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The paradox of reciprocal development of mortality and morbidity

Comment by Uwe Nixdorff, EACPR Prevention, Epidemiology and Population Science Section

Cardiovascular disease in Europe 2014: epidemiological update
M. Nichols et al.
European Heart Journal (EHJ) 2014;DOI:10.1093/eurheartj/ehu299


This special article in the EHJ summarises epidemiologic data on mortality and morbidity on cardiovascular disease (CVD), in particular coronary heart disease (CHD) as well as stroke. Both CV diseases have been thought to be important to overview together since the 4th European Guidelines on CVD Prevention in clinical practice in 2007. This paper is an update of a previous one dated 2013 (1). Data reported have been sourced from the WHO mortality database, the WHO European Region’s Health for All Database, and the Organisation for Economic Cooperation and Development (OECD) health statistics. In total, Europe is defined as the 53 member states of the WHO European region.

CV disease is the leading cause of death in Europe and there are still over 4 million deaths, close to half of all deaths in Europe. The proportion of all deaths that are attributable to CVD is substantially greater among women (51%) than men (42%). Just for comparison, cancer death rates are about 19 and 23%, respectively. However, the data show now 10 European countries in which cancer has developed as the cause of more deaths than CVD among men; however, just in one country this holds true for women. The paper also considered age in respect of premature mortality for which (< 65 as well as < 75 years) the main finding also holds true. Again geographical heterogeneity is depicted in even a 10-fold difference of premature mortality from CVD in men in respect of events occurring < 75 years (age standardised) being < 65/100,000 in San Marino, France, Israel, and Switzerland versus > 560/100,000 in the Russian Federation and Belarus.

The main message is that CV mortality is slightly and continuously decreasing over most of the European countries whereas morbidity, in this paper assessed by hospital discharges of CV diseases, is increasing, although there is high variability between countries. Especially in the east European countries mortality reduction is lower or even not existing respectively.

As a personal comment on those very important data the paradox of reciprocal development of mortality and morbidity is not justifying a concluding statement like “… there is evidence of continuing reduction in the burden of CVD” as importantly morbidity is increasing. At the other side the concluding consideration of an impact of an ageing population is quite reasonable. The clinical paradox resulting in those epidemiology data is not less than the – known from other clinical and epidemiologic studies very well – increased incidence of congestive heart failure resulting from higher rates of surviving post-MI (myocardial infarction) patients.

In respect of CV treatment the challenge seems to be much more morbidity compression by CV prevention than solely further enlargement of life expectancy. It is a positive development to state an ongoing increase of life expectancy, but within the aging process we have to intensify our CV prevention activities to reduce morbidity beside already decreased mortality, although mortality might be reasonably further decreased as being targeted by the World Health Assembly for reducing mortality from non-communicable disease by 25% by the year 2025 which is - challenging enough - almost half of what has been actually presented by this particular paper.

(1) Cardiovascular disease in Europe – epidemiological update.
M. Nichols et al.
European Heart Journal 2013;34:3028-3034