Jad Abou Chakra

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Master's Thesis

LITHUANIAN UNIVERSITY OF HEALTH SCIENCES Academy of Medicine

Institute of Cardiology

Jad Abou Chakra

EVALUATION OF DEATH RATES AND TRENDS OF CARDIOVASCULAR DISEASES AMONG KAUNAS MIDDLE-

AGED POPULATION DURING 2010-2015 (CORONARY HEART DISEASE AND STROKE)

Prof. Dr. Ričardas Radišauskas

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Abstract:

The theme and topic of the thesis: To evaluate the death rates and trends of cardiovascular diseases among Kaunas middle-aged population during 2010-2015 done by Jad Abou Chakra. Master thesis Scientific supervisor Prof. dr. Ričardas

Radišauskas; Lithuanian University of Health Sciences, Medical Academy, Faculty of Medicine, Institute of Cardiology - Kaunas, Lithuania

Aim:To determine and assess trends on mortality structure and rates from

cardiovascular diseases among Kaunas middle-aged population during 2010-2015 years

Objectives:

1. To evaluate cardiovascular diseases mortality structure in overall mortality and mortality from coronary heart diseases and stroke structure in cardiovascular mortality structure and its trends among Kaunas middle-aged population during 2010-2015 by gender and age.

2. To determine and assess mortality rates from cardiovascular diseases, coronary heart diseases and stroke and its trends among Kaunas middle-aged population during 2010-2015 by gender and age.

Key words:mortality rate, cardiovascular disease, coronary heart disease, stroke, trends, official statistics

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SUMMARY

Analysis of mortality structure (CHD and stroke) and rates for both genders, middle- aged group in Lithuania (city of Kaunas) in the period of 2010-2015 Results from Lithuanian University of Health Sciences, Medical Academy, Faculty of Medicine, Department of Cardiology– Kaunas, Lithuania. Author Jad Abou Chakra. Final thesis of Master’s degree/supervisor Prof. Dr. Ričardas Radišauskas.

THE AIM OF THE THESIS: To determine and assess trends on mortality structure and rates from cardiovascular diseases among Kaunas middle-aged population during 2010-2015 years

OBJECTIVES:

MATERIALS AND METHODS: This paper acquired the LSMU bioethics center

permission. In our work we analyzed the data collected from the Civil Registration Office as data of official death statistics for Kaunas middle-aged population (n=150 000).

Death causes were assessed by ICD-10 codes. Overall mortality rate (ICD-10 A00- Z99), mortality rates from CVD (ICD-10 I00-I99), CHD (ICD-10 I20-I25) and stroke (ICD- 10 I60-I69) were calculated by gender and age. Statistical analysis was performed using MS Excel package. Mortality rates were calculated per 100 000 populations and

standardized using World standard. Mortality trends were evaluated by direct regression analysis with 95% confidence level.

RESULTS: Direct regression analysis during the period of (2010-2015) showed that CVD mortality average out of all causes is higher in males 33.8% than in females 23.5%

in Kaunas middle-aged group, while CHD average showed higher mortality in males 51% than in females 32.12% on the other hand stroke showed higher mortality average in females 24.31% than in males 14.22%. mortality rates and trends in CVD remained stable with insignificant decrease in both males -2%yr,P=0.15 and females -

1%/yr,P=0.38, while CHD mortality rates and trends showed insignificant decrease in males -4%/yr,P=0.1 and in females -3%/yr,P=0.3. on the other hand stroke mortality rates and trends showed a pattern of increment during the period of (2010-2015) by +7%/yr,P=0.12 in males and decreased by -0.7%/yr,P=0.93 in females

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CONCLUSION: Cardiovascular diseases mortality in the overall mortality among Kaunas middle-aged people accounts for one third of total deaths, affecting more men than women. Coronary heart disease accounts for almost half the mortality from

cardiovascular disease, more men than women, and stroke accounts for one-sixth of all mortality from CVD, more women than men. The rates of mortality from CVD and

coronary heart diseases among males tended to decrease, and among women

remained stable. The rates of mortality from stroke during the analyzed period showed a tendency to increase in males, and among females remained stable.

KEYWORDS: mortality rate, cardiovascular disease, coronary heart disease, stroke, trends, official statistics

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SANTRAUKA

Kauno vidutinio amžiaus gyventojų mirtingumo nuo širdies ir kraujagyslių ligų rodiklių ir jų trendų vertinimas per 2010-2015 metus. Lietuvos sveikatos mokslų universitetas, Medicinos akademija, Kardiologijos institutas - Kaunas, Lietuva. Autorius Jad Abou Chakra. Baigiamojo magistro darbo vadovas prof. dr. Ričardas Radišauskas.

TYRIMO TIKSLAS: Nustatyti ir įvertinti Kauno vidutinio amžiaus gyventojų mirtingumo nuo širdies ir kraujagyslių ligų struktūrą, rodiklius ir jų pokyčius per 2010-2015 metus.

TIKSLAI:

1. Įvertinti mirtingumo nuo širdies ir kraujagyslių ligų struktūrą bendrame mirtingume ir mirtingumo nuo koronarinės širdies ligos ir insulto struktūrą mirtingume nuo širdies ir kraujagyslių ligų ir jų trendus tarp Kauno vidutinio amžiaus gyventojų per 2010-2015 metus pagal lytį ir amžių.

2. Nustatyti ir įvertinti mirtingumo nuo širdies ir kraujagyslių ligų, koronarinės širdies ligos ir insulto rodiklius bei jų trendus tarp Kauno vidutinio amžiaus gyventojų per 2010- 2015 metus pagal lytį ir amžių.

MEDŽIAGOS IR METODAI: Tyrimui atlikti buvo gautas LSMU Bioetikos centro leidimas. Savo darbe analizavome iš Civilinės metrikacijos biuro gautus oficialius duomenis apie mirusius vidutinio amžiaus Kauno gyventojus (n=150000). Mirtingumo priežastys buvo vertinamos pagal TLK-10 peržiūros kodus: mirtys nuo visų priežasčių (TLK-10 A00-Z99), mirtys nuo širdies ir kraujagyslių ligų (TLK-10 I00-I99), mirtys nuo koronarinės širdies ligos (TLK-10 I20-I25) ir mirtys nuo insulto (TLK-10 I60-I69).

Statistinė analizė buvo atlikta naudojant MS Excel paketą. Mirtingumo rodikliai buvo apskaičiuoti 100000 gyventojų ir standartizuoti pagal Pasaulio standartą. Mirtingumo tendencijos buvo įvertintos tiesiogine regresine analize su 95 proc. patikimumo lygiu.

REZULTATAI: Vertinant oficialiosios mirtingumo statistikos duomenis buvo nustatyta, kad 2010-2015 m. laikotarpiu mirtys nuo širdies ir kraujagyslių ligų tarp Kauno 25-64 metų gyventojų bendrame mirtingume sudarė 30,4 proc. (vyrų 33,8 proc., moterų – 23,5 proc.) ir per analizuotą periodą reikšmingai nekito. Mirtingumo nuo ŠKL struktūroje mirtys nuo koronarinės širdies ligos sudarė beveik pusę (46,3 proc.), daugiau vyrams 51,0 proc. negu moterimis - 32,1 proc., kita vertus, insultas per analizuotą periodą sudarė 16,7 proc. mirčių (daugiau moterų 24,3 proc negu vyrų 14,2 proc) ir reikšmingai didėjo tarp vyrų – 10 proc./metus. Mirtingumo nuo ŠKL rodikliai išliko stabilūs tiek tarp vyrų (-2,0 proc./m., P=0,15), tiek moterų (-1,0 proc/m., P=0,38). Mintingumo nuo koronarinės širdies ligos trendai rodė mažėjimo tendencija tiek tarp vyrų, tiek moterų, atitinkamai -4,0 proc./m, P=0,1 ir -3,0 proc./m, P=0,3. Kita vertus, mirtingumo nuo insulto rodikliai ir tendencijos parodė, kad tyrinėtu laikotarpiu mirtingumo rodikliai tarp vyrų turėjo tendenciją didėti (+7,0 proc./m, P=0,12), o tarp moterų buvo be reikšmingų pokyčių (-0,7 proc./m, P=0,93).

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IŠVADA: Širdies ir kraujagyslių ligos bendrame mirtingume tarp Kauno vidutinio

amžiaus gyventojų sudarę trečdalį mirčių, daugiau vyrų negu moterų. Koronarinė širdies liga tarp mirčių nuo širdies ir kraujagyslių ligų sudarė beveik pusę mirčių, daugiau vyrų nei moterų, o insultas – šeštadalį visų mirčių nuo ŠKL, daugiau moterų negu vyrų.

Mirtingumo nuo ŠKL ir nuo koronarinės širdies ligos rodikliai tarp vyrų turėjo tendenciją mažėti, o tarp moterų išliko stabilūs. Mirtingumo nuo insulto rodikliai per analizuotą periodą tarp vyrų turėjo tendenciją didėti, o tarp moterų išliko stabilūs.

REIKŠMINIAI ŽODŽIAI: mirtingumas, širdies ir kraujagyslių ligos, koronarinės širdies liga, insultas, trendai, oficiali statistika

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ACKNOWLEDGMENT

I would like to express my sincere gratitude and appreciation to my scientific supervisor and thesis supervisor Prof. dr. Ričardas Radišauskas of the Lithuanian University of Health Sciences in Kaunas for the continuous support, for his patience, motivation and knowledge he has provided, he has been of immense help in the time of need to be able to reach the aim of this work and I am grateful for his valuable comments on this master's thesis. His encouragement made it possible to achieve the goal. Reviewer:

Prof. Abdonas tamošiūnas

CONFLICT OF INTERESTS

There was no conflict of interest for the author.

AUTHORIZATION OF ETHICS COMMITTEE

Data analysis permission was issued by the Center of Bioethics of LSMU No. BEC-MF- 120

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ABBREVIATIONS:

• CVD: Cardiovascular disease

• CHD: Coronary heart disease

• GBD: Global burden of disease

• Yr: year

• MSBP: mean systolic blood pressure

• HBP: high blood pressure

• HDL: high density lipoprotein

• LDL: low density lipoprotein

• HRT: hormonal replacement therapy

• IV tPA: intravenous Tissue plasminogen activator

• NOACs: new oral anticoagulants

• EU: European union

TERMS AND DEFINITIONS:

• Premature mortality: death before the age of 70

• Heavy drinking: defined as an intake of 80 grams of alcohol per day or more

• CVD: is an umbrella for much heart disease, this includes blood vessel diseases, like coronary heart disease, arrhythmias and congenital heart defects.

• Stroke: are two types ischemic where a clot occur in a brain vessel or hemorrhagic where the blood vessel itself ruptures

• CHD: blockage of coronary arteries that nourish heart muscles which eventually leads to infarction

• Trend: is a pattern of progressive change in a condition

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INTRODUCTION

Cardiovascular diseases is a term that describes a wide and various heart medical conditions, this paper is going to touch coronary heart disease and stroke mortality rates and structure in the city of Kaunas (Lithuania).

Worldwide speaking CVD continues to be the leading and the most common cause of death among all other disease regardless of the late ebbing of mortality rates due to CVD in Western Europe and North America [1]. CVD causes and risk factors are plentiful and they strongly depend on socioeconomics, behavioral, cultural, hereditary and environmental factors. In spite of the enhancement of CVD primary and secondary prevention and all the newly developed medications, surgical interventions and

diagnostics approaches, not to forget all the researches and publications that have been done to promote a better approach on how to improve our understandings on

decreasing CVD mortality rates, According to a study done by GBD in 2013, CVD lead to the death of 17.3 million people around the world, and attributed to a 31.5% of all other causes of death which is twice more than all types of cancer deaths combined [2].

In higher- income countries such as the United States of America where health care system is more effective, CVD mortality rates showed a decline by 30.8% but still it was number one cause of death in 2011 which attributed to 31.3% of all other causes which is still a relatively high percentage [3]. Despite the financial freedom, advanced

healthcare and insurance, the risk factors for CVD are equally high and present, representing also a burden to the country's public health costs. The costs for

treatments, hospitalizations, rehabilitations for CVD are reaching extreme expenses.

The need for early measures, primary and secondary screenings and regular check-ups is increasing, but representing a great difficulty for the public health reasons mentioned above, as well as the lack of awareness of the population of the risk factors and the risks of CVDs and long term complications as well [3].

The same goes for Europe as well, especially western European countries, where, like in the United States or similar countries (Australia etc.), due to our culture of

overindulgence, over-eating, sedentary lifestyle and stressful office jobs, increasing pressure of overachievement on the younger generation are all representing the major risk factors for CVD, in addition, the rely of the people on their healthcare system, the comfort and the false idea that our generation and the pharma industries are promoting, leads to the unfortunate fact that a big part of the population will rely on treatment and medication, instead of preventing CVD by decreasing the risk factors at first.

In Europe CVD mortality rates ranges from low to high due to the diversity and the number of countries involved, which represents a large variety of hereditary, social, behavioral and cultural aspects. According to a study done by the European society of cardiology, CVD accounts for over than 4 million death per year or 45% of all other causes of death in Europe [2]. Add to that that coronary heart disease (1.8 million) and stroke (1 million) where the two most common causes of death out of all CVD in which women were affected in a higher percentage than men [2].

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Aim and objectives

THE AIM OF THE THESIS: To determine and assess trends on mortality structure and rates from cardiovascular diseases among Kaunas middle-aged population during 2010-2015 years

OBJECTIVES:

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LITERATURE REVIEW

It is believed that genetic inheritance, physiological and psychological, behavioural such as tobacco consumption and alcohol use, as well as cultural factors have the biggest influence on CHD gender gap expansion. Even with the continuous rise among females smokers percentages within the past decade, according to a study 48.9% of males from age of 15 and above are regular smokers while only 12.5% of females are regular smokers, on the other hand the average alcohol consumption for ages between 20-64 showed 7 grams for males while only 2 grams for females per day and a 2.6% of males to 0.6% for females reported heavy drinking habits as well as 27% of males reported the consumption of strong alcohol at least one time a week while a much lesser percentage, only 7% was seen in females among the Lithuanian population [4].A study showed that in spite of the serious increase of hypertension awareness an increase in MSBP and its prevalence from 141.8 to 145.5mmHg was documented, as well as tobacco use

especially among the female gender [5], and an increase in obesity by 7% as well as diabetes prevalence by 9% [6].

In addition, there are solid pathophysiological and even anatomical reasons regarding the heart itself that account for the higher risk and incidence of CHD in males compared to females [16].

A study showed that even though males and females heart looks the same but there are some notable different characteristics in how their hearts reacts to same stimuli.

Generally speaking female’s hearts are smaller than those of males, as well as their chambers and septum (a tissue that divides left and right heart), they beat faster and ejects around 10% less blood than males, under stress females heart pumps faster and more blood while male’s coronary arteries (arteries that nourish the heart muscles) constricts and their systemic blood pressure increases [7].

Furthermore, one may say that females tend to be generally more prudent and cautious on their diet and lifestyle than men, simply because of the fact of childbearing and the importance in the attitude towards lifestyle habits during pregnancy and its impact on the fetus and the later outcome in the life of the child [17]. Not to forget the stress theory with the increase exposure to high level stress, the increasing pressure and

expectations in careers, and lack of physical activity nowadays, this applies for both genders but to a higher extent in males. Moreover, males have limited expressions of their emotions, due to which the psychological burdens tend to build up over time, leading to even more stress, as well as somatization on the heart of this problem [8].

Add to that the distribution of body fat in overweight and obesity and its link to CHD, where it was shown that "apple-shaped bodies", meaning fat is centered mostly around the abdomen, situation which males tend to have more (women tend to have in

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overweight situations a "pear-shaped" figure, meaning fat is distributed more to thighs and hips), are at higher risk for CHD as well as for other medical conditions such as HBP and diabetes [8], as well as metabolic syndrome, high lipid levels, higher

distribution of visceral fat and its deposition in internal organs, such as liver and heart.

Besides that, the main purpose of why females are at lower risk of CHD from males is their hormone levels. Premenopausal females are protected by their high circulating oestrogen levels which increase HDL levels; this gives an extra protection against heart diseases [9]. But this on the other hand creates a dilemma about how same hormones affect the male body. According to a study, higher than normal levels of circulating oestrogen in males have shown to have a negative effect on lipid profile, this means that it increases LDL and decrease HDL which is totally the opposite than what happens in females, favouring once more CHD in males and its higher incidence [8].

On the flip side, with all the endeavors nowadays to decrease the burden of stroke incidence and treatments, and with the significant reduction in incidence of stroke in developed countries, acute stroke still affects 15 million people around the world each year and leave them either permanently disabled or dead [11]. Along with the lack of awareness in the general society, stroke incidence and mortality rates appears to be higher in the female gender, specifically around 55,000 more women than men experience a stroke event each year [10]. This is attributed to multiple physiological and pathological reasons that are poorly understood as well as the oddly presentations of stroke symptoms in females, it is believed that other than the common risk factors that faces both females and males such as HBP, diabetes, smoking and obesity,

females have other unique risks which makes them more prone to stroke such as being on oral contraceptives or HRT and smoking [18], pregnancy itself increases the risk of stroke due to the physiological changes that occur to the female body which results in an increase in blood pressure thus increasing stress on the heart, higher incidence of atrial fibrillation is noticed as females advance in age and not to forget that history of migraines which affects women more than men increases their risk of stroke by two times [10].

In addition, not only stroke incidence is higher in females but also its recurrence within 5 years which is 9% higher as well as their prognosis and outcome which is worse than males because of the impact that it leaves on their health, around 36% of women to only 24% of men will be severely disabled upon discharge [11]. What makes it even more complicated for females is the onset of their symptoms which usually does not present as traditional stroke symptoms [19]. Such as numbness, paralysis, double vison or vertigo but rather they present as nontraditional symptoms such as headache, facial or arm pain, chest pain and palpitation, hallucinations, hiccups and seizures. A study shows that women present with nontraditional symptoms 62% more than men [12].

Which is significantly high and this affects negatively their treatment effectiveness by

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prolonging the establishment of stroke diagnosis which passes the 3 hours treatment window with IV tPA administration [11]. And this burden of stroke sex gap difference is suspected to keep increasing until it doubles by 2050 [13]

Contrarily, on the other hand a study done by the WHO MONICA project among 18 different European and Asian populations, recorded that 28 days stroke fatality was almost equal between males and females after adjusting and controlling comorbidities such as atrial fibrillation and elevated blood pressure [13].

Many prevention approaches have been considered from lifestyle changes and medication, as well as controlling and treating comorbidities [20]. In the past, stroke prevention included anticoagulant drugs like warfarin, which has gone in disuse as prophylaxis, due to its high risk of bleeding, its food and drug interactions and the need to closely monitor by frequent blood tests. However, there are new available oral

medications such as NOACs, which are safe and effective and present with less risks of bleeding compared to older anticoagulants [15].

Add to that studies showed a decreased rate of stroke in females that are daily consumer of omega-3 fatty acid, citrus fruits and low fat products [14].

Needless to say though, that, for both stroke and CHD in both genders, the most important prevention methods are primary screenings, regular check-ups by the physicians, especially if the patient has one or more risk factors are essential,

compliance of the patient with their doctor's advice and recommended diet and lifestyle changes or even medication, therefore cooperation and willingness of the patient are indisputable in prevention in these diseases. Willingness of the patient to: eat in moderation, low in saturated fats and high in fiber and greens, exercise more and be active, regular blood pressure checks, de-stress by taking time off or meditate and very importantly, to stop smoking, are the main individual ways to prevent thousands of CHD and stroke incidents, and the role of the public health system is to promote these

preventive measures.

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Research methodology and methods

In our work we analyzed the data collected from the Civil Registration Office as data of official death statistics for Kaunas middle-aged population during (2010-2015) (n=150 000). Death causes were assessed by ICD-10 codes. Overall mortality rate (ICD-10 A00-Z99), mortality rates from CVD (ICD-10 I00-I99), CHD (ICD-10 I20-I25) and stroke (ICD-10 I60-I69) were calculated by gender and age. Statistical analysis was performed using MS Excel package. Mortality rates were calculated per 100 000 populations and standardized using World standard. Mortality trends were evaluated by direct regression analysis with 95% confidence level.

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RESULTS

Evaluation of the mortality structure from CVD in overall deaths and CHD and stroke in CVD deaths during 2010-2015

There were no statistically significant changes in mortality from CVD, CHD and stroke.

The changes in the mortality rates and trends in males and females in 25-64 age groups in the city of Kaunas are presented in detail in tables.1 to 6 and figures 1 to 6

Table 1 and figure.1 elicit in detail the distribution of CVD mortality structure in males and females among Kaunas population during the studied period from 2010 till 2015 Table.1 CVD percentage in overall cases of death in 25-64 age groups among the population of Kaunas during 2010-2015

CVD % out of all causes ALL MALE FEMALE

2010 30.23 32.95 24.29

2011 31.7 36.06 22.1

2012 31.3 35.07 23.52

2013 29.77 32.49 24.19

2014 29.48 32.56 23.53

2015 29.86 33.68 21.5

2010-2015 30.39 33.80 23.53

CVD mortality structure trends in males and females among Kaunas middle-aged population during the studied period from 2010 till 2015 presented in Figure.1

Figure.1 Death percentages from CVD out of all causes of death in 25-64 age groups among Kaunas males and females population from 2010 to 2015

0 5 10 15 20 25 30 35 40

2009 2010 2011 2012 2013 2014 2015 2016

CVD % out of all causes of death

Male Female -0.7%/yr;P=0.5

-1.1%/yr;P=0.4

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Looking at the table.1 and figure.1, CVD percentages out of all other causes of death, an almost flat curve was seen in both females and males with no significant changes for the 6 years studied period. The significant outcome was that averaged CVD percentage was higher by almost 10% in males 33.80% than in females 23.53%.

Table 2 and figure 2 elicit in detail the distribution of CHD mortality structure out of CVD in males and females among Kaunas population during the studied period from 2010 till 2015

Table.2 CHD percentage in overall cases of CVD in 25-64 age groups among the population of Kaunas during 2010-2015

CHD mortality structure out of CVD trends in males and females among Kaunas middle- aged population during the studied period from 2010 till 2015 are presented in Figure.2

Figure.1 Death percentages from CHD out of CVD in 25-64 age groups among Kaunas males and females population from 2010 to 2015

Table 3 and figure 3 elicit in detail the distribution of stroke mortality rates out of CVD in males and females among Kaunas population during the studied period from 2010 till 2015

0 5 10 15 20 25 30 35 40 45 50 55 60

2009 2010 2011 2012 2013 2014 2015 2016

CHD % out of CVD

MALE FEMALE

CHD % out of CVD ALL MALE FEMALE

2010 48.54 54.97 29.49

2011 48.62 51.96 36.5

2012 46.75 50.22 36.11

2013 43.3 47.56 32.35

2014 43.6 50.54 24.99

2015 46.7 50.77 33.33

2010-2015 46.25 51 32.12

-1.5%/yr;P=0.2

-1.8%/yr;P=0.64

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Table.3 stroke percentage in overall cases of CVD in 25-64 age groups among the population of Kaunas during 2010-2015

stroke % out of CVD ALL MALE FEMALE

2010 16.5 10.8 33.3

2011 13.01 12.2 15.87

2012 15.01 14.02 18.05

2013 15.3 11.8 24.99

2014 21.41 17.9 30.88

2015 19.5 18.65 22.8

2010-2015 16.7 14.22 24.31

Stroke mortality structure out of CVD trends in males and females among Kaunas middle-aged population during the studied period from 2010 till 2015 are presented in Figure.3

Figure.3 Stroke death percentages out of CVD in 25-64 age groups among Kaunas

males and females population from 2010 to 2015

Table 2 and 3 and figure 2 and 3 explain in more details the distribution of CVD

mortality structure into its underlying causes among Kaunas population during the five year period from 2010 till 2015, where it is significantly obvious and showed in table 2 that CHD which account for an average of 46.25% out of all other CVD causes is the leading cause of death specially in males with an average of 51% and in females with an average of 32% of all other CVD causes. On the other hand stroke resulted in an average of 16.7% out of all CVDs and significantly higher in females 24.31% than in males 14.22% as shown in the table 3.

0 5 10 15 20 25 30 35

2009 2010 2011 2012 2013 2014 2015 2016

stroke % out of CVD

MALE FEMALE +10%/yr;P=0.02

+1.2%/yr;P=0.8

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The mortality rates from CVD, CHD and stroke evaluation during 2010- 2015

Table 4 and figure 4 show CVD mortality rates and trends in age adjusted groups per 100,000 population in both females and males from the period of 2010 to 2015 in Kaunas

Table.4 Mortality and trends (%/yrs.) from cardiovascular diseases among Kaunas population by gender and age groups during 2010-2015

Years 2010 2011 2012 2013 2014 2015 Mortali

ty trends

%/yr

P for trend s Total, N

Population Cases Mortality rate/100,000

25-34 years 22.42 23.01 14 13.9 13.69 6.71 -2 0.07 35-44 years 39.72 55.04 62.06 48.44 33.9 40.14 -4 0.4 45-54 years 184.62 169.11 186.27 175.17 127.07 136.1 -6 0.05 55-64 years 499.68 492.92 482.02 405.41 467.45 456.31 -2 0.25 Men, N

25-34 years 43.66 33.03 28.83 23.98 14.37 14.25 -23 0.0008 35-44 years 70.78 92.11 100.69 54.21 60.59 56.47 -8 0.19 45-54 years 325.38 301.35 322.6 331.54 224.53 230.62 -7 0.07 55-64 years 880.4 967.72 892.86 704.13 829.18 883.31 -1 0.5 Women, N

25-34 years 3.82 13.48 ^{no data}

avail 4.48 13.07 ^{No data}

avail -14 0.44

35-44 years 11.89 22.47 28.02 43.31 9.91 25.43 5 0.7 45-54 years 73.43 65.69 79.19 52.73 50.44 61.04 -6 0.1 55-64 years 240.11 173.18 207 200.54 223.14 165.6 -3 0.4

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Males and females

Mortality trends from 25-64 among Kaunas population from 2010 till 2015 is -2%/yr Mortality trends from 25-64 among EU population from 2010 till 2015 is -4%/yr Males

Mortality trends from 25-64 among Kaunas male population from 2010 till 2015 is -2%/yr

Mortality trends from 25-64 among EU male population from 2010 till 2015 is -4%/yr Females

Mortality trends from 25-64 among Kaunas female population from 2010 till 2015 is -1%/yr

Mortality trends from 25-64 among EU female population from 2010 till 2015 is -3%/yr

Figure.4 Age adjusted mortality rate from CVD (per 100.000 population) and trends among Kaunas population aged 25-64 years during 2010-2015

As shown in table.4 and figure.4 the mortality rates for cardiovascular disease were slightly and insignificantly decreasing for the studied period in all age groups for both genders for the population of Kaunas -2%/yr, P=0.07 while a significant decrease was seen in the EU population in all age groups for both genders -4%/yr, P=0.01. This pattern was seen also among males of the population of Kaunas -2%/yr,P=0.15 while on the other hand a slight significant decrease was seen among males of the EU population -4%/yr,P=0.05. This goes for females of Kaunas population as well that showed insignificant decrease over the studied period -1%/yr and for the females of the EU with -3%/yr,P=015.

280.5

302.3 297.4

251.2 251.4 265.8

77.1 68.2 79.3 75.4 75.7

63.9 -2%/yr, p=0.15

-1%/yr, p=0.38

0 50 100 150 200 250 300 350

/100,000 POPULATION

YEARS

Men Women

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Table 5 and figure 5 show CHD mortality rates and trends in age adjusted groups per 100,000 population in both females and males from the period of 2010 to 2015 in Kaunas

Table.5 Mortality and trends (%/yrs.) from coronary heart diseases among Kaunas population by gender and age groups during 2010-2015

Years 2010 2011 2012 2013 2014 2015 Mortal

ity trends

%/yr

25-34 years 4.08 2.3 2.2 2.34 1.9 2.24 -10 0.11

35-44 years 12.54 9.57 12.41 5.1 2.61 5.35 -25 0.06 45-54 years 73.85 78.05 64.31 59.15 37.65 55.9 -10 0.08 55-64 years 280.25 275.05 278.92 218.71 242.86 235.93 -4 0.08 Men, N

25-34 years 8.73 4.72 4.82 4.65 4.8 4.75 -8 0.16

35-44 years 26.54 15.35 26.5 10.84 5.51 11.29 -23 0.09 45-54 years 158.04 148.21 131.05 124.33 74.84 115.31 -10 0.09 55-64 years 554.32 575.22 541.13 411.85 505.28 473.66 -4 0.18 Women, N

25-34 years No data avail

No data avail

No data avail 35-44 years No data

avail

4.49 No data avail

No data avail

No data avail 45-54 years 7.34 23.18 11.88 8.11 8.41 8.72 -7 0.53 55-64 years 93.37 72.92 103.87 89.13 65.63 74.08 -4 0.31

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Males and females

Mortality trends from 25-64 among Kaunas population from 2010 till 2015 is -4%/yr Mortality trends from 25-64 among EU population from 2010 till 2015 is -6%/yr Males

Mortality trends from 25-64 among Kaunas male population from 2010 till 2015 is -4%/yr

Mortality trends from 25-64 among EU male population from 2010 till 2015 is -6%/yr Females

Mortality trends from 25-64 among Kaunas female population from 2010 till 2015 is -3%/yr

Mortality trends from 25-64 among EU female population from 2010 till 2015 is 12%/yr

Figure.5 Age adjusted mortality rate from CHD (per 100.000 population) and trends among Kaunas population aged 25-64 years during 2010-2015

As shown in table.5 and in figure.5 the mortality rates for coronary heart disease were slightly and insignificantly decreasing for the studied period in all age groups for both genders for the population of Kaunas -4%/yr, P=0.08 while a slight significant decrease was seen in the EU population in all age groups for both genders -6%/yr, P=0.03. This pattern was seen also among males of the population of Kaunas -4%/yr,P=0.1 while on the other hand a slight significant decrease was seen among males of the EU

population -6%/yr ,P=0.04. Females not only showed an insignificant decrease in

among Kaunas population -3%/yr,P=0.3 but it showed a pattern of increment among the population of the EU +12.5/yr,P=0.3.

154.2 157.1

149.4

119.5 127.1 135

22.8 24.9 28.6 24.4 18.9 21.3

-4%/yr, p=0.1

-3%/yr, p=0.3

0 20 40 60 80 100 120 140 160 180

/100,000 POPULATION

YEARS

Men Women

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23

Table 6 and figure 6 show stroke mortality rates and trends in age adjusted groups per 100,000

population in both females and males from the period of 2010 to 2015 in Kaunas

Table.6 Mortality and trends (%/yrs.) from stroke among Kaunas population by gender and age groups during 2010-2015

Years 2010 2011 2012 2013 2014 2015 Mortali

ty trends

%/yr

25-34 years 4.78 3.56 4.67 2.32 4.56 2.24 -10 0.23 35-44 years 8.36 9.57 7.45 12.75 2.61 10.7 -6 0.7 45-54 years 24.54 15.18 24.39 25.02 25.88 21.87 3 0.59 55-64 years 92.53 73.53 75.82 58.68 104.46 90.74 1 0.73 Men, N

25-34 years 5.84 5.98 9.61 4.8 4.9 4.75 -6 0.35

35-44 years 4.42 15.35 5.3 5.35 5.51 5.65 -5 0.67 45-54 years 27.89 29.64 40.32 36.26 42.77 21.96 -0.5 0.93 55-64 years 117.39 128.58 135.28 93 155.47 192.02 7 0.23 Women, N

25-34 years No data avail

No data avail

8.71 No data avail

No data avail

No data avail 35-44 years 11.89 4.49 9.34 24.06 10.46 15.26 13 0.36 45-54 years 22.03 3.86 11.88 16.22 12.61 21.8 11 0.54 55-64 years 75.59 36.46 36.13 35.65 70 21.79 -12 0.32 Males and females

Mortality trends from 25-64 among Kaunas population from 2010 till 2015 is 4%/yr Mortality trends from 25-64 among EU population from 2010 till 2015 is 2%/yr

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Males

Mortality trends from 25-64 among Kaunas male population from 2010 till 2015 is 7%/yr Mortality trends from 25-64 among EU male population from 2010 till 2015 is 7.5%/yr Females

Mortality trends from 25-64 among Kaunas female population from 2010 till 2015 is -0.7%/yr

Mortality trends from 25-64 among EU female population from 2010 till 2015 is -0.4%/yr

Figure.6 Age adjusted mortality rate from Stroke (per 100.000 population) and trends among Kaunas population aged 25-64 years during 2010-2015

As for table.6 and figure.6 stroke mortality rates and trends were slightly and

insignificantly increasing among the population of Kaunas +4%/yr;P=0.2 and for the EU population +2%/yr;P=0.4 for both genders in all age groups over the studied period from 2010 to 2015. On the other hand males from the population of Kaunas themselves showed again a slight increase with +7%/yr;P=0.1 while +7.5%y;P=0.2 was recorded for the males population of the EU over the studied period. Add to that females population of Kaunas recorded a very slight and insignificant decrease by -0.7%/yr;P=0.9 while another insignificant decrease was shown among the EU females population by - 0.4%/yr;P=0.9.

30.4

37

41.7

29.9

45.1

49.6

25.7

10.8 14.3

18.9

23.4

14.6 +7%/yrs, p=0.12

-0.7%/yrs, p=0.93

0 10 20 30 40 50 60

/100,000 POPULATION

YEARS

Men Women

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Discussion of results

In Lithuania, according to a study CVD mortality rate is two times higher than the EU average, causing up to 50% of all other mortality causes [4].

What could be the reasons that Lithuania's mortality rate for CVD is higher than the average in Europe? Lithuania is a good example for many Eastern European countries regarding CVD for a number of reasons. A big part of the population in countries like Lithuania is living in rural parts of the country, and only a smaller part of the population, compared to other European countries, is living in the bigger cities, the urban parts of the country, like Vilnius, Kaunas and Klaipeda. This account for a big part of the country's population is also living too far or has not enough direct access to higher quality health care, treatments and hospitals. The isolated lifestyle of many, especially the elderly, and the lower social class population living in these rural areas, also leads to the consequence that they are much less aware and are a less educated regarding the change in lifestyle measures to prevent CVD mortality, not to mention the fact that they often lack the financial possibilities for primary prevention, and screening of

diseases [4]. Furthermore, the lifestyle and diet of North-Eastern European countries is not only due to the fact that the financial possibilities won't allow a healthier way of life, but also for the reason, that the diet in these countries often lack components like fiber, variety of fruits and vegetables due to the disadvantage of the climate, leading to lack of many vitamins and minerals.

The colder climate also forces the people to eat much more red, smoked and high in fat meats and animal products, which are a major risk factor for many CVD diseases, or conditions predisposing CVD, like atherosclerosis, high LDL and Triglyceride levels, low HDL levels, hypertension, and many more. According to a study fat consumption in Lithuania was around 10% higher than Latvian and 40% higher than Estonian, as well as higher BMI and obesity prevalence in all age groups [4].

On the other hand, it is to consider the noticeable improvements in health care over the years in Lithuania and other similar countries, especially after its entry in the European Union, providing better laws, doctor visits and screenings, motivation to improve

lifestyle, and financial support in health care. In the present, the access to treatment and hospital services have boomed, involvement of foreign help, better and expanded

education of health care workers and staff.

Mortality rates and trends for CVD as seen in table.4 and figure4, showed an overall progressively pattern of decrement over the studied period in both genders where for the 25-34 age group the total numbers of cases mortality rates slightly increased going from 2010 into 2011 then decreased in 2012 and then fluctuates and remained stable for the rest of the period only to decrease by almost half in 2015. This goes as well for 35-44 age group where mortality rates slightly increases from 2011 going into 2012 and kept increasing for 2013 then show a pattern of decrement for the rest of the studied period, on the other hand for 45-54 age group mortality rate remained almost stable and

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fluctuating until it showed a decrease going into 2014 and 2015. The burden still with age groups of 55 and above where there is no significant decrease in mortality rates and there trends. For males mortality rates and trends were slightly decreasing by going from 2010 to 2013 but then it decreases significantly by more than half going into 2014 and remained stable for 2015 in 25-34 age group, while in 35-44 age group mortality rates increased significantly going from 2010 to 2012 then decreases by almost half in 2013 and fluctuates and remained stable for the rest of the studied. As for 45-54 age group mortality rates where stable for 2010 to 2014 and showed a slight pattern of increment then start decreasing progressively for the rest of the studied period, while for age groups of 55 and above no significant changes were seen and mortality rate

remained stable for the 6 years studied period. For the female gender there was no data available for age groups 25-34 for 2012 and 2015 but it is noticed a rapid increase in mortality rate going from 2013 into 2014 by almost three folds, as for 35-44 age group, CVD mortality rates showed an overall pattern of increment over the 6 years studied period. Whereas mortality rates for 45-54 remained stable only to show slight decrease in 2013 and 2014 then it goes up to around its previous levels in 2015. Also mortality rates for 55-64 age groups showed a stable pattern only to decrease significantly going from 2014 into 2015

It is also established through the analysis of data from table.2 and figure.2, that overall CHD percentage out of all CVD has shown a relatively decrease between the years 2012-2014, but increased again up until 2015. This overall percentage for both genders is relatively proportional with the percentages for the male gender for the same years.

Even more remarkable changes have been noticed though in the female population:

Before the year 2011, the female population has encountered significantly less

percentage of CHD compared to the male population and even the overall population.

Strikingly then from 2011 this percentage of CHD has increased in the female

population by roughly 7% up until 2012, slightly decreased by 2013, then significantly decreased by year 2014 by around 7%, only to steeply increase back up again in year 2015 even more, by 8%. All in all, since the incidence of CHD in males is overall higher than in females, they also make up the most of the general population of CHD

percentage, making the graph of the overall population relatively proportional to the curve of the male population. On the other hand, as previously pointed out and seen in the undulations of curve of the graph and regarding the percentages in the female population, there are significant changes over 6 years, compared to the overall and thus also the male population, which stay, roughly spoken, relatively stable.

Mortality rates and trends for CHD as seen in table.5, showed an overall progressively pattern of decrement over the studied period in both genders where for the 25-34 age group the total numbers of cases mortality rates decreases by almost half from the year 2010 to 2011 and kept fluctuating around the same number for the rest of the years.

This goes as well for 35-44 age group where mortality rates slightly increases from 2011

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going into 2012 and then showed a progressive decrease over the studied period with a remarkable year 2014 where it was six times less than 2010, this apply also for 45-54 age group where mortality rate kept decreasing starting from the year 2010 till 2015 with a decrease of 2 folds in 2014 comparing to 2010. The burdens still with age groups of 55 and above where there is no significant decrease in mortality rates and there trends.

For males where CHD accounts for more than half of all other CVD cases, mortality rates and trends were decreasing by half going from 2010 to 2011 but then it fluctuates and remains stables for the rest of the years in 25-34 age group, while in 35-44 age group mortality rates decreases from 2010 going into 2011 only to increase back to its previous rate in 2012, then decreases progressively over the rest of the studied period with a 2 times increase from 2014 going into 2015. As for 45-64 age group mortality rates are significantly higher and shows a very slight decrease over the studied period of 5 years. For the female gender there was no data available for age groups 25-34 as well as 35-44, whereas mortality rates for 45-54 age group for unknown reasons showed a 3 times increase going from 2010 into 2011 then decreases by half in 2012 then it fluctuates and remain stable for the rest of the studied period.

Now on the other hand, looking at the table.3 and figure.3, stroke percentages out of all CVD, we see a different situation then before. In males, it has risen only slightly until 2012, and then dropped in 2013 by around 3%, then rose significantly in the next year by roughly 6% and the next year by another 1%. The curve is similar in the general population as well, proportional to the curves of both genders, having only higher

percentages, as seen in the table, which are due to the significantly higher incidences in the female population. The stroke percentage in the female population in the year 2010 is very high, which significantly drops by an astonishing 17%, which only increases again by up to nearly 31%, then drops by 8% by the year 2015. This is a remarkably unstable percentage over a period of six years in the female population of Kaunas, compared to the male population.

Mortality rates and trends for stroke as seen in table.6, showed an overall progressively pattern of increment over the studied period of 5 years in both genders and especially in advanced ages where for the 25-34 age group the total numbers of cases mortality rates remains stable and fluctuates around the same level for the studied period of 5 years. This goes as well for 35-44 age group where mortality rates slightly increases from 2010 going into 2011 and then showed a progressive decrease over the studied period with a remarkable increase in 2013 and then a dramatic decreases by 6 times for 2014 and then increases again in 2015 for around its previous levels. As for 45-54 age group where mortality rate decreased from 2010 going into 2011 and then start

increasing progressively over the next years shows a positive mortality trends percentage over the studied 5 years period. For age groups of 55 and above where there is no significant decrease in mortality rates and there trends where it decreases

Jad Abou Chakra

Master's Thesis

LITHUANIAN UNIVERSITY OF HEALTH SCIENCES Academy of Medicine

Institute of Cardiology

Jad Abou Chakra

EVALUATION OF DEATH RATES AND TRENDS OF CARDIOVASCULAR DISEASES AMONG KAUNAS MIDDLE-

AGED POPULATION DURING 2010-2015 (CORONARY HEART DISEASE AND STROKE)

CONTENTS

Abstract:

SUMMARY

SANTRAUKA

ACKNOWLEDGMENT

CONFLICT OF INTERESTS

AUTHORIZATION OF ETHICS COMMITTEE

ABBREVIATIONS:

TERMS AND DEFINITIONS:

INTRODUCTION

Aim and objectives

LITERATURE REVIEW

Research methodology and methods

RESULTS

CVD % out of all causes of death

CHD % out of CVD

stroke % out of CVD

Discussion of results