Cardiovascular disease, chronic kidney disease, and diabetes mortality burden of cardiometabolic risk factors from 1980 to 2010: A comparative risk assessment

Background: High blood pressure, blood glucose, serum cholesterol, and BMI are risk factors for cardiovascular diseases and some of these factors also increase the risk of chronic kidney disease and diabetes. We estimated mortality from cardiovascular diseases, chronic kidney disease, and diabetes that was attributable to these four cardiometabolic risk factors for all countries and regions from 1980 to 2010. Methods: We used data for exposure to risk factors by country, age group, and sex from pooled analyses of population-based health surveys. We obtained relative risks for the effects of risk factors on cause-specific mortality from meta-analyses of large prospective studies. We calculated the population attributable fractions for each risk factor alone, and for the combination of all risk factors, accounting for multicausality and for mediation of the effects of BMI by the other three risks. We calculated attributable deaths by multiplying the cause-specific population attributable fractions by the number of disease-specific deaths. We obtained cause-specific mortality from the Global Burden of Diseases, Injuries, and Risk Factors 2010 Study. We propagated the uncertainties of all the inputs to the final estimates. Findings: In 2010, high blood pressure was the leading risk factor for deaths due to cardiovascular diseases, chronic kidney disease, and diabetes in every region, causing more than 40% of worldwide deaths from these diseases; high BMI and glucose were each responsible for about 15% of deaths, and high cholesterol for more than 10%. After accounting for multicausality, 63% (10·8 million deaths, 95% CI 10·1-11·5) of deaths from these diseases in 2010 were attributable to the combined effect of these four metabolic risk factors, compared with 67% (7·1 million deaths, 6·6-7·6) in 1980. The mortality burden of high BMI and glucose nearly doubled from 1980 to 2010. At the country level, age-standardised death rates from these diseases attributable to the combined effects of these four risk factors surpassed 925 deaths per 100 000 for men in Belarus, Kazakhstan, and Mongolia, but were less than 130 deaths per 100 000 for women and less than 200 for men in some high-income countries including Australia, Canada, France, Japan, the Netherlands, Singapore, South Korea, and Spain. Interpretation: The salient features of the cardiometabolic disease and risk factor epidemic at the beginning of the 21st century are high blood pressure and an increasing effect of obesity and diabetes. The mortality burden of cardiometabolic risk factors has shifted from high-income to low-income and middle-income countries. Lowering cardiometabolic risks through dietary, behavioural, and pharmacological interventions should be a part of the global response to non-communicable diseases. Funding: UK Medical Research Council, US National Institutes of Health. © 2014 Elsevier Ltd

Stroke Mortality Rates in Poland Did Not Decline between 1984 and 1992

Background and Purpose: Stroke Mortality Has Decreased in Most Industrialized Countries in Recent Decades. in Poland, as in Other Eastern European Countries, Mortality Rates for Stroke Remain High. Methods: The Warsaw Stroke Registry (WSR) Registered Patients in the Mokotow District of Warsaw from 1991 through 1992. the Warsaw Pol-MONICA Study Registered Stroke Patients in the North and South Praga Regions of Warsaw from 1984 through 1992. Stroke Incidence Rates, Case-Fatality Rates, and Stroke Mortality Rates Were Computed based on Both Studies and Compared with Published Mortality Rates based on Death Certificates. Eight-Year Trends of Stroke Incidence, Case-Fatality Rate, and Mortality Were Derived from the Warsaw Pol-MONICA Study. Results: The WSR and Warsaw Pol-MONICA Studies Showed Similar Incidence Rates, Mortality Rates, and 28-Day Case-Fatality Rates for Stroke. Mortality Rates from the WSR and the Warsaw Pol-MONICA Study Were Similar to Rates from Death Certificate Data. Mortality Rates in the Group Aged 35 to 64 Years Were Higher in Men (47.5 to 50/100 000 Per Year) Than in Women (30/100 000 Per Year). Conclusions: Two Different Population-Based Studies Suggest that Stroke Mortality is High in Poland Because of High 28-Day Case-Fatality Rates. Stroke Mortality Failed to Decline in Poland in the Period 1984 through 1992 Because Neither Case Fatality Nor Stroke Incidence Declined in This Period

Challenges in standardization of blood pressure measurement at the population level

Background: Accurate blood pressure measurements are needed in clinical practice, intervention studies and health examination surveys. Blood pressure measurements are sensitive: their accuracy can be affected by measurement environment, behaviour of the subject, measurement procedures, devices used for the measurement and the observer. To minimize errors in blood pressure measurement, a standardized measurement protocol is needed. Methods: The European Health Examination Survey (EHES) Pilot project was conducted in 2009-2012. A pilot health examination survey was conducted in 12 countries using a standardized protocol. The measurement protocols used in each survey, training provided for the measurers, measurement data, and observations during site visits were collected and evaluated to assess the level of standardization. Results: The EHES measurement protocol for blood pressure was followed accurately in all 12 pilot surveys. Most of the surveys succeeded in organizing a quiet and comfortable measurement environment, and staff instructed survey participants appropriately before examination visits. In all surveys, blood pressure was measured three times, from the right arm in a sitting posture. The biggest variation was in the device used for the blood pressure measurement. Conclusions: It is possible to reach a high level of standardization for blood pressure measurements across countries and over time. A detailed, standardized measurement protocol, and adequate training and monitoring during the fieldwork and centrally organized quality assessment of the data are needed. The recent EU regulation banning the sale of mercury sphygmomanometer in European Union Member States has set new challenges for the standardization of measurement devices since the validity of oscillometric measurements is device-specific and performance of aneroid devices depends very much on calibration

SCORE performance in Central and Eastern Europe and former Soviet Union:MONICA and HAPIEE results

AIMS: The Systematic COronary Risk Evaluation (SCORE) scale assesses 10 year risk of fatal atherosclerotic cardiovascular disease (CVD), based on conventional risk factors. The high-risk SCORE version is recommended for Central and Eastern Europe and former Soviet Union (CEE/FSU), but its performance has never been systematically assessed in the region. We evaluated SCORE performance in two sets of population-based CEE/FSU cohorts. METHODS AND RESULTS: The cohorts based on the World Health Organization MONitoring of trends and determinants in CArdiovascular disease (MONICA) surveys in the Czech Republic, Poland (Warsaw and Tarnobrzeg), Lithuania (Kaunas), and Russia (Novosibirsk) were followed from the mid-1980s. The Health, Alcohol, and Psychosocial factors in Eastern Europe (HAPIEE) study follows Czech, Polish (Krakow), and Russian (Novosibirsk) cohorts from 2002–05. In Cox regression analyses, the high-risk SCORE ≥5% at baseline significantly predicted CVD mortality in both MONICA [n = 15 027; hazard ratios (HR), 1.7–6.3] and HAPIEE (n = 20 517; HR, 2.6–10.5) samples. While SCORE calibration was good in most MONICA samples (predicted and observed mortality were close), the risk was underestimated in Russia. In HAPIEE, the high-risk SCORE overpredicted the estimated 10 year mortality for Czech and Polish samples and adequately predicted it for Russia. SCORE discrimination was satisfactory in both MONICA and HAPIEE. CONCLUSION: The high-risk SCORE underestimated the fatal CVD risk in Russian MONICA but performed well in most MONICA samples and Russian HAPIEE. This SCORE version might overestimate the risk in contemporary Czech and Polish populations

Does inclusion of education and marital status improve SCORE performance in Central and Eastern Europe and former Soviet Union?:findings from MONICA and HAPIEE cohorts

The SCORE scale predicts the 10-year risk of fatal atherosclerotic cardiovascular disease (CVD), based on conventional risk factors. The high-risk version of SCORE is recommended for Central and Eastern Europe and former Soviet Union (CEE/FSU), due to high CVD mortality rates in these countries. Given the pronounced social gradient in cardiovascular mortality in the region, it is important to consider social factors in the CVD risk prediction. We investigated whether adding education and marital status to SCORE benefits its prognostic performance in two sets of population-based CEE/FSU cohorts.The WHO MONICA (MONItoring of trends and determinants in CArdiovascular disease) cohorts from the Czech Republic, Poland (Warsaw and Tarnobrzeg), Lithuania (Kaunas), and Russia (Novosibirsk) were followed from the mid-1980s (577 atherosclerotic CVD deaths among 14,969 participants with non-missing data). The HAPIEE (Health, Alcohol, and Psychosocial factors In Eastern Europe) study follows Czech, Polish (Krakow), and Russian (Novosibirsk) cohorts from 2002-05 (395 atherosclerotic CVD deaths in 19,900 individuals with non-missing data).In MONICA and HAPIEE, the high-risk SCORE ≥5% at baseline strongly and significantly predicted fatal CVD both before and after adjustment for education and marital status. After controlling for SCORE, lower education and non-married status were significantly associated with CVD mortality in some samples. SCORE extension by these additional risk factors only slightly improved indices of calibration and discrimination (integrated discrimination improvement <5% in men and ≤1% in women).Extending SCORE by education and marital status failed to substantially improve its prognostic performance in population-based CEE/FSU cohorts

Descriptive characteristics of the study samples.

<p>CZ – Czech Republic; LT – Lithuania; PL-K – Poland (Krakow); PL-T – Poland (Tarnobrzeg); PL-W – Poland (Warsaw); RU – Russia. IQR – interquartile range; N/A – not applicable; SBP – systolic blood pressure; SD – standard deviation; TC – total cholesterol. ^a Primary or incomplete primary education. ^b Single, divorced/separated, and widowed status.</p

Prognostic performance of the high-risk SCORE (≥5% vs. <5%) in MONICA and HAPIEE women before and after inclusion of education (lower vs. higher) and marital status (non-married vs. married).

<p>CZ – Czech Republic; LT – Lithuania; PL-K – Poland (Krakow); PL-T – Poland (Tarnobrzeg); PL-W – Poland (Warsaw); RU – Russia. IDI – integrated discrimination improvement; LRT – likelihood ratio test; N/A – not applicable.</p>a<p>Calculated for continuous high-risk SCORE.</p

Prognostic performance of the high-risk SCORE (≥5% vs. <5%) in MONICA and HAPIEE men before and after inclusion of education (lower vs. higher) and marital status (non-married vs. married).

<p>CZ – Czech Republic; LT – Lithuania; PL-K – Poland (Krakow); PL-T – Poland (Tarnobrzeg); PL-W – Poland (Warsaw); RU – Russia. IDI – integrated discrimination improvement; LRT – likelihood ratio test; N/A – not applicable. ^a Calculated for continuous high-risk SCORE.</p