Contributions of Treatment to Declining CVD Mortality
Contributions of Treatment to Declining CVD Mortality
Developed countries have enjoyed substantial falls in cardiovascular disease (CVD) mortality. However, low and middle income countries are drowning in a rising tide of CVD and other non-communicable diseases. Current and future trends in CVD mortality will therefore require increasing attention in the 21st century. The success of clinical cardiology in providing evidence-based cost-effective treatments should be celebrated. However, the growing understanding of CVD mortality trends highlights the crucial role of tobacco, diet, alcohol and inactivity as key drivers. Pro-active public health approaches focused on 'upstream' population-wide policies are increasingly recognised as being potentially powerful, rapid, equitable and cost-saving. However, the future political challenges could be substantial.
A number of recent papers have addressed the very important issue of the large declines in coronary heart disease (CHD) mortality since the 1960s. They dispute the relative contributions made by lifestyle and by treatments. Nabel and Braunwald recently attributed the mortality declines almost entirely to treatment effects.1 The doyen of cardiology thus made many other cardiologists proud. However, Braunwald's paper was illustrated by a time line which attracted a critical correspondence that emphasised that the declines in coronary mortality mapped quite closely to declines in smoking! Furthermore, three subsequent papers in the BMJ with an accompanying editorial by Tunstall- Pedoe all highlighted the potentially powerful contributions of decreases in other major risk factors such as cholesterol and blood pressure.2–5
Who is right? This review will briefly consider the evidence under the following headings.
Abstract and Introduction
Abstract
Developed countries have enjoyed substantial falls in cardiovascular disease (CVD) mortality. However, low and middle income countries are drowning in a rising tide of CVD and other non-communicable diseases. Current and future trends in CVD mortality will therefore require increasing attention in the 21st century. The success of clinical cardiology in providing evidence-based cost-effective treatments should be celebrated. However, the growing understanding of CVD mortality trends highlights the crucial role of tobacco, diet, alcohol and inactivity as key drivers. Pro-active public health approaches focused on 'upstream' population-wide policies are increasingly recognised as being potentially powerful, rapid, equitable and cost-saving. However, the future political challenges could be substantial.
Introduction
A number of recent papers have addressed the very important issue of the large declines in coronary heart disease (CHD) mortality since the 1960s. They dispute the relative contributions made by lifestyle and by treatments. Nabel and Braunwald recently attributed the mortality declines almost entirely to treatment effects.1 The doyen of cardiology thus made many other cardiologists proud. However, Braunwald's paper was illustrated by a time line which attracted a critical correspondence that emphasised that the declines in coronary mortality mapped quite closely to declines in smoking! Furthermore, three subsequent papers in the BMJ with an accompanying editorial by Tunstall- Pedoe all highlighted the potentially powerful contributions of decreases in other major risk factors such as cholesterol and blood pressure.2–5
Who is right? This review will briefly consider the evidence under the following headings.
Recent coronary heart disease mortality time trends in different populations.
What is driving these disease trends?
What are the implications for clinical care?
What are the implications for public policy?
