Cardiovascular diseases (CVD) are the major non-communicable diseases accountable for nearly a half of deaths from non-communicable diseases. According to the data of the World Health Organization (WHO), in 2008 the CVDs were the cause of death of 17.3 million of people at an international level (30% of all deaths), of whom 7.3 million of deaths were caused by ischemic heart disease and 6.2 million of deaths were caused by cerebrovascular diseases. More than 3 million of these deaths occurred at the age up to 60 years of age. The frequency of premature deaths from CVDs ranges from 4% in high-income countries to 42% in low-income countries. It is estimated that by the year 2030, some 23.6 million of people will die from CVD (1, 2). According to the World Heart Federation, CVD accounts for 10% of burden of diseases expressed by the indicator DALYs (disability adjusted life years — which includes years of life lost due to premature death and disability due to the disease) in low-income countries, and for about 18% of DALYs in highincome countries (3). The indicator of years of life lost (YLL) caused by CVD is four times higher in low-income countries, and two times higher in the middle-income countries than in high-income countries (4).

At the European level, CVD accounts for more than 4 million of deaths on an annual basis, or 47% of all deaths (52% of deaths in women and 42% of deaths in men), and in the European Union (EU) states they account for 40% of deaths (43% of deaths in women and 36% of deaths in men). According to the European statistics on CVD, they are the major cause of deaths in women in all European countries and also in men, except in six countries (France, Israel, Netherlands, San Marino, Slovenia and Spain). Slightly less than a half of the deaths from CVDs are caused by ischemic heart diseases in men and women, about one third of deaths is caused by cerebrovascular diseases in women and one quarter of deaths is caused by cerebrovascular diseases in men. CVDs are the major cause of death up to 65 years of age at the European level (31% of deaths in men and 26% of deaths in women up to 65 years of age), while in the EU states they take the second place with a proportion of 22% being ranked behind the neoplasm with a proportion of 36%. The rates of mortality from CVD are higher in the Central and Eastern European countries than in the western, northern and southern European countries. In the most of the northern, western and southern European countries, mortality, incidence and lethality of CVDs have declined over the past thirty years, and in some central and eastern European countries they are still rising, while in some other countries they stagnate and begin to decline (5).

Even in Croatia, CVD is the major cause of death, accounting for 48.3% of total mortality in 2012. In 2012, 24,988 persons died of CVD of whom 14,133 women and 10,855 men. They are the cause of death of 54.5% of dead women and 42.1% of dead men. In the age group up to 65 years, CVD is the second cause of mortality with 2,702 deaths, or with a frequency of 26.6% in the mortality of this age group. Malignant diseases with 4,056 dead persons, or with a frequency of 40.0% are ranked the first cause of death in this age group. (6) In this age group CVDs are the cause of death in 21.7% of dead women (650 women) and 28.7% of dead men (2,052 men), which shows that more men die at a younger age and more women die from CVD at an older age.

The most common diagnostic subgroups as the cause of death are ischemic heart diseases with a proportion of 22.7% (11,464 dead persons) and cerebrovascular diseases with a proportion of 14.1% (7,291 dead persons) in total mortality, followed by heart failure, with 1,555 dead persons (3.0%) and hypertension with 1,545 dead persons (3.0%) (Table 1).

The analysis of mortality by age in men and women shows that age-specific mortality rates for CVD rise with age and are higher in men than in women in all age groups. An intense rise in mortality begins at the age of 507. 89.2% of persons who died of CVD are recorded to be at the age over 65 (81.1% men and 95.4% women). At the age of 40 to 64 there were 10.4% of dead persons (18.2% of men and 4.4% of women), at the age from 20 to 39 there were 0.4% of dead persons (0.7% for men and 0.2% of women) and at the age from 0 to 19 there were 0.02% of dead persons (0.03% of men and 0.02% of women) (Table 2). However, in the calculation of mortality rates by gender, the greater representation of women in the older age groups, as well as the increasing number of dead women results in a higher overall mortality rate from CVD in women than in men (5). Thus, the overall mortality rate from CVD totaled to 585.5/100,000 in 2012, and the mortality rate was 639.8/100,000 in women and the mortality rater was 527.3/100,000 in men.

Analyzing CVD mortality trends, we have observed the falling mortality trend in the last ten years, which is more pronounced for cerebrovascular diseases than for ischemic heart disease, especially for the age between 0 and 64 years of age (8). The age standardized mortality rate from CVD in Croatia totaled to 572.7/100,000 in 2000 and by the year 2011, it fell to 370.8/100,000, which is a fall in mortality by 35.6%. For ischemic heart disease, the fall in mortality during this period was 18.3%, and it was 39.4% for cerebrovascular diseases (Figure 1).

In the age group up to 64 years of age, the fall in mortality from CVD is 33% during this period. If we compare the mortality from CVD by counties, the age-standardized mortality rates are in the range of up to 475.4 in the Virovitica-Podravina County of up to the minimum of 264.3/100,000 in the Sibenik-Knin County. Basically the rates of death from CVD are higher in the continental part of Croatia, and lower in the Croatian coastal regions, except for the City of Zagreb and Medimurje County that have the mortality rate as low as in the coastal counties (Figure 2).

Compared to the other European countries, Croatia with the standardized mortality rate for CVD of 370.8/100,000 belongs to the countries in Europe that have medium-high mortality rates. The average for the EU “old” member states before the year 2004 is 174.6/100,000, for the EU member states that joined EU after the year 2004 is 428.9/100,000. The neighboring Slovenia has significantly lower mortality rate from cardiovascular diseases, it is 231.8, and the Czech Republic has slightly lower mortality rate than Croatia which is 344/100.000 (9). The eastern European countries generally have higher rates of mortality than Croatia, and countries of western and southern (Mediterranean) Europe have significantly lower rates of death than Croatia with a continuous downward trend.

According to a number of years of life lost which is the indicator of premature mortality (YLL), CVDs take the second place behind the group of neoplasms, with 67,832 years of life lost and twice as many years of life lost in men than in women (Table 3).

In hospital morbidity, CVD have held the first or second place in the number of hospitalizations for years, alternating with malignant diseases. In 2011, they took the first place in the number of hospitalizations (83,935) with a proportion of 14.2% of which 46.7% of hospitalizations have been recorded in women and 53.3% have been recorded in men. However, the analysis by gender shows that CVDs take the first place in men in the number of hospitalizations with a proportion of 15.5%, and among women they take the second place with a proportion of 12.9% followed by neoplasm accounting for 13.7% in the total number of hospitalizations of women. The overall rate of hospitalization was 1,958.9/ 100,000 inhabitants, in men it was 2,165.1/100,000 and in women it was 1,766.8/100,000 (7). The analysis of hospital morbidity by age shows that both the rates of hospitalization for CVD in men and women rise with age and are higher in men than in women in all age groups. An intense rise in hospital morbidity begins at the age over 40. Analyzing hospital morbidity from CVD by age, we can see that 62.5% of hospitalized patients are aged over 65 (54.8% of men and 71.4% of women). At the age from 35 to 64 there were 34.1% of hospitalized patients (41.4% were men and 25.8% were women), at the age from 20 to 34 there were 2.1% of hospitalized patients (2.2% of men and 1.9% of women) and from the age from 0 to 19 there were 1.3% of hospitalized patients (1.6% of men and 0.9% of women) (Table 4). The most common causes of hospitalization were ischemic heart disease with a frequency of 26.5% (usually angina pectoris, myocardial infarction), the subgroup of other forms of cardiac diseases accounting for 26.3% with the most common diagnosis of heart failure and cardiomyopathy and cerebrovascular diseases with a frequency of 21.5% in the group of CVDs (10).

According to a number of bed days (the number of days of treatment) the CVDs take the second place, falling behind mental illnesses and disorders with 864,699 days of hospital treatment, or a proportion of 14%. The major diagnostic subgroups within the group of CVDs according to the number of days of hospital treatment are the group of other cardiac diseases with a proportion of 30.4%, followed by cerebrovascular diseases that account for 26.7%, and ischemic heart diseases accounting for 22%. The average length of stay for CVD totals to 10.3 days (9.7 for men and 11.0 for women) and it rises with age. At the age from 0 to 19, the average length of stay was 7.7 days, and at the age over 65 it is 11.4 days and is longer in women.

Judging by the number of diagnoses recorded in the general/ family medicine in 2011, the CVDs take the second place with a frequency of 12% after respiratory diseases accounting for 15%. The most common diagnostic subgroups were hypertensive diseases with a frequency of 57.6% in the CVD group. They were followed by the subgroup of other cardiac diseases (15.7%), ischemic diseases (9.8%), vascular diseases (8.1%), and cerebrovascular disease with a portion of 4.1% in the CVD group (11).

During the last ten years have seen a downward trend of mortality from CVDs in Croatia, as it has already been observed in the developed countries internationally, but they are still the major cause of mortality and morbidity. While the rates of mortality decline in the EU countries, the number of people living with such diseases rise. It is associated with better life expectancy and better survival of people with CVDs, but also with more effective preventive and therapeutic procedures. Consequently, we are facing higher prevalence of CVDs. Considering the fact that the population is getting older, considering ubiquitous globalization and urbanization, socio-economic situation, high prevalence of some risk factors such as obesity and diabetes, we can expect a growing burden of CVD, unless some comprehensive preventive measures are taken.