Elsevier

Annals of Epidemiology

Volume 22, Issue 1, January 2012, Pages 57-65
Annals of Epidemiology

Determinants of Cardiovascular and All-Cause Mortality in Northwest Russia: A 10-Year Follow-Up Study

https://doi.org/10.1016/j.annepidem.2011.08.008Get rights and content

Purpose

To study conventional and novel risk factors associated with high cardiovascular disease (CVD) and all-cause mortality in Russia.

Methods

A prospective cohort study of 3704 adults was performed in Arkhangelsk. The baseline examination was conducted in 1999–2000. The average follow-up was 10.2 years. Information on lifestyle and marital, educational, and psychosocial status was self-reported in a questionnaire. Data on risk factors were collected in a medical examination that included the drawing of blood samples.

Results

By October 2010 a total of 147 male and 95 female deaths had occurred. In 59 male and 20 female deaths in which a diagnosis was made by a forensic pathologist, the autopsy data were studied to extract information on post-mortem blood alcohol concentration. A positive blood alcohol concentration was found in 21 (36%) male and 6 (30%) female forensic autopsies. Women reporting consumption of at least 80 g of alcohol monthly and consumption of 5 or more alcohol units during one drinking episode had a greater risk of cardiovascular death than abstainers; relative risk (RR) was 5.06 (95% confidence interval [95% CI], 1.54–16.7) and 3.21 (95% CI, 1.07–9.58), respectively. ApoB/ApoA1-ratio was the strongest predictor of CVD and all-cause death in men (RR, 7.62; 95% CI, 3.15–18.4; and RR, 4.39; 95% CI, 2.22–8.68, respectively) and CVD death in women (RR 3.12; 95% CI, 1.08–8.98). Men who were obese and had obtained a university education had a 40% lower risk of all-cause death. Low serum albumin was associated with high mortality in both genders.

Conclusions

Hazardous alcohol consumption is an independent risk factor of CVD mortality in women. The mechanisms behind its damaging effect are not yet clear. Nutritional factors such as serum albumin are important predictors of all-cause mortality in both genders.

Introduction

Cardiovascular and all-cause mortality in Russia are among the greatest in Europe. The age-standardized cardiovascular death rates are greater in all age groups of Russian men and women than the corresponding average estimates for the 27 countries of Western Europe (Eur-A). The difference in working ages is particularly large: cardiovascular death rates in Russia are nine times greater in men and six times greater in women ages 30–44 years and seven times greater in men and women ages 45–59 years than the European average estimates (1). The difference in life expectancy between Russia and other industrialized countries is primarily explained by the increased death rates in these age groups. The total number of deaths exceeded the number of births by almost 1 million in 2000 and by 850,000 in 2005 (2).

There is also a large difference in mortality between men and women in Russia, resulting in gender imbalance with a male-to-female ratio of 0.87 (3), which is among the lowest in the world. The ratio rapidly decreases with age; the male-to-female ratio at 60 years or more was less than 0.5 in 2006 (4), whereas the corresponding ratio for Norway was 0.8 the same year (5). High premature mortality from cardiovascular diseases and external causes among Russian men is the main cause of the large gap in life expectancy between men and women (6). In 2003, life expectancy was 58.6 years for men and 71.8 years for women. Since then, life expectancy in 2009 increased to 62.8 and 74.7 years for men and women, respectively (7), although it is still much lower than in Europe.

Despite high cardiovascular mortality, the authors of population-based studies from Russia have failed to reveal high levels of conventional risk factors, taken either individually 8, 9 or combined as a risk score 10, 11, 12. Instead, hazardous alcohol consumption was suggested as the main determinant of high cardiovascular (13) and all-cause mortality 14, 15 among Russian men. Other risk factors, such as low socioeconomic status 16, 17, unhealthy lifestyle (18), and psychosocial distress, have also been studied in association with cardiovascular mortality (19). It was also suggested that cardiovascular mortality is artificially inflated because of misattribution of alcohol poisonings to cardiovascular deaths (6). However, the authors of another study have not supported this finding (13).

Only two longitudinal studies on factors associated with cardiovascular and all-cause mortality have been performed in Russia. The first included only men ages 40–59 years and was performed during the 1980s in Moscow and St. Petersburg (17). The other included men and women aged 25–64 years, and the authors collected data during the 1990s in Western Siberia. When one takes into account the vast distances and ethnical and cultural heterogeneity, there is still a need for more longitudinal studies in Russia.

The principal aim of this study was to assess the influence of both conventional and novel risk factors (apolipoproteins, C-reactive protein, gamma glutamyl transferase [GGT], serum albumin, and alcohol intake) on cardiovascular and all-cause mortality by gender in a typical Northwestern Russian town.

Section snippets

Methods

This study was approved by the Regional Ethics Committee in Tromsø, Norway, and verbal informed consent was obtained from all participants. A prospective cohort study was conducted in Arkhangelsk, Northwest Russia. Altogether, 1966 men and 1738 women ages 18 years or older who attended one outpatient clinic in 1999–2000 comprised the cohort. The response rate was 98.9%. The participants underwent a medical examination, filled out a 6-page questionnaire, and had blood drawn for laboratory

Results

Baseline characteristics of the cohort by gender are presented in Table 1. Men smoked more and had more hazardous patterns of alcohol consumption. Women scored less than men on the AUDIT and CAGE tests. The proportion of participants that were single and with university education was greater in women. The means of TC levels, glycated hemoglobin levels, and prevalence of obesity (BMI ≥ 30) were greater among women.

Altogether, 242 subjects (147 men and 95 women) died by October 2010 during the

Main Findings

This was the first cohort study from Russia in which a significant dose–response association between hazardous alcohol consumption and the risk of cardiovascular death was found in women. A consumption of at least 80 g of alcohol (250 mL of vodka) monthly was associated with a 5-fold increased risk of cardiovascular death compared with the reference group. Binge drinking (a consumption of ≥5 AU on one occasion) was associated with a 3-fold risk compared with abstainers. A positive answer on one

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