1. Cardiovascular mortality in Russia and other countries
David Leon
London School of Hygiene & Tropical Medicine,
Arctic University of Norway, UiT
Cardiovascular Epidemiology Course
Kazan, April 2015

2. Global trends in life-expectancy at birth

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

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

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

6. Recent European trends

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

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

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

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

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

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

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

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

15. Hazardous alcohol consumption strongly implicated in fluctuations

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

17. Cardiovascular Disease

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

19. 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

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

21. Men Women

22. Men Women

23. Russia and other former communist countries are different

24. Men Women

25. Explaining long term trends is difficult !

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

27. 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

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

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

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

31. Understanding Ischaemic Heart Disease in Russia

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

33. Smoking

34. Estimated contribution of smoking to circulatory disease mortality at ages 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 :

35. But … smoking cannot explain massive fluctuations over time

36. 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

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

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

39. 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

40. 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

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

43. Classic risk factors do not explain international differences
10-year Norwegian myocardial infarction risk score
Men
Women
Arkhangelsk study ( )
33.8
3.9
Finnmark study ( )
55.3
9.6
Tromsø study ( )
45.9
9.8

44. Hazardous Drinking and CVD fluctuations

45. Source : Data provided by Evgueny Andreev

46. 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 ?

47. 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

48. Спасибо Thank you