Worldwide patterns of ischemic heart disease mortality from 1980 to 2010 Cláudia Gouvinhas 1 , Milton Severo 1 , Ana Azevedo 1 , Nuno Lunet ⁎ ,1 Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Portugal Institute of Public Health, University of Porto (ISPUP), Portugal abstract article info Article history: Received 13 December 2012 Accepted 1 November 2013 Available online 13 November 2013 Keywords: Myocardial ischemia Mortality Epidemiology Cluster analysis Background: The trends in the IHD mortality rates vary widely across countries, reflecting the heterogeneity in the variation of the exposure to the main risk factors and in the access to different management strategies among settings. We aimed to identify model-based patterns in the time trends in IHD mortality in 50 countries from the five continents, between 1980 and 2010. Methods and results: Mixed models were used to identify time trends in age-standardized mortality rates (ASMR) (age group 35+ years; world standard population), all including random terms for intercept, slope, quadratic and cubic. Model-based clustering was used to identify the patterns. We identified five main patterns of IHD mortality trends in the last three decades, similar for men and women. Pattern 1 had the highest ASMR and pattern 2 exhibited the most pronounced decrease in ASMR during the entire study period. Pattern 3 was characterized by an initial increase in ASMR, followed by a sharp decline. Coun- tries in pattern 4 had the lowest ASMR throughout the study period. It was further divided into patterns 4a (consistent decrease in ASMR throughout the period of analysis) and 4b (less pronounced declines and highest rates observed mostly between 1996 and 2004). There was no correspondence between the geographic or economical grouping of the analyzed countries and the patterns found in this study. Conclusions: Our study yielded a new framework for the description, interpretation and prediction of IHD mortal- ity trends worldwide. © 2013 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Worldwide, cardiovascular diseases (CVD) were responsible for 17.3 million deaths in 2008, corresponding to 32% of all deaths in women and 27% in men. Ischemic heart disease (IHD) and cerebrovas- cular diseases are responsible for approximately two thirds of the CVD deaths [1], with IHD accounting for 7.3 million deaths yearly. Approxi- mately four fifths of these occur in low and middle income countries (LMIC) [2] and IHD remains the leading cause of death in high income settings [1,3], despite the downward trends observed in the last decades [4]. This decline results primarily from changes in exposure to major risk factors, including decreases in tobacco consumption [5,6] and physical inactivity [7,8], lower blood pressure [9,10] and serum cholesterol [10,11] in the general population, and a better control of dyslipidaemia [8] and hypertension [12–15], as well as from the increasing access to earlier and more effective management of acute coronary syndromes [16,17] and uptake of long-term secondary prevention [14,18]. The trends in the IHD mortality rates vary widely across countries, reflecting the heterogeneity in the variation of the exposure to the main risk factors and in the access to different management strategies among settings. Previous attempts to describe worldwide patterns of IHD mortality trends relied on grouping the countries mostly based on geographical criteria or socio-economic characteristics [19,20]. Howev- er, model-based clustering may allow the definition of more homoge- neous groups of countries, accounting for the mortality rates at the onset of the observation period, as well as the magnitude and slope of its variation, with no a priori constraints. This study aimed to identify patterns of time trends in IHD mortality across countries, using a model-based approach. 2. Methods All European countries, high-income non-European countries and the leading emerg- ing economies jointly referred to as BRICS, as defined by the United Nations (UN) [21], with available data were eligible for the present study. We abstracted death certification data from the World Health Organization (WHO) database [22], for the period between 1980 (or the first calendar year with available data since 1980) and 2010 (or the most recent data available) for each country. Countries with no data available in electronic support (India) or having data available for less than International Journal of Cardiology 170 (2014) 309–314 ⁎ Corresponding author at: Departamento de Epidemiologia Clínica, Medicina Preditiva e Saúde Pública, Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal. Tel.: +351 22551 3652; fax: +351 22551 3653. E-mail address: nlunet@med.up.pt (N. Lunet). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.004 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard