Diverging trends in premature cardiovascular mortality across europe: implications for the evolving heart failure burden
A Draghici, Y Shhab, S Aoun, Z A StepanovAbstract
Background
Cardiovascular disease remains the leading cause of mortality worldwide, with heart failure representing the final common pathway for most cardiovascular conditions. While advances in treatment have driven substantial gains in life expectancy across Europe, these gains mask persistent regional disparities in premature cardiovascular mortality. Eastern European countries, despite recent economic growth, face compounding pressures from the COVID-19 pandemic and geopolitical instability. Understanding long-term trends and their current trajectory is essential to guide resource allocation and reshape European health policy.
Purpose
To examine long-term trends in premature cardiovascular mortality across Europe and assess regional divergence with implications for the evolving heart failure burden.
Methods
We analyzed data from the World Health Organization Mortality Database (2000–2023), including deaths attributed to major cardiovascular causes closely related to heart failure development: ischemic heart disease, hypertensive heart disease, cardiomyopathies, and heart failure. Age-standardized mortality rates (ASMRs) for premature mortality (<70 years) were calculated using the WHO standard population. Countries were grouped into Eastern and Western Europe using a predefined classification. Temporal trends were assessed using log-linear regression to estimate average annual percent change (AAPC) with 95% confidence intervals. Sensitivity analyses excluded Turkey.
Results
A total of 407 country-years from 31 European countries (18 Western Europe, 13 Eastern Europe) were included. In Western Europe, mean ASMRs declined from 16.9 per 100,000 in 2000 to 9.5 per 100,000 in 2023, corresponding to a significant annual reduction (AAPC −2.34%, 95% CI −2.69 to −1.99; p<0.001). In contrast, Eastern Europe exhibited persistently higher premature mortality, increasing from 27.2 per 100,000 in 2000 to 29.7 per 100,000 in 2023, with an overall upward trend (AAPC +0.78%, 95% CI 0.17 to 1.39; p=0.015), including marked increases after 2015. Sensitivity analyses excluding Turkey yielded consistent findings (Eastern Europe AAPC +0.97%, 95% CI 0.38 to 1.55; p=0.002).
Conclusions
Regional inequalities in premature cardiovascular mortality persist across Europe. Western Europe achieved consistent reductions (−2.34% annually, 2000–2023), while Eastern Europe showed the opposite trajectory (+0.78% annually), with acceleration after 2015 despite economic growth — forecasting a growing Eastern European heart failure burden. Addressing this divergence requires targeted prevention, earlier intervention, and equitable access to evidence-based care, supported by continued surveillance and investment in health system capacity.Premature cardiovascular mortality