Trends in cardiovascular diseases burden and vascular risk factors in Italy: The Global Burden of Disease study 1990-2017.

AIMS: An exhaustive and updated estimation of cardiovascular disease burden and vascular risk factors is still lacking in European countries. This study aims to fill this gap assessing the global Italian cardiovascular disease burden and its changes from 1990 to 2017 and comparing the Italian situation with European countries. METHODS: All accessible data sources from the 2017 Global Burden of Disease study were used to estimate the cardiovascular disease prevalence, mortality and disability-adjusted life years and cardiovascular disease attributable risk factors burden in Italy from 1990 to 2017. Furthermore, we compared the cardiovascular disease burden within the 28 European Union countries. RESULTS: Since 1990, we observed a significant decrease of cardiovascular disease burden, particularly in the age-standardised prevalence (-12.7%), mortality rate (-53.8%), and disability-adjusted life years rate (-55.5%). Similar improvements were observed in the majority of European countries. However, we found an increase in all-ages prevalence of cardiovascular diseases from 5.75 m to 7.49 m Italian residents. Cardiovascular diseases still remain the first cause of death (34.8% of total mortality). More than 80% of the cardiovascular disease burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high low density lipoprotein cholesterol, and impaired kidney function. CONCLUSIONS: Our study shows a decline in cardiovascular mortality and disability-adjusted life years, which reflects the success in reducing disability, premature death and early incidence of cardiovascular diseases. However, the burden of cardiovascular diseases is still high. An approach that includes the cooperation and coordination of all stakeholders of the Italian National Health System is required to further reduce this burden.

Burden of Neurological Disorders Across the US From 1990-2017: A Global Burden of Disease Study.

Importance: Accurate and up-to-date estimates on incidence, prevalence, mortality, and disability-adjusted life-years (burden) of neurological disorders are the backbone of evidence-based health care planning and resource allocation for these disorders. It appears that no such estimates have been reported at the state level for the US. Objective: To present burden estimates of major neurological disorders in the US states by age and sex from 1990 to 2017. Design, Setting, and Participants: This is a systematic analysis of the Global Burden of Disease (GBD) 2017 study. Data on incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) of major neurological disorders were derived from the GBD 2017 study of the 48 contiguous US states, Alaska, and Hawaii. Fourteen major neurological disorders were analyzed: stroke, Alzheimer disease and other dementias, Parkinson disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, traumatic brain injury, spinal cord injuries, brain and other nervous system cancers, meningitis, encephalitis, and tetanus. Exposures: Any of the 14 listed neurological diseases. Main Outcome and Measure: Absolute numbers in detail by age and sex and age-standardized rates (with 95% uncertainty intervals) were calculated. Results: The 3 most burdensome neurological disorders in the US in terms of absolute number of DALYs were stroke (3.58 [95% uncertainty interval [UI], 3.25-3.92] million DALYs), Alzheimer disease and other dementias (2.55 [95% UI, 2.43-2.68] million DALYs), and migraine (2.40 [95% UI, 1.53-3.44] million DALYs). The burden of almost all neurological disorders (in terms of absolute number of incident, prevalent, and fatal cases, as well as DALYs) increased from 1990 to 2017, largely because of the aging of the population. Exceptions for this trend included traumatic brain injury incidence (-29.1% [95% UI, -32.4% to -25.8%]); spinal cord injury prevalence (-38.5% [95% UI, -43.1% to -34.0%]); meningitis prevalence (-44.8% [95% UI, -47.3% to -42.3%]), deaths (-64.4% [95% UI, -67.7% to -50.3%]), and DALYs (-66.9% [95% UI, -70.1% to -55.9%]); and encephalitis DALYs (-25.8% [95% UI, -30.7% to -5.8%]). The different metrics of age-standardized rates varied between the US states from a 1.2-fold difference for tension-type headache to 7.5-fold for tetanus; southeastern states and Arkansas had a relatively higher burden for stroke, while northern states had a relatively higher burden of multiple sclerosis and eastern states had higher rates of Parkinson disease, idiopathic epilepsy, migraine and tension-type headache, and meningitis, encephalitis, and tetanus. Conclusions and Relevance: There is a large and increasing burden of noncommunicable neurological disorders in the US, with up to a 5-fold variation in the burden of and trends in particular neurological disorders across the US states. The information reported in this article can be used by health care professionals and policy makers at the national and state levels to advance their health care planning and resource allocation to prevent and reduce the burden of neurological disorders.

Determinants of social inequalities in stroke incidence across Europe: a collaborative analysis of 126 635 individuals from 48 cohort studies.

BACKGROUND: Knowledge on the origins of the social gradient in stroke incidence in different populations is limited. This study aims to estimate the burden of educational class inequalities in stroke incidence and to assess the contribution of risk factors in determining these inequalities across Europe. MATERIALS AND METHODS: The MORGAM (MOnica Risk, Genetics, Archiving and Monograph) Study comprises 48 cohorts recruited mostly in the 1980s and 1990s in four European regions using standardised procedures for baseline risk factor assessment and fatal and non-fatal stroke ascertainment and adjudication during follow-up. Among the 126 635 middle-aged participants, initially free of cardiovascular diseases, generating 3788 first stroke events during a median follow-up of 10 years, we estimated differences in stroke rates and HRs for the least versus the most educated individuals. RESULTS: Compared with their most educated counterparts, the overall age-adjusted excess hazard for stroke was 1.54 (95% CI 1.25 to 1.91) and 1.41 (95% CI 1.16 to 1.71) in least educated men and women, respectively, with little heterogeneity across populations. Educational class inequalities accounted for 86-413 and 78-156 additional stroke events per 100 000 person-years in the least compared with most educated men and women, respectively. The additional events were equivalent to 47%-130% and 40%-89% of the average incidence rates. Inequalities in risk factors accounted for 45%-70% of the social gap in incidence in the Nordic countries, the UK and Lithuania-Kaunas (men), but for no more than 17% in Central and South Europe. The major contributors were cigarette smoking, alcohol intake and body mass index. CONCLUSIONS: Social inequalities in stroke incidence contribute substantially to the disease rates in Europe. Healthier lifestyles in the most disadvantaged individuals should have a prominent impact in reducing both inequalities and the stroke burden.

We all want to live longer, but not grow old.

Population ageing represents a "triumph" and a "challenge" for society. The increase in life expectancy corresponds to an increase of risk factors and age-associated non communicable diseases, with consequent rise in health care costs and the burden of healthcare sustainability. Aim of this analysis is to describe the prevalence of non communicable diseases, comorbidity and disability in non-institutionalized elderly population, aged 75-79 years, examined within the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey. Cardiovascular disease is the most frequent occurring in 27% of the examined population, followed by diabetes (24%) and chronic kidney disease (21%); 60% of examined elderly population suffers of one or more chronic diseases, while 40% is in a good health. Ninety-three per cent of the examined population is free of disability; cognitive function disorders, assessed by the Folstein's Mini Mental State Examination, are recorded in 21% men and 29% women. In the context of prevention, there is still much that needs to be done. It is important to initiate or maintain preventive actions concerning also this age-group at both community and individual level, to promote the cultural notion that a good quality of life in advanced age is built day by day starting from one's youth through a healthy diet, regular physical activity and non-smoking habit.

Combined use of short-term and long-term cardiovascular risk scores in primary prevention: an assessment of clinical utility.

AIMS: To evaluate the clinical utility of cardiovascular disease (CVD) risk stratification based on a combined use of short-term and long-term risk scores in the primary prevention setting. METHODS: CVD-free participants 40-65 years old initially to seven population-based cohorts enrolled in northern and central Italy were stratified as 'low' (ESC-SCORE ≤ 1%), 'intermediate' (SCORE 1-4%) and 'moderate/high' short-term CVD risk (SCORE ≥ 4% or diabetes). The long-term CVD risk was estimated using the CAMUNI-MATISS model, validated for the Italian population. Participants were followed up for a median time of 16 years to ascertain the first major CVD event, fatal or nonfatal. To compare the 'combined' (SCORE + CAMUNI-MATISS) with the 'current' (SCORE alone) stratification, we estimated the difference in Net Benefit between the two strategies. RESULTS: Study sample included 3935 men (468 CVD events) and 4393 women (210 events). Under the 'current' stratification, 76% of men and 21% of women were at 'intermediate' risk and eligible to treatment. Only 40% of them had elevated predicted long-term risk and could have received indication to treatment under the 'combined' strategy. The latter would have saved 3 and 3.5 unnecessary treatments per every CVD case in men and women, respectively, and the Net Benefit significantly increased [men: 4.1, 95% confidence interval (CI): 2.7-5.6; women: 4.4, 95% CI: 1.7-6.9].Similarly, among the 74% of women not receiving indication for prevention because at 'low' short-term risk, the 'combined' stratification significantly increased the Net Benefit (1.4, 95% CI: 0.6-2.1) and reduced from 40 to 10% the proportion of events occurring among women not eligible to any preventive action. CONCLUSION: In the Italian population, a combination of validated short-term and long-term CVD risk scores has the potential to select for prevention women whose risk is currently not fully addressed and to reduce unnecessary costly treatment.

Educational class inequalities in the incidence of coronary heart disease in Europe.

OBJECTIVE: To estimate the burden of social inequalities in coronary heart disease (CHD) and to identify their major determinants in 15 European populations. METHODS: The MORGAM (MOnica Risk, Genetics, Archiving and Monograph) study comprised 49 cohorts of middle-aged European adults free of CHD (110 928 individuals) recruited mostly in the mid-1980s and 1990s, with comparable assessment of baseline risk and follow-up procedures. We derived three educational classes accounting for birth cohorts and used regression-based inequality measures of absolute differences in CHD rates and HRs (ie, Relative Index of Inequality, RII) for the least versus the most educated individuals. RESULTS: N=6522 first CHD events occurred during a median follow-up of 12 years. Educational class inequalities accounted for 343 and 170 additional CHD events per 100 000 person-years in the least educated men and women compared with the most educated, respectively. These figures corresponded to 48% and 71% of the average event rates in each gender group. Inequalities in CHD mortality were mainly driven by incidence in the Nordic countries, Scotland and Lithuania, and by 28-day case-fatality in the remaining central/South European populations. The pooled RIIs were 1.6 (95% CI 1.4 to 1.8) in men and 2.0 (1.7 to 2.4) in women, consistently across population. Risk factors accounted for a third of inequalities in CHD incidence; smoking was the major mediator in men, and High-Density-Lipoprotein (HDL) cholesterol in women. CONCLUSIONS: Social inequalities in CHD are still widespread in Europe. Since the major determinants of inequalities followed geographical and gender-specific patterns, European-level interventions should be tailored across different European regions.

Validity of a long-term cardiovascular disease risk prediction equation for low-incidence populations: the CAMUNI-MATISS Cohorts Collaboration study.

BACKGROUND: Before introducing long-term cardiovascular disease (CVD) risk models in clinical practice, their external validity should be investigated. We assessed the validity of the CArdiovascular Monitoring Unit in Northern Italy (CAMUNI) 20-year risk score, developed in Northern Italy, and published previously, when applied to a population with different risk factors distribution and event incidence. METHODS: The validation sample consisted of 5307 35-69 year-old subjects (2418 men) enrolled in Central Italy during the 1980s (Malattia ATerosclerotica Istituto Superiore di Sanità (MATISS) study). Baseline risk factor assessment and follow-up procedures, including MONICA definition of acute events, followed a shared protocol with the derivation cohorts. We estimated model calibration and discrimination (area under the ROC curve, AUC) in the validation set; as well as the net benefit of using the CAMUNI risk score as second-level screening in subjects at different levels of short-term risk. RESULTS: The 20-year risk of event was 14% in men and 7% in women. Model calibration was satisfactory, and the strength of the association between predictors and the endpoint was the same as in the derivation population. The AUC was 0.734 (men) and 0.802 (women). The net benefit of the CAMUNI score was 3.9 (95% confidence interval: 2.1-5.7) and 2.9 (1.7-4.3) in men and women at low 10-year risk, respectively. Among subjects at high short-term risk, a significant net benefit of 9.8 was observed in men only. A pooled CAMUNI-MATISS risk score is provided. CONCLUSIONS: In this low-incidence European population, long-term CVD prediction through the CAMUNI risk score is accurate and it has the potential to improve current primary prevention strategies based on short-term risk scores alone.

Clinical epidemiology, management and outcome of acute coronary syndromes in the Italian network on acute coronary syndromes (IN-ACS Outcome study).

BACKGROUND: The Italian network on acute coronary syndromes outcome (IN-ACS Outcome) study is a nationwide observational, multicenter study with the aim to describe clinical epidemiology, management, 30-days and one-year outcomes of ACS in Italy. METHODS: All consecutive patients admitted for ACS to 38 hospitals, between December 2005 and February 2007, were enrolled in the study. Patient in-hospital details and follow-up data at 30-days and one-year were collected using a web-based CRF and stored in a central database. RESULTS: A total of 6045 patients (age 68 ± 13 years) were enrolled: 2313 patients (38.3%) had ST elevation myocardial infarction (STEMI) and 3732 (61.7%) patients had NSTE-ACS. Primary PCI was performed in 1085 (46.9%) STEMI patients, thrombolysis in 590 (25.5%) patients, whereas 638 (27.6%) patients were not reperfused. Among patients with NSTE-ACS, coronary angiography was performed in 2797 (75%) patients, PCI in 1797 (48.2%) patients and CABG in 213 (5.7%) patients. Thirty-days and one-year mortality rates were 5.8% and 9.8%, in STEMI patients and 3.1% and 8.6%, in NSTE-ACS patients. CONCLUSIONS: The IN-ACS Outcome study showed that the management of ACS is still suboptimal. Although 30-days mortality is low, the one-year mortality is still substantial.

Mortality from circulatory diseases by specific country of birth across six European countries: test of concept.

BACKGROUND: Important differences in cardiovascular disease (CVD) mortality by country of birth have been shown within European countries. We now focus on CVD mortality by specific country of birth across European countries. METHODS: For Denmark, England and Wales, France, The Netherlands, Scotland and Sweden mortality information on circulatory disease, and the subcategories of ischaemic heart disease, and cerebrovascular disease, was analysed by country of birth. Information on population was obtained from census data or population registers. Directly age-standardized rates per 100 000 were estimated by sex for each country of birth group using the WHO World Standard population 2000-25 structure. For differences in the results, at least one of the two 95% confidence intervals did not overlap. RESULTS: Circulatory mortality was similar across countries for men born in India (355.7 in England and Wales, 372.8 in Scotland and 244.5 in Sweden). For other country of birth groups-China, Pakistan, Poland, Turkey and Yugoslavia-there were substantial between-country differences. For example, men born in Poland had a rate of 630.0 in Denmark and 499.3 in England and Wales and 153.5 in France; and men born in Turkey had a rate of 439.4 in Denmark and 231.4 in The Netherlands. A similar pattern was seen in women, e.g. Poland born women had a rate of 264.9 in Denmark, 126.4 in England and Wales and 54.4 in France. The patterns were similar for ischaemic heart disease mortality and cerebrovascular disease mortality. CONCLUSION: Cross-country comparisons are feasible and the resulting findings are interesting. They merit public health consideration.

Social status and cardiovascular disease: a Mediterranean case. Results from the Italian Progetto CUORE cohort study.

BACKGROUND: Social factors could offer useful information for planning prevention strategy for cardiovascular diseases. This analysis aims to explore the relationship between education, marital status and major cardiovascular risk factors and to evaluate the role of social status indicators in predicting cardiovascular events and deaths in several Italian cohorts. METHODS: The population is representative of Italy, where the incidence of the disease is low. Data from the Progetto CUORE, a prospective study of cohorts enrolled between 1983-1997, were used; 7520 men and 13127 women aged 35-69 years free of previous cardiovascular events and followed for an average of 11 years. Educational level and marital status were used as the main indicators of social status. RESULTS: About 70% of the studied population had a low or medium level of education (less than high school) and more than 80% was married or cohabitating. There was an inverse relationship between educational level and major cardiovascular risk factors in both genders. Significantly higher major cardiovascular risk factors were detected in married or cohabitating women, with the exception of smoking. Cardiovascular risk score was lower in married or cohabitating men. No relationship between incidence of cardiac events and the two social status indicators was observed. Cardiovascular case-fatality was significantly higher in men who were not married and not cohabitating (HR 3.20, 95%CI: 2.21-4.64). The higher cardiovascular risk observed in those with a low level of education deserves careful attention even if during the follow-up it did not seem to determine an increase of cardiac events. CONCLUSIONS: Preventive interventions on cardiovascular risk should be addressed mostly to people with less education. Cardiovascular risk score and case-fatality resulted higher in men living alone while cardiovascular factors were higher in women married or cohabitating. Such gender differences seem peculiar of our population and require further research on unexpected cultural and behavioural influences.

[Cardiovascular Risk Assessment: preliminary results]. / Osservatorio del Rischio Cardiovascolare: primi risultati.

BACKGROUND: The Italian National Prevention plan includes 10-year cardiovascular risk (CR) assessment of the Italian general population aged 35-69 years using the CUORE Project risk score. A national training program for general practitioners (GPs) was launched by the Ministry of Health in 2003. GPs were encouraged to collect data on risk factors and risk assessment and to contribute to the CUORE Project Cardiovascular Risk Observatory (CRO). The aim of this analysis is to demonstrate the feasibility and effectiveness of risk assessment in primary care. METHODS: The cuore.exe software, free of charge for GPs and easily downloadable from the CUORE Project web site (www.cuore.iss.it), is the frame for the GP data collection. The CRO provides a platform to analyze data collected on risk assessment and risk factors, and compare results at regional and national level in order to support health policy makers in their decision process. RESULTS: From January 2007 to April 2009, 2858 GPs have downloaded the cuore.exe software; 102,113 risk assessments were sent to the CRO based on risk factors profile of 87,556 persons (3617 persons had more than 1 risk assessment). Mean level of CR was 3.1% in women and 8.4% in men; 30% of men and 65% of women were at low risk (CR < 3%), 9% of men and 0.4% of women were found at high risk (CR > or = 20%). Among those with at least 2 risk assessments, 8% shifted to a lower class of risk after 1 year. Mean level of systolic and diastolic blood pressure decreased by about 1% in 1 year; total cholesterol more than 2%, and prevalence of smokers decreased by about 3% in the second risk assessment. CONCLUSIONS: These data demonstrate that risk assessment can be included as a first step of prevention in primary care. The CUORE Project individual score is expected to become an important tool for GPs to assess their patients' CR, to promote primary prevention, and to focus attention to healthy lifestyle adoption.

[Assessment of the absolute global cardiovascular risk: comparison between the risk chart and the individual score of the CUORE Project]. / La valutazione del rischio cardiovascolare globale assoluto: confronto tra carta e punteggio del Progetto CUORE.

BACKGROUND: To evaluate 10-year cardiovascular risk, the risk chart and the individual risk score from the CUORE Project were recently introduced in Italy. These tools differ as for age range and some risk factors. Therefore, the aim of this study is to evaluate the difference between the global absolute risk assessed by the risk chart and the individual risk score using the data collected through the Osservatorio Epidemiologico Cardiovascolare (OEC). METHODS: From the Osservatorio Epidemiologico Cardiovascolare sample, 6508 people aged 40-69 years without clinical manifestations of atherosclerosis were selected. Cardiovascular risk was assessed using risk chart and individual risk score and the 10-year risk was categorized in six classes (< 5%, 5-9%, 10-14%, 15-19%, 20-29%, > or = 30%). As coefficient of agreement between risk chart and individual risk score, Cohen kappa statistic was computed using the Cicchetti-Allison weights (k(w)). RESULTS: From contingency tables of the two methods distribution, k(w) was 0.71 (p < 0.0001 and 95% confidence interval 0.70-0.72). Using the 20% risk threshold reported in Nota 13 of Agenzia Italiana del Farmaco and excluding persons who were treated for hyperlipemia refunded regardless of their chart or individual score estimation of cardiovascular risk, the differences between the two tools classification resulted in the 2.6% of the sample (1.4% were assessed as at non-high risk [< 20%] using the risk chart and at high risk using the individual risk score, and the opposite for 1.2%). CONCLUSIONS: Classification difference between risk charts and the individual risk score is quite small. Updating of predictive functions of two tools could improve their concordance also for individual evaluation, including older people and better reflecting current Italian lifestyle.

Socio-economic-position overall and cause-specific mortality in an Italian rural population.

STUDY OBJECTIVE: To investigate the association between socio-economic position, overall and cause-specific mortality, and risk factors in a sample of men and women in the Italian population. DESIGN: Cohort study. MATISS Project (Malattie Aterosclerotiche Istituto Superiore di Sanità). SETTING: Rural area, Province of Latina, Lazio, central Italy. PARTICIPANTS: Baseline data were obtained for 8512 subjects (3982 men and 4530 women), 20-75 years of age, of whom 713 died during 11 (range 2; 15) years of follow-up. Education and occupation (used as measures of socio-economic position), smoking history, alcohol consumption, health status measures, blood pressure, plasma lipids and ECGs were collected at baseline. Linear and logistic regressions were performed to examine the association between socioeconomic position and risk factors. The hazard ratios (HRs) of all-cause, CVD and cancer mortality, according to educational level and occupational categories were computed using Cox proportional hazard models. MAIN RESULTS: The lower social groups had a more adverse risk factors profile with the exception of smoking habit in women and HDL cholesterol in men. The risk of death in college educated men was 50% of that found for men with no formal education. The risk of cancer in the least educated was 60% higher than for highly educated men. No clear pattern was observed in women. The HRs were not substantially changed when controlling for potential confounding factors. In both men and women mortality did not vary by occupational class. CONCLUSIONS: The association observed between education and mortality was stronger than previously reported in Italy. This may reflect changes in risk factors profile; in particular with regard to smoking habit. The effect of changes in risk factor distribution will become apparent in future mortality and morbidity patterns.