Cardiovascular disease disproportionately affects middle-income countries, finds study

Cardiovascular disease (CVD) remains the most common cause of death across Europe, but while CVD mortality rates are generally decreasing, the decline is much less in middle-income countries than in high-income countries, according to new data from the European Society of Cardiology (ESC) Atlas of Cardiology, published in the European Heart Journal.

The fourth edition of ESC Atlas statistics again demonstrates that CVD is the most common cause of death in the 55 ESC member countries studied. There are over 3 million deaths due to CVD per year—the equivalent of 8,500 deaths per day—which represents 37.4% of all deaths annually. Of note, age-standardized mortality rates (ASMRs) were at least 2.5-times higher in middle-income countries than in high-income countries. Between 1990 and 2021, median CVD ASMRs decreased by more than 50% in all high-income countries, but in middle-income countries, the decrease was less than 12%.

According to the latest data from ESC member countries:

• CVD mortality is higher in middle-income countries (46% of all deaths in males; 53% of all deaths in females) than in high-income countries (30% of all deaths in males; 34% of all deaths in females).

• The estimated age-standardized potential years of life lost was more than three times higher in middle-income countries than in high-income countries.

Professor Adam Timmis, first author of the report, said, "The new statistics on deaths due to CVD illustrate the scale of the problem and underscore the urgent need for effective strategies in prevention and management. The inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic and clinical risk factors."

According to the latest data from ESC member countries:

• Around one-quarter of persons aged ≥15 years were estimated to be tobacco-product users (25.4%), with rates as high as 40.9% among males in middle-income countries.

• Hypertension affected >40% of both sexes in middle-income countries vs. <30% of females and <40% of males in high-income countries.

• The prevalence of diabetes was 7.7% in middle-income countries vs. 6.0% in high-income countries.

• More than half (55%) of people were overweight and 17% were obese, with similarly high rates for middle-income and high-income countries.

Professor Timmis also pointed to new data suggesting that treatment factors may contribute to inequalities in CVD mortality, with middle-income countries substantially under-resourced in terms of specialist staffing and diagnostic and therapeutic procedure rates compared with high-income countries. Across ESC member countries, there were twice as many cardiologists per million inhabitants in high-income countries as in middle-income countries (100 vs. 55, respectively).

In addition, middle-income countries reported lower rates per million of percutaneous coronary intervention (1,355 vs. 2,330, respectively), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries.

The data presented in the fourth edition has been enriched with economic data from the ESC's Burden of CVD project developed in collaboration with Nuffield Department of Population Health, Oxford University. Overall, CVD is estimated to cost the EU economy €282 billion annually—a cost of €630 per person, ranging from €381 in Cyprus to €903 in Germany. Of the total cost of CVD, 46% was due to health care, 9% to social care, 28% to informal care and 17% to productivity loss.

Professor Panos Vardas, a past president of the ESC and Chief Strategy Officer of the ESC's European Heart Agency in Brussels, said, "Informed decision-making is key to tackling the challenges posed by CVD, but this can only happen with accurate and comprehensive data. Since the first ESC Atlas statistics were published in 2017, we have gathered compelling evidence on the clinical, economic and societal harms of CVD, and the need for targeted action, especially in those ESC member countries where the burden of disease is the greatest."

The ESC Atlas of Cardiology project is widely recognized as a pivotal tool for leveraging cardiovascular care. It presents evidence of trends, disparities, gaps and associations between fundamental variables, not just as one snapshot, but over time. Up-to-date statistics enable policymakers, health care providers and researchers to allocate resources efficiently, design targeted interventions and monitor the progress of public health initiatives. Atlas data was recently presented to EU health ministers in ongoing discussions towards building national and EU Cardiovascular Health Plans.

In addition to publications, the ESC Atlas has a new website where 300 CVD-related variables from ESC member countries can be freely accessed, with downloadable comparable graphs and charts across ESC countries. Furthermore, ESC Cardiovascular Realities 2024 presents the data in the context of policy change to support heart health.

"The ESC is committed to advancing cardiovascular health through research, education and advocacy. The ESC Atlas is a testament to that commitment and will serve as a valuable resource for all stakeholders involved in cardiovascular health," concluded Professor Vardas.