Abstract

This paper provides an update for 2014 on the burden of cardiovascular disease (CVD), and in particular coronary heart disease (CHD) and stroke, across the countries of Europe. Cardiovascular disease causes more deaths among Europeans than any other condition, and in many countries still causes more than twice as many deaths as cancer. There is clear evidence in most countries with available data that mortality and case-fatality rates from CHD and stroke have decreased substantially over the last 5–10 years but at differing rates. The differing recent trends have therefore led to increasing inequalities in the burden of CVD between countries. For some Eastern European countries, including Russia and Ukraine, the mortality rate for CHD for 55–60 year olds is greater than the equivalent rate in France for people 20 years older.

Introduction

Cardiovascular disease (CVD) remains the leading cause of death among Europeans and around the world. The Global Burden of Disease study estimated that 29.6% of all deaths worldwide (15 616.1 million deaths) were caused by CVD in 2010, more than all communicable, maternal, neonatal and nutritional disorders combined, and double the number of deaths caused by cancers.1 This paper provides an update for 2014 on the burden of CVD, and in particular coronary heart disease (CHD) and stroke, across the countries of Europe. This overview updates the work published in this journal in 20132 and provides an up-to-date synopsis of the key data in relation to mortality and morbidity from CVD across Europe.

Methods

This overview brings together a number of European and international data sources to give an outline of comparable data for the region. In selecting the data sources for inclusion, the key considerations were data quality, sources with coverage of the greatest number of countries, and the most recently updated sources. The scope of this update covers the mortality, morbidity, and treatment data associated with CVD in Europe, with additional focus on the two most common forms of CVD, CHD, and stroke. These data are fundamental to our understanding of the burden and distribution of CVD in Europe, and sources are updated relatively frequently through routine and administrative data collections. Information on medical and behavioural risk factors and co-morbidities, by comparison, tend to be less frequently updated and there are greater challenges to comparability across countries. Data reported in this paper have been sourced from the World Health Organization (WHO) mortality database,3 the WHO European Region's Health for All Database,4 and the Organisation for Economic Co-operation and Development (OECD) health statistics.5 Europe is here defined as the 53 member states of the WHO European region. Comparability and quality of the data vary by topic, and there were no ‘ideal’ data sources that provided complete, up-to-date, high-quality, and representative information for all 53 countries for any topic in this overview.

All mortality statistics, including estimates of mortality rates and proportions by cause, were calculated using age- and cause-specific data by country from the WHO Mortality Database,3 using the most recent (February 2014) update. All analyses, interpretations, and conclusions are those of the authors, not the WHO, which is responsible only for the provision of the original information. Age standardization was to the European Standard Population (ESP).6 Note that to maintain consistency and comparability with the previous epidemiological update published in 2013,2 the same ESP has been used, in preference to the more recently updated standard population developed by the European Commission for the EU27+EFTA countries.7

The WHO database collates data reported by national authorities based on their civil registration systems and contains data for 52 of 53 European countries (no data available for Andorra). Where data are presented for the ‘most recent year’, this relates to the most recent data for which both mortality and population data were available in the WHO datasets, with the exceptions of Monaco, Montenegro, and Turkey, for which no population data were available. These countries are included in the calculations for total numbers of deaths and premature deaths, but could not be included in the section on age-standardized death rates. The data are relatively up-to-date, and data for 40 of the 52 countries were available up to 2010, 2011, or 2012; however, only 18 countries have provided updated numbers in the year since our previous report.2 The years to which the data relate for each country are given in the tables. Consistent with our previous update, data are presented for mortality before both 65 and 75 years. In this report, all data are presented as age standardized, with the exception of the hospital discharge rates, for which this was not possible as no standardized or age-specific data are published.

Mortality

Cardiovascular disease is the leading cause of death in Europe, and despite recent decreases in mortality rates in many countries, it is still responsible for over 4 million deaths per year, close to half of all deaths in Europe (Table 1). The proportion of all deaths that are attributable to CVD is substantially greater among women (51%) than men (42%). Coronary heart disease, when considered separately, accounts for almost 1.8 million deaths, or 20% of all deaths in Europe annually. The gender differences in the proportional contribution of CVD to total mortality is driven far more by stroke and other CVD, and among both men and women, CHD causes one in five of all deaths.

Table 1

Number and percentage of deaths from cardiovascular diseases in Europe—latest available yeara

 Cardiovascular disease (total)
 
Coronary heart disease
 
Cerebrovascular disease
 
Other cardiovascular diseases
 
Males 
 Total deaths (all ages) 1 862 774 42% 876 017 20% 429 756 10% 557 001 12% 
 Premature deaths–before age 75 939 698 36% 473 501 18% 201 780 8% 264 417 10% 
 Premature deaths–before age 65 508 132 31% 253 432 16% 95 249 6% 159 451 10% 
Females 
 Total deaths (all ages) 2 219 326 51% 903 330 21% 627 227 14% 688 769 16% 
 Premature deaths–before age 75 536 712 37% 232 683 16% 155 702 11% 148 327 10% 
 Premature deaths–before age 65 201 492 27% 77 166 10% 54 470 7% 69 856 9% 
Total 
 Total deaths (all ages) 4 082 100 46% 1 779 347 20% 1 056 983 12% 1 245 770 14% 
 Premature deaths–before age 75 1 476 410 37% 706 184 18% 357 482 9% 412 744 10% 
 Premature deaths–before age 65 709 624 30% 330 598 14% 149 719 6% 229 307 10% 
 Cardiovascular disease (total)
 
Coronary heart disease
 
Cerebrovascular disease
 
Other cardiovascular diseases
 
Males 
 Total deaths (all ages) 1 862 774 42% 876 017 20% 429 756 10% 557 001 12% 
 Premature deaths–before age 75 939 698 36% 473 501 18% 201 780 8% 264 417 10% 
 Premature deaths–before age 65 508 132 31% 253 432 16% 95 249 6% 159 451 10% 
Females 
 Total deaths (all ages) 2 219 326 51% 903 330 21% 627 227 14% 688 769 16% 
 Premature deaths–before age 75 536 712 37% 232 683 16% 155 702 11% 148 327 10% 
 Premature deaths–before age 65 201 492 27% 77 166 10% 54 470 7% 69 856 9% 
Total 
 Total deaths (all ages) 4 082 100 46% 1 779 347 20% 1 056 983 12% 1 245 770 14% 
 Premature deaths–before age 75 1 476 410 37% 706 184 18% 357 482 9% 412 744 10% 
 Premature deaths–before age 65 709 624 30% 330 598 14% 149 719 6% 229 307 10% 

aNo data available for Andorra. Source: World Health Organization Mortality Database.

Cardiovascular disease continues to cause a much greater mortality burden among Europeans than any other disease. Overall, CVD caused 51% of deaths among women and 42% among men in the last year of data, compared with 19 and 23%, respectively, for all cancers (Figure 1). In individual countries, however, the patterns vary widely. There are now 10 European countries in which cancer is the cause of more deaths than CVD among men (Belgium, Denmark, France, Israel, Luxembourg, Netherlands, Portugal, Slovenia, Spain, and San Marino). The latest data also show that for the first time, cancer has surpassed CVD as a cause of death among women in one country (Denmark). Conversely, in 32 of 52 countries, the most recent data show more than double the number of deaths from CVD compared with cancer in women, and of those, 15 countries where CVD causes more than four times more deaths than cancer. Among men, there are 21 countries where CVD deaths are more than double cancer deaths, and 6 countries where they are more than four times greater.

Figure 1

Proportion of all deaths due to major causes in Europe, latest available year, among men (A) and women (B).

Figure 1

Proportion of all deaths due to major causes in Europe, latest available year, among men (A) and women (B).

Premature mortality

The proportion of all deaths that are caused by CVD increases with age, therefore, the proportion of premature deaths among Europeans caused by CVD was substantially lower than the overall rate. Three in every ten deaths of Europeans aged under 65 in the latest year of data were caused by CVD, as were 37% of all deaths occurring before age 75 (Table 1). In total, 1.48 million deaths before age 75 in Europe were caused by CVD, more than half of which were in people aged 65–74 years. In contrast to overall deaths (‘all ages’), the proportion of premature deaths, either before age 65 or before age 75, that are caused by CVD shows limited gender differences.

Mortality rates across European countries

The most up-to-date data on CVD in Europe show that the burden of mortality continues to show large geographic inequalities. Updated data from Denmark and Norway show that they now have among the lowest rates of age-adjusted CVD mortality (<180 per 100 000 men at all ages, <120 per 100 000 women), and Denmark in particular has joined countries, including France, Portugal, the Netherlands, and Spain, with the lowest rates of CHD mortality (Table 2). Setting aside Turkmenistan, for which the latest available mortality data are from 1998, the highest rates of CVD mortality were found in the Russian Federation and Belarus for men (915 and 892 per 100 000, respectively), and Uzbekistan and Kyrgyzstan for women (662 and 588 per 100 000).

Table 2

Age-standardized death rates from cardiovascular disease and coronary heart disease by country and sex (per 100 000 population)

Country Latest year Males
 
Females
 
CVD—total
 
CHD
 
CVD—total
 
CHD
 
Age-standardized mortality rate 10-year change in mortality rate Age-standardized mortality rate 10-year change in mortality rate Age-standardized mortality rate 10-year change in mortality rate Age-standardized mortality rate 10-year change in mortality rate 
Albania 2004 490.7 10% 156.5 56% 354.8 42% 89.6 123% 
Armenia 2012 524.5 −28% 351.8 −26% 356.5 −34% 211.4 −33% 
Austria 2011 241.4 −36% 125.5 −29% 161.0 −36% 65.3 −30% 
Azerbaijan 2007 616.8 −18% 149.3 −72% 488.9 0% 93.2 −70% 
Belarus 2009 892.7 −5% 642.2 −1% 427.6 −21% 283.6 −16% 
Belgium 2010 197.5 −32%a 72.9 −39%a 129.6 −31% 31.1 −41% 
Bosnia and Herzegovina 2011 474.7 n/a 93.5 n/a 385.4 n/a 54.8 n/a 
Bulgaria 2011 732.4 −14% 145.6 −40% 478.3 −19% 73.5 −49% 
Croatia 2012 415.5 −30% 202.8 −4% 283.0 −30% 123.8 2% 
Cyprus 2011 219.2 n/a 99.3 n/a 161.2 n/a 42.7 n/a 
Czech Republic 2012 403.1 −28% 214.9 −11% 264.0 −30% 126.2 −6% 
Denmark 2011 173.5 −46% 67.1 −57% 110.8 −43% 32.6 −59% 
Estonia 2012 501.0 −33% 255.9 −44% 269.3 −38% 117.9 −51% 
Finland 2011 275.8 −25% 165.5 −30% 146.1 −30% 71.4 −37% 
France 2010 149.6 −33% 47.3 −37% 86.7 −32% 17.5 −41% 
Georgia 2010 325.1 −62% 80.3 −84% 190.1 −66% 38.7 −87% 
Germany 2012 229.6 −34% 101.7 −39% 162.4 −31% 51.3 −43% 
Greece 2011 246.7 −32% 89.1 −28% 195.4 −34% 36.9 −34% 
Hungary 2012 509.4 −20% 270.0 −8% 323.4 −21% 160.6 −6% 
Iceland 2009 218.6 −31% 117.5 −41% 131.9 −34% 54.6 −44% 
Ireland 2009 237.9 −45% 143.7 −43% 151.4 −42% 69.2 −44% 
Israel 2011 140.5 −38% 67.7 −41% 98.7 −37% 34.7 −48% 
Italy 2010 196.4 −33% 76.9 −27% 131.0 −33% 37.6 −28% 
Kazakhstan 2010 809.8 −24% 264.9 −55% 485.3 −22% 124.3 −58% 
Kyrgyzstan 2010 841.8 4% 534.2 23% 588.4 3% 373.4 35% 
Latvia 2012 654.9 −19% 354.7 −19% 353.4 −24% 174.3 −16% 
Lithuania 2010 667.0 1% 436.2 5% 383.0 −8% 238.8 −1% 
Luxembourg 2011 204.1 −30% 65.7 −37% 134.4 −35% 32.7 −37% 
Malta 2011 288.6 −14% 177.4 −13% 185.6 −25% 91.5 −27% 
Netherlands 2011 170.9 −40% 54.6 −53% 113.4 −35% 24.5 −53% 
Norway 2012 179.4 −40% 77.3 −50% 117.2 −34% 39.8 −44% 
Poland 2011 415.3 −26% 128.2 −34% 244.8 −29% 59.5 −35% 
Portugal 2011 174.7 −44% 49.1 −42% 126.8 −44% 24.2 −44% 
Republic of Moldova 2012 790.3 −22% 527.5 −26% 564.2 −25% 365.4 −29% 
Romania 2010 647.3 −16% 238.3 −16% 453.9 −22% 146.3 −22% 
Russian Federation 2010 915.1 −13% 500.9 −7% 516.8 −18% 254.5 −5% 
San Marino 2005 242.2 −30% 30.9 −46% 155.5 −6% 8.3 −73% 
Serbia 2012 540.9 −21% 121.7 −24% 423.1 −25% 70.1 −30% 
Slovakia 2010 551.8 −17% 333.8 −9% 360.2 −18% 209.5 −11% 
Slovenia 2010 269.2 −34% 94.9 −36% 178.0 −29% 40.5 −46% 
Spain 2011 162.0 −30% 62.0 −32% 106.5 −32% 25.7 −35% 
Sweden 2010 227.5 −31% 111.4 −37% 144.9 −27% 54.4 −35% 
Switzerland 2010 181.2 −31% 80.4 −38% 115.9 −31% 38.4 −41% 
TFYR Macedonia 2010 626.9 −5% 112.9 −26% 490.6 −5% 56.9 −23% 
Tajikistan 2004 710.3 −1% 303.6 −12% 503.9 −17% 185.6 −28% 
Turkmenistan 1998 1017.4 19% 562.8 6% 716.9 17% 352.5 3% 
Ukraine 2012 873.3 −16% 599.7 −14% 532.6 −18% 356.0 −13% 
UK 2010 205.2 −42%a 111.1 −48%a 129.0 −40% 49.4 −51% 
Uzbekistan 2005 858.0 −4% 453.6 −19% 662.3 −5% 320.9 −23% 
Country Latest year Males
 
Females
 
CVD—total
 
CHD
 
CVD—total
 
CHD
 
Age-standardized mortality rate 10-year change in mortality rate Age-standardized mortality rate 10-year change in mortality rate Age-standardized mortality rate 10-year change in mortality rate Age-standardized mortality rate 10-year change in mortality rate 
Albania 2004 490.7 10% 156.5 56% 354.8 42% 89.6 123% 
Armenia 2012 524.5 −28% 351.8 −26% 356.5 −34% 211.4 −33% 
Austria 2011 241.4 −36% 125.5 −29% 161.0 −36% 65.3 −30% 
Azerbaijan 2007 616.8 −18% 149.3 −72% 488.9 0% 93.2 −70% 
Belarus 2009 892.7 −5% 642.2 −1% 427.6 −21% 283.6 −16% 
Belgium 2010 197.5 −32%a 72.9 −39%a 129.6 −31% 31.1 −41% 
Bosnia and Herzegovina 2011 474.7 n/a 93.5 n/a 385.4 n/a 54.8 n/a 
Bulgaria 2011 732.4 −14% 145.6 −40% 478.3 −19% 73.5 −49% 
Croatia 2012 415.5 −30% 202.8 −4% 283.0 −30% 123.8 2% 
Cyprus 2011 219.2 n/a 99.3 n/a 161.2 n/a 42.7 n/a 
Czech Republic 2012 403.1 −28% 214.9 −11% 264.0 −30% 126.2 −6% 
Denmark 2011 173.5 −46% 67.1 −57% 110.8 −43% 32.6 −59% 
Estonia 2012 501.0 −33% 255.9 −44% 269.3 −38% 117.9 −51% 
Finland 2011 275.8 −25% 165.5 −30% 146.1 −30% 71.4 −37% 
France 2010 149.6 −33% 47.3 −37% 86.7 −32% 17.5 −41% 
Georgia 2010 325.1 −62% 80.3 −84% 190.1 −66% 38.7 −87% 
Germany 2012 229.6 −34% 101.7 −39% 162.4 −31% 51.3 −43% 
Greece 2011 246.7 −32% 89.1 −28% 195.4 −34% 36.9 −34% 
Hungary 2012 509.4 −20% 270.0 −8% 323.4 −21% 160.6 −6% 
Iceland 2009 218.6 −31% 117.5 −41% 131.9 −34% 54.6 −44% 
Ireland 2009 237.9 −45% 143.7 −43% 151.4 −42% 69.2 −44% 
Israel 2011 140.5 −38% 67.7 −41% 98.7 −37% 34.7 −48% 
Italy 2010 196.4 −33% 76.9 −27% 131.0 −33% 37.6 −28% 
Kazakhstan 2010 809.8 −24% 264.9 −55% 485.3 −22% 124.3 −58% 
Kyrgyzstan 2010 841.8 4% 534.2 23% 588.4 3% 373.4 35% 
Latvia 2012 654.9 −19% 354.7 −19% 353.4 −24% 174.3 −16% 
Lithuania 2010 667.0 1% 436.2 5% 383.0 −8% 238.8 −1% 
Luxembourg 2011 204.1 −30% 65.7 −37% 134.4 −35% 32.7 −37% 
Malta 2011 288.6 −14% 177.4 −13% 185.6 −25% 91.5 −27% 
Netherlands 2011 170.9 −40% 54.6 −53% 113.4 −35% 24.5 −53% 
Norway 2012 179.4 −40% 77.3 −50% 117.2 −34% 39.8 −44% 
Poland 2011 415.3 −26% 128.2 −34% 244.8 −29% 59.5 −35% 
Portugal 2011 174.7 −44% 49.1 −42% 126.8 −44% 24.2 −44% 
Republic of Moldova 2012 790.3 −22% 527.5 −26% 564.2 −25% 365.4 −29% 
Romania 2010 647.3 −16% 238.3 −16% 453.9 −22% 146.3 −22% 
Russian Federation 2010 915.1 −13% 500.9 −7% 516.8 −18% 254.5 −5% 
San Marino 2005 242.2 −30% 30.9 −46% 155.5 −6% 8.3 −73% 
Serbia 2012 540.9 −21% 121.7 −24% 423.1 −25% 70.1 −30% 
Slovakia 2010 551.8 −17% 333.8 −9% 360.2 −18% 209.5 −11% 
Slovenia 2010 269.2 −34% 94.9 −36% 178.0 −29% 40.5 −46% 
Spain 2011 162.0 −30% 62.0 −32% 106.5 −32% 25.7 −35% 
Sweden 2010 227.5 −31% 111.4 −37% 144.9 −27% 54.4 −35% 
Switzerland 2010 181.2 −31% 80.4 −38% 115.9 −31% 38.4 −41% 
TFYR Macedonia 2010 626.9 −5% 112.9 −26% 490.6 −5% 56.9 −23% 
Tajikistan 2004 710.3 −1% 303.6 −12% 503.9 −17% 185.6 −28% 
Turkmenistan 1998 1017.4 19% 562.8 6% 716.9 17% 352.5 3% 
Ukraine 2012 873.3 −16% 599.7 −14% 532.6 −18% 356.0 −13% 
UK 2010 205.2 −42%a 111.1 −48%a 129.0 −40% 49.4 −51% 
Uzbekistan 2005 858.0 −4% 453.6 −19% 662.3 −5% 320.9 −23% 

Rate for most recent year of data and percentage change in rates over 10 years.

Rates not available for Monaco, Montenegro, or Turkey due to missing population data. No mortality data available for Andorra. Source: World Health Organization Mortality Database. Age standardized to the European Standard Population.

aChange in rates for Belgium and UK is over 11 years due to missing data for the past 10 years.

n/a, not available.

Premature mortality from CVD among men varied almost 10-fold from <65 per 100 000 before age 75 (age standardized) in San Marino, France, Israel, and Switzerland, to over 560 per 100 000 in the Russian Federation and Belarus. Among women, the magnitude of variation between countries was similar, from five countries with fewer than 25 deaths per 100 000 before age 75 (France, Iceland, Switzerland, Israel, and Spain) to 10 countries with rates exceeding 200 per 100 000. Details of premature mortality rates are given in the Supplementary material online, Table S1 (mortality rates before age 65 and before age 75).

Mortality rates increase with age in all countries; however, due to the wide variation between countries, there are many cases where the mortality rate among (for example) 65–69 year olds in one country may be equivalent to or higher than the mortality rate for 75–79 year olds in another country. Taking the most recent mortality rates among 75–79 year olds in France as the reference (the first age group not considered a ‘premature’ death under usual definitions, and the country with the lowest mortality rates for that age group in both sexes), we calculated the age groups in all other countries for which the rates in the latest year were equal to or greater than the referent (Figure 2). Countries with no data within the last 5 years were excluded. This showed that among men, there were five countries where the CVD death rates among 55–59 year olds was higher than the referent, a further 5 countries where the CVD rate among 60–64 year olds was higher than the referent, and 10 countries where equivalent mortality rates were reached at ages at least 10 years younger than in France. This means that CVD mortality rates among 55–59-year-old men in Belarus, Kazakhstan, Kyrgyzstan, Russia, and Ukraine were higher than equivalent rates in French men 20 years older. The results were similar among women, although the disparities were slightly less marked. Coronary heart disease mortality rates showed even bigger differences in many countries. There were three countries (Belarus, the Russian Federation, and Ukraine) where men aged 50–54 years old had a higher risk of dying from CHD than 75–79-year-old men in France.

Figure 2

Inequalities in rates of premature death: age groups for which rates of CVD and CHD in each country match or exceed those of 75–79 year olds in France.

Figure 2

Inequalities in rates of premature death: age groups for which rates of CVD and CHD in each country match or exceed those of 75–79 year olds in France.

Trends in mortality

Mortality rates continue to fall in most but not all European countries, and the magnitude of change has varied dramatically between countries over the last 10 years (Table 2). The age-standardized mortality rate from CVD has decreased over the last 10 years of available data in all but five countries for men, and all but four countries for women, and has decreased by a third or more among men in 14 countries and among women in 15 countries. Decreases in CHD rates have been in many cases even more dramatic; the most recent mortality rates from CHD were less than half the rates 10 years earlier in eight countries for women and six countries for men, although again, there were a small number of countries where the rates had increased over the same period.

Case-fatality rates

Among the 25 countries with data available, age- and sex-standardized admission-based case-fatality rates after acute myocardial infarction (AMI) for the most recent year (2011 for most countries) as documented by the OECD varied up to 5-fold between countries (Table 3). Most countries, however, have seen substantial reductions in these hospitalized case-fatality rates for AMI over the last 5 years. The median annual reduction was just over 5%, or a total median reduction in case-fatality rates over that period of around one-quarter. Although the absolute case-fatality rates varied widely, the documented reductions in case-fatality rates have been far more consistent across countries than other trends in CVD. Almost all countries with data available demonstrated clear reductions in case fatality after AMI, and most improvements (19 of 23) were in the range of 3–6% per year on average over the last 5 years. Reported admission-based case-fatality rates for haemorrhagic stroke were as high as 40.5 per 100 patients in Hungary, while for ischaemic stroke the highest rate was in Latvia (19.0 per 100 patients). Clear reductions were apparent in case-fatality rates for both stroke types in most countries over the last 5 years, largely in the range of 1–4% per year on average for haemorrhagic stroke and 2–5% for ischaemic stroke.

Table 3

Admission-based case-fatality rates after acute myocardial infarction and stroke, adults aged 45 years and over

 Year Case fatality after acute myocardial infarction
 
Case fatality after haemorrhagic stroke
 
Case fatality after ischaemic stroke
 
Age- and sex-standardized rate per 100 discharges Annual change in rate (%) over last 5 yearsa Age- and sex-standardized rate per 100 discharges Annual change in rate (%) over last 5 yearsa Age- and sex-standardized rate per 100 discharges Annual change in rate (%) over last 5 yearsa 
Country 
Austria 2011 7.7 −5.0% 14.4 −1.5% 6.0 −4.0% 
Belgium 2009 7.6 −5.9% 30.5 −0.4% 9.2  0.2% 
Czech Republic 2011 6.8 −5.7%a 24.5 −4.6%a 9.5 −4.9%a 
Denmark 2012 2.9 −8.2% 17.9 −3.8% 3.5 −7.7% 
Finland 2011 7.0 −3.7% 13.1 −1.3% 5.4 −1.1% 
France 2010 6.2 −4.3% 24.0 −1.2% 8.5 −4.0% 
Germany 2011 8.9 −3.5% 17.5 −1.9% 6.7 −3.5% 
Hungary 2009 13.9 −4.5% 40.5 −0.9% 9.6 −4.8% 
Iceland 2011 5.7 −4.2% 16.7  0.4% 7.4 −7.9% 
Ireland 2011 6.8 −5.4% 26.2 −2.6% 9.9 −2.3% 
Israel 2010 7.1 −1.6% 24.7 −2.5% 6.3 −2.0% 
Italy 2011 5.8 −3.2% 19.9 −0.6% 6.5 −1.7% 
Latvia 2009 14.8 2.8%a 32.5 4.8%a 19.0 −1.0%a 
Luxembourg 2011 8.8 −5.5% 18.3 −7.6% 10.7 0.6% 
Netherlands 2010 6.8 −5.8% 25.9 −3.1% 7.5 −4.8% 
Norway 2011 4.5 −5.7% 15.3 −3.7% 5.3 −3.7% 
Poland 2011 5.2 −6.3%     
Portugal 2011 8.4 −5.5% 23.8 −2.1% 10.5 −1.7% 
Slovak Republic 2011 7.6 −8.9%a 28.0 −4.2%a 11.0 −4.5%a 
Slovenia 2011 7.0 −2.7%a 28.7 −6.5%a 12.8 −9.0%a 
Spain 2011 8.5 −2.8% 26.4 −2.1% 10.2 −2.1% 
Sweden 2011 4.5 −5.0% 15.8 −2.3% 6.4 −2.7% 
Switzerland 2010 5.9 −7.0% 16.5 −3.5% 7.0 −3.9% 
Turkey 2012 10.7 n/a 32.0 n/a 11.8 n/a 
UK 2011 7.8 −5.7%a 29.6 −0.8%a 10.4 −9.9%a 
 Year Case fatality after acute myocardial infarction
 
Case fatality after haemorrhagic stroke
 
Case fatality after ischaemic stroke
 
Age- and sex-standardized rate per 100 discharges Annual change in rate (%) over last 5 yearsa Age- and sex-standardized rate per 100 discharges Annual change in rate (%) over last 5 yearsa Age- and sex-standardized rate per 100 discharges Annual change in rate (%) over last 5 yearsa 
Country 
Austria 2011 7.7 −5.0% 14.4 −1.5% 6.0 −4.0% 
Belgium 2009 7.6 −5.9% 30.5 −0.4% 9.2  0.2% 
Czech Republic 2011 6.8 −5.7%a 24.5 −4.6%a 9.5 −4.9%a 
Denmark 2012 2.9 −8.2% 17.9 −3.8% 3.5 −7.7% 
Finland 2011 7.0 −3.7% 13.1 −1.3% 5.4 −1.1% 
France 2010 6.2 −4.3% 24.0 −1.2% 8.5 −4.0% 
Germany 2011 8.9 −3.5% 17.5 −1.9% 6.7 −3.5% 
Hungary 2009 13.9 −4.5% 40.5 −0.9% 9.6 −4.8% 
Iceland 2011 5.7 −4.2% 16.7  0.4% 7.4 −7.9% 
Ireland 2011 6.8 −5.4% 26.2 −2.6% 9.9 −2.3% 
Israel 2010 7.1 −1.6% 24.7 −2.5% 6.3 −2.0% 
Italy 2011 5.8 −3.2% 19.9 −0.6% 6.5 −1.7% 
Latvia 2009 14.8 2.8%a 32.5 4.8%a 19.0 −1.0%a 
Luxembourg 2011 8.8 −5.5% 18.3 −7.6% 10.7 0.6% 
Netherlands 2010 6.8 −5.8% 25.9 −3.1% 7.5 −4.8% 
Norway 2011 4.5 −5.7% 15.3 −3.7% 5.3 −3.7% 
Poland 2011 5.2 −6.3%     
Portugal 2011 8.4 −5.5% 23.8 −2.1% 10.5 −1.7% 
Slovak Republic 2011 7.6 −8.9%a 28.0 −4.2%a 11.0 −4.5%a 
Slovenia 2011 7.0 −2.7%a 28.7 −6.5%a 12.8 −9.0%a 
Spain 2011 8.5 −2.8% 26.4 −2.1% 10.2 −2.1% 
Sweden 2011 4.5 −5.0% 15.8 −2.3% 6.4 −2.7% 
Switzerland 2010 5.9 −7.0% 16.5 −3.5% 7.0 −3.9% 
Turkey 2012 10.7 n/a 32.0 n/a 11.8 n/a 
UK 2011 7.8 −5.7%a 29.6 −0.8%a 10.4 −9.9%a 

Latest year and annual percentage change in rates over last 5 years, by country.

Source: OECDstat http://stats.oecd.org.

aWhere data were not available for 5 years prior to most recent estimate, the closest available year was used. Exceptions and the span of data over which estimates were calculated were: Latvia—1 year; Slovenia—2 years; UK—3 years; Slovak Republic and Czech Republic—4 years. Only 1 year of data available for Turkey.

Morbidity

The most comparable data available across European countries to track the burden of CVD morbidity are hospital discharge data. The most recent available data (Table 4) show that the population-based rates of hospitalization for CVD have tended to trend upward since the early 2000s. The median numbers of hospital discharges per 100 000 population in 2012 (or most recent year) by country were 2097 for CVD, 608 for CHD, and 298 for stroke, up from 1829, 532 and 258 in 2001. In contrast to mortality rates, which have fallen significantly in almost all European countries in recent years, more countries (34) have experienced an increase in hospital discharge rates for CVD than have experienced decreases (15), and similarly for stroke there were 32 countries with an increase, and 18 with a decrease. For CHD, there have been an almost equal number of increases and decreases (24 vs. 26) and across all three disease categories the changes in rates of hospitalization vary between very small (<5% changes) and more than doubling. High variability between countries is also evident in hospitalization rates. Variations may reflect both true differences in incidence as well as differences in the rates at which incident cases result in death before or without hospitalization due to differences in health system organization and efficiency, coding practices, etc.

Table 4

Hospital discharges for cardiovascular disease, coronary heart disease, and cerebrovascular disease per 100 000 population, by country, 2001–2012

  Cardiovascular disease
 
Coronary heart disease
 
Cerebrovascular disease
 
2001a 2012a 2001a 2012a 2001a 2012a 
Albania (2001–2011) 520 776 146 247 82 199 
Andorra (2001–2012) 610 749 126 165 107 127 
Armenia (2001–2012) 599 1666 258 717 129 264 
Austria (2001–2009) 3615 3697 923 881 577 565 
Azerbaijan (2001–2012) 484 783 162 305 48 87 
Belarus (2001–2012) 4749 6401 2296 3206 912 1258 
Belgium (2001–2008) 2347 2173 719 616 393 353 
Bulgaria (2001–2010) 2013 3617 542 1196 468 589 
Croatia (2001–2010) 1692 1847 457 488 394 393 
Cyprus (2001–2008) 927 672 360 198 149 120 
Czech Republic (2001–2010) 3430 3086 1107 715 625 547 
Denmark (2001–2010) 2546 2634 803 720 435 363 
Estonia (2001–2009) 3245 3327 1094 900 499 714 
Finland (2001–2007) 3654 2913 1140 791 661 550 
France (2001–2009) 2303 2282 512 498 220 228 
Georgia (2001–2012) 427 1116 193 475 74 166 
Germany (2001–2009) 3305 3500 1011 890 464 530 
Greece (2001–2007) 2432 2786 829 951 424 449 
Hungary (2001–2010) 4039 3678 943 716 845 995 
Iceland (2001–2009) 1919 1440 763 525 228 179 
Ireland (2001–2010) 1492 1154 485 352 258 163 
Israel (2001–2008) 1925 1482 815 501 258 235 
Italy (2001–2009) 2572 2120 593 503 494 432 
Kazakhstan (2001–2012) 1389 2074 519 772 234 473 
Kyrgyzstan (2001–2011) 1036 1473 324 642 155 272 
Latvia (2001–2010) 3137 2884 1278 999 669 601 
Lithuania (2001–2010) 3890 4490 1374 1385 698 912 
Luxembourg (2001–2007) 2364 2172 868 606 184 168 
Malta (2001–2010) 665 1341 204 349 77 158 
Monaco 2012  4004  385  338 
Montenegro (2001–2012) 1539 1732 487 610 185 249 
Netherlands (2001–2009) 1369 1694 510 528 185 239 
Norway (2001–2010) 2366 2368 944 880 321 306 
Poland (2003–2009) 2880 2885 2880 811 370 336 
Portugal (2001–2010) 1156 1307 272 299 342 290 
Republic of Moldova (2001–2012) 1311 2532 373 686 247 623 
Romania (2001–2010) 2741 2982 809 330 404 575 
Russian Federation (2001–2012) 3020 3693 1168 1373 653 858 
San Marino 2011  1642  284  256 
Serbia (2001–2012) 1587 2199 423 670 360 439 
Slovakia (2001–2010) 2569 2689 954 749 473 461 
Slovenia (2001–2009) 1738 1976 381 411 230 232 
Spain (2001–2009) 1342 1295 361 289 221 221 
Sweden (2001–2009) 2556 2334 895 621 474 429 
Switzerland (2002–2009) 1699 1729 518 469 212 222 
Tajikistan (2001–2012) 561 1072 136 306 44 90 
TFYR Macedonia (2001–2007) 1398 1443 573 551 240 261 
Turkey (2001–2010) 1009 1502 226 666 166 149 
Turkmenistan (2001–2012) 1247 1933 54 16 134 244 
Ukraine (2001–2010) 2791 3854 1284 1860 585 901 
UK (2001–2010) 1405 1291 521 403 206 225 
Uzbekistan (2001–2012) 1059 1615 347 477 94 147 
  Cardiovascular disease
 
Coronary heart disease
 
Cerebrovascular disease
 
2001a 2012a 2001a 2012a 2001a 2012a 
Albania (2001–2011) 520 776 146 247 82 199 
Andorra (2001–2012) 610 749 126 165 107 127 
Armenia (2001–2012) 599 1666 258 717 129 264 
Austria (2001–2009) 3615 3697 923 881 577 565 
Azerbaijan (2001–2012) 484 783 162 305 48 87 
Belarus (2001–2012) 4749 6401 2296 3206 912 1258 
Belgium (2001–2008) 2347 2173 719 616 393 353 
Bulgaria (2001–2010) 2013 3617 542 1196 468 589 
Croatia (2001–2010) 1692 1847 457 488 394 393 
Cyprus (2001–2008) 927 672 360 198 149 120 
Czech Republic (2001–2010) 3430 3086 1107 715 625 547 
Denmark (2001–2010) 2546 2634 803 720 435 363 
Estonia (2001–2009) 3245 3327 1094 900 499 714 
Finland (2001–2007) 3654 2913 1140 791 661 550 
France (2001–2009) 2303 2282 512 498 220 228 
Georgia (2001–2012) 427 1116 193 475 74 166 
Germany (2001–2009) 3305 3500 1011 890 464 530 
Greece (2001–2007) 2432 2786 829 951 424 449 
Hungary (2001–2010) 4039 3678 943 716 845 995 
Iceland (2001–2009) 1919 1440 763 525 228 179 
Ireland (2001–2010) 1492 1154 485 352 258 163 
Israel (2001–2008) 1925 1482 815 501 258 235 
Italy (2001–2009) 2572 2120 593 503 494 432 
Kazakhstan (2001–2012) 1389 2074 519 772 234 473 
Kyrgyzstan (2001–2011) 1036 1473 324 642 155 272 
Latvia (2001–2010) 3137 2884 1278 999 669 601 
Lithuania (2001–2010) 3890 4490 1374 1385 698 912 
Luxembourg (2001–2007) 2364 2172 868 606 184 168 
Malta (2001–2010) 665 1341 204 349 77 158 
Monaco 2012  4004  385  338 
Montenegro (2001–2012) 1539 1732 487 610 185 249 
Netherlands (2001–2009) 1369 1694 510 528 185 239 
Norway (2001–2010) 2366 2368 944 880 321 306 
Poland (2003–2009) 2880 2885 2880 811 370 336 
Portugal (2001–2010) 1156 1307 272 299 342 290 
Republic of Moldova (2001–2012) 1311 2532 373 686 247 623 
Romania (2001–2010) 2741 2982 809 330 404 575 
Russian Federation (2001–2012) 3020 3693 1168 1373 653 858 
San Marino 2011  1642  284  256 
Serbia (2001–2012) 1587 2199 423 670 360 439 
Slovakia (2001–2010) 2569 2689 954 749 473 461 
Slovenia (2001–2009) 1738 1976 381 411 230 232 
Spain (2001–2009) 1342 1295 361 289 221 221 
Sweden (2001–2009) 2556 2334 895 621 474 429 
Switzerland (2002–2009) 1699 1729 518 469 212 222 
Tajikistan (2001–2012) 561 1072 136 306 44 90 
TFYR Macedonia (2001–2007) 1398 1443 573 551 240 261 
Turkey (2001–2010) 1009 1502 226 666 166 149 
Turkmenistan (2001–2012) 1247 1933 54 16 134 244 
Ukraine (2001–2010) 2791 3854 1284 1860 585 901 
UK (2001–2010) 1405 1291 521 403 206 225 
Uzbekistan (2001–2012) 1059 1615 347 477 94 147 

Source: World Health Organization European Regional Office, Health for All Database.

aWhere data for 2001 and/or 2012 were not available, the closest available year was included. Years are given in the table for each country.

Summary and discussion

The burden of CVD in Europe remains high overall, and varies dramatically between countries. More than 4 million Europeans die of CVD every year, and many more are hospitalized after acute episodes or treated for chronic cardiovascular ill health.

Since our update published in 2013, which was based on the extensive data reported in European Cardiovascular Disease Statistics,8 the overall pattern of distribution and trends of CVD burden in Europe have been relatively stable, and there is evidence of continuing reductions in the burden of CVD. The proportion of all deaths in Europe caused by CVD, and specifically by CHD and stroke, has remained stable, whereas the total number of deaths caused by CVD has decreased slightly (2561 fewer CVD deaths overall). There have however been greater improvements in premature deaths, with 14 639 fewer deaths occurring before the age of 75 (∼1% fewer deaths). In the 18 countries with updated mortality data since the last report, there was evidence in all of them of continued decreases among men in age-standardized death rates from CVD. Similarly, there were further decreases in death rates from CHD among men in 16 of these countries (rates stable in Estonia and Greece). Among women, however, the evidence in these 18 countries is more mixed; in Latvia and Luxembourg, CVD death rates among women were stable, whereas in Hungary, Israel, Norway, and Serbia, there were small increases. In CHD, death rates were stable since the last report in Israel, Latvia, and Norway, while there were small increases in Croatia, Hungary, Luxembourg, and Serbia. It will be important to continue to monitor the gender-specific trends in CVD and CHD mortality amid this and other evidence that decreases in mortality rates may have begun to slow or even reverse in some specific subpopulations.9,10 Updated data have also shown substantial reductions in admission-based case-fatality rates after AMI and stroke, in almost all countries over the last 5 years of available data.5 The most recent hospital morbidity data included in this update have shown that in contrast to ongoing decreases in mortality, hospitalizations for CVD have increased in the majority of countries. Given that these data are not age standardized, the overall increases likely reflect, at least to some extent, the impact of an ageing population. Despite this, increased rates of hospitalization are an important observation that emphasizes the continued high burden of CVD in European populations despite dramatic decreases in age-adjusted mortality rates.

Two years have now passed since the World Health Assembly adopted a global target of reducing mortality from non-communicable diseases (NCDs) by 25% by the year 2025.11 Worldwide, there have been few moments in history during which NCDs have enjoyed such a prominent place in the world's attention, with CVD at the forefront of the activity. Despite this, there has been little commitment at the national or regional level to greater monitoring and reporting of risk factors and outcomes for CVD. It is clear that in many countries of Europe, CVD mortality has continued to decrease substantially in recent years and will make a large contribution to achieving this goal. In these (predominantly high income) countries, a ‘tipping point’ is rapidly approaching, when cancer deaths will outnumber CVD deaths, particularly among men. In many other countries, however, the CVD burden dwarfs that of cancer, and a large proportion of the populations will lose their lives prematurely to heart disease and stroke.

Supplementary material

Supplementary material is available at European Heart Journal online.

Funding

This study received no specific funding. M.N. is supported by funding from the National Heart Foundation of Australia for ‘HeartStats: The Heart Foundation/Deakin University Australian Heart Disease Statistics Project’. N.T., P.S. and M.R. receive funding from the British Heart Foundation.

Conflict of interest: none declared.

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