Original article Analyzing the Coronary Heart Disease Mortality Decline in a Mediterranean Population: Spain 1988-2005 Gemma Flores-Mateo, a,b Marı ´a Grau, c Martin O’Flaherty, d Rafel Ramos, a,e Roberto Elosua, c,f Concepcio ´n Violan-Fors, a Miquel Quesada, a,e Ruth Martı ´, a,e Joan Sala, g Jaume Marrugat, c and Simon Capewell d, * a Institut d’Investigacio ´ en Atencio ´ Prima `ria Jordi Gol, Barcelona, Spain b CIBER de Fisiopatologı´a de la Obesidad y Nutricio ´n (CIBEROBN), Instituto Salud Carlos III, Madrid, Spain c Grupo de Epidemiologı´a y Gene ´tica Cardiovascular, Programa de Investigacio ´n en Procesos Inflamatorios y Cardiovasculares, Institut de Recerca Hospital del Mar (IMIM), Barcelona, Spain d Division of Public Health, University of Liverpool, Liverpool, United Kingdom e Unitat de Suport a la Recerca de Girona, Institut d’Investigacio ´ en Atencio ´ Prima `ria Jordi Gol, Institut Catala ` de la Salut, Barcelona, Spain f CIBER de Epidemiologı´a y Salud Pu ´blica, Instituto Salud Carlos III, Madrid, Spain g Departamento de Cardiologı´a, Hospital Universitari Dr. Josep Trueta, Girona, Spain Rev Esp Cardiol. 2011;64(11):988–996 Article history: Received 7 January 2011 Accepted 5 May 2011 Available online 1 October 2011 Keywords: Coronary disease Mortality Drugs Risk factors Population A B S T R A C T Introduction and objectives: To examine the extent to which the decrease in mortality rates in Spain between 1988 and 2005 could be explained by changes in cardiovascular risk factors and by the use of medical and surgical treatments. Methods: We used the previously validated IMPACT model to examine the contributions of exposure factors (risk factors and treatments) to the main outcome, changes in the mortality rates of death from coronary heart disease, among adults 35 to 74 years of age. Main data sources included official mortality statistics, results of longitudinal studies, national surveys, randomized controlled trials, and meta-analyses. The difference between observed and expected coronary heart disease deaths in 2005 was then partitioned between treatments and risk factors. Results: From 1988 to 2005, the age-adjusted coronary heart disease mortality rates fell by almost 40%, resulting in 8530 fewer coronary heart disease deaths in 2005. Approximately 47% of the fall in deaths was attributed to treatments. The major treatment contributions came from initial therapy for acute coronary syndromes (11%), secondary prevention (10%), and heart failure (9%). About 50% of the fall in mortality was attributed to changes in risk factors. The largest mortality benefit came from changes in total cholesterol (about 31% of the mortality fall) and in systolic blood pressure (about 15%). However, some substantial gender differences were observed in risk factor trends with an increase in diabetes and obesity in men and an increase in smoking in young women. These generated additional deaths. Conclusions: Approximately half of the coronary heart disease mortality fall in Spain was attributable to reductions in major risk factors, and half to evidence-based therapies. These results increase understanding of past trends and will help to inform planning for future prevention and treatment strategies in low-risk populations. ß 2011 Sociedad Espan ˜ola de Cardiologı ´a. Published by Elsevier Espan ˜a, S.L. All rights reserved. Ana ´ lisis de la disminucio ´n de la mortalidad por enfermedad coronaria en una poblacio ´n mediterra ´ nea: Espan ˜a 1988-2005 Palabras clave: Enfermedad coronaria Mortalidad Tratamientos Factores de riesgo Poblacio ´n R E S U M E N Introduccio ´n y objetivos: Examinar el grado en que la disminucio ´n de las tasas de mortalidad por cardiopatı ´a isque ´ mica en Espan ˜a entre 1988 y 2005 podrı ´a explicarse por cambios en los factores de riesgo cardiovascular y por el uso de tratamientos me ´ dicos y quiru ´ rgicos. Me ´todos: Se utilizo ´ el modelo IMPACT previamente validado para combinar y analizar datos de las tendencias en la prevalencia de factores de riesgo y el uso y la efectividad de tratamientos cardiacos basados en la evidencia, entre varones y mujeres adultos de 35-74 an ˜os de edad. Las principales fuentes de datos incluyeron estadı ´sticas oficiales de mortalidad, resultados de estudios longitudinales, encuestas nacionales, ensayos clı ´nicos aleatorizados y metaana ´ lisis. La diferencia entre las muertes coronarias observadas y esperadas en 2005 se distribuyo ´ entre los tratamientos y los factores de riesgo. Resultados: Desde 1988 a 2005, la tasa de mortalidad ajustada por edad cayo ´ un 40%, y hubo 8.530 muertes menos en 2005. Aproximadamente el 47% de la caı ´da en la mortalidad se ha atribuido a los SEE RELATED ARTICLE: DOI: 10.1016/j.rec.2011.07.007, Rev Esp Cardiol. 2011;64:962–4. * Corresponding author: Division of Public Health, University of Liverpool, Whelan Building, Quadrangle, Liverpool, L69 3GB, United Kingdom. E-mail address: capewell@liverpool.ac.uk (S. Capewell). 1885-5857/$ – see front matter ß 2011 Sociedad Espan ˜ola de Cardiologı ´a. Published by Elsevier Espan ˜a, S.L. All rights reserved. doi:10.1016/j.rec.2011.05.035 Document downloaded from http://www.revespcardiol.org, day 26/10/2011. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.