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OP53 Contrasting cardiovascular mortality trends in Eastern Mediterranean populations – contributions from risk factor changes and treatments: modelling study
  1. J Critchley1,2,
  2. S Capewell1,3,
  3. M O’Flaherty3,
  4. N Abu-Rmeileh2,
  5. K Sozmen4,
  6. A Husseini2,
  7. F Fouaud5,
  8. O Saidi6,
  9. H Romdhane6,
  10. B Unal4,
  11. P Bandosz3,
  12. K Bennett7,
  13. W Maziak5,8,
  14. N Unwin9,
  15. P Phillimore10,
  16. R Bjork3,
  17. E Vartiainen9,
  18. T Zdrojewski11
  1. 1Division of Population Health Sciences and Education, St George’s, University of London, London, UK
  2. 2Institute of Community and Public Health, Birzeit University, Birzeit, Occupied Palestinian Territory
  3. 3Department of Public Health and Policy, University of Liverpool, Liverpool, UK
  4. 4Department of Public Health, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
  5. 5Syrian Center for Tobacco Studies, Syrian Center for Tobacco Studies, Aleppo, Syria
  6. 6Cardiovascular Epidemiology and Prevention Research Laboratory, Cardiovascular Epidemiology and Prevention Research Laboratory, Tunis, Tunisia
  7. 7Department of Pharmacology and Therapeutics, Trinity College, Dublin, Ireland
  8. 8Robert Stempel College of Public Health and Social Work, Florida International University, Miami, USA
  9. 9The Faculty of Medical Sciences, University of the West Indies, Bridgetown, Barbados
  10. 10Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
  11. 11Department of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland


Background Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a previously validated CHD mortality model (IMPACT) to examine recent trends in CHD mortality in Tunisia, Syria, the occupied Palestinian territory (oPt – West Bank) and Turkey.

Methods Data on populations, mortality, patient groups and numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points. Populations of studied countries and timeframes for this analysis were: Tunisia (10 million, 1997–2009), Syria (19 million, 1996–2006), OPt (2.5 million, 1998–2009) and Turkey (73 million, 1995–2008). We integrated and analysed data using the IMPACT model, with uncertainty explored using probabilistic sensitivity analyses. We reported the percentage of the observed change in CHD deaths explained by changes in uptake of medical and surgical treatments and major CHD risk factors for each country.

Results Risk factor trends: Regional smoking prevalences were high in men, persisting in Syria but decreasing in Tunisia (-11%), oPt (-25%) and Turkey (-45%). Obesity (body mass index) rose by 1–2kg/m2 and diabetes prevalence increased by 40%–50% in all four countries. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria but decreased in oPt and stayed constant in Turkey. Mortality trends: Age adjusted CHD mortality rates rose by 30% in Tunisia (49/105 to 64/105) and by 56% in Syria (108/105 to 169/105). Much of this increase (98% in Tunisia, and 80% in Syria) was attributable to adverse trends in major risk factors, and occurred despite some improvements in treatment uptake. CHD mortality rates fell by 25% in oPt (85/105 to 64/105) and by 17% in Turkey (418/105 to 345/105), with risk factor changes accounting for around 65% and 60% of this reduction respectively. Increased uptake of community treatments accounted for the remainder. The IMPACT model explained approximately 77% of the observed mortality trends in Turkey and oPt, but less in Syria and Tunisia. Results remained fairly consistent following sensitivity analyses.

Conclusion Eastern Mediterranean countries have shown highly heterogeneous trends in blood pressure, blood cholesterol and CHD mortality. Death rates are rising in Tunisia and Syria, whilst Turkey and occupied Palestinian territories demonstrate clear mortality falls, reflecting improvements in major cardiovascular risk factors, plus contributions from community-based medical treatments. However, across the region, smoking prevalence remains very high in men, and obesity and diabetes levels are rising dramatically. Powerful prevention policies exist and should now be implemented.

  • cardiovascular
  • risk factor
  • treatment

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