Decline of coronary heart disease mortality is strongly effected by changing patterns of underlying causes of death: an
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MORTALITY
Decline of coronary heart disease mortality is strongly effected by changing patterns of underlying causes of death: an analysis of mortality data from 27 countries of the WHO European region 2000 and 2013 Susanne Stolpe1,2 · Bernd Kowall1 · Andreas Stang1,3 Received: 27 July 2020 / Accepted: 12 November 2020 © The Author(s) 2020
Abstract Mortality rates for coronary heart disease (CHD) experience a longstanding decline, attributed to progress in prevention, diagnostics and therapy. However, CHD mortality rates vary between countries. To estimate whether national patterns of causes of death impact CHD mortality, data from the WHO “European detailed mortality database” for 2000 and 2013 for populations aged ≥ 80 years was analyzed. We extracted mortality rates for total mortality, cardiovascular diseases, neoplasms, dementia and ill-defined causes. We calculated proportions of selected causes of death among all deaths, and proportions of selected cardiovascular causes among cardiovascular deaths. CHD mortality rates were recalculated after recoding ill-defined causes of death. Association between CHD mortality rates and proportions of CHD deaths was estimated by population-weighted linear regression. National patterns of causes of death were divers. In 2000, CHD was assigned as cause of death in 13–53% of all cardiovascular deaths. Until 2013, this proportion changed between − 65% (Czech Republic) and + 57% (Georgia). Dementia was increasingly assigned as underlying cause of death in Western Europe, but rarely in eastern European countries. Ill-defined causes accounted for between 90% of deaths from atherosclerosis (I70) had been actually coded with I70.9. We do not claim that our redistribution of ill-defined deaths results in true mortality rates for CHD.
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However, the impact of differing prevalence of ill-defined causes of death on CHD mortality rates gets clearly visible. The redistributed rates still underestimate the true CHD mortality. Using the most detailed, publicly available, information on causes of death in Europe, we are the first to our knowledge to describe in depth the national particularities in certifying death, which particularly result in distorted declining CHD mortality rates. This distortion prevents valid comparisons of CHD mortality rates between countries and points of time.
Conclusion National particularities in certifying death revealed diverse patterns of diseases identified as underlying cause of death. These patterns changed over time and especially impacted CHD mortality rates. Due to the differential use of ill-defined and competing causes of death in certifying, national registry data for coronary heart disease mortality are distorted and lead to underestimation of the true underlying morbidity to a varying, unknown extent. Comparisons of CHD mortality rates as reported in national mortality registries between countries and over time are highly compromised. Therefore, the discussion on the factors causing the longstanding decline in CHD mortality, such as
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