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Analysing CHD mortality trends: ‘There are risk factors to explain the risk factors’

Comment by Sandy Gupta, EACPR Prevention, Epidemiology and Population Science Section


How would one respond to learning of a fall in coronary heart disease (CHD) death rate of nearly 40% in a 8 year period?…. perhaps ‘dramatic’ and ‘commendable’?
Such a trend in England (over the period 2000 to 2007, population aged 25 years and above) was highlighted and scrutinised by Bajekal et al. using an established and robust epidemiological model they assessed and stratified by age, gender and markers of deprivation.

Around 38,000 fewer CHD deaths were recorded in the final year of analysis and around 86% of the mortality reduction could be explained. Treatment effect and uptake accounted for around half of the decline – whether lipid management, antianginal therapies or secondary prevention in general. Furthermore, this was equitable across all socio-economic groups – evidence to support the uniform standard of service strived for across the whole NHS. The contribution of CV risk factor modification was less impressive – and accounted for around a third of CHD deaths averted. This ranged from about 44% in most deprived populations to 29% in the most affluent quintile. Fall in systolic blood pressure (in untreated), cholesterol reduction, smoking cessation and increased physical activity all contributed…in such an order of effect. In contrast, mortality increases related to greater obesity and diabetes rates had the influence of offsetting the over picture of CHD death reduction; particularly noticeable in more deprived communities.

In England, the policies set through the National Service Framework for CHD and the Quality and Outcomes Framework in Primary Care has clearly contributed to the impressive CHD death rate reduction – and in a relatively short period of time. Medical prescribing and ‘interventions’ have worked. However, what now merits more attention (and vigour) is to address the modifiable CV risk factors…and the battle for reducing inequalities. A ‘nudge’ and encouragement effect on reducing high salt, fat, sugar and calorie intake (especially in fast-foods, sugary drinks, etc) may not be that effective. Clear, decisive legislation whether with food standards, ‘penalties’ or taxation policies, the authors feel is the way forward. This is already effective in other countries.

The paper is profound and encouraging…but also thought-provoking with some ‘bitter-sweet’ messaging.

We need to be wary that those defined by the lowest socio-economic quintile in the year 2000 may not be the same people identified in such a group in the year 2007. This could perhaps help to explain any inconsistencies in the variables to CHD death rate reduction. Furthermore we need to factor in and understand compliance, communication, follow-up, uptake and also ethnicity/cultural issues…factors that run through all aspects of primary and secondary prevention.

One could say ‘...There are risk factors to explain the risk factors…’