Cardiovascular mortality in Russia and other countries David Leon (david.leon@lshtm.ac.uk) London School of Hygiene & Tropical Medicine, Arctic University of Norway, UiT Cardiovascular Epidemiology Course Kazan, April 2015

Global trends in life-expectancy at birth

Trends in life expectancy at birth by global region 1950-2010 World

Trends in life expectancy at birth by global region 1950-2010 N America Oceania Latin America Asia

Trends in life expectancy at birth by global region 1950-2010 Europe Africa

Recent European trends

Trends in European life expectancy 1970-2009 Source : Leon, IJE, 2011

Life expectancy at birth 1955 - 2010 EU members (pre-2005) Russia

Life expectancy at birth 1955 - 2010 Russia 64 (2011) UK 79 (2011) Russia 76 (2011) UK 83 (2011) Ru and Tatarstan from Evgueny Andreev. UK and Norway from GBD

Life expectancy at birth 1955 - 2010 EU members (pre-2005) Russia Gorbachev anti-alcohol campaign Gorbachev anti-alcohol campaign

Life expectancy at birth 1955 - 2010 EU members (pre-2005) Russia Collapse of Soviet Union Collapse of Soviet Union

Life expectancy at birth 1955 - 2010 EU members (pre-2005) Russia Chaos and economic liberalisation Chaos and economic liberalisation

Life expectancy at birth 1955 - 2010 EU members (pre-2005) Foreign currency crisis Russia Foreign currency crisis

Life expectancy at birth 1955 - 2010 EU members (pre-2005) Putin elected Russia Putin elected

Hazardous alcohol consumption strongly implicated in fluctuations

Strong evidence that alcohol drives fluctuations in male life expectancy in Russia 1965 -2008 Source : V. Shkolnikov and E. Andreev

Cardiovascular Disease

Two major classes of cardiovascular mortality Ischaemic Heart Disease (includes heart attack / myocardial infarction) Stroke (cerebrovascular event/accident)

Cardiovascular disease makes a major contribution to Russia’s low life expectancy Life expectancy at birth (years) in 2009 Men Women United Kingdom 78.1 82.3 Russian Federation 62.7 74.7 Difference (UK minus Russia) 15.4 7.6 Contribution of CVD to difference 7.5 6.3 Contribution of IHD to difference 4.0 3.2 Cardiovascular disease accounts for 49% of life expectancy difference between UK and Russia and 83% for women

International trends in cardiovascular mortality rates in adults from 1950 (30+ years) Source : M. Ezzati et al Nat.Rev.Cardiol. 2015 (In Press)

Men Women

Men Women

Russia and other former communist countries are different

Men Women

Explaining long term trends is difficult !

Classic Risk Factors for IHD Cholesterol (low-density lipoprotein) Smoking Obesity / Physical activity Blood pressure Diabetes

Revolution in treatment of cardiovascular disease Probably relatively little until the mid 1960s but then things gradually changed Hypertension Thiazide diuretics Beta blockers ACE inhibitors Lipids Statins Arrythmias Calcium channel blockers Pacemakers Catheter ablation Acute myocardial infarction Anti-arrhythmics Thrombolysis, now primary percutaneous coronary intervention Anti-platelet agents Secondary prevention with beta blockers, ACE inhibitors, anti-platelet agents, and statins

What explains the improvement in cardiovascular outcomes in western countries after 1980 ? Findings using the “IMPACT” model Note : This is a “model”

Explaining the fall in IHD deaths in the USA 1980-2000 NEJM 2007; 356: 2388. Risk Factors worse +17% Obesity (increase) +7% Diabetes (increase) +10% Risk Factors better -61% Population BP fall -20% Smoking -12% Cholesterol (diet) -24% Physical activity -5%  Treatments -47% AMI treatments -10% Secondary prevention -11% Heart failure -9% Angina:CABG & PTCA -5% Hypertension therapies -7% Statins (primary prevention) -5%   Unexplained -9% CHD deaths 341,745 fewer deaths in 2000  1980 2000

IHD mortality fall Poland 1991-2005 P. Bandoz et al BMJ 2012 Risk Factors worse +7% Obesity (increase) +4.5% Diabetes (increase) +2.5% Risk Factors better -66% Cholesterol (diet) -39% Smoking - 11% Physical activity -10% Population BP fall 0% (Men Women)  Treatments -38% AMI treatments -5 % Unstable angina -4% Secondary prevention -7% Heart failure -12% Angina: CABG surgery -2% Angina ASA - 1 % Hypertension therapies -2% Statins (Primary prevention) -3%   Unexplained -10% 26,200 fewer deaths in 2005  1991 2005 30

Understanding Ischaemic Heart Disease in Russia

Understanding Ischaemic Heart Disease in Russia ... Inadequate data ....

Smoking

Estimated contribution of smoking to circulatory disease mortality at ages 35-69 years 33% male deaths 3% female deaths [in 2010] The percentages were from report sent to DL on 14 May 2013 of updated analyses for 2010 Source : http://www.ctsu.ox.ac.uk/deathsfromsmoking/

But … smoking cannot explain massive fluctuations over time

Ischaemic heart disease mortality, in Russia, 1970 – 2010 (age <65 years) Men Age-standardised rate per 100,000 Russia UK Norway Source : WHO HFA database

Trends of adult smoking rates in Russia, 1992–2009 Source : Lunze K &Migliorini L. BMC Public Health 2013;13:64

Smoking cannot explain why Russian women have such high rates compared to other countries

Hypertension High rates in Russia compared to other European countries Poor rates of control Likely to be an important factor Note : no good national data available

Paradoxical lipid profile relative to other countries Prevalence of raised total cholesterol not high Levels of low density lipoprotein (LDL - bad cholesterol) tend to be average or below average Levels of high density lipoprotein (HDL - “good” cholesterol) above average Note : no good national data available

Lipid profiles in Russia, USA and Finland “Good” cholesterol marker “Bad” cholesterol marker Source : M. Averina et al Clin.Chem. 50 (2):346-354, 2004

Classic risk factors do not explain international differences 10-year Norwegian myocardial infarction risk score Men Women Arkhangelsk study (1999-2000) 33.8 3.9 Finnmark study (1987-88) 55.3 9.6 Tromsø study (1994-95) 45.9 9.8

Hazardous Drinking and CVD fluctuations

Source : Data provided by Evgueny Andreev

Heart disease (IHD) mortality in Russia is not typical Lipid profiles are not very pro-atherogenic relative to other countries although good data limited Very high excess burden cardiovasclar mortality at working ages relative to other countries Massive fluctuations in ischaemic heart disease mortality over time Hazardous alcohol drinking implicated (mechanism unclear) Many deaths attributed to “other ischaemic heart disease” [ICD10 I24]. Is there misclassification ?

Conclusion Reasons for Russia’s very high mortality from cardiovascular disease not fully understood Contribution of barriers to effective treatment unknown Alcohol effects are a challenge to the dominant view that it is cardioprotective

Спасибо Thank you