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Epidemiology
Original article
Trends in cardiovascular mortality and hospitalisations, and potential contribution of inhospital case-fatality rates to changes in national mortality in the Czech Republic 1994–2009
  1. Hana Davídkovová1,2,3,
  2. Jan Kyselý1,
  3. Bohumír Kříž4,5,
  4. Petr Vojtíšek6,
  5. Martin Bobák7
  1. 1Institute of Atmospheric Physics, Academy of Sciences of the Czech Republic, Prague, Czech Republic
  2. 2Faculty of Science, Charles University, Prague, Czech Republic
  3. 3Institute of Geophysics, Academy of Sciences of the Czech Republic, Prague, Czech Republic
  4. 4Centre for Epidemiology and Microbiology, National Institute of Public Health, Prague, Czech Republic
  5. 5Third Faculty of Medicine, Charles University, Prague, Czech Republic
  6. 6Department of Cardiology, Regional Hospital, Pardubice, Czech Republic
  7. 7Department of Epidemiology and Public Health, University College London, London, UK
  1. Correspondence to Hana Davídkovová, Institute of Atmospheric Physics AS CR, Boční II 1401, Prague 141 31, Czech Republic; davidkov{at}ufa.cas.cz

Abstract

Objectives To analyse trends in cardiovascular disease (CVD) mortality and hospitalisations in the Czech Republic in 1994–2009 and to assess the contribution of inhospital case-fatality rates (CFR) to changes in national CVD mortality.

Design National hospitalisation and mortality registers were used to estimate rates of hospital admissions and mortality for hypertension, angina pectoris, acute myocardial infarction (AMI), chronic ischaemic heart disease chronic (IHD), heart failure and stroke.

Patients All hospitalisations and deaths from CVD during 1994–2009.

Main Outcome Measures Average annual relative changes in age-standardised mortality, hospital admission and inhospital CFR.

Results Between 1994 and 2009, 5 409 407 hospital admissions and 930 659 deaths from CVD were recorded. The age-standardised CVD mortality rate fell from 561 to 357 per 100 000 population (mean annual decline 3.1%) but hospitalisation rates remained relatively stable, with 2800 admissions per 100 000 per year (annual decline 0.7%). Inhospital CFR decreased significantly in all examined diagnoses but most rapidly for AMI (by 5.5% per year) and stroke (4.2% per year). The improvements were larger in the younger population than in elderly persons. Calculations based on unlinked mortality and hospitalisation data suggest that a decline in inhospital CFR may explain approximately 24%, 41% and 61% of the decline in national deaths from IHD, AMI and stroke, respectively.

Conclusions During the study period, the overall CVD hospitalisation rates remained high but inhospital CFR declined considerably. The improved case-fatality seems to have made a substantial contribution to the decline in the national CVD mortality, particularly for AMI and stroke.

  • Heart Failure
  • Hypertension
  • Myocardial Ischaemia And Infarction (IHD)
  • Coronary Artery Disease

https://doi.org/10.1136/heartjnl-2012-303123

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    Introduction

    Despite declining trends in cardiovascular disease (CVD) mortality, incidence and case fatality in most European countries,1–3 CVD remains the leading cause of illness and death in Europe.4 Over the past few decades, mortality rates from ischaemic heart disease (IHD) and stroke have been considerably higher in central and eastern Europe than in western Europe.2 ,5 ,6 In the Czech Republic, a decrease in mortality from CVD in men and women (25–64 years of age) has been reported since 1984;7 ,8 the declining trend has been attributed to improvement and control of CVD risk factors, such as hypertension and high cholesterol.8 This is consistent with estimates for the decline in IHD in Poland and other European countries,9 although the contribution of improved treatment in the Czech Republic remains unknown.

    A major limitation of most studies on the population level of CVD is the reliance on routine mortality registration; since the termination of the WHO MONICA project (in 1990), information on trends in non-fatal CVD is sparse in most European countries. The lack of data on non-fatal CVD is important, because it hampers answering crucial questions about trends in rates of overall (fatal plus non-fatal) and non-fatal disease and about the contribution of improved survival. Indeed, most estimates of the role of treatment and survival in overall mortality are based on modelling10 rather than directly observed data.

    The aim of this study is to shed light on the levels and trends in fatal and non-fatal CVD in the Czech Republic. In particular, we investigated trends in hospital admissions and inhospital case-fatality of selected cardiovascular diagnoses, compared them with national CVD mortality in 1994–2009, and estimated the potential contribution of improved case-fatality rates (CFR) to declining mortality from acute myocardial infarction (AMI) and stroke.

    Methods

    Data on mortality

    Data on mortality were collected and processed by the Czech Statistical Office; the database was transferred to the Institute of Health Information and Statistics (IHIS), which provided us with deaths from CVD. The database covers all deaths with CVD coded as the primary cause of death over 1994–2009 in the Czech Republic using the International Classification of Disease, version 10 (ICD-10) classification (adopted in the Czech Republic since 1994), a total of 930 659 records. The autopsy rate in the Czech Republic remains relatively high (29%), with little change since 1994.11 Each record includes the day of death, age at death, gender and district. The following ICD-10 codes were analysed: all CVD: I00–I99, AMI: I21–I22, chronic IHD: I25; heart failure: I50; and stroke: I60–I64.

    Data on hospital admissions and inhospital CFR

    Data on hospitalisation for CVD were obtained from the National Registry of Hospitalised Patients, administered by IHIS. The database consists of admissions for a CVD event among all resident people to any hospital in the Czech Republic from 1994 to 2009, a total of 5 409 407 records. Each record includes patient demographic information (age, gender, occupation and district), date of admission and primary diagnosis according to ICD-10. The primary diagnosis is defined as the condition most responsible for a patient's hospitalisation and coded on discharge from hospital. Registration of all discharged patients in the National Registry of Hospitalised Patients is mandatory, and data are coded by physicians. The same diagnoses as for mortality were analysed; in addition, hypertension (I10–I15) and angina pectoris (I20), for which numbers of deaths were small, were also included.

    Possible multiple records of a single CVD episode were merged to a single record (processed by IHIS) to avoid double-counting. As each hospitalisation was recorded at discharge, the incomplete data at the end of 2009 were supplemented using discharges recorded in 2010 so that the 16-year period of 1994–2009 is covered fully. Total CVD admissions were defined as all hospital admissions for CVD, including those resulting in death. Inhospital CFR was defined as the proportion of deaths among admissions to hospital with CVD being primarily responsible for hospitalisation.

    Statistical analysis

    The population of the Czech Republic was 10 336 162 in 1994 and 10 491 492 in 2009.12 Annual counts of CVD hospitalisations and deaths, for each diagnosis separately, were stratified by gender and 5-year age groups (from 0 to 85+ years), and age-adjusted hospital rates of admissions, mortality and inhospital CFR per 100 000 persons were calculated by the direct method, using the mid-year population of the Czech Republic and the standard WHO European population as the standard. In addition, we also calculated age-specific hospitalisation and death rates per 100 000 population in several age bands: 20–49, 50–64, 65–74 and 75+ years. Trends in age-standardised rates were assessed by linear regression and expressed as the average annual relative change. The statistical significance of the trends was evaluated using the t test.

    The contribution of declining inhospital CFR to changes in the total number of deaths between 1994 and 2009 was estimated for IHD (I20, I21, I22, I25), AMI and stroke (diagnoses with sufficient numbers of events). First, we calculated the predicted reduction in absolute number of deaths between 1994 and 2009 by subtracting the estimated number of deaths in 2009 (obtained by multiplying the observed number of deaths in 1994 by the ratio of age-standardised mortality rates in 2009–1994) from observed deaths in 1994. Second, we estimated the reduction in inhospital deaths by multiplying the observed number of admissions in 1994 by the 2009 CFR and subtracting it from the number of observed inhospital deaths in 1994. Finally, the reduction in inhospital deaths was divided by the reduction in all deaths to obtain the proportion of the national mortality reduction that could be explained by a reduction in inhospital deaths.

    Results

    Mortality

    In men and women combined, the age-standardised mortality from all CVD declined from 561 in 1994 to 357 per 100 000 in 2009, with an annual relative reduction of approximately 3.1% (table 1). Rapid declines were observed for deaths from AMI and stroke (annual relative reduction of 6.8% and 5.1%, respectively) but not for deaths from chronic IHD and heart failure (figure 1). As expected, men were more likely to die from CVD than women (accounting for 60% of CVD deaths), and the difference was more pronounced in middle-aged individuals (table 2). In the oldest age group (75+ years), the most common cause of death was chronic IHD, with more than 2000 deaths per 100 000 men and women. In age-stratified analyses, chronic IHD death rates decreased noticeably only at younger ages (20–49 years) and in the 65–74 years age group, but mortality from AMI and stroke fell in all age groups (table 2).

    View this table:
    Table 1

    CVD mortality, hospital admissions and inhospital case-fatality in the Czech Republic, 1994–2009

    View this table:
    Table 2

    CVD mortality per 100 000 population in the Czech Republic, 1994–2009

    Figure 1
    Figure 1

    Age-standardised cardiovascular mortality rates by primary cause of death per 100 000 population in the Czech Republic, in 1994–2009. Rates are calculated using the European population as the standard.

    Hospital admissions

    The age-standardised hospitalisation rate for all CVD increased between 1994 and 1996, remained high from 1997 to 2004, and declined slightly thereafter (to 2438 per 100 000 in 2009). A large decline was observed in both angina pectoris and chronic IHD admission rates, with average annual decrease of approximately 5.4% and 4.2%, respectively (table 1, figure 2); for both diagnoses the age-standardised rates decreased by more than 50% over 1994–2009. AMI admission rates experienced a more modest decline (average annual decrease of approximately 1.7%). In contrast, the age-standardised rate for heart failure increased steadily during the study period (by 5.7% per year), and heart failure became the third most common cause of CVD hospitalisation in 2009, while it was the least frequent of the examined diagnoses in 1994. The age-standardised rate for stroke declined slightly (by 1.2% per year), and admissions for hypertension increased slightly (by 0.6% per year).

    Figure 2
    Figure 2

    Age-standardised rates of hospital admissions by cardiovascular disease per 100 000 population in the Czech Republic, in 1994–2009. Rates are calculated using the European population as the standard.

    Trends in age-standardised rates of hospital admissions for the examined CVD by age group and gender are shown in table 3. Men accounted for 60% of all CVD hospitalisations and this tendency was increasing over the study period (from 58% in 1994 to 61% in 2009). CVD admission rates declined in most age groups in both men and women, except for heart failure (all age groups) and hypertension (65+ years); the decreases were less pronounced in the elderly (75+ years) and most significant in younger age groups (20–49 and 50–64 years). The largest reductions were found for angina pectoris in the youngest age groups in both men and women. In both the male and female population, chronic IHD was the most frequent cause of hospitalisation. Women had more hypertension admissions than men and the risk was higher in older age groups.

    View this table:
    Table 3

    CVD hospital admissions per 100 000 population in the Czech Republic, 1994–2009

    Inhospital CFR

    A significant decrease in inhospital case-fatality occurred in both men and women in all diseases examined (table 1). A greater decline was seen in men with an average annual reduction of approximately 3.3% (not shown in table 1). Stroke was the main cause of inhospital deaths, despite a large annual reduction in the CFR (4.2% per year) (figure 3). CFR for AMI improved most dramatically (average annual decline 5.5%), particularly after 2001; for heart failure it decreased only slightly and it remained stable for angina pectoris and hypertension.

    Figure 3
    Figure 3

    Inhospital case-fatality by cardiovascular disease in the Czech Republic, in 1994–2009. Inhospital case-fatality (in percentage) is calculated as a ratio between the age-standardised rate of inhospital deaths and the age-standardised rate of all hospital admissions.

    Contribution of inhospital CFR to decline in national mortality

    For AMI at all ages, inhospital CFR declined by 59%, which is equivalent to over 2000 fewer deaths; this reduction represents approximately 41% of the decline in deaths from AMI reported in the national mortality register (table 4). For all IHD and stroke, the contribution of decreased CFR to the reduction in total deaths was 24% and 61%, respectively.

    View this table:
    Table 4

    Contribution of improved CFR to reduction of national mortality from AMI, stroke and IHD

    Discussion

    Our analyses of Czech national data show a marked decline in mortality from AMI and stroke but stable or increasing mortality trends for chronic IHD and heart failure. For hospital admissions, a marked decline was only seen for chronic IHD but not for other diagnoses. Inhospital CFR declined for all examined diseases, and the improved CFR seem to have made an important contribution to declining national mortality from AMI and stroke.

    Strengths and limitations

    This study has several limitations. First, data on mortality and hospitalisation are collected independently and the data cannot be linked. Second, we were unable to link the discharge records with clinical data and treatments, and the hospitalisation dataset did not include information on comorbidity. Finally, we cannot distinguish between first and recurrent admissions and to calculate the incidence of diseases in the population. All this limits our ability to investigate the determinants of the changes in the incidence of the disease, particularly at the individual level.

    On the other hand, this is, to our knowledge, the first study of CVD hospitalisations and inhospital CFR at the national level in any of the central and eastern European countries. A major strength of this study is the availability of national registers, because they avoid biases related to using data from selected hospitals13 and because they provide an empirical test of modelling-based estimates.10

    CVD trends

    Consistently with previous reports from the Czech Republic,7 ,8 we found that CVD mortality declined significantly between 1994 and 2009. Nevertheless, CVD mortality at the end of the study period was still at least twice of that in western Europe6 and Canada14 ,15 and approximately 50% higher than in the USA.16 Although CVD mortality has also declined in many other former communist countries over the past decade,9 ,11 the rates in the Czech Republic are among the lowest in the region; for example, CVD mortality in the Czech Republic was less than half that in Russia in 2010.11

    The positive change in IHD mortality seems to be driven mainly by declining mortality from AMI across age groups and genders. By contrast, mortality from chronic IHD, accounting for between one half and three quarters of all CVD deaths, has increased since 2000, predominantly in persons aged 75 years and older. These contradictory trends may be explained by the fact that improved treatment, leading to higher survival of patients with acute coronary events, and better secondary prevention might increase the number of people with the chronic form of IHD. This, combined with population aging, is likely to underlie the rising mortality rates from chronic IHD in older persons.

    Trends in AMI

    Both hospital admissions and mortality from AMI decreased significantly over 1994–2009. This is similar to reports from Sweden,17 ,18 Ireland,3 Scotland,19 The Netherlands20 and the USA,21 whereas an increase in AMI morbidity was found in Greece22 and Canada.23 Mortality from IHD has also declined in most of central and eastern Europe recently,11 but we are not aware of reliable recent data on trends in the incidence of AMI or hospitalisations in the region. The Czech Republic has one of the highest levels of treatment of AMI in Europe, with reperfusion therapy widely available.24 Improvements in treatment, including percutaneous coronary angioplasty and thrombolytic therapy, have led to better survival of patients with acute coronary syndrome and significantly reduced inhospital CFR. Patients surviving the first event are at higher risk of recurrent events, and as we were not able to distinguish between first and recurrent events, rehospitalisation could be responsible for increased AMI admission rates observed in the elderly.

    Our estimates suggest that approximately 24% and 41% of the national decline in mortality from IHD and AMI, respectively, could have been due to reduced inhospital CFR. As the mortality and hospitalisations were assessed in two different datasets, which could not be linked, these calculations provide only a rough guidance. Nevertheless, the magnitude of the contribution of treatment is consistent with the approximately 40% estimated in different countries by the IMPACT model.9 ,25 ,26

    Trends in AMI incidence depend on changes in diagnostic criteria. In our data, an increase in admissions was observed between 1997 and 2004; this is likely to be due to the introduction of troponin testing in the Czech Republic,27 following new criteria for the diagnosis of AMI.28 It has previously been shown that the inclusion of troponin to the diagnostic criteria for AMI resulted in an increased number of diagnosed AMI.14 ,28 Consequently, hospitalisations for AMI have decreased more slowly during the past decade than they would have if the diagnostic criteria had not changed. In addition, the new criteria diagnose as AMI events with lower CFR, such as unstable angina. This could lead to an overestimation of the fall in CFR of hospitalised AMI and to an overestimation of the contribution of CFR to trends in national AMI mortality.

    Trends in stroke

    Diverging trends in stroke morbidity and mortality have been documented globally.14 ,29 ,30 In general, a higher burden of stroke was reported in eastern than western Europe,31 although over the past 10 years or so mortality from stroke has been declining in most post-communist countries.11 In the Czech population, stroke mortality fell significantly in all age groups, while hospitalisations for stroke declined more rapidly in young and middle-aged individuals. Despite a lower occurrence of stroke in women, the course of illness in women is more severe than in men,32 most likely due to increased age and a higher prevalence of comorbidity and other risk factors, such as hypertension.33 The admission data also suggest a rapid decline in inhospital CFR, which, according to our calculations, could have made a major impact on the national mortality from stroke. Our data on trends are consistent with reports of declining stroke CFR from a number of populations; the improved survival is probably related to improved inpatient care.34 The fact that mortality and inhospital CFR declined for both ischaemic and haemorrhagic strokes supports the view that improved treatment played a major role.

    Trends in hypertension

    A favourable change in hypertension morbidity was found only in the youngest age group (20–49 years) in men and women. Among those aged 75+ years, hospitalisation rates increased continually from 1994 to 2009 and the rate of admission for hypertension in women was almost double that in men. In the Czech Republic, the prevalence of hypertension has been high over the past two decades,35 and control of hypertension has been unsatisfactory both in the general population36 and in people with IHD, stroke and diabetes.37 The favourable trend in hypertension admissions, observed in the youngest age group, may be related to the higher usage of antihypertensive medication in this group.35

    Trends in heart failure

    Hospitalisations for heart failure as the primary diagnosis increased dramatically in the Czech population from 1994 to 2009 in all age groups, but mostly in the elderly. Some studies documented an epidemic of increasing heart failure morbidity in western Europe in the 1980s and 1990s.38 ,39 Heart failure hospitalisation rates declined in Canada14 and Sweden,18 but in the past decade the rates increased in the USA,40 Germany,41 Italy42 and Spain.43 In the Czech population, hospitalisations due to heart failure increased in all age groups, and by 2009 it became the most common cause of CVD hospitalisations in the elderly. It is likely that heart failure morbidity will continue rising in the future because of population aging44 and improved survival attributable to improved secondary prevention and treatment.40 ,41 Mortality rates for heart failure in the Czech population were comparable to those in Canada14 and remained stable during the study period.

    Trends in individual population groups

    The greatest improvement in CVD mortality was achieved in young men (20–49 years); in this age group mortality fell by 60%, mainly due to declines in AMI (79%), chronic IHD (49%) and stroke (63%). The corresponding mortality rates in women 20–49 years old declined less sharply, but from a lower baseline. These results are consistent with trends in the young adult population in 12 European countries over 1980–2007;45 the steepest declines were found in men and in the Czech Republic. In young women, stroke and hypertension were the most common causes of hospitalisations in young women (20–49 years), and there was no decline in stroke admissions.

    Conclusions

    The declines in inhospital CFR for several major CVD in the Czech Republic were substantial, and the data suggest that improvement in treatment and acute case management made a significant contribution to the fall in the national CVD mortality. In addition to positive trends in cardiovascular risk factors during the post-communist transition, there have been dramatic improvements in the availability of modern diagnostic and treatment methods, particularly in cardiology. For example, by 2005, the Czech Republic was among the top 10 European countries with the highest use of coronary angiogram percutaneous coronary interventions.46 These favourable developments may provide encouragement for other countries in the region because they suggest that the combined effects of a population-level approach towards risk factors and high availability of modern treatments have a major impact on public health, even in countries undergoing the post-communist transition.

    Acknowledgments

    The data were provided by the Institute of Health Information and Statistics of the Czech Republic and the Czech Statistical Office. The authors thank two anonymous reviewers for their valuable comments.

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    Footnotes

    • Contributors HD, JK and MB participated in the design of the study and wrote the manuscript. HD researched the data, made statistical analyses and drafted the manuscript. JK, MB, PV and BK participated in interpretation of the data and reviewed/edited the manuscript. All authors read and approved the final version of the manuscript.

    • Funding The study was supported by the Czech Science Foundation, project P209/11/1985.

    • Competing interests None.

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