Direct medical costs of ischemic heart disease in urban Southern China: a 5-year retrospective analysis of an all-payer health claims database in Guangzhou City

Introduction

This study aimed to estimate the direct medical costs and out-of-pocket (OOP) expenses associated with inpatient and outpatient care for IHD, based on types of health insurance. Additionally, we sought to identify time trends and factors associated with these costs using an all-payer health claims database among urban patients with IHD in Guangzhou City, Southern China.

Methods

Data were collected from the Urban Employee-based Basic Medical Insurance (UEBMI) and the Urban Resident-based Basic Medical Insurance (URBMI) administrative claims databases in Guangzhou City from 2008 to 2012. Direct medical costs were estimated in the entire sample and by types of insurance separately. Extended Estimating Equations models were employed to identify the potential factors associated with the direct medical costs including inpatient and outpatient care and OOP expenses.

Results

The total sample included 58,357 patients with IHD. The average direct medical costs per patient were Chinese Yuan (CNY) 27,136.4 [US dollar (USD) 4,298.8] in 2012. The treatment and surgery fees were the largest contributor to direct medical costs (52.0%). The average direct medical costs of IHD patients insured by UEBMI were significantly higher than those insured by the URBMI [CNY 27,749.0 (USD 4,395.9) vs. CNY 21,057.7(USD 3,335.9), P < 0.05]. The direct medical costs and OOP expenses for all patients increased from 2008 to 2009, and then decreased during the period of 2009-2012. The time trends of direct medical costs between the UEBMI and URBMI patients were different during the period of 2008-2012. The regression analysis indicated that the UEBMI enrollees had higher direct medical costs (P < 0.001) but had lower OOP expenses (P < 0.001) than the URBMI enrollees. Male patients, patients having percutaneous coronary intervention operation and intensive care unit admission, patients treated in secondary hospitals and tertiary hospitals, patients with the LOS of 15-30 days, 30 days and longer had significantly higher direct medical costs and OOP expenses (all P < 0.001).

Conclusions

The direct medical costs and OOP expenses for patients with IHD in China were found to be high and varied between two medical insurance schemes. The type of insurance was significantly associated with direct medical costs and OOP expenses of IHD.

Temporal trend in mortality of cardiovascular diseases and its contribution to life expectancy increase in China, 2013 to 2018

BACKGROUNDS

Cardiovascular disease (CVD) remains the leading cause of deaths nationwide. However, little is understood about its temporal trend and corresponding influence on longevity improvements. We aimed to describe the updated tendency in CVD mortality and to quantify its impact on life expectancy (LE) increase in China.

METHODS

All-cause mortality rates were calculated with population sizes from the National Bureau of Statistics and death counts from the National Health Commission. We estimated CVD mortality rates by allocating age- and sex-based mortality envelopes to each CVD subtype based on its proportion derived from the Disease Surveillance Points system. The probability of CVD premature deaths and LE were calculated with life tables and we adopted Arriaga's method to quantitate age- and cause-specific contributions to LE gains.

RESULTS

During 2013 to 2018, the age-standardized mortality rate of CVD decreased from 289.69 (95% confidence interval [CI]: 289.03, 290.35)/100,000 to 272.37 (95%CI: 271.81, 272.94)/100,000, along with a decline in probability of CVD premature deaths from 9.05% (95%CI: 9.02%, 9.09%) to 8.13% (95%CI: 8.10%, 8.16%). The gap in CVD mortality across sexes expanded with more remarkable declines in females, especially for those aged 15 to 64 years. Among major subtypes, the probability of premature deaths from hemorrhage stroke declined fastest, while improvements of ischemic stroke and ischemic heart disease were limited, and there was an increase in stroke sequelae. LE in China reached 77.04 (95%CI: 76.96, 77.12) years in 2018 with an increase of 1.38 years from 2013. Of the total LE gains, 21.15% (0.29 years) were attributed to reductions of CVD mortality in the overall population, mostly driven by those aged >65 years.

CONCLUSIONS

The general process in reducing CVD mortality has contributed to longevity improvements in China. More attention should be paid to prevention and control of atherosclerotic CVD and stroke sequelae, especially for the elderly. Working-age males also deserve additional attention due to inadequate improvements.

Health Inequalities of STEMI Care Before Implementation of a New Regional Network: A Prefecture-Level Analysis of Social Determinants of Healthcare in Yunnan, China

BACKGROUND

As one of the most serious types of coronary heart disease, ST-elevation myocardial infarction (STEMI) faces huge challenges in the equal management and care of patients due to its life-threatening and time-critical condition. Health inequalities such as sex and age differences in STEMI care have been reported from developed countries. However, limited outcomes have been investigated and the major drivers of inequality are still unclear, especially in under-developed areas. This study aimed to explore the major drivers of health inequalities in STEMI care before implementation of a new regional network in the south-west of China.

METHODS

Prefecture-level data of STEMI patients before the implementation of a regional network were analysed retrospectively. Drivers of inequality were identified from six social determinants of health, namely area of residence, ethnicity, sex, age, education and occupation. Outcomes of STEMI care included timely presentation, reperfusion therapy, timely reperfusion therapy, heart failure, inpatient mortality, length of hospital stay, hospital costs, and various intervals of ischaemic time.

RESULTS

A total of 376 STEMI patients in the research area before implementation of the STEMI network were included. Compared with urban residents, rural patients were significantly less likely to have timely presentation (odds ratio [OR]=0.47, 95% CI: 0.28-0.80, P=.004) and timely reperfusion therapy (OR=0.32, 95% CI: 0.14-0.70, P=.005). Rural residents were less likely to present to hospital promptly than urban residents (HR=0.65, 95% CI=0.52-0.82, P<.001). In the first 3 hours of percutaneous coronary intervention (PCI) reperfusion delay and first 6 hours of total ischaemic time, rural patients had a significantly lower probability to receive prompt PCI (hazard ratio [HR]=0.40, 95% CI: 0.29-0.54, P<.001) and reperfusion therapy (HR=0.37, 95% CI: 0.25-0.56, P<.001) compared to urban patients.

CONCLUSION

Rural residents were a major vulnerable group before implementation of the regional STEMI network. No obvious inequalities in ethnicity, sex, age, education or occupation existed in STEMI care in Chuxiong Prefecture of China.

Chemical composition, quality control, pharmacokinetics, pharmacological properties and clinical applications of Fufang Danshen Tablet: A systematic review

ETHNOPHARMACOLOGICAL RELEVANCE

Fufang Danshen Tablet (FDT) is a traditional Chinese medicine (TCM) formula composed of three Chinese medicinal materials comprising Salviae Miltiorrhizar Radix et Rhizoma (Dan-Shen in Chinese), Notoginseng Radix et Rhizoma (San-Qi), and Borneolum Syntheticum (Bing-Pian). It has been documented to exert significant effects in promoting blood circulation and removing blood stasis, and become a frequently used formula in the treatment of cardiovascular and cerebrovascular diseases.

AIM OF THE REVIEW

To systematically analyze and summarize the research findings concerning the chemical composition, quality control, pharmacokinetics, pharmacological properties, clinical applications, and toxicity of FDT, so as to point out some typical problems and provides opinions for future study.

MATERIALS AND METHODS

Literatures involving FDT were collected from online scientific databases including China National Knowledge Infrastructure, WanFang Data, PubMed, Science Direct, Scopus, Web of Science, Springer Link, SciFinder, and Google Scholar up to March 2021. All eligible studies are analyzed and summarized in this review.

RESULTS

This review summarizes reported results concerning the post-marketing quality and efficacy of FDT. Some problems are pointed out for FDT. Hereon we propose several directions for future study: (a) improvement of quality control based on exact overall chemical profiles, entire production process monitoring, and biopotency-associated multi-index content determination method; (b) clarification of functional mechanisms focused on pharmacokinetic profiles in human, interplay with gut microbiota, and integration of multi-omics technologies; (c) reconfirmation of clinical effectiveness and safety from large-scale clinical studies based on evidence-based medicine.

CONCLUSIONS

FDT is a typical TCM formula in treating cardiovascular and cerebrovascular diseases, but there are also some troubles. Future studies should focus on the improvement of quality control, the clarification of functional mechanisms, as well as the reconfirmation of clinical effectiveness and safety.

Aloin antagonizes stimulated ischemia/reperfusion-induced damage and inflammatory response in cardiomyocytes by activating the Nrf2/HO-1 defense pathway

Myocardial ischemia/reperfusion injury (I/RI) frequently incurs in acute myocardial infarction with high morbidity and mortality worldwide and is characterized with cardiomyocyte apoptosis and inflammatory response. Aloin is a major anthraquinone from Aloe species and fulfills pleiotropic protective functions in several disease models including hepatic injury. Nevertheless, the potential of aloin in MI/RI remains elusive. Intriguingly, aloin had modest cytotoxicity in H9c2 cardiomyocytes. Importantly, aloin dose-dependently ameliorated cell viability that was inhibited in response to simulated ischemia/reperfusion (SI/R) stimulation. Moreover, the enhanced apoptosis in cells under SI/R conditions were reduced after aloin treatment, concomitant with the decrease in pro-apoptotic Bax protein levels and increase in anti-apoptotic Bcl-2 protein expression. Of interest, aloin administration attenuated SI/R-induced oxidant stress by decreasing reactive oxygen species (ROS) production, lactate dehydrogenase (LDH), and malondialdehyde (MDA) release and increasing activity of anti-oxidant stress enzyme superoxide dismutase (SOD). Additionally, the elevated pro-inflammatory cytokine levels were counteracted after aloin treatment in cells under SI/R conditions, including TNF-α, IL-6, and IL-1β. Mechanically, aloin further enforced the activation of the NF-E2-related factor 2 (Nrf2)/heme oxygenase-1 (HO-1) signaling. Noticeably, blockage of this pathway by si-Nrf2 transfection blunted aloin-mediated cardioprotective efficacy against SI/R-evoked oxidative stress injury and inflammatory response. Thus, these findings corroborate that aloin may antagonize SI/R-induced cardiomyocyte injury by attenuating excessive oxidative stress and inflammation, thereby endorsing its potential as a promising therapeutic agent against myocardial infarction.

Spatiotemporal variations in ischemic heart disease mortality and related risk factors in China between 2010 and 2015: a multilevel analysis

Background

To explore the relationship between geographical differences of mortality and related risk factors in ischemic heart disease (IHD) in China.

Methods

Data were collected from the nationally representative China Mortality Surveillance System to calculate annual IHD mortality counts (2010–2015). Descriptive analysis was used to analyze the IHD mortality among Chinese population from 2010 to 2015. Negative binomial regression was used to investigate potential spatiotemporal variation and correlations with age, gender, urbanization, and region.

Results

The overall IHD mortality was 221.17/100,000, accounting for 1.51 million deaths in 2015. The standardized IHD mortality rate increased by 5.51% from 2010 to 2015 among people aged 40 years and older. Multilevel analysis indicated significant differences in gender, regions, and age. High urbanization rate (risk ratio [RR] = 0.728, 95% confidence interval [CI] = (0.631, 0.840)) and average high-density lipoprotein (HDL) (RR = 0.741, 95%CI: 0.616,0.891) were negatively associated with IHD mortality. IHD mortality was significantly higher in populations with a low rate of medical insurance coverage (RR = 1.218, 95%CI: 1.007, 1.473), as well as the average body mass index (BMI) (RR = 1.436, 95%CI: 1.135, 1.817) and systolic blood pressure (SBP) (RR = 1.310, 95%CI: 1.019, 1.684). While the relationship with current smoking rate, excessive intake of red meat, insufficient vegetable or fruits intake didn’t show the statistical significance. The negative correlation between the average sedentary time and IHD mortality was not conclusive due to the possible deviation of the data.

Conclusions

The mortality of IHD showed an upward trend for people aged 40 years and older in China during 2010–2015, which should be paid attention to. Therefore, some risk factors should be controlled, such as SBP, overweight/obesity. HDL is a protective factor, as well as higher urbanization rate, family income level, and medical insurance coverage.

miR-708 affords protective efficacy in anoxia/reoxygenation-stimulated cardiomyocytes by blocking the TLR4 signaling via targeting HMGB1

Ischemic heart disease is a proverbial and common cardiovascular disease, and constitutes a leading cause of disability and mortality globally. Myocardial ischemic/reperfusion (MI/R) injury is a highly orchestrated phenomenon that involves the excessive activation of high mobility group box 1 (HMGB1) signaling. In the present study, we sought to investigate the function of miR-708 in MI/R injury due to the predicted binding to HMGB1. Intriguingly, down-regulation of miR-708 and up-regulation of HMGB1 were observed in MI/R rat model and H9c2 cardiomyocytes exposed to hypoxia/reoxygenation (H/R) conditions. Dual luciferase reporter assays substantiated that HMGB1 was a direct target of miR-708. Moreover, miR-708 overexpression suppressed the mRNA and protein expression of HMGB1. Noticeably, elevation of miR-708 antagonized H/R-induced inhibition in cell viability; whilst, increased cell apoptosis evoked by H/R was restrained after miR-708 up-regulation. Simultaneously, miR-708 elevation suppressed H/R exposure-increased lactate dehydrogenase (LDH) release and reactive oxygen species (ROS) generation, but elevated the activity of anti-oxidative stress superoxide dismutase (SOD). Additionally, H/R-increased production of pro-inflammatory cytokine TNF-α and IL-6 was offset following miR-708 overexpression. Moreover, enhancement of miR-708 inhibited H/R-evoked activation of the HMGB1-TLR4-NF-κB pathway by inhibiting the protein levels of HMGB1, TLR4 and p-p65 NF-κB. Specially, restoring this pathway offset the protective effects of miR-708 on H/R-induced cardiomyocyte injury. Together, these data indicate that miR-708 may protect against H/R-induced cardiomyocyte damage by directing targeting HMGB1 signaling, implying a promising therapeutic agent against ischemic heart disease including myocardial infarction.

Holiday and weekend effects on mortality for acute myocardial infarction in Shanxi, China: a cross-sectional study

OBJECTIVES

To examine the effects of holiday and weekend admission on in-hospital mortality for patients with acute myocardial infarction (AMI) in China.

METHODS

Patients with AMI in 31 tertiary hospitals in Shanxi, China from 2014 to 2017 were included (N = 54,968). Multivariable logistic regression models were used to examine the effects of holiday and weekend admission on in-hospital mortality.

RESULTS

Compared to non-holiday and weekday admissions, holiday and weekend admissions, respectively, were associated with increases in risk-adjusted mortality rates. Chinese National Day was associated with an additional 10 deaths per 1000 admissions (95% confidence interval (CI): (0, 20))-a relative increase from baseline mortality of 64% (95% CI: (1%, 128%)). Sunday was associated with an additional 4 deaths per 1000 admissions (95% CI: (0, 7))-a relative increase from baseline mortality of 23% (95% CI: (3%, 45%)). We found no evidence of gender differences in holiday or weekend effects on mortality.

CONCLUSIONS

Holiday and weekend admissions were associated with in-hospital AMI mortality. The admissions on Chinese National Day and Sunday contributed to the observed "holiday effect" and "weekend effect," respectively.

Ischaemic heart disease and stroke mortality by specific coal type among non-smoking women with substantial indoor air pollution exposure in China

BACKGROUND

Lifetime use of bituminous ('smoky') coal is associated with nearly a 100-fold higher risk of lung cancer mortality compared with anthracite ('smokeless') coal use in rural Xuanwei, China, among women. Risk of mortality from ischaemic heart disease (IHD) and stroke for these coal types has not been evaluated.

METHODS

A cohort of 16 323 non-smoking women in Xuanwei, who were lifetime users of either smoky or smokeless coal, were followed up from 1976 to 2011. We estimated hazard ratios (HRs) and 95% confidence intervals (CI) to evaluate lifetime use of coal types and stoves in the home in relation to risk of IHD and stroke mortality.

RESULTS

Among lifetime users of smokeless coal, higher average exposure intensity (≥4 tons/year vs <2.5 tons/year, HR = 7.9, 95% CI = 3.5-17.8; Ptrend =<0.0001) and cumulative exposure (>64 ton-years vs ≤28 ton-years, HR = 6.5, 95% CI = 1.5-28.3; Ptrend =0.003) during follow-up and over their lifetime was associated with increased IHD mortality, and ventilated stove use dramatically reduced this risk (HR = 0.2, 95% CI 0.1-0.5). Higher cumulative exposure to smoky coal during follow-up showed positive associations with IHD mortality, but the evidence for other metrics was less consistent compared with associations with smokeless coal use.

CONCLUSIONS

Higher use of smokeless coal, which is burned throughout China and is generally regarded to be a cleaner fuel type, is associated with IHD mortality. Use of cleaner fuels or stove interventions may be effective in reducing the increasing burden of IHD in developing regions that currently rely on smokeless coal for cooking and heating.

European Society of Cardiology: Cardiovascular Disease Statistics 2019

AIMS

The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets.

METHODS AND RESULTS

In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5-23.1%] vs. 15.7% (IQR 14.5-21.1%)}, diabetes [7.7% (IQR 7.1-10.1%) vs. 5.6% (IQR 4.8-7.0%)], and among males smoking [43.8% (IQR 37.4-48.0%) vs. 26.0% (IQR 20.9-31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0-10.8) vs. 16.7% (IQR 13.9-19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655-8115)] compared with high-income [2235 (IQR 1896-3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures.

CONCLUSION

A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest.

FREQUENCY, DISTRIBUTION AND DETERMINANTS OF DIABETES MELLITUS IN ADULT ACUTE CORONARY SYNDROME POPULATION OF D.I.KHAN DIVISION, PAKISTAN

Background: Global Health Estimates 2015 has shown IHD as second leading global cause of death and 3rd leading global cause for DALYs for 2015. The objectives of this study were to determine frequency, distribution and determinants of DM in adult acute coronary syndrome (ACS) population of D.I.Khan Division, Pakistan. Materials & Methods: This cross-sectional study was conducted in Departments of Ophthalmology & Community Medicine, Gomal Medical College, D.I.Khan, from February 1, 2017 to April 30, 2017. 331 cases were selected with margin of error 4.511%, 90%CL and 25% prevalence of DM in 73,438 adults assumed to have IHD. All indoor adult patients of ACS were eligible. Sex, age groups, and residence and presence of DM were variables. Frequency and distribution were analyzed by count and percentage. Hypotheses for distribution were substantiated by chi-square goodness-of-fit and of association by chi-square test of association. Results: Out of 331 patients with ACS, 225 (68.0%) were men and 106 (32.0%) women, 221 (66.8%) ≤60 years and 110 (33.2%) >60 years, and 210 (63.4%) urban and 121 (35.6%) rural. Frequency of DM was 79/331 (23.87%). Out of 79 patients with DM, men were 44 (13.29%), women 35 (10.57%), age group ≤60 years 57 (17.22%), >60 years 22 (6.65%), urban 53 (16.01%) and rural 60 (7.85%). Our prevalence of DM was lower than expected (p=.00214), our distribution by sex was similar to expected (p=.4993) while our distribution for age groups (p=.01209) and residence (p=.00005) were not similar to expected. Presence of DM was associated to sex (p=.011) but not to age groups (p=.0304) and residence (p=.5241). Conclusion: Prevalence of DM in adult ACS population of D.I.Khan Division, Pakistan was found lower than expected. The prevalence was more in men than women, more in younger age group (≤60 years) than older age group (>60 years) and more in urban than rural population. Our prevalence of DM was lower than expected, our distribution by sex was similar to expected while our distribution for age groups and residence were not similar to expected. The presence of DM was associated to sex but not to age groups and residence.

Factors Associated With Hospitalization Costs of Coronary Heart Disease in Township Hospitals in Rural China

In large proportions of rural areas in many developing countries, health care delivery system is less developed and is less likely to be equipped to conduct sophisticated treatment for coronary heart disease (CHD) patients locally. This study aims at describing the status quo of and exploring factors associated with hospitalization costs of CHD in township hospitals where only drug therapy was available for CHD conditions. We collected data of inpatients with CHD from discharge records from 10 township hospitals in rural Liaoning from December 2013 to December 2014. We used multilevel linear regression to analyze the factors associated with CHD hospitalization costs. A total of 4635 inpatients were included in the analysis. We found that the average hospitalization costs were 6249.97 RMB (US$1012.47) with the average of 8.89 days of hospitalization in township hospitals in Liaoning. Age, gender, length of stay, the number of times of admissions, by which route was hospitalized, and type of CHD were all the factors significantly associated with hospitalization costs of CHD in township hospitals. The factors associated with hospitalization costs of CHD in township hospitals in rural China showed some different features from the existing studies. When the government designs the related policy, the policy makers need to consider the specific feature of hospitalization costs of CHD in township hospitals in rural areas.

Pre-hospital thrombolysis for ST-segment elevation myocardial infarction in regional Australia: long-term follow up

BACKGROUND

Delivering reperfusion therapy to patients with ST-segment elevation myocardial infarction (STEMI) in regional areas without access to tertiary cardiology care remains challenging. The systems of care in Hunter New England Health, New South Wales, Australia (area covered = 130 000 km² ) to provide reperfusion to patients with STEMI involve a 12-lead electrocardiogram in the ambulance, discussion between cardiologist and paramedic, followed by pre-hospital thrombolysis (PHT) delivered in ambulance to appropriate patients >60 min from the cardiac catheterisation laboratories. Patients who can access the cardiac catheterisation laboratories within 60 min are treated with primary percutaneous coronary intervention (PCI).

AIMS

We have previously reported excellent 12-month outcomes for patients receiving PHT and the aim of the current analysis is to look at the long term outcomes.

METHODS

We assessed long-term all-cause mortality and major adverse cardiovascular events of STEMI patients undergoing PHT in our health district from August 2008 to August 2013 and compared with the primary PCI group.

RESULTS

One hundred and fifty (mean age: 62 ± 13 years, males: 76%, n = 114) patients were administered PHT and 334 patients (mean age: 65 ± 13 years, males: 75%, n = 251) underwent primary PCI during the study period. During a median follow up of 6.2 years (interquartile range: 4.8-7.4 years) all-cause mortality was 16% and 19% in the PHT and primary PCI groups respectively (P = 0.4).

CONCLUSION

Our real-world experience shows that PHT followed by early transfer to a primary PCI-capable centre is an effective reperfusion strategy, with comparable results to primary PCI, and mortality benefits are sustained to more than 6 years.

European Society of Cardiology: Cardiovascular Disease Statistics 2017

Aims

The European Society of Cardiology (ESC) Atlas has been compiled by the European Heart Agency to document cardiovascular disease (CVD) statistics of the 56 ESC member countries. A major aim of this 2017 data presentation has been to compare high-income and middle-income ESC member countries to identify inequalities in disease burden, outcomes, and service provision.

Methods and results

The Atlas utilizes a variety of data sources, including the World Health Organization, the Institute for Health Metrics and Evaluation, and the World Bank to document risk factors, prevalence, and mortality of cardiovascular disease and national economic indicators. It also includes novel ESC-sponsored survey data of health infrastructure and cardiovascular service provision provided by the national societies of the ESC member countries. Data presentation is descriptive with no attempt to attach statistical significance to differences observed in stratified analyses. Important differences were identified between the high-income and middle-income member countries of the ESC with regard to CVD risk factors, disease incidence, and mortality. For both women and men, the age-standardized prevalence of hypertension was lower in high-income countries (18% and 27%) compared with middle-income countries (24% and 30%). Smoking prevalence in men (not women) was also lower (26% vs. 41%) and together these inequalities are likely to have contributed to the higher CVD mortality in middle-income countries. Declines in CVD mortality have seen cancer becoming a more common cause of death in a number of high-income member countries, but in middle-income countries declines in CVD mortality have been less consistent where CVD remains the leading cause of death. Inequalities in CVD mortality are emphasized by the smaller contribution they make to potential years of life lost in high-income countries compared with middle-income countries both for women (13% vs. 23%) and men (20% vs. 27%). The downward mortality trends for CVD may, however, be threatened by the emerging obesity epidemic that is seeing rates of diabetes increasing across all the ESC member countries. Survey data from the National Cardiac Societies showed that rates of cardiac catheterization and coronary artery bypass surgery, as well as the number of specialist centres required to deliver them, were greatest in the high-income member countries of the ESC. The Atlas confirmed that these ESC member countries, where the facilities for the contemporary treatment of coronary disease were best developed, were often those in which declines in coronary mortality have been most pronounced. Economic resources were not the only driver for delivery of equitable cardiovascular health care, as some middle-income ESC member countries reported rates for interventional procedures and device implantations that matched or exceeded the rates in wealthier member countries.

Conclusion

In documenting national CVD statistics, the Atlas provides valuable insights into the inequalities in risk factors, health care delivery, and outcomes of CVD across the ESC member countries. The availability of these data will underpin the ESC's ambitious mission 'to reduce the burden of cardiovascular disease' not only in its member countries but also in nation states around the world.