Introduction

This is the fourth in a series of papers describing the burden of cardiovascular disease (CVD) within Europe.1–3 CVD remains the most common cause of death worldwide, with the 2013 Global Burden of Disease (GBD) study estimating that CVD caused 17.3 million deaths globally. It accounted for 31.5% of all deaths and 45% of all non-communicable disease deaths, more than twice that caused by cancer, as well as more than all communicable, maternal, neonatal and nutritional disorders combined. The 2013 GBD also reported that CVD caused a greater number of deaths and was responsible for a greater percentage of all deaths than in 1990 when 12.3 million deaths were attributed to CVD, corresponding to 25.9% of total deaths.4 Previous publications in this series have reported that despite the decreases in CVD mortality in Europe more than 4 million people die from CVD across the continent every year, with more than 1.4 million dying prematurely, before the age of 75 years.1–3 In this article we present an updated overview of the burden of CVD in Europe, including new statistics for mortality, morbidity, and treatment. Where possible we provide statistics for all CVD and for coronary heart disease (CHD) and stroke in particular. All data included here are updated from previous publications and we present prevalence statistics for the first time. This series of publications describing the current burden and distribution of CVD and CHD in Europe has been based on the European Cardiovascular Disease Statistics 2012 report,5 the fourth in a series of Europe-wide compendia, which was published jointly by the European Heart Network and the European Society of Cardiology.

Methods

Throughout this article, we present statistics from a number of data sources chosen with consideration of data quality, date of most recent update, and coverage of the European region. Rather than collected data from individual countries we utilized major data sources which make their statistics publically available. Specifically, we aimed to obtain data for as many European countries as possible from as recently as possible. In order to present data on CVD throughout Europe, with a particular focus on the two most common forms of CVD: CHD and stroke, we identified international sources that collect and report comparable data for a number of countries. Commonly, such sources are updated through routine and administrative data collections and provide an overview of the burden and distribution of CVD in Europe through the mortality, morbidity, and treatment associated with CVD across the continent. However, these data sources generally rely on individual countries to provide the data they collate, this means that in some cases the data that we obtain from a central source, in order to be consistent and comparable between countries and across Europe, may not be as up to date as could be obtained from some individual countries’ own databases.

In this article, we define Europe as the 53 member states of the World Health Organization (WHO) European region. 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 and comparability and quality of the data varies by topic. We also present data for EU-15 countries, those in the European Union (EU) prior to the accession of 10 candidate countries on 1 May 2004: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden, UK, and the EU-28 countries which include these 15 countries and the 13 additional countries which have subsequently joined the EU: Bulgaria, Croatia, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia, Slovenia.

Mortality data come from the WHO Mortality Database using the most recent (25 November 2015) update of age- and cause-specific mortality data, and age-specific population data, by country.6 All analyses, interpretations, and conclusions are those of the authors, not the WHO, which is responsible only for the provision of the original information. The WHO database collates data reported by national authorities based on their civil registration systems and contains data for 52 of 53 European countries, with no data available for Andorra. Age-standardized rates can only be calculated where data on the absolute number of an outcome and the population are available in comparable age-specific aggregates. Where rates are presented for the ‘most recent year’, this relates to the most recent data for which both mortality and population data were available. Mortality data for Turkmenistan, for example, are now available for 2013, but the most recent population data come from 1998, hence rates for this country are from the earlier year. For one country (Monaco), although mortality data were available, no population data were. These could not, therefore, be used in the presentation of age-standardized death rates (ASDRs) but were included in the calculations for total number of deaths and premature deaths in Europe.

In order to calculate rates, population data from the same database were applied to these mortality data and were standardized using the 2013 European Standard Population (ESP). The 2013 ESP was developed by the European Commission for the EU27 + European Free Trade Association countries as an update to the 1976 ESP, to reflect the current age structure of the present European population.7 On average, when using the same data, CHD ASDRs for European countries calculated using the 2013 ESP are around twice as large as those calculated using the previous (1976) ESP.8 This means that although comparisons can be made within this study between countries in which ASDRs have been calculated using the same 2016 ESP, comparisons cannot be made to other studies, including earlier papers from this series, which have used the 1976 ESP to calculate standardized rates.

WHO mortality and population data are relatively up to date, with the most recent data for only 11 of the 52 countries dating from 2010 or before; however, data from five countries were not available for any years more recent than 2005: Albania (2004), San Marino (2005), Tajikistan (2004), Turkmenistan (1998), and Uzbekistan (2005). Mortality rates are presented for CVD and CHD for all ages and for those under the ages of 65 and 75 years separately; deaths before these ages are often described as premature or preventable.

Morbidity data come from the WHO9 and the European Social Survey.10 Disability-adjusted life years (DALYs) are available for the entire WHO European Region from the WHO’s Health Statistics and Information Systems11 and allow for a comparison of disease burden between both countries and conditions. One DALY is equivalent to 1 year of healthy life lost and is a composite measure of years of life lost due to death from a condition and years lived with disability due to a condition. The WHO has calculated DALYs for all conditions and all countries using estimates that draw on the methods used by the GBD project.9

Prevalence data come from the European Social Survey.10 This is a European Commission-funded cross-sectional survey that is repeated every 2 years with face-to-face data collection. Using random probability methods, samples are drawn from each participating country and aim to be representative of all people aged 15 and over in that country. Data are only available for selected countries that participated in the 2014 survey. The question relating to CVD prevalence was included in 2014 in the ‘health inequalities’ module and asked people to recall if they had had any health problems listed on a showcard in the last 12 months; with heart or circulation problems as an option.

Hospital discharge data come from the WHO European Region’s Health for All Database.12 Data are sourced from the national registries of each country and provide an indication of the burden of CVD on health services within European countries. In addition to discharge data, the average length of stay in hospitals (ALOS) is often regarded as a good indicator of health service efficiency. The Organization for Economic Co-operation and Development (OECD) presents the ALOS as the mean number of days that patients spend in hospital.13 ALOS is generally measured by dividing the total number of days stayed by all patients during a year by cause-specific admissions or discharges. The data cover all inpatient cases with the exception of the Netherlands where data refer to curative acute care only, resulting in an under estimation.

The OECD also presents 30-day case-fatality rate as a percentage of people aged 45 and over who die within 30 days following admission to hospital for acute myocardial infarction (AMI) and ischaemic stroke (IS), which represents around 85% of all cerebrovascular disease cases. The OECD presents case fatality through ‘admission-based’ and ‘patient-based’ data.13 Admission-based data refer to deaths occurring in the same hospital as the initial admission. Rates based on patient data refer to a death occurring in the same hospital, a different hospital, or out of hospital. This indicator is more robust because it captures fatalities more comprehensively. More countries can report the same-hospital ‘admission-based’ measure, with ‘patient-based’ data requiring a unique patient identifier and linked data which are not currently available in all countries. Admissions resulting in a transfer were excluded for some countries. This exclusion generally increases the case-fatality rate compared with those countries which do not exclude these transfers.13

Results

Mortality

Using the latest available data, CVD causes more than 4 million deaths each year across Europe, accounting for 45% of all deaths. CHD and cerebrovascular disease were the most common causes of CVD deaths, accounting for 1.8 million and 1.0 million deaths, respectively. The number of deaths from CVD is higher in women (2.2 million) than men (1.8 million), with CVD accounting for 49% of all deaths in women and 40% of all deaths in men. With similar numbers of men and women dying from CHD, these sex differences arise from a greater number of women dying from cerebrovascular disease and ‘other cardiovascular diseases’ (Table1, Figure1).

Figure 1

Proportion of all deaths due to major causes in Europe, latest available year, among men (A) and women (B). Note: No data are available for Andorra. Source: WHO Mortality Database.

Figure 1

Proportion of all deaths due to major causes in Europe, latest available year, among men (A) and women (B). Note: No data are available for Andorra. Source: WHO Mortality Database.

Table 1

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

 Cardiovascular disease (total) Coronary heart disease Cerebrovascular disease  Other cardiovascular diseases 
     
 n n n n 
Males 
    Total deaths (all ages) 1 829 496 40 874 920 19 417 113 537 463 12 
    Premature deaths—before age 75 899 415 35 465 842 18 191 819 241 754 
    Premature deaths—before age 65 490 221 31 252 427 16 93 131 144 663 
Females         
    Total deaths (all ages) 2 173 136 49 892 297 20 599 380 14 681 459 15 
    Premature deaths—before age 75 507 625 36 227 140 16 146 142 10 134 343 
    Premature deaths—before age 65 193 143 26 77 629 10 53 424 62 090 
Total         
    Total deaths (all ages) 4 002 632 45 1 767 217 20 1 016 493 11 1 218 922 14 
    Premature deaths—before age 75 140 7040 35 692 982 17 337 961 376 097 
    Premature deaths—before age 65 683 364 29 330 056 14 146 555 206 753 
 Cardiovascular disease (total) Coronary heart disease Cerebrovascular disease  Other cardiovascular diseases 
     
 n n n n 
Males 
    Total deaths (all ages) 1 829 496 40 874 920 19 417 113 537 463 12 
    Premature deaths—before age 75 899 415 35 465 842 18 191 819 241 754 
    Premature deaths—before age 65 490 221 31 252 427 16 93 131 144 663 
Females         
    Total deaths (all ages) 2 173 136 49 892 297 20 599 380 14 681 459 15 
    Premature deaths—before age 75 507 625 36 227 140 16 146 142 10 134 343 
    Premature deaths—before age 65 193 143 26 77 629 10 53 424 62 090 
Total         
    Total deaths (all ages) 4 002 632 45 1 767 217 20 1 016 493 11 1 218 922 14 
    Premature deaths—before age 75 140 7040 35 692 982 17 337 961 376 097 
    Premature deaths—before age 65 683 364 29 330 056 14 146 555 206 753 

Latest available years for each country are the same as those presented in Table2, except for: Albania (2009), Lithuania (2013), Monaco (1987), Slovakia (2014), Tajikistan (2005), and Turkmenistan (2013).

a

No data are available for Andorra.

Source: WHO Mortality Database.

Premature mortality

Although more than three-fifths of all CVD deaths occur in those over the age of 75 years, 1.4 million people under the age of 75 and just under 700 000 under the age of 65 die from CVD in Europe each year. More men (0.9 million) than women (0.5 million) die from CVD before the age of 75, however due to the greater number of total premature deaths in men CVD accounts for a similar proportion of deaths before 75 years in both sexes. The observed sex differences in number of deaths are greater at younger ages, with more than twice as many men than women dying from CVD under the age of 65. The greatest differences between the sexes in number of premature deaths are found for CHD, despite similar numbers of CHD deaths for all ages in men and women (Table1).

Mortality rates across European countries

Large differences in the burden of CVD between countries in the European Region remain. Of the 3.8 million total deaths in the EU-15 countries, 33% of these were caused by CVD (1.3 million), compared with 38% of deaths in the EU-28 countries (1.9 million) and 54% of deaths in non-EU member countries (2.1 million). In countries of the EU-15, ASDRs for CVD in men, calculated using the 2013 ESP (ESP13), ranged from 275.2/100 000 men in France to 480.7/100 000 in Finland and amongst women from 174.1/100 000 women in France to 391.3/100 000 in Greece. In the EU-28, additional countries to the EU-15 ASDRs ranged from 407.7/100 000 men in Malta to 1299.5/100 000 men in Bulgaria and in women from 317.0/100 000 women in Malta to 959.6/100 000 in Bulgaria. Countries outside of the EU (restricted to those which had data from 2010 or later) had the largest range of rates. CVD ASDRs for men in these countries ranged from 255.0/100 000 in Israel to 1544.9/100 000 in Ukraine. For women, CVD ASDRs in non-EU countries ranged from 194.9/100 000 in Israel to 1087.4/100 000 in Kyrgyzstan. All seven countries for which data from 2010 onwards were not available were from outside the EU (Table2).

Table 2

ASDRs from CVD and CHD by country and sex (per 100 000 population); rate for most recent year of data and percentage change in rates over 10 years

  Males Females 
  CVD—total CHD CVD—total CHD 
Country Latest year 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 950.7 20.5 278.5 85.9 724.5 50.2 175.4 143.5 
Armenia 2012 946.5 −30.8 621.6 −30.1 743.9 −33.1 445.3 −33.8 
Austria 2014 457.1 −25.2 226.4 −25.2 348.0 −25.7 132.4 −33.0 
Azerbaijan 2007 1078.1 −14.6 250.1 −72.5 944.7 6.5 178.1 −69.3 
Belarus 2011 1448.0 −9.3 1060.7 −5.2 726.9 −26.8 498.4 −23.6 
Belgium 2012 357.1 −34.3 119.6 −42.8 252.9 −34.1 53.6 −49.0 
Bosnia and Herzegovina 2011 918.6 NA 159.19 NA 805.2 NA 107.3 NA 
Bulgaria 2012 1299.5 −18.4 271.0 −40.1 959.6 −20.5 165.8 −45.2 
Croatia 2013 761.4 −34.3 357.6 −6.0 581.2 −35.2 246.4 −20.2 
Cyprus 2012 428.8 NA 161.9 NA 343.9 NA 70.9 NA 
Czech Republic 2013 747.6 −32.4 425.3 −4.1 538.2 −43.0 279.6 0.13 
Denmark 2012 337.6 −43.9 123.9 −52.6 229.9 −42.3 67.3 −55.1 
Estonia 2012 920.3 −30.3 480.6 −42.1 572.4 −35.1 259.8 −48.4 
Finland 2013 480.7 −27.7 281.3 −32.9 295.6 −30.4 145.1 −38.8 
France 2011 275.2 −34.0 83.6 −37.3 174.1 −35.2 34.7 −44.6 
Georgiaa 2014 891.6 −40.1 266.3 −68.6 608.7 −42.2 169.5 −70.6 
Germany 2013 477.2 −29.7 204.1 −35.2 362.1 −29.9 111.2 −41.4 
Greece 2012 485.0 −31.3 145.3 −28.3 391.3 −38.6 67.7 −39.0 
Hungary 2013 921.3 −21.9 488.3 −11.8 646.3 −22.6 319.2 −12.4 
Iceland 2009 441.6 −29.3 238.2 −36.8 297.5 −30.8 125.0 −40.0 
Ireland 2012 420.5 −37.7 236.4 −37.0 290.2 −35.4 124.4 −41.7 
Israel 2013 255.0 −37.8 115.4 −46.4 194.9 −37.4 66.5 −41.8 
Italy 2012 393.8 −27.9 148.0 −23.8 290.0 −25.3 82.7 −25.5 
Kazakhstan 2012 779.9 −56.5 290.2 −71.7 437.5 −65.6 139.3 −78.9 
Kyrgyzstan 2013 1443.9 −1.3 983.7 13.6 1087.4 −6.3 746.6 15.2 
Latvia 2012 1156.8 −18.2 632.3 −15.5 718.6 −21.6 362.7 −13.1 
Lithuania 2012 1096.9 −15.3 740.4 −14.4 706.4 −20.3 450.4 −18.4 
Luxembourg 2013 332.7 −49.7 109.9 −55.4 254.9 −42.5 64.6 −51.5 
Malta 2014 407.7 −29.2 240.4 −27.1 317.0 −33.1 162.7 −27.0 
Montenegro 2009 922.3 NA 137.6 NA 829.4 NA 72.2 NA 
The Netherlands 2013 332.0 −39.2 90.1 −53.8 233.5 −31.9 45.1 −52.0 
Norway 2013 334.7 −38.9 136.8 −49.0 235.1 −35.8 73.4 −48.3 
Poland 2013 756.0 −23.9 190.8 −39.0 505.6 −26.5 99.0 −58.2 
Portugal 2013 347.0 −40.1 88.6 −39.5 259.7 −42.9 48.0 −46.9 
Republic of Moldova 2013 1380.2 −27.7 936.5 −31.8 1071.6 −28.0 706.4 −33.2 
Romania 2012 1143.9 −25.2 400.3 −23.9 903.9 −25.8 284.1 −24.5 
Russian Federation 2011 1423.1 −19.0 790.3 −10.4 914.0 −23.9 465.6 −9.1 
San Marino 2005 516.6 −28.5 56.8 −51.0 322.0 −11.2 18.9 −71.0 
Serbia 2013 990.9 −22.0 198.6 −27.8 836.4 −26.0 122.8 −34.3 
Slovakia 2010 1048.1 −13.1 643.6 −4.8 758.5 −15.5 450.3 −7.6 
Slovenia 2010 532.9 −30.6 175.2 −35.0 390.6 −26.3 86.2 −45.6 
Spain 2013 292.4 −33.2 104.0 −35.8 221.5 −33.1 47.3 −41.9 
Sweden 2013 414.8 −30.6 185.7 −40.6 292.3 −25.9 99.3 −38.7 
Switzerland 2013 339.2 −30.0 141.0 −36.4 242.0 −27.7 74.4 −40.8 
Tajikistan 2004 1332.5 4.8 550.3 −9.0 920.0 −12.8 340.4 −25.4 
TFYR Macedonia 2010 1228.8 −6.3 187.6 −21.7 1012.5 −8.5 103.1 −21.5 
Turkey 2013 582.7 NA 244.1 NA 458.2 NA 144.6 NA 
Turkmenistan 1998 1748.3 17.5 1001.4 4.3 1300.0 15.5 677.4 3.2 
Ukraine 2012 1544.9 −15.5 1077.4 −12.5 1065.8 −15.7 721.2 −9.8 
UK 2013 334.3 −42.2 177.2 −44.3 227.9 −42.8 86.5 −48.7 
Uzbekistan 2005 1492.4 −7.9 803.2 −23.0 1225.1 −7.4 604.8 −26.7 
  Males Females 
  CVD—total CHD CVD—total CHD 
Country Latest year 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 950.7 20.5 278.5 85.9 724.5 50.2 175.4 143.5 
Armenia 2012 946.5 −30.8 621.6 −30.1 743.9 −33.1 445.3 −33.8 
Austria 2014 457.1 −25.2 226.4 −25.2 348.0 −25.7 132.4 −33.0 
Azerbaijan 2007 1078.1 −14.6 250.1 −72.5 944.7 6.5 178.1 −69.3 
Belarus 2011 1448.0 −9.3 1060.7 −5.2 726.9 −26.8 498.4 −23.6 
Belgium 2012 357.1 −34.3 119.6 −42.8 252.9 −34.1 53.6 −49.0 
Bosnia and Herzegovina 2011 918.6 NA 159.19 NA 805.2 NA 107.3 NA 
Bulgaria 2012 1299.5 −18.4 271.0 −40.1 959.6 −20.5 165.8 −45.2 
Croatia 2013 761.4 −34.3 357.6 −6.0 581.2 −35.2 246.4 −20.2 
Cyprus 2012 428.8 NA 161.9 NA 343.9 NA 70.9 NA 
Czech Republic 2013 747.6 −32.4 425.3 −4.1 538.2 −43.0 279.6 0.13 
Denmark 2012 337.6 −43.9 123.9 −52.6 229.9 −42.3 67.3 −55.1 
Estonia 2012 920.3 −30.3 480.6 −42.1 572.4 −35.1 259.8 −48.4 
Finland 2013 480.7 −27.7 281.3 −32.9 295.6 −30.4 145.1 −38.8 
France 2011 275.2 −34.0 83.6 −37.3 174.1 −35.2 34.7 −44.6 
Georgiaa 2014 891.6 −40.1 266.3 −68.6 608.7 −42.2 169.5 −70.6 
Germany 2013 477.2 −29.7 204.1 −35.2 362.1 −29.9 111.2 −41.4 
Greece 2012 485.0 −31.3 145.3 −28.3 391.3 −38.6 67.7 −39.0 
Hungary 2013 921.3 −21.9 488.3 −11.8 646.3 −22.6 319.2 −12.4 
Iceland 2009 441.6 −29.3 238.2 −36.8 297.5 −30.8 125.0 −40.0 
Ireland 2012 420.5 −37.7 236.4 −37.0 290.2 −35.4 124.4 −41.7 
Israel 2013 255.0 −37.8 115.4 −46.4 194.9 −37.4 66.5 −41.8 
Italy 2012 393.8 −27.9 148.0 −23.8 290.0 −25.3 82.7 −25.5 
Kazakhstan 2012 779.9 −56.5 290.2 −71.7 437.5 −65.6 139.3 −78.9 
Kyrgyzstan 2013 1443.9 −1.3 983.7 13.6 1087.4 −6.3 746.6 15.2 
Latvia 2012 1156.8 −18.2 632.3 −15.5 718.6 −21.6 362.7 −13.1 
Lithuania 2012 1096.9 −15.3 740.4 −14.4 706.4 −20.3 450.4 −18.4 
Luxembourg 2013 332.7 −49.7 109.9 −55.4 254.9 −42.5 64.6 −51.5 
Malta 2014 407.7 −29.2 240.4 −27.1 317.0 −33.1 162.7 −27.0 
Montenegro 2009 922.3 NA 137.6 NA 829.4 NA 72.2 NA 
The Netherlands 2013 332.0 −39.2 90.1 −53.8 233.5 −31.9 45.1 −52.0 
Norway 2013 334.7 −38.9 136.8 −49.0 235.1 −35.8 73.4 −48.3 
Poland 2013 756.0 −23.9 190.8 −39.0 505.6 −26.5 99.0 −58.2 
Portugal 2013 347.0 −40.1 88.6 −39.5 259.7 −42.9 48.0 −46.9 
Republic of Moldova 2013 1380.2 −27.7 936.5 −31.8 1071.6 −28.0 706.4 −33.2 
Romania 2012 1143.9 −25.2 400.3 −23.9 903.9 −25.8 284.1 −24.5 
Russian Federation 2011 1423.1 −19.0 790.3 −10.4 914.0 −23.9 465.6 −9.1 
San Marino 2005 516.6 −28.5 56.8 −51.0 322.0 −11.2 18.9 −71.0 
Serbia 2013 990.9 −22.0 198.6 −27.8 836.4 −26.0 122.8 −34.3 
Slovakia 2010 1048.1 −13.1 643.6 −4.8 758.5 −15.5 450.3 −7.6 
Slovenia 2010 532.9 −30.6 175.2 −35.0 390.6 −26.3 86.2 −45.6 
Spain 2013 292.4 −33.2 104.0 −35.8 221.5 −33.1 47.3 −41.9 
Sweden 2013 414.8 −30.6 185.7 −40.6 292.3 −25.9 99.3 −38.7 
Switzerland 2013 339.2 −30.0 141.0 −36.4 242.0 −27.7 74.4 −40.8 
Tajikistan 2004 1332.5 4.8 550.3 −9.0 920.0 −12.8 340.4 −25.4 
TFYR Macedonia 2010 1228.8 −6.3 187.6 −21.7 1012.5 −8.5 103.1 −21.5 
Turkey 2013 582.7 NA 244.1 NA 458.2 NA 144.6 NA 
Turkmenistan 1998 1748.3 17.5 1001.4 4.3 1300.0 15.5 677.4 3.2 
Ukraine 2012 1544.9 −15.5 1077.4 −12.5 1065.8 −15.7 721.2 −9.8 
UK 2013 334.3 −42.2 177.2 −44.3 227.9 −42.8 86.5 −48.7 
Uzbekistan 2005 1492.4 −7.9 803.2 −23.0 1225.1 −7.4 604.8 −26.7 

Rates are not available for Monaco due to missing population data. No mortality data are available for Andorra.

Age-standardized to the 2013 European Standard Population.

NA, not available.

a

Change in rates for Georgia is over 11 years due to missing data for the year 10 years previous.

Source: WHO Mortality Database.

Similar between-country inequalities in rates were found for premature mortality. In the EU-15, 21.4% of deaths under the age of 75 years were from CVD (0.25 million deaths), with ASDRs for this age group in men ranging from 72.8/100 000 men in France to 146.5/100 000 in Greece and in women ranging from 26.4/100 000 women in France to 56.6/100 000 in Greece. In the EU-28, 26.0% of deaths under the age of 75 years were from CVD (0.45 million deaths), with ASDRs from additional countries to the EU-15 ranging from 105.9/100 000 men in Malta to 467.2/100 000 men in Latvia and from 39.2/100 000 women in Cyprus to 206.5/100 000 women in Bulgaria. In non-EU countries, 35.8% of deaths under the age of 75 (1.3 million deaths) were from CVD, with ASDRs (from countries which had data from 2010 or later) ranging from 66.7/100 000 men in Israel to 697.4/100 000 in Belarus. For women CVD ASDRs in non-EU countries ranged from 27.9/100 000 women in Switzerland to 278.3/100 000 in the Republic of Moldova (see

). CVD mortality rates under 65 years showed similar patterns but at lower rates (see ).

Trends in mortality

Comparing ASDRs calculated for the most recent year to those for 10 years earlier, as a percentage increase of the earlier year, most of the countries in the European region experienced substantial decreases in ASDRs for CVD and CHD from 2003 onwards (see

). The exceptions were Kyrgyzstan, which reported an increase in CHD ASDRs over 10 years for both sexes and the Czech Republic that saw a small increase in female CHD ASDRs. Although other countries reported apparent increases in rates for both CVD and CHD these were within countries without recent data, i.e. latest available year of data was before 2010, such as Tajikistan. The proportional decreases in ASDRs over 10 years varied between countries. In the EU-15, 10-year decreases (to the latest year available) in CVD ASDRs in men ranged from 25.2% in Austria to 49.7% in Luxembourg and in women from 25.3% in Italy to 42.9% in Portugal. In the EU-28, decreases in CVD from additional countries to the EU-15 ranged from 13.1% in Slovakia to 34.4% in Croatia and in women from 15.5% in Slovakia to 43.0% in the Czech Republic. In non-EU countries, CVD decreases ranged from 1.3% in Kyrgyzstan to 56.5% in Kazakhstan, and in women from 6.3% in Kyrgyzstan to 65.6% in Kazakhstan.

CVD vs. cancer

As a result of the observed decreases in CVD, a number of countries now record a greater number of deaths from cancer than from CVD annually, despite cancer accounting for less than half the number of deaths than CVD in Europe as a whole. According to the most recent data more men die from cancer than CVD in 12 countries and in two countries for women. All of these countries are in Western Europe as defined by the GBD Study (2015),14 with 9 of the 12 countries from the EU-15. This transition from CVD to cancer as the most common cause of death for men was first seen in France in 1998, with Spain (1999) the only other country to experience it before the year 2000. There were two countries in which cancer killed more individuals than CVD for both sexes, with this change occurring in the same year in Denmark (2010) and 3 years apart in Israel (Table3). Those countries in which cancer overtook CVD as the most common cause of death earliest also now have higher ratios of cancer to CVD deaths, suggesting that trends of an increasing burden of cancer mortality compared with CVD mortality continue after this transition Figure2.

Figure 2

The year the higher absolute number of deaths changed from CVD to cancer by ratio of cancer to CVD deaths, by sex and European country. Note: Male Portugal and male Israel same year and similar ratio. Gender symbols are only included for countries in which the number of deaths from cancer is greater than the number of deaths from CVD for women as well as men: Israel and Portugal. Data for all other countries, i.e. those without a gender symbol, are for men only. Source: WHO Mortality Database.

Figure 2

The year the higher absolute number of deaths changed from CVD to cancer by ratio of cancer to CVD deaths, by sex and European country. Note: Male Portugal and male Israel same year and similar ratio. Gender symbols are only included for countries in which the number of deaths from cancer is greater than the number of deaths from CVD for women as well as men: Israel and Portugal. Data for all other countries, i.e. those without a gender symbol, are for men only. Source: WHO Mortality Database.

Table 3

European countries where the number of cancer deaths exceeds the number of deaths from CVD for men and women

Country Latest year Men N of deaths Year of change Women N of deaths Year of change 
  Cancer CVD  Cancer CVD  
Belgium 2012 15 920 14 299 2006    
Denmark 2012 8226 6442 2010 7613 6654 2010 
France 2011 92 375 64 659 1988    
Italy 2012 99 794 99 661 2012    
Israel 2013 5455 4819 2009 5507 5217 2012 
Luxembourg 2013 566 523 2010    
The Netherlands 2013 23 766 18 026 2004    
Norway 2013 5788 5630 2013    
Portugal 2013 15 746 13 981 2009    
Slovenia 2010 3245 3071 2007    
Spain 2013 67 711 53 487 1999    
UK 2013 87 511 79 935 2011    
Country Latest year Men N of deaths Year of change Women N of deaths Year of change 
  Cancer CVD  Cancer CVD  
Belgium 2012 15 920 14 299 2006    
Denmark 2012 8226 6442 2010 7613 6654 2010 
France 2011 92 375 64 659 1988    
Italy 2012 99 794 99 661 2012    
Israel 2013 5455 4819 2009 5507 5217 2012 
Luxembourg 2013 566 523 2010    
The Netherlands 2013 23 766 18 026 2004    
Norway 2013 5788 5630 2013    
Portugal 2013 15 746 13 981 2009    
Slovenia 2010 3245 3071 2007    
Spain 2013 67 711 53 487 1999    
UK 2013 87 511 79 935 2011    

Morbidity

Disability-adjusted life years

Disability-adjusted life years are a composite measure of years of life lost due to death from a condition and years lived with disability due to a condition. One DALY is therefore equivalent to 1 year of healthy life lost. Crude rates of WHO estimates for the number of DALYs attributable to CVD in 2012 for European countries were highest in the Ukraine, with only five countries suffering CVD DALYs per 1000 population of more than 150: Ukraine (194/1000), Russian Federation (181/1000), Bulgaria (167/1000), Belarus (163/1000), and Lativa (153/1000). Five countries had DALYs attributed to CVD of <40/1000 individuals: Luxembourg (39/1000), Cyprus (37/1000), Ireland (35/1000), Iceland (32/1000), and Israel (26/1000). More DALYs were attributed to CVD and CHD in men than women in almost all countries, with Tajikistan the only country in which women suffered greater DALYs due to CVD than men. No country reported more DALYs for women than men for CHD; however this trend did not hold for stroke, with similar number of countries suffering higher DALYs for each of the sexes (Table4, Figure3).

Figure 3

Estimated DALYs per 1000 population for all cardiovascular diseases, coronary heart disease and stroke, WHO European Region 2012. Source: World Health Organization, Health Statistics and Information Systems: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html (accessed April 2016).

Figure 3

Estimated DALYs per 1000 population for all cardiovascular diseases, coronary heart disease and stroke, WHO European Region 2012. Source: World Health Organization, Health Statistics and Information Systems: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html (accessed April 2016).

Table 4

Estimated DALYs per 1000 population by cause and sex, WHO European Region 2012

 Cardiovascular diseases Ischaemic heart disease Stroke 
 All Men Women All Men Women All Men Women 
Albania 100 102 98 43 49 38 39 36 42 
Austria 61 63 58 29 34 23 10 10 
Azerbaijan 75 85 65 44 52 35 19 19 19 
Belarus 163 194 136 114 138 92 36 38 35 
Belgium 51 56 46 21 27 15 11 11 11 
Bosnia and Herzegovina 100 109 92 45 55 36 41 38 43 
Bulgaria 167 187 149 74 87 62 58 58 57 
Croatia 95 102 87 47 56 40 27 28 27 
Cyprus 37 42 31 18 25 11 
Czech Republic 85 94 76 47 56 38 15 15 16 
Denmark 43 49 37 16 21 12 11 11 11 
Estonia 110 126 95 52 64 41 15 16 14 
Finland 63 76 51 33 43 24 13 13 13 
France 40 44 36 12 15 
Georgia 144 159 130 73 85 62 46 46 46 
Germany 67 72 62 27 34 21 12 11 12 
Greece 77 85 69 38 46 29 27 26 28 
Hungary 114 128 102 61 71 51 23 25 22 
Iceland 32 35 28 15 19 11 
Ireland 35 40 29 20 25 15 
Israel 26 28 23 10 13 
Italy 54 57 51 21 25 16 13 13 14 
Kazakhstan 124 146 103 71 86 57 36 35 36 
Kyrgyzstan 76 89 64 44 51 37 22 25 20 
Latvia 153 177 134 83 99 69 36 35 36 
Lithuania 120 137 105 69 81 59 28 26 30 
Luxembourg 39 41 36 12 16 10 
Malta 51 58 44 31 38 24 11 12 10 
Montenegro 112 114 110 40 57 23 32 39 26 
The Netherlands 42 46 38 14 17 10 10 
Norway 42 46 38 18 22 14 10 10 
Poland 90 106 74 44 56 32 28 30 27 
Portugal 47 52 43 15 19 11 18 19 17 
Republic of Moldova 143 155 131 89 98 80 40 42 39 
Romania 125 139 111 49 59 38 37 38 35 
Russian Federation 181 217 150 107 136 82 58 59 57 
Serbia 118 125 111 36 46 26 31 30 32 
Slovakia 94 107 81 59 69 49 23 24 21 
Slovenia 55 58 53 20 26 15 17 17 17 
Spain 43 48 39 16 21 11 10 10 10 
Sweden 55 60 50 24 29 19 12 11 13 
Switzerland 41 44 37 16 21 12 
Tajikistan 55 52 57 30 30 29 18 15 21 
Turkey 62 72 53 29 36 22 19 21 17 
Turkmenistan 127 150 104 80 99 62 29 30 28 
Ukraine 194 214 177 135 151 121 46 45 46 
UK 46 53 39 21 29 15 11 10 12 
Uzbekistan 81 89 74 50 58 43 23 23 23 
 Cardiovascular diseases Ischaemic heart disease Stroke 
 All Men Women All Men Women All Men Women 
Albania 100 102 98 43 49 38 39 36 42 
Austria 61 63 58 29 34 23 10 10 
Azerbaijan 75 85 65 44 52 35 19 19 19 
Belarus 163 194 136 114 138 92 36 38 35 
Belgium 51 56 46 21 27 15 11 11 11 
Bosnia and Herzegovina 100 109 92 45 55 36 41 38 43 
Bulgaria 167 187 149 74 87 62 58 58 57 
Croatia 95 102 87 47 56 40 27 28 27 
Cyprus 37 42 31 18 25 11 
Czech Republic 85 94 76 47 56 38 15 15 16 
Denmark 43 49 37 16 21 12 11 11 11 
Estonia 110 126 95 52 64 41 15 16 14 
Finland 63 76 51 33 43 24 13 13 13 
France 40 44 36 12 15 
Georgia 144 159 130 73 85 62 46 46 46 
Germany 67 72 62 27 34 21 12 11 12 
Greece 77 85 69 38 46 29 27 26 28 
Hungary 114 128 102 61 71 51 23 25 22 
Iceland 32 35 28 15 19 11 
Ireland 35 40 29 20 25 15 
Israel 26 28 23 10 13 
Italy 54 57 51 21 25 16 13 13 14 
Kazakhstan 124 146 103 71 86 57 36 35 36 
Kyrgyzstan 76 89 64 44 51 37 22 25 20 
Latvia 153 177 134 83 99 69 36 35 36 
Lithuania 120 137 105 69 81 59 28 26 30 
Luxembourg 39 41 36 12 16 10 
Malta 51 58 44 31 38 24 11 12 10 
Montenegro 112 114 110 40 57 23 32 39 26 
The Netherlands 42 46 38 14 17 10 10 
Norway 42 46 38 18 22 14 10 10 
Poland 90 106 74 44 56 32 28 30 27 
Portugal 47 52 43 15 19 11 18 19 17 
Republic of Moldova 143 155 131 89 98 80 40 42 39 
Romania 125 139 111 49 59 38 37 38 35 
Russian Federation 181 217 150 107 136 82 58 59 57 
Serbia 118 125 111 36 46 26 31 30 32 
Slovakia 94 107 81 59 69 49 23 24 21 
Slovenia 55 58 53 20 26 15 17 17 17 
Spain 43 48 39 16 21 11 10 10 10 
Sweden 55 60 50 24 29 19 12 11 13 
Switzerland 41 44 37 16 21 12 
Tajikistan 55 52 57 30 30 29 18 15 21 
Turkey 62 72 53 29 36 22 19 21 17 
Turkmenistan 127 150 104 80 99 62 29 30 28 
Ukraine 194 214 177 135 151 121 46 45 46 
UK 46 53 39 21 29 15 11 10 12 
Uzbekistan 81 89 74 50 58 43 23 23 23 

Source: World Health Organization, Health Statistics and Information Systems http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html (accessed April 2016).11

Prevalence

Total prevalence of people reporting heart or circulation problems in the last 12 months in the European Social Survey, for all countries combined, was the same for both sexes at 9.2%. There were five countries in which more than 10% of men reported having heart or circulation problems: Poland (14.7%), Finland (13.0%), the Netherlands (12.4%), Germany (11.6%), and Austria (10.4%). This was the case for women in four countries: Poland (20.2%), Germany (14.1%), Slovenia (13.6%), and Finland (10.9%). Two countries reported a prevalence below 6% for men, Ireland (5.1%) and the Czech Republic (5.5%), and three for women, Ireland (3.7%), the Czech Republic (4.4%) and Norway (5.8%) (Table5, Figure4).

Figure 4

Percentage of population reporting heart or circulation problems in the last 12 months, by country and sex 2014. Note: Percentages weighted to correct for unequal probabilities for selection. Source: ESS Round 7: European Social Survey Round 7 Data (2014). Data file edition 1.0. Norwegian Social Science Data Services, Norway—Data Archive and distributor of ESS data for ESS ERIC.

Figure 4

Percentage of population reporting heart or circulation problems in the last 12 months, by country and sex 2014. Note: Percentages weighted to correct for unequal probabilities for selection. Source: ESS Round 7: European Social Survey Round 7 Data (2014). Data file edition 1.0. Norwegian Social Science Data Services, Norway—Data Archive and distributor of ESS data for ESS ERIC.

Table 5

Percentage of population reporting heart or circulation problems in the last 12 months, by country and sex 2014

 Male Female Both 
 (%) (%) (%) 
Austria 10.4 9.7 10.0 
Belgium 8.3 9.3 8.8 
Switzerland 7.4 6.7 7.0 
Czech Republic 5.5 4.4 5.0 
Germany 11.6 14.1 12.8 
Denmark 8.6 7.3 8.0 
Finland 13.0 10.9 11.9 
France 7.6 7.7 7.6 
Ireland 5.1 3.7 4.3 
The Netherlands 12.4 7.5 9.7 
Norway 7.5 5.8 6.7 
Poland 14.7 20.2 17.7 
Sweden 7.5 8.1 7.8 
Slovenia 9.9 13.6 11.9 
Total 9.2 9.2 9.2 
 Male Female Both 
 (%) (%) (%) 
Austria 10.4 9.7 10.0 
Belgium 8.3 9.3 8.8 
Switzerland 7.4 6.7 7.0 
Czech Republic 5.5 4.4 5.0 
Germany 11.6 14.1 12.8 
Denmark 8.6 7.3 8.0 
Finland 13.0 10.9 11.9 
France 7.6 7.7 7.6 
Ireland 5.1 3.7 4.3 
The Netherlands 12.4 7.5 9.7 
Norway 7.5 5.8 6.7 
Poland 14.7 20.2 17.7 
Sweden 7.5 8.1 7.8 
Slovenia 9.9 13.6 11.9 
Total 9.2 9.2 9.2 

Note: Percentages weighted to correct for unequal probabilities for selection.

Source: ESS Round 7: European Social Survey Round 7 Data (2014). Data file edition 1.0. Norwegian Social Science Data Services, Norway—Data Archive and distributor of ESS data for ESS ERIC.

Treatment

Hospital discharges

The WHO collates data on rates of hospital discharges for CVD, CHD, and stroke. The highest rates of hospitalization were in Belarus (last available year 2013) with 6276 hospital discharges for CVD per 100 000 population; this represented a 27% increase from 2000. The majority of countries had an increase in hospitalization rates from the year 2000 (Table6). For CHD, the pattern was less clear with around half of countries demonstrating an increase in hospitalization rates and the other half experiencing a decrease. For stroke, 35 of the 52 countries experienced increases in hospitalization rates. It should be noted that the data are not age-standardized; therefore, changes in rates over time and differences between countries could be due to differences and changes in population age distributions.

Table 6

Hospital discharges for CVD, CHD, and cerebrovascular disease per 100 000 population, by country, 2000 to latest year

  Cardiovascular disease Coronary heart disease Cerebrovascular disease 
 Years available 2000a Last available year 2000a Last available year 2000a Last available year 
Albania 2000–12 540 929 157 202 80 155 
Andorra 2000–13 586 824 126b 172 107b 123 
Armenia 2000–13 639 1737 282 710 130 257 
Austria 2000–09 3674 3697 757 881 679 565 
Azerbaijan 2000–13 472 708 154 289 45 87 
Belarus 2000–13 4577 6276 2212 3171 896 1236 
Belgium 2000–08 2356 2173 736 616 390 353 
Bulgaria 2000–10 1869 3617 542 1196 426 589 
Croatia 2000–10 1760 1847 495 488 411 393 
Cyprus 2000–08 818 672 332 198 140 120 
Czech Republic 2000–10 3261 3086 1041 715 619 547 
Denmark 2000–10 2543 2634 790 720 452 363 
Estonia 2000–09 3176 3327 1095 900 492 714 
Finland 2000–07 3785 2913 1160 791 658 550 
France 2000–09 2307 2282 503 498 222 228 
Georgia 2000–13 454 1341 194 559 74 193 
Germany 2000–09 3267 3500 1060 890 462 530 
Greece 2000–07 2309 2786 777 951 404 449 
Hungary 2000–10 4239 3678 1113 716 832 995 
Iceland 2000–09 1863 1440 724 525 237 179 
Ireland 2000–10 1420 1154 457 352 250 163 
Israel 2000–08 1911 1482 823 501 259 235 
Italy 2000–09 2582 2120 600 503 489 432 
Kazakhstan 2000–13 1314 2044 419 732 210 494 
Kyrgyzstan 2000–13 1041 1451 322 689 153 290 
Latvia 2000–10 3151 3078 1266 1066 640 642 
Lithuania 2000–10 4102 4765 1415 1469 780 968 
Luxembourg 2000–07 2610 2172 818 606 232 168 
Malta 2000–10 666 1346 184 350 79 158 
Monaco 2012 only 4004 4004 385 385 338 338 
Montenegro 2000–13 1400 1705 421 555 169 280 
The Netherlands 2000–09 1403 1694 523 528 184 239 
Norway 2000–10 2349 2368 876 880 320 306 
Poland 2003–09 2880 2885 958 811 370 336 
Portugal 2000–10 1118 1307 275 299 334 290 
Republic of Moldova 2000–13 1315 2516 419 710 271 607 
Romania 2000–10 2422 2982 752 330 328 575 
Russian Federation 2000–13 2763 3653 1103 1331 595 871 
San Marino 2011–13 1642 1521 284 272 256 336 
Serbia 2000–12 1455 2199 373 670 338 439 
Slovakia 2000–10 2443 2689 955 749 452 461 
Slovenia 2000–09 1685 1976 366 411 230 232 
Spain 2000–09 1333 1295 363 289 213 221 
Sweden 2000–09 2630 2334 890 621 506 429 
Switzerland 2002–09 1699 1729 518 469 212 222 
Tajikistan 2000–12 533 1072 122 306 38 90 
TFYR Macedonia 2000–10 1267 1722 480 551c 218 261c 
Turkey 2000–10 954 1502 216 666 155 149 
Turkmenistan 2000–13 1405 1984 416 733 132 258 
Ukraine 2000–13 2612 3913 1197 1905 540 949 
UK 2000–10 1422 1291 523 403 204 225 
Uzbekistan 2000–13 959 1688 300 553 79 143 
  Cardiovascular disease Coronary heart disease Cerebrovascular disease 
 Years available 2000a Last available year 2000a Last available year 2000a Last available year 
Albania 2000–12 540 929 157 202 80 155 
Andorra 2000–13 586 824 126b 172 107b 123 
Armenia 2000–13 639 1737 282 710 130 257 
Austria 2000–09 3674 3697 757 881 679 565 
Azerbaijan 2000–13 472 708 154 289 45 87 
Belarus 2000–13 4577 6276 2212 3171 896 1236 
Belgium 2000–08 2356 2173 736 616 390 353 
Bulgaria 2000–10 1869 3617 542 1196 426 589 
Croatia 2000–10 1760 1847 495 488 411 393 
Cyprus 2000–08 818 672 332 198 140 120 
Czech Republic 2000–10 3261 3086 1041 715 619 547 
Denmark 2000–10 2543 2634 790 720 452 363 
Estonia 2000–09 3176 3327 1095 900 492 714 
Finland 2000–07 3785 2913 1160 791 658 550 
France 2000–09 2307 2282 503 498 222 228 
Georgia 2000–13 454 1341 194 559 74 193 
Germany 2000–09 3267 3500 1060 890 462 530 
Greece 2000–07 2309 2786 777 951 404 449 
Hungary 2000–10 4239 3678 1113 716 832 995 
Iceland 2000–09 1863 1440 724 525 237 179 
Ireland 2000–10 1420 1154 457 352 250 163 
Israel 2000–08 1911 1482 823 501 259 235 
Italy 2000–09 2582 2120 600 503 489 432 
Kazakhstan 2000–13 1314 2044 419 732 210 494 
Kyrgyzstan 2000–13 1041 1451 322 689 153 290 
Latvia 2000–10 3151 3078 1266 1066 640 642 
Lithuania 2000–10 4102 4765 1415 1469 780 968 
Luxembourg 2000–07 2610 2172 818 606 232 168 
Malta 2000–10 666 1346 184 350 79 158 
Monaco 2012 only 4004 4004 385 385 338 338 
Montenegro 2000–13 1400 1705 421 555 169 280 
The Netherlands 2000–09 1403 1694 523 528 184 239 
Norway 2000–10 2349 2368 876 880 320 306 
Poland 2003–09 2880 2885 958 811 370 336 
Portugal 2000–10 1118 1307 275 299 334 290 
Republic of Moldova 2000–13 1315 2516 419 710 271 607 
Romania 2000–10 2422 2982 752 330 328 575 
Russian Federation 2000–13 2763 3653 1103 1331 595 871 
San Marino 2011–13 1642 1521 284 272 256 336 
Serbia 2000–12 1455 2199 373 670 338 439 
Slovakia 2000–10 2443 2689 955 749 452 461 
Slovenia 2000–09 1685 1976 366 411 230 232 
Spain 2000–09 1333 1295 363 289 213 221 
Sweden 2000–09 2630 2334 890 621 506 429 
Switzerland 2002–09 1699 1729 518 469 212 222 
Tajikistan 2000–12 533 1072 122 306 38 90 
TFYR Macedonia 2000–10 1267 1722 480 551c 218 261c 
Turkey 2000–10 954 1502 216 666 155 149 
Turkmenistan 2000–13 1405 1984 416 733 132 258 
Ukraine 2000–13 2612 3913 1197 1905 540 949 
UK 2000–10 1422 1291 523 403 204 225 
Uzbekistan 2000–13 959 1688 300 553 79 143 

‘Years available’ column refers to Cardiovascular disease data only.

b

From 2001 and cuntil 2007, correspond to CHD and cerebrovascular disease data only.

a

Some countries start from later years.

b

From 2001.

c

Until 2007.

Source: World Health Organization Regional Office for Europe. European Health for All Database.12

Case fatality

Latvia had the highest case fatalities, age–sex standardized to the 2010 OECD population aged 45+, for both AMI and IS, measured through admission-based and patient-based outcomes. Although patient-based outcomes were greater than admission-based ones for all countries and both disease types, seven countries did not provide patient-based data and one country did not present any IS data (Poland). The lowest admission-based case fatalities for AMI were found in Sweden (4.5%) and Poland (4.7%), and the highest was found in Latvia (15.4%). Only two other countries had an admission-based case fatality for AMI >10%: Austria (10.0%) and Estonia (11.5%). Finland (5.1%) and Norway (5.4%) were the only countries to have admission-based case fatality for IS <6%; Estonia (13%), Slovenia (13.2%), and Latvia (18.4%) all reported IS case fatalities above 11%. On average, case fatality was lower for AMI than IS. However, six countries had admission-based case fatalities that were greater for AMI than IS: the Netherlands, Israel, UK, Norway, Spain, Finland, Germany, and Austria (Table7).

Table 7

Case-fatality rates after AMI and stroke, latest year, by country

Country Year Case fatality after acute myocardial infarction Case fatality after ischaemic stroke 
  Admission based Patient based Admission based Patient based 
Austria 2013 10.0 — 6.4 — 
Belgiuma 2013 7.3 — 9.3 — 
Czech Republic 2013 6.7 10.5 9.6 13.0 
Denmarka 2013 5.7 8.3 9.1 10.2 
Estonia 2013 11.5 13.1 13.0 13.2 
Finland 2013 6.5 8.5 5.1 6.8 
France 2013 7.2 — 7.9 — 
Germany 2013 8.7 — 6.4 — 
Iceland 2013 6.9 — 8.0 — 
Irelanda 2013 6.4 — 9.7 — 
Israela 2013 6.7 8.8 6.0 8.1 
Italy 2013 5.5 7.5 6.2 9.0 
Latvia 2013 15.4 19.1 18.4 27.0 
Luxembourga 2012 7.0 10.5 9.1 11.1 
The Netherlandsa 2011 7.6 7.7 7.1 9.6 
Norway 2013 6.7 7.6 5.4 8.4 
Poland 2013 4.7 8.2 — — 
Portugal 2013 9.4 10.4 10.2 10.8 
Slovak Republica 2012 7.2 — 10.8 — 
Slovenia 2013 5.2 9.0 13.2 14.9 
Spain 2013 7.8 8.2 9.7 9.9 
Swedena 2013 4.5 8.3 6.4 9.6 
Switzerland 2013 7.7 8.9 6.9 8.2 
UKa 2013 7.6 9.1 9.2 10.6 
Country Year Case fatality after acute myocardial infarction Case fatality after ischaemic stroke 
  Admission based Patient based Admission based Patient based 
Austria 2013 10.0 — 6.4 — 
Belgiuma 2013 7.3 — 9.3 — 
Czech Republic 2013 6.7 10.5 9.6 13.0 
Denmarka 2013 5.7 8.3 9.1 10.2 
Estonia 2013 11.5 13.1 13.0 13.2 
Finland 2013 6.5 8.5 5.1 6.8 
France 2013 7.2 — 7.9 — 
Germany 2013 8.7 — 6.4 — 
Iceland 2013 6.9 — 8.0 — 
Irelanda 2013 6.4 — 9.7 — 
Israela 2013 6.7 8.8 6.0 8.1 
Italy 2013 5.5 7.5 6.2 9.0 
Latvia 2013 15.4 19.1 18.4 27.0 
Luxembourga 2012 7.0 10.5 9.1 11.1 
The Netherlandsa 2011 7.6 7.7 7.1 9.6 
Norway 2013 6.7 7.6 5.4 8.4 
Poland 2013 4.7 8.2 — — 
Portugal 2013 9.4 10.4 10.2 10.8 
Slovak Republica 2012 7.2 — 10.8 — 
Slovenia 2013 5.2 9.0 13.2 14.9 
Spain 2013 7.8 8.2 9.7 9.9 
Swedena 2013 4.5 8.3 6.4 9.6 
Switzerland 2013 7.7 8.9 6.9 8.2 
UKa 2013 7.6 9.1 9.2 10.6 

Case-fatality rate measures the percentage of people aged 45 and over who die within 30 days following admission to hospital for a specific acute condition.

Total rates have been age–sex standardized to the 2010 OECD population (45+).

Admission-based rates refer to death occurring in the same hospital as the initial admission.

Patient-based rates refer to death occurring in the same hospital as the initial admission, a different hospital, or out of hospital.

Three-year average for Iceland and Luxembourg.

a

Admissions resulting in a transfer are included.

Source: OECD Health Statistics 2015, http://dx.doi.org/10.1787/health-data-en.

Length of stay

Amongst OECD European countries the average length of stay (ALOS) following AMI was 6.7 days, with the shortest ALOS found in Denmark (3.9), Norway (4.0) and Sweden (4.7), with Slovakia the only other country to report an ALOS shorter than 5 days (4.9). ALOS following AMI was longest in Germany, the only country to report an ALOS of more than 10 days (10.3). Austria (8.1), Estonia (9.1), and Finland (8.3) were the only other countries to report ALOS of longer than 8 days (Table8).

Table 8

Average length of hospital stay following AMI, latest year, by country

Country Year Average length of stay 
Austria 2013 8.1 
Belgium 2012 6.9 
Czech Republic 2013 6.1 
Denmark 2010 3.9 
Estonia 2013 9.1 
Finland 2013 8.3 
France 2013 6.0 
Germany 2013 10.3 
Greece 2010 6.1 
Hungary 2012 7.9 
Iceland 2013 5.5 
Ireland 2013 7.1 
Israel 2013 6.0 
Italy 2013 7.8 
Luxembourg 2013 6.9 
The Netherlandsa 2012 5.6 
Norway 2010 4.0 
Poland 2013 6.2 
Portugal 2009 7.9 
Slovakia 2012 4.9 
Slovenia 2013 7.4 
Spain 2013 7.3 
Sweden 2010 4.7 
Switzerland 2012 7.3 
UK 2013 7.1 
Country Year Average length of stay 
Austria 2013 8.1 
Belgium 2012 6.9 
Czech Republic 2013 6.1 
Denmark 2010 3.9 
Estonia 2013 9.1 
Finland 2013 8.3 
France 2013 6.0 
Germany 2013 10.3 
Greece 2010 6.1 
Hungary 2012 7.9 
Iceland 2013 5.5 
Ireland 2013 7.1 
Israel 2013 6.0 
Italy 2013 7.8 
Luxembourg 2013 6.9 
The Netherlandsa 2012 5.6 
Norway 2010 4.0 
Poland 2013 6.2 
Portugal 2009 7.9 
Slovakia 2012 4.9 
Slovenia 2013 7.4 
Spain 2013 7.3 
Sweden 2010 4.7 
Switzerland 2012 7.3 
UK 2013 7.1 

Average length of stay (ALOS) provides the mean number of days the patients spend in hospital.

Excluding day cases.

Data cover all inpatient cases with the exception of the Netherlands.

a

Only curative/acute admission cases are considered, not all inpatient cases.

Source: OECD Health Statistics 2015, http://dx.doi.org/10.1787/health-data-en.

Summary and discussion

Mortality statistics show that CVD remains the most common cause of death in Europe, accounting for 45% of all deaths; 49% of deaths among women and 40% among men. More than 4 million people die from CVD across Europe every year, with 1.4 million of these deaths before the age of 75 years.

There remains evidence of wide inequalities across Europe in the burden of CVD mortality and the changes in rates of death from these diseases. In this article we demonstrate that along with the higher rates found in Eastern Europe, as discussed in the 2015 update,8 EU member countries, on average, suffer a lesser burden from CVD mortality, with EU-15 countries that have been members of the EU the longest, on average experiencing the lowest burden. In addition the 12 countries in which the mortality burden from CVD decreased sufficiently, such that the number of deaths from CVD is less than that from cancer in men, along with the two countries in which this has happened in women, are all found in Western Europe.

Although death rates for all countries were age-standardized for between-country and across time comparability, it should be noted that these rates are only standardized for the age structure of the population and do not standardize other aspects of these populations. For example, migration and other features of population structure may vary between countries and across the years of data presented here, but these changes are not accounted for when standardizing using the ESP13.

The burden of CVD in Europe is not confined to mortality and this is the first time in this series of papers that we present data on DALYs and prevalence. DALYs, presented here as crude population rates, were higher in Eastern European countries; however, as these rates are not standardized for age or sex, some differences may be due to different population distributions between countries. The European Social Survey collects self-reported data from individuals on whether they have suffered heart or circulation problems and once again show large inequalities in prevalence between countries. It should be noted that self-reported prevalence estimates can be subject to recall and reporting bias. An apparently higher prevalence may also be an indication of more efficient identification and diagnosis of these conditions in the population, such that it does not account for undiagnosed CVD, which may cause a large hidden burden to countries. In addition, although the European Social Survey asks participants to report whether they have suffered these problems in the past 12 months, it may not account for individuals who have ever suffered CVD problems, which would provide a more meaningful measure of prevalence, i.e. those who have recovered from heart or circulation problems, or who are having it controlled, may report that they do not currently suffer such problems. In addition, as there is no measure of whether the problems started in the preceding 12 months or earlier, this cannot be used as a measure of incidence. With such prevalence and incidence data unavailable from a central source the survey provides the best cross-European data we have identified.

Increasing hospitalization rates demonstrate an increasing burden of CVD in health systems despite decreasing mortality rates. Differences between countries in rates of discharge may be a reflection of health service access and efficiency as well as CVD burden. It is influenced by not only the quality of care provided in hospitals but also differences in hospital transfers, average length of stay, and severity of condition on admission.15 A number of factors can help to reduce case-fatality, including access to high-quality acute care, timely transportation of patients, evidence-based medical interventions, and high-quality specialized health facilities for AMI and stroke.15

Several factors can explain differences between countries in length of stay following CVD events. In addition to the clinical need of the patient, these variations are also likely to reflect differences in clinical practices and payment systems. In order to encourage shorter ALOS many countries have adopted a number of options, including increased uptake of less invasive surgical procedures, changes in hospital payment methods, and support for hospitals to improve the co-ordination of care across diagnosis, treatment and follow-up.15 The average length of stay (ALOS) in hospitals is often regarded as a good indicator of health system efficiency as shorter stays should result in a smaller financial burden on the health service of that country. However, although a correlation has been found between average hospital costs and ALOS following AMI, too short an ALOS could also cause adverse effects on health outcomes, meaning that costs per episode of illness may fall only slightly, or even rise.16,17 In addition, a life-threatening illness such as AMI can have a profound psychological effect on patients and they may not be emotionally prepared for discharge at 72 h even if no complications have occurred.18

In addition to the limitations of the data described in the Methods and Discussion, the main limitation of this article is that it aims to be a descriptive piece compiling data on CVD in Europe, to provide an overview of the burden of CVD across the continent. It cannot, therefore, explain some of the patterns in CVD that are presented throughout it. In addition, as the study does not have access to the raw data on many occasions, we are not able to present measures on the robustness of all the statistics we present here. In addition, where we do report data and standardize them using crude or age-standardized population rates, we cannot account for migration, non-citizens, and other features of population structure.

This latest update on the epidemiology of CVD within Europe presents new evidence on the inequality in CVD burden, described through mortality, morbidity, and treatment throughout Europe. This supports calls for more research into improved outcomes in Western and EU countries and the collection of improved data to make comparisons on mortality and morbidity between countries, in order that interventions can be better targeted to combat inequalities. In particular incidence and prevalence data across Europe are weak in comparison to mortality statistics and these along with data on the hidden burden of CVD, i.e. CVD conditions that are currently not identified by health services or within national statistics, would be invaluable to epidemiologists and those working in public health.

Supplementary material

is available at European Heart Journal online.

Funding

N.T., L.W., P.B., K.W. (006/P&C/CORE/2013/OXFSTATS), and M.R. (006/PSS/CORE/2016/OXFORD) received funding from the British Heart Foundation. MN is supported by an Alfred Deakin Postdoctoral Fellowship.

Conflict of interest: none declared.

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