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Cardiovascular mortality trends in Russia: possible mechanisms

Nature Reviews Cardiology volume 12, page 740 (2015)Cite this article

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I read with interest the Review by Professor Majid Ezzati et al. (Contributions of risk factors and medical care to cardiovascular mortality trends. Nat. Rev. Cardiol. 12, 508–530; 2015).1 In the abstract, the authors write: “In Russia and some other former Soviet countries, changes in volume and patterns of alcohol consumption have caused sharp rises in cardiovascular disease (CVD) mortality since the early 1990s.”1 I believe that this statement is questionable for the reasons outlined in this Correspondence. The cause of the high CVD mortality registered in the former Soviet Union, and of its increase after 1990, is evident to anatomical pathologists. Since the Soviet era, an autopsy has remained obligatory for all patients who die in hospitals, but the autopsy rate has decreased and the quality deteriorated, especially during the 1990s—autopsies are often perfunctorily performed.2 Decreases in the quality of anatomical pathology, and in health care in general, during the 1990s coincided with the increase in cardiovascular-related3 and hypertension-related4 mortality. If a cause of death is not entirely clear, it has been usual in Russia to write 'ischaemic heart disease with cardiac insufficiency' or a similar formulation on the death certificate. A tendency to overdiagnose CVD also exists for people dying at home who do not undergo autopsy. In support of this concept is the statement that “Increases and decreases in mortality [have been] related to CVD, particularly to 'other forms of acute and chronic ischaemia' and 'atherosclerotic heart disease', but not to myocardial infarction, the proportion of which in Russian CVD-related mortality is extremely low.”5 The diagnosis of myocardial infarction is usually based on clear clinical or morphological criteria, whereas ischaemic or atherosclerotic heart disease with cardiac insufficiency is often diagnosed post mortem without strong evidence.6 I believe that a tendency exists in Russian literature to exaggerate alcohol abuse and its cause–effect relationship with mortality, particularly CVD-related mortality.7,8,9,10,11 In this way, responsibility for the increase in mortality after 1990, partly caused by shortcomings of the health-care system and toxicity of some legally sold alcoholic beverages,9 is shifted onto the patients, as being a result of self-inflicted diseases caused by excessive alcohol consumption.

In an autopsy study, all 654 deceased individuals who had had a high alcohol intake were diagnosed post mortem with cardiomyopathy.8 According to a later publication by the same authors, cardiomyopathy was diagnosed in 696 of 787 deceased individuals who had abused alcohol, whereas in almost all 172 deceased individuals who had been treated for alcoholism, cardiomyopathy was graded as pronounced.12 Registered cardiomyopathy mortality in Russia is about 100-fold higher than in Finland, France, and the USA.13 One study showed that clinically significant cardiomyopathy was diagnosed in ∼50% of habitual alcohol consumers.7 Accordingly, the diagnosis of cardiomyopathy was routinely used in cases of sudden death of alcohol consumers,8 whereas the actual cause could have been poisoning or an unknown disease.5

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  1. People's Friendship University of Russia, Clementovski per 6-82, Moscow, 115184, Russia

    Sergei V. Jargin

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Correspondence to Sergei V. Jargin.

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Jargin, S. Cardiovascular mortality trends in Russia: possible mechanisms. Nat Rev Cardiol 12, 740 (2015). https://doi.org/10.1038/nrcardio.2015.166

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