International Journal of Cardiology 176 (2014) 1367–1368
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Cardiovascular mortality and the financial crisis in Greece: Trends and outlook Nikolaos Vlachadis a,b,⁎, Zoe Iliodromiti a, Maria Vlachadi c, Theodoros Xanthos a, Eftichios Ktenas b, Dionisios Vrachnis d, Eleni Kornarou b, Nikolaos Vrachnis a a
National and Kapodistrian University of Athens, School of Medicine, Athens, Greece National School of Public Health, Department of Epidemiology and Biostatistics, Athens, Greece Department of Political Sciences, University of Crete, Rethymno, Greece d University of Patras, Faculty of Medicine, Patras, Greece b c
a r t i c l e
i n f o
Article history: Received 28 July 2014 Accepted 29 July 2014 Available online 6 August 2014 Keywords: Cardiovascular mortality Greece Economic crisis
At the end of 2008, Greece was hit by an unprecedented financial crisis, the most serious that any western country has experienced in peacetime, with GDP falling by 22% at constant prices and unemployment rising from 8% to 26% in just four years [1]. Since studies have shown that unemployment, implicating increased psychosocial stress and problematic access to health services, is a significant risk factor for acute cardiovascular events, death rates attributable to cardiovascular disease are likely to increase during a financial depression [2]. A higher incidence of acute myocardial infarction in a region of Greece (southwestern Peloponnese) has recently been reported, which was attributed to the economic crisis [3]. To further investigate the possible impact of economic recession on cardiovascular mortality, we analyzed official national data for causes of deaths in Greece according to death certificates obtained from the Hellenic Statistical Authority (http://www.statistics.gr/portal/page/ portal/ESYE). We present trends in cardiovascular mortality in Greece, defined as the number of deaths attributable to cardiovascular disease (International Classification of Diseases 9th Revision, codes 390–459) per 100,000 inhabitants, during 2004–2012. Cardiovascular mortality rates were standardized to the 2008 population of Greece using direct standardization. Trends were evaluated using the chi square test for
⁎ Corresponding author at: National and Kapodistrian University of Athens, Aretaieio hospital, 76 Vasilissis Sofias Avenue, GR-11528, Athens, Greece. E-mail address: [email protected] (N. Vlachadis).
http://dx.doi.org/10.1016/j.ijcard.2014.07.275 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
linear trend in proportions and the statistical significance of differences between annual rates was assessed by the chi square test (Fig. 1). Pre-crisis 2004–2008, Greece witnessed significant decreasing trends in cardiovascular mortality overall and for both men and women (p b 0.001 for all trends). Cardiovascular mortality in Greece in 2004–2008 declined overall by 15% and by 16% in men and 15% in women (p b 0.001 for all comparisons), these decreasing trends notably remaining unaffected during the crisis period 2008–2012. Specifically, from 2008 through 2012, cardiovascular mortality rates in Greece decreased by 13% overall and by 12% in men and 15% in women (p b 0.001 for all trends, p b 0.001 for all comparisons). The relative reduction in cardiovascular mortality in Greece was more pronounced (14%, p b 0.001 for trend, p b 0.001) for older individuals (aged ≥65 years), whereas the corresponding decline in premature cardiovascular death rate (subjects aged b65 years) was 4% (p = 0.02 for trend, p = 0.05). It is however noteworthy that during the last year with available data (2012 compared with 2011), the steady decline ceased and cardiovascular mortality in Greece leveled off. Following a 7-year period of an overall 26% decrease (25% for men and 27% for women, p b 0.001 for trend, p b 0.001), cardiovascular mortality rates in Greece did not differ between 2011 and 2012 overall (p = 0.75) and for both men and women (p = 0.70 and p = 0.37, respectively). Despite the impressive decrease in cardiovascular mortality rates during the last decade, these rates remain unfavorable among the European Union countries, with Greece ranking 15th and 18th for men and women, respectively, while Greece has the 9th highest premature death rate (b65 years) from cardiovascular disease among men in the European Union and the highest among western European countries [4]. The reasons possibly are Greece's very high smoking rates (highest in the EU) [5] and high childhood and adult obesity prevalence rates [6,7]. Our analysis of the official national data indicates that the agestandardized mortality attributable to cardiovascular disease was not adversely affected by the economic recession in Greece. During the period 2008–2012, cardiovascular mortality rates in Greece decreased for men and women at a similar rate as the pre-crisis quadrennium 2004–2008. Older individuals of both sexes seem to have benefited the most, this finding revealing that the Greek Health system has
Age-Standardized Cardiovascular Mortality Rate
1368
N. Vlachadis et al. / International Journal of Cardiology 176 (2014) 1367–1368
reversed during 2011–2012 [10]. In accordance, our findings suggest that the financial crisis did not affect cardiovascular death rates in Greece. However, attention should be paid to the plateauing of cardiovascular mortality during 2011–2012, this probably caused by longerterm non-adherence to medical treatment which could lead to complications of chronic conditions. While the health system in Greece is currently being reorganized with lower funding, it should also focus on coverage of treatment of uninsured, chronically ill patients with cardiovascular disease.
550
500
450
Conflict of interest 400
350 2004
The authors report no relationships that could be construed as a conflict of interest.
2005
2006
2007
2008
2009
2010
2011
2012
Year Both Sexes
Men
Women
Fig. 1. Age-standardized cardiovascular mortality rates per 100,000 inhabitants in Greece. 2004–2012.
coped despite the severe austerity measures and the huge reduction in funds. A further partial explanation could be the current declines in risk factors: there is evidence that smoking prevalence has decreased, while the prevalence of physical activity has increased in Greece during the crisis period [8]. Certain studies have demonstrated that periods of financial recession have been associated with a significant reduction in mortality, with the exception of suicide mortality rates [9]. This has been attributed to the abovementioned beneficial lifestyle changes including decrease in smoking, increase in physical activity as well as reduction in work-related stress. In Greece, it has been shown that mortality rates during the first 3-year period of the economic downturn declined at a higher rate than in the pre-crisis period, although this trend was
References [1] Vlachadis N, Vlachadi M, Iliodromiti Z, Kornarou E, Vrachnis N. Greece's economic crisis and suicide rates: overview and outlook. J Epidemiol Commun Health 2014. http://dx.doi.org/10.1136/jech-2014-204407. [2] Dupre ME, George LK, Liu G, Peterson ED. The cumulative effect of unemployment on risks for acute myocardial infarction. Arch Intern Med 2012;172:1731–7. [3] Makaris E, Michas G, Micha R, et al. Greek socio-economic crisis and incidence of acute myocardial infarction in Southwestern Peloponnese. Int J Cardiol 2013;168: 4886–7. [4] Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe: epidemiological update. Eur Heart J 2013;34:3028–34. [5] European Commission. Special Eurobarometer 332 ‘Tobacco’/ Wave 72.3 — TNS Opinion & Social. Brussels, Belgium: 2010. http://ec.europa.eu/public_opinion/ index_en.htm. [6] International Association for the Study of Obesity. IASO Obesity Data Portal: World Map of Obesity. http://www.iaso.org/resources/world-map-obesity/. [7] International Association for the Study of Obesity. IASO Obesity Data Portal: Overweight in children in EU 27. http://www.iaso.org/resources/obesity-dataportal/resources/tables/. [8] Filippidis FT, Schoretsaniti S, Dimitrakaki C, et al. Trends in cardiovascular risk factors in Greece before and during the financial crisis: the impact of social disparities. Eur J Public Health Mar 10 2014 [Epub ahead of print]. [9] Ruhm CJ. Are recessions good for your health? Q J Econ 2000;115(2):617–50. [10] Vlachadis N, Vrachnis N, Ktenas E, Vlachadi M, Kornarou E. Mortality and the economic crisis in Greece. Lancet 2014;383:691.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Cardiovascular mortality and the financial crisis in Greece: Trends and outlook Nikolaos Vlachadis a,b,⁎, Zoe Iliodromiti a, Maria Vlachadi c, Theodoros Xanthos a, Eftichios Ktenas b, Dionisios Vrachnis d, Eleni Kornarou b, Nikolaos Vrachnis a a
National and Kapodistrian University of Athens, School of Medicine, Athens, Greece National School of Public Health, Department of Epidemiology and Biostatistics, Athens, Greece Department of Political Sciences, University of Crete, Rethymno, Greece d University of Patras, Faculty of Medicine, Patras, Greece b c
a r t i c l e
i n f o
Article history: Received 28 July 2014 Accepted 29 July 2014 Available online 6 August 2014 Keywords: Cardiovascular mortality Greece Economic crisis
At the end of 2008, Greece was hit by an unprecedented financial crisis, the most serious that any western country has experienced in peacetime, with GDP falling by 22% at constant prices and unemployment rising from 8% to 26% in just four years [1]. Since studies have shown that unemployment, implicating increased psychosocial stress and problematic access to health services, is a significant risk factor for acute cardiovascular events, death rates attributable to cardiovascular disease are likely to increase during a financial depression [2]. A higher incidence of acute myocardial infarction in a region of Greece (southwestern Peloponnese) has recently been reported, which was attributed to the economic crisis [3]. To further investigate the possible impact of economic recession on cardiovascular mortality, we analyzed official national data for causes of deaths in Greece according to death certificates obtained from the Hellenic Statistical Authority (http://www.statistics.gr/portal/page/ portal/ESYE). We present trends in cardiovascular mortality in Greece, defined as the number of deaths attributable to cardiovascular disease (International Classification of Diseases 9th Revision, codes 390–459) per 100,000 inhabitants, during 2004–2012. Cardiovascular mortality rates were standardized to the 2008 population of Greece using direct standardization. Trends were evaluated using the chi square test for
⁎ Corresponding author at: National and Kapodistrian University of Athens, Aretaieio hospital, 76 Vasilissis Sofias Avenue, GR-11528, Athens, Greece. E-mail address: [email protected] (N. Vlachadis).
http://dx.doi.org/10.1016/j.ijcard.2014.07.275 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
linear trend in proportions and the statistical significance of differences between annual rates was assessed by the chi square test (Fig. 1). Pre-crisis 2004–2008, Greece witnessed significant decreasing trends in cardiovascular mortality overall and for both men and women (p b 0.001 for all trends). Cardiovascular mortality in Greece in 2004–2008 declined overall by 15% and by 16% in men and 15% in women (p b 0.001 for all comparisons), these decreasing trends notably remaining unaffected during the crisis period 2008–2012. Specifically, from 2008 through 2012, cardiovascular mortality rates in Greece decreased by 13% overall and by 12% in men and 15% in women (p b 0.001 for all trends, p b 0.001 for all comparisons). The relative reduction in cardiovascular mortality in Greece was more pronounced (14%, p b 0.001 for trend, p b 0.001) for older individuals (aged ≥65 years), whereas the corresponding decline in premature cardiovascular death rate (subjects aged b65 years) was 4% (p = 0.02 for trend, p = 0.05). It is however noteworthy that during the last year with available data (2012 compared with 2011), the steady decline ceased and cardiovascular mortality in Greece leveled off. Following a 7-year period of an overall 26% decrease (25% for men and 27% for women, p b 0.001 for trend, p b 0.001), cardiovascular mortality rates in Greece did not differ between 2011 and 2012 overall (p = 0.75) and for both men and women (p = 0.70 and p = 0.37, respectively). Despite the impressive decrease in cardiovascular mortality rates during the last decade, these rates remain unfavorable among the European Union countries, with Greece ranking 15th and 18th for men and women, respectively, while Greece has the 9th highest premature death rate (b65 years) from cardiovascular disease among men in the European Union and the highest among western European countries [4]. The reasons possibly are Greece's very high smoking rates (highest in the EU) [5] and high childhood and adult obesity prevalence rates [6,7]. Our analysis of the official national data indicates that the agestandardized mortality attributable to cardiovascular disease was not adversely affected by the economic recession in Greece. During the period 2008–2012, cardiovascular mortality rates in Greece decreased for men and women at a similar rate as the pre-crisis quadrennium 2004–2008. Older individuals of both sexes seem to have benefited the most, this finding revealing that the Greek Health system has
Age-Standardized Cardiovascular Mortality Rate
1368
N. Vlachadis et al. / International Journal of Cardiology 176 (2014) 1367–1368
reversed during 2011–2012 [10]. In accordance, our findings suggest that the financial crisis did not affect cardiovascular death rates in Greece. However, attention should be paid to the plateauing of cardiovascular mortality during 2011–2012, this probably caused by longerterm non-adherence to medical treatment which could lead to complications of chronic conditions. While the health system in Greece is currently being reorganized with lower funding, it should also focus on coverage of treatment of uninsured, chronically ill patients with cardiovascular disease.
550
500
450
Conflict of interest 400
350 2004
The authors report no relationships that could be construed as a conflict of interest.
2005
2006
2007
2008
2009
2010
2011
2012
Year Both Sexes
Men
Women
Fig. 1. Age-standardized cardiovascular mortality rates per 100,000 inhabitants in Greece. 2004–2012.
coped despite the severe austerity measures and the huge reduction in funds. A further partial explanation could be the current declines in risk factors: there is evidence that smoking prevalence has decreased, while the prevalence of physical activity has increased in Greece during the crisis period [8]. Certain studies have demonstrated that periods of financial recession have been associated with a significant reduction in mortality, with the exception of suicide mortality rates [9]. This has been attributed to the abovementioned beneficial lifestyle changes including decrease in smoking, increase in physical activity as well as reduction in work-related stress. In Greece, it has been shown that mortality rates during the first 3-year period of the economic downturn declined at a higher rate than in the pre-crisis period, although this trend was
References [1] Vlachadis N, Vlachadi M, Iliodromiti Z, Kornarou E, Vrachnis N. Greece's economic crisis and suicide rates: overview and outlook. J Epidemiol Commun Health 2014. http://dx.doi.org/10.1136/jech-2014-204407. [2] Dupre ME, George LK, Liu G, Peterson ED. The cumulative effect of unemployment on risks for acute myocardial infarction. Arch Intern Med 2012;172:1731–7. [3] Makaris E, Michas G, Micha R, et al. Greek socio-economic crisis and incidence of acute myocardial infarction in Southwestern Peloponnese. Int J Cardiol 2013;168: 4886–7. [4] Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe: epidemiological update. Eur Heart J 2013;34:3028–34. [5] European Commission. Special Eurobarometer 332 ‘Tobacco’/ Wave 72.3 — TNS Opinion & Social. Brussels, Belgium: 2010. http://ec.europa.eu/public_opinion/ index_en.htm. [6] International Association for the Study of Obesity. IASO Obesity Data Portal: World Map of Obesity. http://www.iaso.org/resources/world-map-obesity/. [7] International Association for the Study of Obesity. IASO Obesity Data Portal: Overweight in children in EU 27. http://www.iaso.org/resources/obesity-dataportal/resources/tables/. [8] Filippidis FT, Schoretsaniti S, Dimitrakaki C, et al. Trends in cardiovascular risk factors in Greece before and during the financial crisis: the impact of social disparities. Eur J Public Health Mar 10 2014 [Epub ahead of print]. [9] Ruhm CJ. Are recessions good for your health? Q J Econ 2000;115(2):617–50. [10] Vlachadis N, Vrachnis N, Ktenas E, Vlachadi M, Kornarou E. Mortality and the economic crisis in Greece. Lancet 2014;383:691.
