Decline of coronary heart disease mortality is strongly effected by changing patterns of underlying causes of death: an analysis of mortality data from 27 countries of the WHO European region 2000 and 2013

Abstract

Mortality rates for coronary heart disease (CHD) experience a longstanding decline, attributed to progress in prevention, diagnostics and therapy. However, CHD mortality rates vary between countries. To estimate whether national patterns of causes of death impact CHD mortality, data from the WHO "European detailed mortality database" for 2000 and 2013 for populations aged ≥ 80 years was analyzed. We extracted mortality rates for total mortality, cardiovascular diseases, neoplasms, dementia and ill-defined causes. We calculated proportions of selected causes of death among all deaths, and proportions of selected cardiovascular causes among cardiovascular deaths. CHD mortality rates were recalculated after re-coding ill-defined causes of death. Association between CHD mortality rates and proportions of CHD deaths was estimated by population-weighted linear regression. National patterns of causes of death were divers. In 2000, CHD was assigned as cause of death in 13-53% of all cardiovascular deaths. Until 2013, this proportion changed between - 65% (Czech Republic) and + 57% (Georgia). Dementia was increasingly assigned as underlying cause of death in Western Europe, but rarely in eastern European countries. Ill-defined causes accounted for between < 1% and 53% of all cardiovascular deaths. CHD mortality rates were closely linked to a countries' proportion of cardiovascular deaths assigned to CHD (R² = 0.95 for 2000 and 0.99 for 2013). We show that CHD mortality is considerably influenced by national particularities in certifying death. Changes in CHD mortality rates reflect changes in certifying competing underlying causes of death. This must be accounted for when discussing reasons for the CHD mortality decline.

Keywords: Causes of death; Coronary heart disease mortality; Mortality patterns; Mortality registry data.

Fig. 1

Mortality rate for cardiovascular diseases (CVD, I00-I99) for the population 80 years and older in 2000 and 2013 in the WHO European region. Countries with CVD mortality data available for 2000 (UK: 2001) and 2013 (DK: 2012), ordered by CVD mortality rate 2000. Abbr. BE Belgium, CH Switzerland, CZ Czech Republic, DE Germany, DK Denmark, EE Estonia, ES Spain, FI Finland, FR France, GE Georgia, HR Croatia, HU Hungary, IL Israel, KG Kyrgyzstan, LT Lithuania, LU Luxembourg, LV Latvia, MD Moldova, MT Malta, NL The Netherlands, NO Norway, PL Poland, RO Romania, RS Serbia, SE Sweden, SK Slovakia, UK United Kingdom. Countries of the WHO European Region include: Albania, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Montenegro, Netherlands, Norway, Poland, Portugal, Republic of Moldova, Romania, Russian Federation, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, The former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, United Kingdom, Uzbekistan

Fig. 2

Mortality rates for coronary heart disease (CHD, ICD10: I20-I25) in the population 80 years and older in 2000 and 2013 in the WHO European Region. Countries with CHD mortality data available for 2000 (UK: 2001) and 2013 (DK: 2012). Countries ordered by CHD mortality rate 2000. Panel A: as reported. Panel B: after redistribution and recoding of ill-defined deaths (ICD-10: I10, I46, I50, I70 and R-codes). Coding method: black asterisk automated coding, green asterisk manual coding, red asterisk change between 2000 and 2013 from manual to automated coding (https://ec.europa.eu/eurostat/cache/metadata/en/hlth_cdeath_esms.htm. Access 14.9.2020). BE and DE implemented automated coding only in some parts of the country. Information on mortality statistics in the Republic of Moldova indicate manual coding. No information available for Israel, Georgia and Kazakhstan. Abbr.: BE Belgium, CH Switzerland, CZ Czech Republic, DE Germany, DK Denmark, EE Estonia, ES Spain, FI Finland, FR France, GE Georgia, HR Croatia, HU Hungary, IL Israel, KG Kyrgyzstan, LT Lithuania, LU Luxembourg, LV Latvia, MD Moldova, MT Malta, NL The Netherlands, NO Norway, PL Poland, RO Romania, RS Serbia, SE Sweden, SK Slovakia, UK United Kingdom

Fig. 3

Among all deaths, proportions of deaths from cardiovascular diseases (CVD, I00-I99), neoplasms (C00-D48), R-coded and dementia related (F01, F03, G30) deaths in the population 80 years and older in the WHO European Region in 2000 (left panel) and 2013 (right panel). Countries ordered by proportion of deaths from cardiovascular diseases in 2000. Numbers within bars represent the proportions; proportions less than 0.5 are not given. Abbr.: BE Belgium, CH Switzerland, CZ Czech Republic, DE Germany, DK Denmark, EE Estonia, ES Spain, FI Finland, FR France, GE Georgia, HR Croatia, HU Hungary, IL Israel, KG Kyrgyzstan, LT Lithuania, LU Luxembourg, LV Latvia, MD Moldova, MT Malta, NL The Netherlands, NO Norway, PL Poland, RO Romania, RS Serbia, SE Sweden, SK Slovakia, UK United Kingdom

Fig. 4

Among all cardiovascular deaths, proportion of deaths from selected cardiovascular diseases in populations 80 years and older in the WHO European Region in 2000 (left panel) and 2013 (right panel). Ill-defined cardiovascular causes (essential hypertension, cardiac arrest, heart failure and atherosclerosis) are indicated by reddish filling. Numbers represent the respective proportions. Numbers in the reddish bar indicate the proportion of all selected ill-defined causes combined; proportions less 0.5 are not given. Countries are ordered according to their proportion of deaths from coronary heart disease in 2000. Abbr.: BE Belgium, CH Switzerland, CZ Czech Republic, DE Germany, DK Denmark, EE Estonia, ES Spain, FI Finland, FR France, GE Georgia, HR Croatia, HU Hungary, IL Israel, KG Kyrgyzstan, LT Lithuania, LU Luxembourg, LV Latvia, MD Moldova, MT Malta, NL The Netherlands, NO Norway, PL Poland, RO Romania, RS Serbia, SE Sweden, SK Slovakia, UK United Kingdom

Fig. 5

Association of the proportion of coronary heart disease among all causes of death and the coronary heart disease mortality rate in populations 80 years and older in the WHO European region in 2000 (red dots) and 2013 (blue dots). Explained variances of population-weighted linear regression: R² = 0.95 for 2000 and R² = 0.99 for 2013. (Not shown due to better readability of the graph: data for MD in 2000: 62; 11.385 and 2013: 61; 8.111 and for KG in 2013: 62; 8.826). Abbr.: BE Belgium, CH Switzerland, CZ Czech Republic, DE Germany, DK Denmark, EE Estonia, ES Spain, FI Finland, FR France, GE Georgia, HR Croatia, HU Hungary, IL Israel, KG Kyrgyzstan, LT Lithuania, LU Luxembourg, LV Latvia, MD Moldova, MT Malta, NL The Netherlands, NO Norway, PL Poland, RO Romania, RS Serbia, SE Sweden, SK Slovakia, UK United Kingdom

Fig. 6

Association of the proportion of coronary heart disease among all causes of death and the coronary heart disease mortality rate in populations 80 years and older in the WHO European region in 2000 and 2013. Explained variances: R² = 0.95 for 2000 and R² = 0.99 for 2013