Article Estimation of contribution of changes in classic risk factors to trends in coronary-event rate across the WHO MONICA Project populations

Kari Kuulasmaa, Hugh Tunstall-Pedoe, Annette Dobson,Stephen Fortmann,Susana Sans,HannaTolonen, Alun Evans, MarcoFerrario, JaakkoTuomilehtofor the WHO MONICA Project*→*Participating centres of the WHO MONICA Projectlisted at pp. 685-686MST Hobbs, K Jamrozik, RW Parsons, C Spencer, PL Thompson, H Alexander, R Heller, P Colley, G De Backer, F van Onsem, S De Henauw, D De Bacquer, M Kornitzer, L Berghmans, M Lannoy, R Desqueve, L Bara, I Beriot, M Candeur, P de Smet, R D Gregor, HK Wolf, BR Mackenzie, PM Rautaharju, IR Bata, Wu Zhaosu, Wu Yingkai, Yao Chonghua, Zhao Dong, Z Skodová, , Z Pisa, Z Hejl, P Vojtisek, K Emrová, Z Cícha, L Berka, M Hoke, J Pikhartová, K Hrdlicková, E Wiesner, R Poledne, D Grafnetter, M Schroll, M Kirchhoff, A Sjoel, K K Thomsen, T Joergensen, M Madsen, P Puska, M Arstila, C Ehnholm, P Immonen-Räihä, P Jousilahti, E Kaarsalo, M Ketonen, S Lehto, H Miettinen, H Mustaniemi, M Niemelä, A Nissinen, P Palomäki, K Pyörälä, M Romo, V Salomaa, J Sundvall, J Torppa, E Vartiainen, T Vuorenmaa, P Ducimetiere, JL Richard, A Bingham, T Lang, J Ferrieres, JB Ruidavets, P Marqués-Vidal, JP Cambou, P Rodier, C Saulet, D Arveiler, P Schaffer, B Haas, N Lamamy, A Wagner, V Sartori, P Amouyel, M Montaye-Faivre, J-L Salomez, M-C Nuttens, D Cottel, N Marecaux, S Beauchant, C Graux, B Lemaire, C Steclebout, E Greiser, B Herman, G Stüdemann, U Keil, HLöwel, J Stieber, HW Hense, A Döring, B Filipiak, M Lewis, A Hörmann, J Gostomzyk, HD Bolte, W Barth, L Heinemann, E Classen, D Quietzsch, S Brasche, S Böthig, G Voigt, NSigfusson, II Gudmundsdottir, I Stefansdottir, ThThorsteinsson, H Sigvaldason, A Menotti, S Giampaoli, A Verdecchia, D Vanuzzo, GA Feruglio, L Pilotto, G Zanata, M Scarpa, G B Cignacco, R Marini, M Spanghero, G Zilio, GC Cesana, MT Gussoni, G De Vito, R Sega, F Valagussa, F Achilli, J Bluzhas,SDomarkiene, R Grazuleviciene, V Grinius, R Grybauskiene, A Janusauskas, K Jurieniene, L Margeviciene, ZPetrokiene, D Rasteniene, D Rastenyte, R Radisauskas, R Reklaitiene, D Sidlauskiene, A Tamosiunas, E Varanauskiene, R Beaglehole, RT Jackson, AW Stewart, W Bingley, A Pajak, J Sznajd, E Kawalec, R Topor-Madry, E Baczynska, A Celinski, H Czarnecka, A Hebda, B Idzior-Walus, E Kozek, M Magdon, M Malczewska-Malec, M Malecki, A Markiewicz, P Misiowiec, R Mizera, R Morawski, W Rostworowski, I Trznadel-Morawska, U Zeman, A Zarnecki, SL Rywik, G Broda, M Polakowska, A Pytlak, H Wagrowska, P Kurjata, W Kupsc, G Zhukovsky, T Varlamova, R Oganov, V Naumova, N Popova, Yu P Nikitin, S Malyutina, V Gafarov, G Simonova, I Balaguer-Vintró, L Balana, A Puigdefàbregas, G Paluzie, F Gonzales, L Wilhelmsen, S Johansson, M Falkman, G Lappas, T Messner, F Huhtasaari, V Lundberg, E Jägare Westerberg, B Wikström, S Boström, K Asplund, PO Wester, B Stegmayr, M Peltonen, F Gutzwiller, M Rickenbach, V Wietlisbach, F Barazzoni, F Paccaud, ZM Mathewson, EE McCrum, A Hall, T Falconer, EL McIlmoyle, WCS Smith, R Tavendale, C Brown, M Shewry, M-K Hannah, C Morrison, G Watt, W Leslie, J Hooper, B Fitzpatrick, A Varady, M Winkleby, M Hull, M Planojevic, D Jakovljevic, T Djapic, MSolak, D Stojsic, M Zikic, I Martin, I Gyarfas, SRA Dodu, MJ Watson, M Hill, A Molarius, M Mähönen, V Moltchanov, E Ruokokoski, A-M Rajakangas,Z Cepaitis,POfner, A Madai, K Barrett, C Brown, MFerrario, A Shatchkute, V Zaitsev, MJ Karvonen, RJ Prineas, M Feinleib, FH Epstein, OD Williams.

Lancet 2000; 355: 675–687 THE LANCET • Vol 355 ●Issue 9205• February 26, 2000

Summary

Background

From the mid-1980s to mid-1990s, the WHO MONICA Project monitored coronary events and classic risk factors for coronary heart disease (CHD) in 38 populations from 21 countries. We assessed the extent to which changes in these risk factors explain the variation in the trends in coronary-event rates across the populations.

Methods

In men and women aged 35—64 years, non-fatal myocardial infarction and coronary deaths were registered continuously to assess trends in rates of coronary events. We carried out population surveys to estimate trends in risk factors. Trends in event rates were regressed on trends in risk score and in individual risk factors.

Findings

Smoking rates decreased in most male populations but trends were mixed in women; mean blood pressures and cholesterol concentrations decreased, bodymass index increased, and overall risk scores and coronary-event rates decreased. The model of trends in 10-year coronary-event rates against risk scores and single risk factors showed a poor fit, but this was improved with a 4-year time lag for coronary events. The explanatory power of the analyses was limited by imprecision of the estimates and homogeneity of trends in the study populations.

Interpretation

Changes in the classic risk factors seem to partly explain the variation in population trends in CHD. Residual variance is attributable to difficulties in measurement and analysis, including time lag, and to factors that were not included, such as medical interventions. The results support prevention policies based on the classic risk factors but suggest potential for prevention beyond these.