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Original research
Progress in reducing inequalities in cardiovascular disease mortality in Europe
  1. Chiara Di Girolamo1,2,
  2. Wilma J Nusselder2,
  3. Matthias Bopp3,
  4. Henrik Brønnum-Hansen4,
  5. Giuseppe Costa5,
  6. Katalin Kovács6,
  7. Mall Leinsalu7,8,
  8. Pekka Martikainen9,
  9. Barbara Pacelli10,
  10. José Rubio Valverde2,
  11. Johan P Mackenbach2
  1. 1 Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
  2. 2 Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands
  3. 3 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
  4. 4 Department of Public Health, University of Copenhagen, Copenhagen, Denmark
  5. 5 Department of Clinical Medicine and Biology, University of Turin, Torino, Italy
  6. 6 Demographic Research Institute, Budapest, Hungary
  7. 7 Stockholm Centre for Health and Social Change, Södertörn University, Huddinge, Sweden
  8. 8 Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallin, Estonia
  9. 9 Population Research Unit, University of Helsinki, Helsinki, Finland
  10. 10 Regional Health and Social Care Agency of Emilia-Romagna, Bologna, Italy
  1. Correspondence to Professor Johan P Mackenbach, Department of Public Health, Erasmus Medical Center, Rotterdam 3062 PA, Netherlands; j.mackenbach{at}


Objective To assess whether recent declines in cardiovascular mortality have benefited all socioeconomic groups equally and whether these declines have narrowed or widened inequalities in cardiovascular mortality in Europe.

Methods In this prospective registry-based study, we determined changes in cardiovascular mortality between the 1990s and the early 2010s in 12 European populations by gender, educational level and occupational class. In order to quantify changes in the magnitude of differences in mortality, we calculated both ratio measures of relative inequalities and difference measures of absolute inequalities.

Results Cardiovascular mortality has declined rapidly among lower and higher socioeconomic groups. Relative declines (%) were faster among higher socioeconomic groups; absolute declines (deaths per 100 000 person-years) were almost uniformly larger among lower socioeconomic groups. Therefore, although relative inequalities increased over time, absolute inequalities often declined substantially on all measures used. Similar trends were seen for ischaemic heart disease and cerebrovascular disease mortality separately. Best performer was England and Wales, which combined large declines in cardiovascular mortality with large reductions in absolute inequalities and stability in relative inequalities in both genders. In the early 2010s, inequalities in cardiovascular mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries.

Conclusions Lower socioeconomic groups have experienced remarkable declines in cardiovascular mortality rates over the last 25 years, and trends in inequalities can be qualified as favourable overall. Nevertheless, further reducing inequalities remains an important challenge for European health systems and policies.

  • cardiovascular diseases
  • mortality
  • inequalities
  • socioeconomic position
  • europe

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  • Contributors CDG conceptualised the study, analysed the data and prepared the first and subsequent drafts of themanuscript. JPM conceptualised the study, contributed to the interpretation of the results, critically reviewed the manuscript and contributed to the writing. WJN contributed to the data harmonisation, the study conceptualisation and commented on the manuscript. MB, HB-H, GC, KK, ML, PM and BP prepared the data and commented on the manuscript. JRV participated in the analysis. All authors approved the final version. JPM acts as guarantor of the study.

  • Funding This study was conducted as part of the LIFEPATH project, which has received financial support from the European Commission (Horizon 2020 grant number 633666). Data were partly collected as part of the DEMETRIQ project, which also received support from the European Commission (FP7-CP-FP grant number 278511). The mortality data for Switzerland were obtained from the Swiss National Cohort, which is based on mortality and census data provided by the Federal Statistical Office and supported by the Swiss National Science Foundation (grant nos. 3347CO-108806, 33CS30_134273 and 33CS30_148415). CeLSIUS is supported by the ESRC Census of Population Programme (Award Ref: ES/K000365/1). Chiara Di Girolamo was financially supported by a scholarship from the University of Bologna.

  • Disclaimer The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. This work uses research datasets that may not exactly reproduce National Statistics aggregates. The authors alone are responsible for the interpretation of the data.

  • Competing interests JPM reports grants from European Commission (Horizon 2020 grant number 633666, and FP7-CP-FP grant number 278511) during the conduct of the study.

  • Patient consent for publication Not required.

  • Ethics approval This work is based on a secondary analysis of routinely collected and fully anonymised administrative data and does not contain any studies with human participants performed by any of the authors. Informed consent or approval by a medical ethics board was not required under national regulations.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

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