’Flaherty’s presentation can be found in https://www.oecd.org/health/is-cardiovascular-disease-slowing-improvements-in-life-expectancy-47a04a11-en.htm.

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