Introduction Middle income countries are facing an epidemic of non-communicable diseases, especially diabetes, stroke and coronary heart disease (CHD). We analysed population and mortality trends in Palestine, Syria, Tunisia and Turkey.

Methods Populations and timeframes. West Bank Occupied Palestine Territory (2.5 million population, 1998–2009); Turkey (73 million, 1995–2008); Tunisia (10 million, 1997–2009); Syria (20 million, 1996–2006).

Data Sources National and local surveys, routine national and WHO statistics. Data on populations, mortality, patient groups and numbers, treatments and risk factor trends were critically appraised. Data were integrated and analysed using a previously validated CHD policy model.

Results CHD mortality rates fell by 20% in Palestine and by 44% in Turkey, but increased by 17% in Tunisia and by 60% in Syria. Smoking prevalences were high in men, ranging from 24% to 39%. Male smoking persisted in Tunisia and Syria but decreased 10% in Palestine and 15% in Turkey. Population blood pressure levels decreased in Palestine and Turkey, but increased slightly in Tunisia and Syria. Conversely, cholesterol levels decreased in Palestine and Tunisia but increased in Turkey and Syria. BMI rose by 1–2 kg/m² and diabetes increased by 20%–30% in all four countries, especially among women. Modelling demonstrated that part of the mortality decreases were attributable to treatments, particularly for secondary prevention and heart failure. However, the contributions from statins, surgery, and angioplasty were consistently small.

Conclusions Recent trends in CHD mortality were complex. They mainly reflect changes in major cardiovascular risk factors, modestly alleviated by treatments.