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Cardiovascular disease in Europe 2014: epidemiological update

Melanie Nichols, Nick Townsend, Peter Scarborough, Mike Rayner
DOI: http://dx.doi.org/10.1093/eurheartj/ehu299 2950-2959 First published online: 19 August 2014


This paper provides an update for 2014 on the burden of cardiovascular disease (CVD), and in particular coronary heart disease (CHD) and stroke, across the countries of Europe. Cardiovascular disease causes more deaths among Europeans than any other condition, and in many countries still causes more than twice as many deaths as cancer. There is clear evidence in most countries with available data that mortality and case-fatality rates from CHD and stroke have decreased substantially over the last 5–10 years but at differing rates. The differing recent trends have therefore led to increasing inequalities in the burden of CVD between countries. For some Eastern European countries, including Russia and Ukraine, the mortality rate for CHD for 55–60 year olds is greater than the equivalent rate in France for people 20 years older.

  • Cardiovascular disease
  • Epidemiology
  • Coronary heart disease
  • Mortality
  • Morbidity
  • Treatment


Cardiovascular disease (CVD) remains the leading cause of death among Europeans and around the world. The Global Burden of Disease study estimated that 29.6% of all deaths worldwide (15 616.1 million deaths) were caused by CVD in 2010, more than all communicable, maternal, neonatal and nutritional disorders combined, and double the number of deaths caused by cancers.1 This paper provides an update for 2014 on the burden of CVD, and in particular coronary heart disease (CHD) and stroke, across the countries of Europe. This overview updates the work published in this journal in 20132 and provides an up-to-date synopsis of the key data in relation to mortality and morbidity from CVD across Europe.


This overview brings together a number of European and international data sources to give an outline of comparable data for the region. In selecting the data sources for inclusion, the key considerations were data quality, sources with coverage of the greatest number of countries, and the most recently updated sources. The scope of this update covers the mortality, morbidity, and treatment data associated with CVD in Europe, with additional focus on the two most common forms of CVD, CHD, and stroke. These data are fundamental to our understanding of the burden and distribution of CVD in Europe, and sources are updated relatively frequently through routine and administrative data collections. Information on medical and behavioural risk factors and co-morbidities, by comparison, tend to be less frequently updated and there are greater challenges to comparability across countries. Data reported in this paper have been sourced from the World Health Organization (WHO) mortality database,3 the WHO European Region's Health for All Database,4 and the Organisation for Economic Co-operation and Development (OECD) health statistics.5 Europe is here defined as the 53 member states of the WHO European region. Comparability and quality of the data vary by topic, and there were no ‘ideal’ data sources that provided complete, up-to-date, high-quality, and representative information for all 53 countries for any topic in this overview.

All mortality statistics, including estimates of mortality rates and proportions by cause, were calculated using age- and cause-specific data by country from the WHO Mortality Database,3 using the most recent (February 2014) update. All analyses, interpretations, and conclusions are those of the authors, not the WHO, which is responsible only for the provision of the original information. Age standardization was to the European Standard Population (ESP).6 Note that to maintain consistency and comparability with the previous epidemiological update published in 2013,2 the same ESP has been used, in preference to the more recently updated standard population developed by the European Commission for the EU27+EFTA countries.7

The WHO database collates data reported by national authorities based on their civil registration systems and contains data for 52 of 53 European countries (no data available for Andorra). Where data are presented for the ‘most recent year’, this relates to the most recent data for which both mortality and population data were available in the WHO datasets, with the exceptions of Monaco, Montenegro, and Turkey, for which no population data were available. These countries are included in the calculations for total numbers of deaths and premature deaths, but could not be included in the section on age-standardized death rates. The data are relatively up-to-date, and data for 40 of the 52 countries were available up to 2010, 2011, or 2012; however, only 18 countries have provided updated numbers in the year since our previous report.2 The years to which the data relate for each country are given in the tables. Consistent with our previous update, data are presented for mortality before both 65 and 75 years. In this report, all data are presented as age standardized, with the exception of the hospital discharge rates, for which this was not possible as no standardized or age-specific data are published.


Cardiovascular disease is the leading cause of death in Europe, and despite recent decreases in mortality rates in many countries, it is still responsible for over 4 million deaths per year, close to half of all deaths in Europe (Table 1). The proportion of all deaths that are attributable to CVD is substantially greater among women (51%) than men (42%). Coronary heart disease, when considered separately, accounts for almost 1.8 million deaths, or 20% of all deaths in Europe annually. The gender differences in the proportional contribution of CVD to total mortality is driven far more by stroke and other CVD, and among both men and women, CHD causes one in five of all deaths.

View this table:
Table 1

Number and percentage of deaths from cardiovascular diseases in Europe—latest available yeara

Cardiovascular disease (total)Coronary heart diseaseCerebrovascular diseaseOther cardiovascular diseases
 Total deaths (all ages)1 862 77442%876 01720%429 75610%557 00112%
 Premature deaths–before age 75939 69836%473 50118%201 7808%264 41710%
 Premature deaths–before age 65508 13231%253 43216%95 2496%159 45110%
 Total deaths (all ages)2 219 32651%903 33021%627 22714%688 76916%
 Premature deaths–before age 75536 71237%232 68316%155 70211%148 32710%
 Premature deaths–before age 65201 49227%77 16610%54 4707%69 8569%
 Total deaths (all ages)4 082 10046%1 779 34720%1 056 98312%1 245 77014%
 Premature deaths–before age 751 476 41037%706 18418%357 4829%412 74410%
 Premature deaths–before age 65709 62430%330 59814%149 7196%229 30710%
  • aNo data available for Andorra. Source: World Health Organization Mortality Database.

Cardiovascular disease continues to cause a much greater mortality burden among Europeans than any other disease. Overall, CVD caused 51% of deaths among women and 42% among men in the last year of data, compared with 19 and 23%, respectively, for all cancers (Figure 1). In individual countries, however, the patterns vary widely. There are now 10 European countries in which cancer is the cause of more deaths than CVD among men (Belgium, Denmark, France, Israel, Luxembourg, Netherlands, Portugal, Slovenia, Spain, and San Marino). The latest data also show that for the first time, cancer has surpassed CVD as a cause of death among women in one country (Denmark). Conversely, in 32 of 52 countries, the most recent data show more than double the number of deaths from CVD compared with cancer in women, and of those, 15 countries where CVD causes more than four times more deaths than cancer. Among men, there are 21 countries where CVD deaths are more than double cancer deaths, and 6 countries where they are more than four times greater.

Figure 1

Proportion of all deaths due to major causes in Europe, latest available year, among men (A) and women (B).

Note: no data available for Andorra. Source: World Health Organization Mortality Database.

Premature mortality

The proportion of all deaths that are caused by CVD increases with age, therefore, the proportion of premature deaths among Europeans caused by CVD was substantially lower than the overall rate. Three in every ten deaths of Europeans aged under 65 in the latest year of data were caused by CVD, as were 37% of all deaths occurring before age 75 (Table 1). In total, 1.48 million deaths before age 75 in Europe were caused by CVD, more than half of which were in people aged 65–74 years. In contrast to overall deaths (‘all ages’), the proportion of premature deaths, either before age 65 or before age 75, that are caused by CVD shows limited gender differences.

Mortality rates across European countries

The most up-to-date data on CVD in Europe show that the burden of mortality continues to show large geographic inequalities. Updated data from Denmark and Norway show that they now have among the lowest rates of age-adjusted CVD mortality (<180 per 100 000 men at all ages, <120 per 100 000 women), and Denmark in particular has joined countries, including France, Portugal, the Netherlands, and Spain, with the lowest rates of CHD mortality (Table 2). Setting aside Turkmenistan, for which the latest available mortality data are from 1998, the highest rates of CVD mortality were found in the Russian Federation and Belarus for men (915 and 892 per 100 000, respectively), and Uzbekistan and Kyrgyzstan for women (662 and 588 per 100 000).

View this table:
Table 2

Age-standardized death rates from cardiovascular disease and coronary heart disease by country and sex (per 100 000 population)

CountryLatest yearMalesFemales
Age-standardized mortality rate10-year change in mortality rateAge-standardized mortality rate10-year change in mortality rateAge-standardized mortality rate10-year change in mortality rateAge-standardized mortality rate10-year change in mortality rate
Bosnia and Herzegovina2011474.7n/a93.5n/a385.4n/a54.8n/a
Czech Republic2012403.1−28%214.9−11%264.0−30%126.2−6%
Republic of Moldova2012790.3−22%527.5−26%564.2−25%365.4−29%
Russian Federation2010915.1−13%500.9−7%516.8−18%254.5−5%
San Marino2005242.2−30%30.9−46%155.5−6%8.3−73%
TFYR Macedonia2010626.9−5%112.9−26%490.6−5%56.9−23%
  • Rate for most recent year of data and percentage change in rates over 10 years.

  • Rates not available for Monaco, Montenegro, or Turkey due to missing population data. No mortality data available for Andorra. Source: World Health Organization Mortality Database. Age standardized to the European Standard Population.

  • aChange in rates for Belgium and UK is over 11 years due to missing data for the past 10 years.

  • n/a, not available.

Premature mortality from CVD among men varied almost 10-fold from <65 per 100 000 before age 75 (age standardized) in San Marino, France, Israel, and Switzerland, to over 560 per 100 000 in the Russian Federation and Belarus. Among women, the magnitude of variation between countries was similar, from five countries with fewer than 25 deaths per 100 000 before age 75 (France, Iceland, Switzerland, Israel, and Spain) to 10 countries with rates exceeding 200 per 100 000. Details of premature mortality rates are given in the Supplementary material online, Table S1 (mortality rates before age 65 and before age 75).

Mortality rates increase with age in all countries; however, due to the wide variation between countries, there are many cases where the mortality rate among (for example) 65–69 year olds in one country may be equivalent to or higher than the mortality rate for 75–79 year olds in another country. Taking the most recent mortality rates among 75–79 year olds in France as the reference (the first age group not considered a ‘premature’ death under usual definitions, and the country with the lowest mortality rates for that age group in both sexes), we calculated the age groups in all other countries for which the rates in the latest year were equal to or greater than the referent (Figure 2). Countries with no data within the last 5 years were excluded. This showed that among men, there were five countries where the CVD death rates among 55–59 year olds was higher than the referent, a further 5 countries where the CVD rate among 60–64 year olds was higher than the referent, and 10 countries where equivalent mortality rates were reached at ages at least 10 years younger than in France. This means that CVD mortality rates among 55–59-year-old men in Belarus, Kazakhstan, Kyrgyzstan, Russia, and Ukraine were higher than equivalent rates in French men 20 years older. The results were similar among women, although the disparities were slightly less marked. Coronary heart disease mortality rates showed even bigger differences in many countries. There were three countries (Belarus, the Russian Federation, and Ukraine) where men aged 50–54 years old had a higher risk of dying from CHD than 75–79-year-old men in France.

Figure 2

Inequalities in rates of premature death: age groups for which rates of CVD and CHD in each country match or exceed those of 75–79 year olds in France.

Trends in mortality

Mortality rates continue to fall in most but not all European countries, and the magnitude of change has varied dramatically between countries over the last 10 years (Table 2). The age-standardized mortality rate from CVD has decreased over the last 10 years of available data in all but five countries for men, and all but four countries for women, and has decreased by a third or more among men in 14 countries and among women in 15 countries. Decreases in CHD rates have been in many cases even more dramatic; the most recent mortality rates from CHD were less than half the rates 10 years earlier in eight countries for women and six countries for men, although again, there were a small number of countries where the rates had increased over the same period.

Case-fatality rates

Among the 25 countries with data available, age- and sex-standardized admission-based case-fatality rates after acute myocardial infarction (AMI) for the most recent year (2011 for most countries) as documented by the OECD varied up to 5-fold between countries (Table 3). Most countries, however, have seen substantial reductions in these hospitalized case-fatality rates for AMI over the last 5 years. The median annual reduction was just over 5%, or a total median reduction in case-fatality rates over that period of around one-quarter. Although the absolute case-fatality rates varied widely, the documented reductions in case-fatality rates have been far more consistent across countries than other trends in CVD. Almost all countries with data available demonstrated clear reductions in case fatality after AMI, and most improvements (19 of 23) were in the range of 3–6% per year on average over the last 5 years. Reported admission-based case-fatality rates for haemorrhagic stroke were as high as 40.5 per 100 patients in Hungary, while for ischaemic stroke the highest rate was in Latvia (19.0 per 100 patients). Clear reductions were apparent in case-fatality rates for both stroke types in most countries over the last 5 years, largely in the range of 1–4% per year on average for haemorrhagic stroke and 2–5% for ischaemic stroke.

View this table:
Table 3

Admission-based case-fatality rates after acute myocardial infarction and stroke, adults aged 45 years and over

YearCase fatality after acute myocardial infarctionCase fatality after haemorrhagic strokeCase fatality after ischaemic stroke
Age- and sex-standardized rate per 100 dischargesAnnual change in rate (%) over last 5 yearsaAge- and sex-standardized rate per 100 dischargesAnnual change in rate (%) over last 5 yearsaAge- and sex-standardized rate per 100 dischargesAnnual change in rate (%) over last 5 yearsa
Belgium20097.6−5.9%30.5−0.4%9.2 0.2%
Czech Republic20116.8−5.7%a24.5−4.6%a9.5−4.9%a
Iceland20115.7−4.2%16.7 0.4%7.4−7.9%
Slovak Republic20117.6−8.9%a28.0−4.2%a11.0−4.5%a
  • Latest year and annual percentage change in rates over last 5 years, by country.

  • Source: OECDstat http://stats.oecd.org.

  • aWhere data were not available for 5 years prior to most recent estimate, the closest available year was used. Exceptions and the span of data over which estimates were calculated were: Latvia—1 year; Slovenia—2 years; UK—3 years; Slovak Republic and Czech Republic—4 years. Only 1 year of data available for Turkey.


The most comparable data available across European countries to track the burden of CVD morbidity are hospital discharge data. The most recent available data (Table 4) show that the population-based rates of hospitalization for CVD have tended to trend upward since the early 2000s. The median numbers of hospital discharges per 100 000 population in 2012 (or most recent year) by country were 2097 for CVD, 608 for CHD, and 298 for stroke, up from 1829, 532 and 258 in 2001. In contrast to mortality rates, which have fallen significantly in almost all European countries in recent years, more countries (34) have experienced an increase in hospital discharge rates for CVD than have experienced decreases (15), and similarly for stroke there were 32 countries with an increase, and 18 with a decrease. For CHD, there have been an almost equal number of increases and decreases (24 vs. 26) and across all three disease categories the changes in rates of hospitalization vary between very small (<5% changes) and more than doubling. High variability between countries is also evident in hospitalization rates. Variations may reflect both true differences in incidence as well as differences in the rates at which incident cases result in death before or without hospitalization due to differences in health system organization and efficiency, coding practices, etc.

View this table:
Table 4

Hospital discharges for cardiovascular disease, coronary heart disease, and cerebrovascular disease per 100 000 population, by country, 2001–2012

Cardiovascular diseaseCoronary heart diseaseCerebrovascular disease
Czech Republic(2001–2010)343030861107715625547
Republic of Moldova(2001–2012)13112532373686247623
Russian Federation(2001–2012)3020369311681373653858
San Marino20111642284256
TFYR Macedonia(2001–2007)13981443573551240261
  • Source: World Health Organization European Regional Office, Health for All Database.

  • aWhere data for 2001 and/or 2012 were not available, the closest available year was included. Years are given in the table for each country.

Summary and discussion

The burden of CVD in Europe remains high overall, and varies dramatically between countries. More than 4 million Europeans die of CVD every year, and many more are hospitalized after acute episodes or treated for chronic cardiovascular ill health.

Since our update published in 2013, which was based on the extensive data reported in European Cardiovascular Disease Statistics,8 the overall pattern of distribution and trends of CVD burden in Europe have been relatively stable, and there is evidence of continuing reductions in the burden of CVD. The proportion of all deaths in Europe caused by CVD, and specifically by CHD and stroke, has remained stable, whereas the total number of deaths caused by CVD has decreased slightly (2561 fewer CVD deaths overall). There have however been greater improvements in premature deaths, with 14 639 fewer deaths occurring before the age of 75 (∼1% fewer deaths). In the 18 countries with updated mortality data since the last report, there was evidence in all of them of continued decreases among men in age-standardized death rates from CVD. Similarly, there were further decreases in death rates from CHD among men in 16 of these countries (rates stable in Estonia and Greece). Among women, however, the evidence in these 18 countries is more mixed; in Latvia and Luxembourg, CVD death rates among women were stable, whereas in Hungary, Israel, Norway, and Serbia, there were small increases. In CHD, death rates were stable since the last report in Israel, Latvia, and Norway, while there were small increases in Croatia, Hungary, Luxembourg, and Serbia. It will be important to continue to monitor the gender-specific trends in CVD and CHD mortality amid this and other evidence that decreases in mortality rates may have begun to slow or even reverse in some specific subpopulations.9,10 Updated data have also shown substantial reductions in admission-based case-fatality rates after AMI and stroke, in almost all countries over the last 5 years of available data.5 The most recent hospital morbidity data included in this update have shown that in contrast to ongoing decreases in mortality, hospitalizations for CVD have increased in the majority of countries. Given that these data are not age standardized, the overall increases likely reflect, at least to some extent, the impact of an ageing population. Despite this, increased rates of hospitalization are an important observation that emphasizes the continued high burden of CVD in European populations despite dramatic decreases in age-adjusted mortality rates.

Two years have now passed since the World Health Assembly adopted a global target of reducing mortality from non-communicable diseases (NCDs) by 25% by the year 2025.11 Worldwide, there have been few moments in history during which NCDs have enjoyed such a prominent place in the world's attention, with CVD at the forefront of the activity. Despite this, there has been little commitment at the national or regional level to greater monitoring and reporting of risk factors and outcomes for CVD. It is clear that in many countries of Europe, CVD mortality has continued to decrease substantially in recent years and will make a large contribution to achieving this goal. In these (predominantly high income) countries, a ‘tipping point’ is rapidly approaching, when cancer deaths will outnumber CVD deaths, particularly among men. In many other countries, however, the CVD burden dwarfs that of cancer, and a large proportion of the populations will lose their lives prematurely to heart disease and stroke.


This study received no specific funding. M.N. is supported by funding from the National Heart Foundation of Australia for ‘HeartStats: The Heart Foundation/Deakin University Australian Heart Disease Statistics Project’. N.T., P.S. and M.R. receive funding from the British Heart Foundation.

Conflict of interest: none declared.


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