Verica Kralj

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Uvodnik / EditorialKardiovaskularne bolesti — veliËina problema imoguÊnosti prevencijeCardiovascular diseases — magnitude of theproblem and possibilities of preventionVerica Kralj*Hrvatski zavod za javno zdravstvo, Zagreb, HrvatskaCroatian National Institute of Public Health, Zagreb, CroatiaGlobal size of the problemCardiovascular diseases (CVD) are the leading cause ofdeath in almost all countries of the world. According to thedata of the World Health Organization, they are the cause ofdeath of 17.3 million people worldwide, that cause 30% of alldeaths. Out of these deaths, 7.3 million people die from is-chemic heart disease (IHD), and 6.2 million people die fromcerebrovascular diseases. The portion of premature deathsfrom CVD ranges from 4% in high-income countries to 42%in low-income countries, leading to growing inequalities inthe incidence and outcome of CVD among the countries andpopulations. It is estimated that by 2030, some 23.6 personswill be dying from CVD. At the European level, this group of diseases is responsiblefor 4.3 million deaths on an annual basis, or 48% of alldeaths (54% of deaths in women and 43% of deaths inmen), and in the European Union it is responsible for 42% ofdeaths. Somewhat less than a half of deaths from CVD arecaused by IHD, and about a third of deaths is caused bycerebrovascular diseases. CVD are the leading cause ofdeath at the age up to 65 at the European level (31% ofdeaths in men and 29% of deaths in women under 65), whilein the EU countries, CVD takes the second place with a por-tion of 24%, followed by neoplasms with a portion of 35%. Inmost of northern, western and southern European countries,the mortality from CVD has decreased over the past thirtyyears, while in the countries of Eastern Europe it is still gro-wing or stagnates, however, the rates of hospital treatmentshow a rising trend in most European countries. Magnitude of the problem in CroatiaIn Croatia CVD also represents the leading cause of death,accounting for 48.7% of total mortality in 2011. This is thecause of death of 55.4% of dead women and 41.8% of deadmen. There is a positive indicator that this is the third yearthat the portion of CVD in total mortality is under 50% (in2009, the portion was 49.6% and in 2010 the portion was49.2%) after many years when the portion of this group ofdiseases was over 50% in total mortality.2012;7(9-10):231.Globalna veliËina problemaKardiovaskularne bolesti (KVB) predstavljaju glavni uzroksmrti u gotovo svim zemljama svijeta. Prema podacima Svjet-ske zdravstvene organizacije, one su uzrok smrti 17,3 mili-juna ljudi diljem svijeta, odnosno uzrokuju 30% sveukupnesmrtnosti. Od toga je 7,3 milijuna smrti od ishemijskih bole-sti srca (IBS), a 6,2 milijuna od cerebrovaskularnih bolesti.Udio prijevremenih smrti od KVB kreÊe se od 4% u visokodohodovnim zemljama do 42% u nisko dohodovnim zemlja-ma, πto dovodi do rastuÊe nejednakosti u pojavnosti i ishoduod KVB meu zemljama i populacijama. Procjenjuje se daÊe do 2030. godine umirati 23,6 milijuna ljudi zbog KVB.Na razini Europe ova skupina bolesti odgovorna je za 4,3milijuna smrti godiπnje, odnosno 48% svih smrti (54% smrtiu æena i 43% smrti u muπkaraca), a u zemljama EuropskeUnije odgovorna je za 42% smrti. Neπto manje od polovinesmrti od KVB uzrokovano je IBS, a oko treÊine cerebro-vaskularnim bolestima. KVB su i vodeÊi uzrok smrti u dobido 65 godina na razini Europe (31% smrti u muπkaraca i29% smrti u æena do 65 godine), dok su u zemljama EU nadrugom mjestu s udjelom od 24%, iza novotvorina s udjelomod 35%. U veÊini zemalja sjeverne, zapadne i juæne Europesmrtnost od KVB smanjuje se zadnjih tridesetak godina, doku zemljama i istoËne Europe joπ uvijek raste ili stagnira, me-utim stope bolniËkog lijeËenja pokazuju trend porasta u ve-Êini europskih zemalja. VeliËina problema u HrvatskojU Hrvatskoj su KVB takoer vodeÊi uzrok smrti s udjelom od48,7% u ukupnom mortalitetu 2011. godine. Uzrok su smrti55,4% umrlih æena i 41,8% umrlih muπkaraca. Pozitivan jepokazatelj πto je ovo treÊa godina u kojoj je udio udio KVB uukupnom mortalitetu ispod 50% (2009. godine udio je izno-sio 49,6%, a 2010. 49,2%), a nakon dugogodiπnjeg udjelaove skupine bolesti s viπe od 50% u ukupnoj smrtnosti.U 2011. godini od KVB umrla je 24.841 osoba, od toga14.319 æene i 10.522 muπkaraca. U dobnoj skupini do 65godina KVB su drugi uzrok smrtnosti s 2.731 umrlih i udje-lom od 26,4% u mortalitetu te dobne skupine, a na prvomCardiologia CROATICAmjestu uzrok smrtnosti u toj dobi su maligne bolesti s 4.213umrlih, odnosno s udjelom od 40,7%. VodeÊe dijagnostiËke podskupine su IBS s udjelom od21,3% (10.866 umrle osobe) i cerebrovaskularne bolesti sudjelom od 14,7% (7.508 umrlih osoba) u ukupnom mortali-tetu, zatim slijede srËana insuficijencija s 1.844 umrlih osoba(3,6%) i hipertenzija s 1.494 umrlih (2,9%).Posljednjih deset godina prisutan je pozitivan trend smanje-nja smrtnosti od KVB Hrvatskoj, πto je izraæenije za cerebro-vaskularne bolesti, nego za IBS i to posebice za dob do 64godine. UsporeujuÊi smrtnost od KVB u Hrvatskoj s drugim zemlja-ma Europe, Hrvatska sa standardiziranom stopom smrtnostiod 386/100.000 u 2009. godini, pripada meu zemlje uEuropi koje imaju srednje visoke stope smrtnosti. Prosjek zazemlje Europske regije iznosi 415/100.000, za zemlje EU235/100.000,   a   raspon   stopa   za  zemlje  EU  je  od127-611/100.000. Zemlje IstoËne Europe imaju uglavnom vi-πe stope smrtnosti od Hrvatske, Ruska Federacija ima sko-ro dvostruko viπu stopu smrtnosti (782/100.000), a zemljeZapadne i Juæne (mediteranske) Europe imaju znatno niæestope smrtnosti od Hrvatske sa stalnim trendom smanjenja. MoguÊnosti prevencije kardiovaskularnihbolestiPrema studijama provedenim u razliËitim populacijama, Ëak44-76% smanjenja smrtnosti od IBS pripisuje se prevenciji ipromjeni riziËnog ponaπanja, dok se 23-47% smanjenjasmrtnosti pripisuje terapijskim intervencijama.Suvremeni pristup prevenciji zalaæe se za uravnoteæenukombinaciju populacijskog pristupa i pristupa visoko riziËnimskupinama za postizanje uËinkovitog nadzora nad epidemi-jom KVB. Dakle, preventivne mjere mogu biti usmjerene po-jedincu, odnosno lijeËenju Ëimbenika rizika u visoko riziËnimskupinama i cijeloj populaciji. Populacijski pristup ukljuËujemjenjanje naËina æivota i Ëimbenika okoliπa, druπtvenih iekonomskih odrednica te mora biti sastavnim dijelom javnepolitike i ukljuËivati druge sektore druπtva. Geoffrey Rose jedevedesetih godina dao kljuËni argument da je populacijskipristup najisplativiji i ima najveÊi uËinak na incidenciju, pre-valenciju i mortalitet. Naime, on je dokazao da male prom-jene u cijeloj populaciji postiæu veÊe smanjenje smrtnosti ne-go velike promjene u relativno malom broju osoba s visokimrizikom.Prema Europskim smjernicama za prevenciju KVB iz 2012.godine moguÊe je sprijeËiti 80-90% KVB. Implementacijompreventivnih mjera na razini populacije, kao πto je poveÊanjeporeza i reguliranje oglaπavanja duhana, alkohola, nezdravehrane, moguÊe je izbjeÊi 50% smrti od KVB u Europi. Najis-plativije intervencije na populacijskoj razini jesu: zaπtita odduhanskog dima ukljuËujuÊi zabranu puπenja na javnim mje-stima, upozorenja o opasnosti uporabe duhana, provedbazabrane oglaπavanja i reklamiranja duhanskih proizvoda tesponzorstva duhanske industrije, poveÊanje poreza na du-hanske proizvode, ograniËavanje dostupnosti alkohola, pro-vedba zabrane oglaπavanja alkoholnih piÊa, poveÊanje po-reza na alkohol, smanjenje unosa soli i koliËine soli u hrani,zamjena trans-masnih kiselina u hrani s viπestruko nezasi-Êenim kiselinama, podizanje svijesti o vaænosti pravilne pre-hrane i provoenja tjelesne aktivnosti. Posljednjih desetljeÊa na meunarodnoj razini jaËaju ak-tivnosti usmjerene prevenciji KVB. Stoga je na razini Europenastao velik broj strateπkih dokumenata, deklaracija, rezolu-In 2011, some 24,841 persons died of CVD, of whom 14,319women and 10,522 men. In the group of persons aged up to65, CVD are the second cause of mortality with 2,731deaths and a portion of 26.4% in mortality of this age group,while malignant diseases with 4,213 dead persons are thefirst cause of mortality in this age group, that is, with a por-tion of 40.7%. The leading diagnostic subgroups are IHD with a portion of21.3% (10,866 dead persons) and cerebrovascular diseasewith a portion of 14.7% (7,508 deaths) in total mortality, fol-lowed by heart failure with 1,844 deaths (3.6%) and hyper-tension with 1,494 of dead persons (2.9%).In the last ten years there is a positive trend in reducing mor-tality from CVD in Croatia, which is more pronounced forcerebrovascular diseases, than for IHD, particularly for thepersons aged up to 64. Comparing mortality from CVD in Croatia with mortality insome other European countries, Croatia with a standardizedmortality rate of 386/100.000 in 2009 is among the countriesin Europe that record medium-high mortality rates. The aver-age for countries in the European region is 415/100,000, theaverage for EU countries is 235/100,000, and rates for theEU countries ranges from 127 to 611/100,000. The EasternEuropean countries have generally higher mortality ratesthan Croatia, while the Russian Federation has almost twiceas high mortality rate (782/100,000), while Western andSouthern (Mediterranean) European countries have signifi-cantly lower mortality rates than Croatia that records a con-tinuous downward trend.Possibilities of preventing cardiovasculardiseasesAccording to the studies conducted in different populations,even 44-76% of reduction in mortality from IHD is attributedto the prevention and changes in risk behavior, while 23-47% of reduction in deaths is attributed to therapeutic inter-ventions.A modern approach to prevention advocates a balancedcombination of population approach and approach to high-risk groups for achieving effective control of the CVD epi-demic. Thus, preventive measures can be focused on an in-dividual or the treatment of risk factors in high-risk groupsand general population. The population approach involveschanging lifestyle and environmental factors, social and eco-nomic policies, and must be an integral part of public policyand include any other sectors of the society. In the nineties,Geoffrey Rose gave the key rationale that the populationapproach is the most cost effective and has the greatest im-pact on the incidence, prevalence and mortality. He namelyproved that small changes in the overall population result ingreater reduction of mortality than major changes in a rela-tively small number of high-risk persons.According to the 2012 European guidelines for CVD preven-tion, it is possible to prevent 80-90% of CVD. The implemen-tation of preventive measures at the population level, suchas an increase in taxes and regulation of advertising tobac-co, alcohol, unhealthy foods may result in avoidance of 50%of deaths from CVD in Europe. Most cost-effective inter-ventions at a population level include: protection from to-bacco smoke, including a ban on smoking in public places,warning about the danger of tobacco use, enforcement ofthe ban on commercials and advertisement of tobacco pro-ducts and tobacco industry sponsorship, increase in taxes2012;7(9-10):232.Cardiologia CROATICA2012;7(9-10):233. Cardiologia CROATICAcija i smjernica kojima se potiËu zemlje da na nacionalnoj ra-zini priu rjeπavanju problematike KVB. Jedna od najznaËa-jnijih aktivnosti, bio je sastanak na najviπem nivou unutarOpÊe skupπtine Ujedinjenih naroda (UN) o prevenciji i kon-troli nezaraznih bolesti odræan u New Yorku, 19. i 20. rujna2011. godine. Na sastanku je prihvaÊen dokument pod na-zivom PolitiËka deklaracija sastanka na visokom nivou OpÊeskupπtine UN o prevenciji i kontroli nezaraznih bolesti kojipredstavlja osnovu buduÊeg djelovanja na nacionalnom imeunarodnom nivou u borbi protiv kroniËnih nezaraznihbolesti, ukljuËujuÊi i KVB. Dokument naglaπava vaænostuËinkovitih populacijskih intervencija usmjerenih na sprjeËa-vanje Ëimbenika rizika, ali takoer i mjere lijeËenja u primar-noj zdravstvenoj zaπtiti usmjerenih na one koji veÊ imaju riz-iËne Ëimbenike ili kroniËnu nezaraznu bolest.Prevencija KVB zahtjeva strategiju koja zagovara sveobuh-vatni i integrirani pristup te koja istodobno na populacijskojrazini promiËe zdravlje i provodi preventivne programe, ak-tivno pristupa pojedincima i skupinama s visokim rizikom,osigurava maksimimalni obuhvat populacije uËinkovitim lije-Ëenjem te utjeËe na determinante zdravlja. on tobacco products, limitation of the availability of alcohol,enforcement of a ban on advertising alcoholic drinks, increa-se in tax on alcohol, reduction of salt intake and the amountof salt in food, replacement of trans-fatty acids in food withpolyunsaturated fatty acids, raising awareness about theimportance of proper nutrition and doing physical exercises. Activities focused on the prevention of CVD have beenstrengthened internationally in the last few decades. There-fore, a large number of policy documents, declarations, re-solutions and guidelines have been created in Europe thatencourage the countries to start addressing the problem ofCVD at a national level. One of the most important activitieswas the meeting at the highest level within the General As-sembly of the United Nations (UN) on prevention and controlof noncommunicable diseases that took place on 19 and 20September 2011 in New York. At this meeting the membersadopted the document entitled Political declaration at a highlevel meeting of the General Assembly of UN on preventionand control of noncommunicable diseases, which is thebasis for future action at the national and international levelin fighting against chronic noncommunicable diseases, in-cluding CVD. The document emphasizes the importance ofeffective population interventions aimed not only at the pre-vention of risk factors, but also the measures of treatment inprimary healthcare aimed at those who already had risk fac-tors or chronic noncommunicable disease. CVD prevention requires a strategy that advocates a com-prehensive and integrated approach that simultaneouslypromotes health at the population level and implements pre-ventive health programs, actively approaches high-risk indi-viduals and groups and includes the population in efficienttreatment to a maximum degree and affects the health de-terminants at the population level. Received: 13th Sep 2012*Address for correspondence: Hrvatski zavod za javno zdravstvo, Rockefellerova 7,HR- 10000 Zagreb, CroatiaPhone: +385-1-4863271E-mail: verica.kralj@hzjz.hrLiterature1. WHO. Global status report on noncommunicable diseases 2010. Geneva 2011.2. Mendis S, Puska P, Norrving B. Global Atlas on cardiovacular disease prevention and control. WHO, Geneva 2011.3. WHO. Gaining Health, The European Strategy for the Prevention and Control of Noncommunicable Diseases. WHO- Regional Office for Europe, Copenhagen 2006.4. Allender S, Scarborough P, Peto V, et al. European cardiovascular disease statistics, 2008 edition. University of Oxford, 2008.5. Kralj V, ∆oriÊ T, TomiÊ B, Hrabak-ÆerjaviÊ V. Izvori podataka za pokazatelje mortalitetata i morbiditeta kardiovaskularnih bolesti. Kardio list. 2011;6(1-2):2-9.6. ∆oriÊ T i sur. IzvjeπÊe o umrlim osobama u Hrvatskoj u 2011. godini. Hrvatski zavod za javno zdravstvo, Sluæba za javno zdravstvo. Zagreb, 2012.7. Graham I, Atar D, Borch-Johnsen K, Boysen G, et al. European guidelines on cardiovasular disease prevention in clinical practice:executive summary. Eur Heart J 2012;33:1635-701.8. Jorgensen T, Capewell S, Prescott E, Allender S, et al. Population-level changes to promote cardiovasular health. Eur J Prev Cardiol. 2012 May 9. [Epub ahead of print].9. Rose G. Strategy of preventive medicine. Oxford: Oxford University Press,1992.

Cardiovascular diseases – magnitude of problem and possibilities of prevention.

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