Cardiovascular burden and percutaneous interventions in Russian Federation: systematic epidemiological update

Abstract

The situation with cardiovascular (CV) burden in Russian population is alerting, and becomes of interest due to high CV mortality, and shorter lifespan if compare with the Western society amid the absence of the established monitoring or screening system for major CV risk factors. The purpose of this systematic epidemiological update was to explore CV burden in Russia. The study represents pooled results with a systematic epidemiological review of the national mass screening, selected randomized clinical trials and statistical datasets of the national public health CV institutions exploring the trends of the CV burden in all 83 regions of Russia. We overviewed data from a number of the available Russian-speaking national data sources of 2001-2014, and NANOM-FIM trial (NCT01270139) as the only available real-world population study. The CV diseases in Russia accounted for 54.9% of all deaths in 2011-2014. The death rate was 13.3 per 1,000 citizens with CV mortality of 653.9 per 100,000. The life expectancy achieves 64.3 years for male and 76.1 years for female. The mean age of pts in trial was 51.6 years (77.2% males). A total of 175 Russian PCI centers implemented 205,902 angio a year, and 75,378 PCI achieving 531 PCI per 1,000,000 with placement of 101,451 stents (1.37 stents per PCI; 48,057 DES). The smoking (17.3% of screened with a 2,786 cigarettes a year; 70.6% in trial), excessive alcohol consumption (1.8% of screened with a 11.6 L per year; 50.6% in trial), unhealthy Russian diet (abundance of carbohydrates/sugar, saturated and trans fats in 24.3% of screened), psychosocial factors (20%) and physical inactivity (19.6% of screened) remain the major modifiable risk factors. They, in turn, affect such risk factors as dyslipidemia (86.7% in trial), obesity (16.7% of screened; BMI in trial was 28.4), and hypertension (40.8% suffered; 86.1% in trial). CV mortality was not directly associated with a level of poverty (r=0.26, P=0.02) or socio-economic development (P>0.05) in regions. The documented 27% 10-year decline of CV mortality was interpreted as a success of the national policy. Mortality statistics show the stark reality of a high CV burden in Russia. New national program and aggressive emerging efforts are required to tackle CV diseases in Russia.

Keywords: Cardiovascular burden; Russia; percutaneous cardiovascular interventions (PCIs); public health.

Conflict of interest statement

The author has no conflicts of interest to declare.

Figures

Figure 1

Patterns of death rates through the last 35 years. Russian mortality was initially relatively high as we are able to appreciate at the panel (A) compared with Western Europe or U.S. between 1980 and 1991 (11.0 per 1,000 in Russia vs. 9.9 in the E.U. in 1980), and has dramatically increased further in the subsequent decade after the dissolution of the Soviet Union (U.S.S.R.). The anti-alcohol campaign of 1984–1987 has significantly improved the situation dropping total mortality from 11.6 to 10.4. The previous publications have associated fluctuations in mortality with the underlying economic and social factors. On an individual level, alcohol consumption was strongly implicated in being at least partially responsible for many of these trends. The public health system reforms of minister Dmitrieva in 1997–1998 brought Russia to a sharp improvement and decline of mortality from 15.0 to 13.6 by 1998. Mortality increased substantially after the economic crisis in 1998 (‘default of Russia’), with life expectancy falling to 58.9 years among men and 71.8 years among women by 2001. Most of these fluctuations were due to changes in mortality from vascular disease and violent deaths (mainly suicides, homicides, unintentional poisoning, and traffic incidents) among young and middle aged adults. Trends were similar in all 7 Federal districts of Russia with a growth of mortality up to 16.4 in 2003. An extra 2.5–3 million Russian adults died in middle age in the period 1992–2001 than would have been expected based on 1991 mortality. Russia experienced a further economic crisis in 2008–2011 (global financial crisis or ‘great recession’), including rapid devaluation of its currency and increases in poverty. The country faced the crisis amid the new wave of reforms (since 2006) with the advanced national program of health care development and decrease in mortality from 16.1 in 2005 to 14.5 in 2008 saving at least 680,000 lives. Despite the certain delay in reduction of mortality in 2009–2010 due to pronounced ‘socioeconomic stress’ of the general population, the health care reforms and economic stability amid strong oil and gas markets allowed to drop mortality from 14.2 in 2010 to 13.0 in 2013 securing another 236,000 lives. The new tensions between Russia and the Western society started in 2014 after the MH17-shotdown accident and further anti-Russian sanctions with the shrinking of the energy markets set up unpredictable prognosis for the death rate dynamics in the different regions Russia as you can see at the panel (B). The worst scenario implies substantial increase in mortality from 13.1 in 2014 (if compare with 5.7 in the E.U. in 2014, and 7.4 in the U.S. in 2011) up to 13.9 in 2017 with 520,000 ‘extra’ deaths. Notwithstanding, Rosstat reported (13) the ongoing decline in total mortality from 13.7 in 2015 to 13.2 by June 2016 with the relevant decrease of CV mortality from 688.4 per 100,000 population in 2015 to 639.3 by June 2016. The panel (C) demonstrates a comparison between the age distribution between 2011–2020 projection of the European Standard Population (ESP) [data provided by Eurostat (22)], WHO Standard Population Average 2000–2025 (EIP/GPE/EBD World Health Organization 2001) and Russian population in 2015 [data provided by Rosstat (13)]. The coefficient of determination and Pearson correlation between EU-27 and Russian distributions achieved R2 =0.5390, r=0.7341 (P=0.002), notwithstanding, there was no strong correlation with WHO Standard population (R2=0.0677, r=−0.2602, P=0.35 with EU-27, and R2 =0.0054, r=−0.0734, P=0.80 with Russia).

Figure 2

Associations between cardiovascular (CV) mortality and socio-economic situation in Russia. The plot (C) delineates the insignificant association (polynomial regression of degree 6 demonstrated R2=0.1752, r=0.0540, P=0.63) between cardiovascular mortality (A) in Russia (in comparison with Europe at the panel B) and RIA (D) integral rating (in case of poverty or per cent of people with income below a living wage, R2=0.1999, r=0.2574, P=0.02). The correlation between RIA rating and poverty performed r=0.5144 (P>0.05, R2=0.2646). It might be very tough task to explain the phenomenon of high CV mortality in the Eastern Europe, but obviously there are some risk factors which are related to the complex situation with the industrial pollution of this region (including radioactive pollution after Chernobyl accident in Ukraine of 1986 up to 5 Ci/km2), poverty, and specific diet which includes mostly sugars, saturated and trans fat taking into account high consumption of strong alcohol and heavy smoking. This is quite remarkable that the Russian regions which were mostly exposed for radioactive pollution after the disaster in Chernobyl have very good current ecological situation and very moderate CV mortality. For instance, Bryansk oblast which has got at least a 40 Ci/km2 radioactive pollution is not among outsiders and CV mortality to the moment achieves 788.1 which is slightly above Russian average of 653.9.

Figure 3

Life span, poverty, and major national risk factors in Russia. The life expectancy you would see at the panel (A) becomes crucial when the reproduction is declined in few generations. The positive dynamics of the estimated life expectancy at birth since 2005 is comparable to the period of 1985–1988 when the anti-alcohol campaign was deployed, and the lifespan was the longest through the Russian history 70.1 years. According to the preliminary data of Rosstat, the life expectancy at birth in 2014 achieves 71.0 years (76.5 years for females and 65.3 years for males). The areas radioactively polluted in 1957 in Ozersk and in 1986 in Chernobyl specially marked with a grey color on the map. The panel (B) demonstrates macronutrient composition of the diet in Russian adults aged 19–55 years and revealed major national risk factors. Data for high cholesterol (86.7% of patients were revealed in NANOM-FIM trial) and diabetes (no such patients in NANOM-FIM trial) were not provided due to absence of the necessary information at the national screening database (14,15) and a dataset of Petrukhin et al. (5). The major factor presented in comparison of three databases of the National screening (screen) (14,15), Petrukhin et al. (P-khin) (5), and NANOM-FIM trial (NANOM) (18-20). The map (C) performs the situation with poverty in Russia which is not directly associated with CV mortality (R2 =0.1999, r=0.2574, P=0.02). The moderate but insignificant correlation (R2 =0.2646, r=0.5144, P>0.05) was confirmed between a level of poverty and RIA index of the socio-economic development in Russia which was higher than any associations with CV mortality. The highest consumption of vodka (red-marked) was revealed in the regions with high poverty and particularly in the rural suburb of Novosibirsk, a Koltsovo ‘science town’, with a 45.4 L of the absolute alcohol per capita a year, Smyshlyaevka and Petra Dubrava villages in Samara oblast with 41.4 L and 22.8 L respectively, Izyayu village in the Republic of Komi with 13.6 L, and the Republic of Tatarstan with an average 13.7 L per year (maximum of 20.4 L registered in Laishevo town). The lowest consumption of vodka documented in the Russian Caucasus with a mean 1.1 L of the absolute alcohol per person per year due to predominance of the ‘wine-and-brandy culture’ at this region.

Figure 4

Affordability of coronary PCI in Russia. (A) Shows a dynamics of the coronary PCI growth in Russia since 2001 thru 2013 (n, number of PCI centers); (B) reflects the annual dynamics of the stent placement’s increase in Russia with a proportion between bare-metal stents (BMS) and drug-eluting stents (DES) in 2006–2013 (n, number of PCI centers); (C) performs a map of the coronary PCI affordability across Russia with some details (number of DES, number of PCI centers and interventions per unit of the Russian general population) for 8 federal districts of Russia in panel (D). The Northwestern Federal district with 27 PCI centers was the most fast-growing emerging part of Russia (2.02 PCI centers PMRP, and 3,388.5 interventions PMRP), but with the highest density of PCI centers in the Central Federal district (n=67, 1.81 PCI-centers PMRP, and 2,855.3 interventions PMRP). The healthiest region of Russia, a Russian Caucasus, was among outsiders with 7 PCI centers (0.75 PMRP) and 758.1 interventions PMRP.