The State of Cardiovascular Health in the European Union

3. Preventing and identifying CVD: Targeting key risk factors

Abstract

Cardiovascular disease (CVD) remains the leading cause of mortality in the European Union, yet 74% of its burden can be attributed to modifiable risk factors. This chapter examines metabolic, behavioural, and environmental determinants of CVD, highlighting trends and policy implications. Metabolic risks – particularly hypertension, diabetes, obesity, and dyslipidaemia – are the largest contributors, accounting for two‑thirds of CVD-related disability. Behavioural factors such as tobacco use, harmful alcohol consumption, poor diet, physical inactivity, and inadequate sleep persist despite some improvements, while vaping and cannabis use are rising among younger populations. Environmental stressors, including air pollution and extreme temperatures, compound risks, especially for vulnerable groups. Non-modifiable factors like ageing and sex-specific risks also play a contributing role. Despite established clinical guidelines, gaps in prevention, screening, and lifestyle counselling remain.

In Brief

• Metabolic risks, along with behavioural and environmental risks, are driving cardiovascular disease (CVD). While exposure to many risk factors, such as tobacco use, harmful alcohol consumption, depressive symptoms, and exposure to air pollution have been trending down – others, including, diabetes, high blood pressure, vaping, work-related stress, respiratory infections, and exposure to extreme heat are increasing in most EU countries.

• In the EU, 74% of Disability-Adjusted Life‑Years (DALYs) due to CVD are attributable to modifiable risk factors, nearly double the proportion of DALYs due to all causes combined attributable to risk factors (38%). This underscores the need to tackle risk factors to minimise the burden of CVD.

• Diabetes significantly increases the risk of CVD. Currently, one out of every 13 people in the EU lives with diabetes – a rate that has more than doubled since 1990. Women with diabetes are 2.5 times more likely to have acute coronary syndrome compared to those without diabetes, while for men with diabetes the risk is 1.7 times higher compared to those without diabetes. Outcomes are also worse in individuals with diabetes, who face a 50‑60% higher risk of heart failure following a myocardial infarction compared to those without diabetes.

• Hypertension is one of the most important and prevalent modifiable risk factors for CVD. Across the EU, one‑in-five (22%) people 15 years and older report having high blood pressure. For every 10‑mm Hg increase in systolic blood pressure, there is a 53% higher risk for atherosclerotic CVD. Hypertension has been attributed to approximately 60% of cases of ischaemic and haemorrhagic stroke.

• Obesity is a major risk factor for CVD and a critical driver of the global burden of noncommunicable disease. At EU level in 2022, 51% of adults lived with overweight and 15% lived with obesity. Childhood overweight and obesity remain a major concern in Europe, with 9% of children aged 5 to 19 in EU27 countries living with obesity and 25% living with overweight, underscoring the need for early prevention. Between 2017 and 2022, obesity rates in the EU showed minimal change, declining slightly from 14.9% to 14.8%. Across all EU countries, men consistently report higher rates of overweight and obesity than women.

• While mental illness can increase the risk of developing CVD, evidence also shows that CVD itself is a risk factor for depression. In 2022, almost one‑in-three Europeans (27%) aged 45 and older reported depressive symptoms. Rates of depressive symptoms are higher in people with CVD and related risk factors (31% vs. 20%), higher in women than men (32% vs. 20%), and rising in several EU countries.

• At EU level in 2025, almost one‑in-three workers (29%) report work-related stress, depression or anxiety – up from 27% in 2022. Country and gender differences are pronounced, with rates varying more than two‑fold across EU countries, from 19% in Denmark to over 40% in Spain, Cyprus, Poland, Finland and Greece, and higher among women than men.

• Lifestyle factors contribute significantly to CVD risk. Approximately 21% of deaths due to coronary heart diseases are attributable to tobacco use and exposure to second-hand smoke. In 2023, an average of 18% of adults smoked daily across EU countries. The use of E‑cigarettes and recreational drugs (particularly cannabis) is increasingly linked to adverse cardiovascular outcomes – particularly among younger people. Trends in vaping have shown a 45% increase between 2016 and 2024 and approximately 12% (11.8 million) of individuals aged 15 to 34 in EU countries reported cannabis use in the last year. The average alcohol consumption in the EU has been declining modestly (‑7%) between 2010 and 2022. However, notable changes have occurred in several countries, with 11 EU countries reporting a decrease of at least 10% in their average consumption per capita.

• Physical activity, healthy dietary habits (increasing consumption of vegetables and fruits and reducing consumption of sugar, saturated fats and salt), and good sleep hygiene reduce the risk of CVD. Yet, more than one‑in-four adults in the 27 EU Member States are insufficiently physically active. For people between 60 and 79 years old, CVD accounts for 40% of all diseases due to insufficient physical activity, and nearly three‑quarters of the burden for people over 80 years old. Only about 60% of adults in the EU consume fresh vegetables and fruits at least once a day and most EU countries report having a salt intake above the WHO recommended level. In 2022, sleep problems were widespread in Europe, affecting 34% of Europeans aged 45 and over. Sleep problems are more common among people with CVD and related clinical risk factors than those without (37% vs. 27%), more frequent among women than men (39% vs. 26%), and rising in several EU countries. 

• Environmental risk factors also drive a portion of CVD risk. While air pollution has improved, extreme temperatures pose a rising risk for cardiovascular events. In 2023, one‑in-three Europeans (34%) experienced at least one hot day (>35°C) and two in three Europeans (67%) experienced at least one icy day (<0°C).

• Older adults are especially vulnerable to CVD. Structural and functional changes – such as increased arterial stiffness and reduced cardiac efficiency – make older adults more susceptible to CVD. As populations age, the number of individuals at higher risk will grow: the share of adults aged 65 and over rose from 18% to 22% between 2000 and 2024, and is projected to reach 29% by 2050.

• Multimorbidity further increases cardiovascular risk in older adults. Age‑related risk factors – such as diabetes, obesity and metabolic syndrome, reduced physical activity, cognitive decline, depression and chronic kidney disease – further contribute to the burden of CVD in older adults.

• While the burden of CVD is higher in men in earlier life, women experience similar or greater rates from midlife onwards. A range of sex-specific risks across the life course contribute to women’s elevated cardiac risk, including early and late menarche, polycystic ovary syndrome (PCOS), infertility, hypertension during pregnancy or preeclampsia, assisted reproductive technology, adverse pregnancy outcomes, hormonal contraceptives and menopause.

• Clinical practice guidelines call for clinicians to encourage lifestyle changes and support adherence to drug therapy, yet in the EU, few healthcare users aged 45 and over report receiving advice on healthy behaviours (49% on physical activity, 34% on healthy eating, 28% on the risks of tobacco, and only 13% on alcohol consumption). Addressing behavioural and lifestyle risk factors in primary care by screening and advising on them are key tools in primary care to identify and prevent cardiovascular conditions in Europe. School health to detect obesity, physical inactivity and mental disorders is not universally available.

• Early detection and management of modifiable risk factors can reduce risk of CVD. A CVD risk assessment is recommended for individuals with at least one vascular risk factor (i.e. family history of premature CVD, familial hypercholesterolemia, CVD risk factors such as smoking, arterial hypertension, diabetes mellitus, raised lipid level, obesity, or comorbidities increasing CVD risk) or men 40 years and older and women 50 years and older. Screening rates for diabetes, high cholesterol and high blood pressure are already relatively high, but more can be done – on average, only 68% of people aged 45 to 55 report having had a blood pressure check in the past year, and 94% in the past five years. In this same age group over 85% have had cholesterol or glucose measurements in the past five years. Insufficient monitoring of modifiable risks can increase CVD risk by delaying detection and treatment. Ensuring continuity of care through effective, sustained management is therefore critical – an issue explored in greater detail in Chapter 4 of this report.

Infographic 3.1. Preventing and identifying CVD: Targeting key risk factors

Cardiovascular disease (CVD) remains the leading cause of mortality in the European Union (EU) and worldwide. Given the substantial burden of CVD in the EU (Chapter 2), a focus is warranted on the significant portion of CVD mortality and morbidity that could be mitigated by addressing related risk factors.

Cardiovascular conditions are impacted by a range of non-modifiable and modifiable risk factors. Non-modifiable risk factors – such as sex, age, family history, and ethnicity and race – are inherent characteristics that may increase the risk of developing a cardiovascular condition. Modifiable risk factors include clinical and metabolic risks, lifestyle and behavioural risks, as well as environmental risks (Figure 3.1). The main causal risk factors are the clinical and metabolic risks which include dyslipidaemia (e.g. high low-density lipoprotein (LDL) cholesterol), high blood pressure (i.e. hypertension), diabetes mellitus, obesity, respiratory infections, and mental ill health. Smoking is one of the main behavioural and lifestyle risk factors for CVD, alongside unhealthy diet, sedentary lifestyle, harmful use of alcohol, and poor sleep. Environmental risks relate to the physical environment – such as air pollution and extreme heat and cold exposure – as well as occupational hazards. These risk factors are shaped by broader social and commercial factors of health, including for example education, income, migration status and labour market conditions, which interact with all risk factors to either protect against or further compound overall CVD risk. See Chapter 2 for more detail on the socio-economic inequalities in CVD.

Figure 3.1. Cardiovascular conditions are impacted by a range of lifestyle, clinical, environmental and individual factors

A number of intermediate clinical risk factors are influenced by the same risk factors that also influence CVD more directly

CVD burden can be estimated by using attributable disability-adjusted life‑years (DALYs), available for the main risk factor groups presented in Figure 3.2. One DALY represents the loss of the equivalent of one year of full health (see Annex 3.A for more details). As such, DALYs go beyond measures of mortality to include poor health, providing insight into the impact of each risk factor on the population by considering both deaths and the experience of those living with CVD. In the EU, 74% of DALYs due to CVD are attributable to modifiable risk factors, nearly double the proportion of DALYs due to all causes combined attributable to risk factors (38%). This underscores the need to tackle risk factors to minimise the burden of CVD.

High-level risk factor categories include metabolic, behavioural, and environmental or occupational factors (IHME, 2021[1]).Metabolic risks are the risk factors that contribute the most CVD DALYs (65%), with CVD 135 million DALYs attributable to high systolic blood pressure, the predominant risk factor in this group. Behavioural risk factors account for 39% of CVD DALYs, dietary risks – having a low fruit and vegetable diet, high sodium intake, among others – predominate in this category, accounting for CVD 74 million DALYs. Environmental or occupational risk factors account for 17% of CVD DALYs, air pollution being the predominant risk factor in this group. These risk factors are not mutually exclusive and do not only affect cardiovascular conditions, but also conditions such as diabetes, kidney disease, cancer, and respiratory conditions.

Figure 3.2. Metabolic risk factors are the main contributor to cardiovascular disease DALYs in the EU

Cardiovascular disease DALYs per 100 000 attributable to risk factors in the EU, 2021

Note: DALYs can be attributed to several risk factors at once and are not summative. Environmental risks refer to environmental or occupational risk factors. LDL: Low-density lipoprotein; BMI: Body Mass Index; LPA: Low physical activity.

Source: IHME (2021[1]), GBD Compare, https://healthdata-digex.healthdata.org/data-tools-practices/interactive-data-visuals.

Globally, 83% of all deaths due to CVD in 2021 were attributable to modifiable risk factors, and in the EU this figure falls to 76%. Metabolic risk factors are the predominant group, accounting for 70% and 68% of CVD deaths globally and in the EU, respectively. Behavioural risks are the second largest group accounting for 42% of the CVD deaths globally and 37% in the EU. Environmental risk factors account for 33% of CVD deaths globally, and 18% in the EU. On average, in the EU, risk factors account for a smaller proportion of deaths due to CVD compared to the global average (IHME, 2021[1]). Deaths and can be attributed to several risk factors at once and are not summative.

Recent trends in cardiovascular risk factors across Europe reveal several growing public health challenges (see Table 3.1). Concerningly, many metabolic and clinical risks have been increasing or remain at high levels. Between 2012 and 2022, among adults aged 18 and over, age‑standardised diabetes prevalence rose to 7.8% in the EU, a 22% increase. Hypertension prevalence among people aged 15 and over increased by 1% between 2014 and 2019, reaching 22%. Obesity among adults aged 18 and over reduced to 15%, a 1% reduction between 2017 and 2022. Depressive symptoms among adults aged 45 and over declined by 9% but still affects nearly a third of this population group (27%). This increased exposure to metabolic and clinical risks is, at least in part, driven by population ageing; the proportion of adults aged 65 and over has surged by 23% since 2000, reaching 22% in 2024.

Lifestyle or behavioural risk factors show mixed progress. Tobacco use among people aged 15 and over has dropped by 16% over the past decade, now at 18%, and harmful alcohol consumption in the same age group declined slightly by 7% to 9.6 litres per person. However, vaping among people aged 15 and over in the EU surged by 45%, reaching 4% in 2024, raising concerns about emerging nicotine habits. Between 2017 and 2022, daily fruit consumption among the total population decreased by 4% to 61%, and vegetable intake declined by 6%, to 60%. Insufficient physical activity among adults aged 18 and over decreased by 3% yet still affects almost a third of the population (28%). Sleep problems among adults aged 45 and over also declined slightly (by 5%) but remain prevalent at 34%. Work-related stress increased by 7% among employed workers aged 16 and over, now impacting about a third (29%) of this group, reflecting growing mental health pressures in the workplace. Finally, indicators on exposure to environmental factors show varied outcomes: exposure to extreme heat (at least one day above 35°C) increased to 34%, a 9% increase, while population-weighted exposure to air pollution dropped significantly by 30% to 11 µg/m³. Lifestyle and behavioural risk factor profile also differ between men and women, for 25 EU countries, men report higher rates of smoking daily (22%) than women (14%). On the other hand, women report higher levels of physical inactivity (28%) than men (25%).

Table 3.1. Dashboard on cardiovascular risk factors: Metabolic, clinical and non-modifiable risk factors

	Diabetes (%)		Hypertension (%)		Obesity (%)		Depressive symptoms (%)		Adults aged 65 and over (%)
	2022	% change (2012‑2022)	2019	% change (2014‑2019)	2022	% change (2017‑2022)	2022	% change (2012‑2022)	2024	% change (2000‑2024)
EU average	7.8	22 ⬆	22	1 ⬆	15	‑1 ⬇	27	‑9 ⬇	22	23 ⬆
Austria	5.2	3 ⬆	22	3 ⬆	18	18 ⬆	22	7 ⬆	20	32 ⬆
Belgium	6.7	46 ⬆	17	5 ⬆	16	7 ⬆	32	6 ⬆	20	17 ⬆
Bulgaria	10.8	37 ⬆	30	0 ➡	12	‑17 ⬇	26	NA	24	48 ⬆
Croatia	9.1	31 ⬆	37	52 ⬆	17	‑8 ⬇	26	NA	23	44 ⬆
Cyprus	7.3	0 ➡	19	9 ⬆	14	‑8 ⬇	19	NA	18	61 ⬆
Czechia	7.7	18 ⬆	26	11 ⬆	18	‑13 ⬇	28	10 ⬆	21	47 ⬆
Denmark	2.3	‑14 ⬇	19	7 ⬆	19	8 ⬆	20	23 ⬆	21	38 ⬆
Estonia	8.8	40 ⬆	23	2 ⬆	22	5 ⬆	35	‑13 ⬇	20	36 ⬆
Finland	7.4	30 ⬆	27	10 ⬆	22	6 ⬆	26	NA	23	56 ⬆
France	2.7	‑35 ⬇	17	15 ⬆	15	‑1 ⬇	32	‑6 ⬇	21	34 ⬆
Germany	6.6	‑2 ⬇	26	‑8 ⬇	19	‑4 ⬇	27	16 ⬆	22	40 ⬆
Greece	7.2	1 ⬆	20	‑6 ⬇	12	3 ⬆	18	NA	23	37 ⬆
Hungary	11.2	30 ⬆	32	‑1 ⬇	22	11 ⬆	21	‑44 ⬇	21	38 ⬆
Ireland	7.8	42 ⬆	12	‑25 ⬇	20	30 ⬆	12	NA	15	41 ⬆
Italy	7.2	19 ⬆	20	‑1 ⬇	7	20 ⬆	31	‑2 ⬇	24	35 ⬆
Latvia	9.3	36 ⬆	32	8 ⬆	23	8 ⬆	23	NA	21	42 ⬆
Lithuania	11.2	27 ⬆	30	6 ⬆	21	18 ⬆	40	NA	20	45 ⬆
Luxembourg	5.9	6 ⬆	16	‑6 ⬇	17	6 ⬆	28	‑2 ⬇	15	0 ➡
Malta	9.6	5 ⬆	18	‑15 ⬇	26	2 ⬆	35	NA	18	53 ⬆
Netherlands	6.4	18 ⬆	16	‑4 ⬇	14	6 ⬆	20	6 ⬆	20	46 ⬆
Poland	10.8	50 ⬆	27	15 ⬆	19	10 ⬆	30	‑26 ⬇	20	71 ⬆
Portugal	7.4	14 ⬆	27	5 ⬆	16	1 ⬆	41	2 ⬆	24	51 ⬆
Romania	13.3	91 ⬆	16	‑8 ⬇	10	‑1 ⬇	33	NA	20	54 ⬆
Slovak Republic	8.9	37 ⬆	28	10 ⬆	17	19 ⬆	14	NA	18	67 ⬆
Slovenia	10.8	37 ⬆	25	2 ⬆	18	3 ⬆	22	‑13 ⬇	22	56 ⬆
Spain	3.6	‑40 ⬇	19	3 ⬆	15	6 ⬆	31	‑12 ⬇	20	20 ⬆
Sweden	5.1	18 ⬆	18	12 ⬆	17	‑1 ⬇	25	23 ⬆	21	21 ⬆
Iceland¹	5.4	22 ⬆	25	26 ⬆	21	0 ➡	NA	NA	16	30 ⬆
Norway¹	5.6	8 ⬆	15	19 ⬆	17	22 ⬆	NA	NA	19	24 ⬆

1. non-EU European Economic Area countries. Dark blue: Lower than the 25th percentile; Light blue: Between the 25th and 50th percentile; Light red: Between the 50th and 75th percentile; Dark red: Above the 75th percentile.

Diabetes: Percentage of people aged 18 years and over with fasting plasma glucose ≥ 126 mg/dl, or glycated haemoglobin ≥ 6.5%, or on glucose‑lowering medication for diabetes. Age‑standardised to the WHO world population, therefore crude rates and percentage change from national sources may differ.

Source: WHO Global Health Observatory (2024).

Hypertension refers to the percentage of people aged 15 and over with high blood pressure.

Obesity refers to the percentage of people aged 18 and over with a BMI ≥30 kg/m². For Iceland, 2017 data was used instead of 2022. For Germany, data was obtained from different studies: 2017 data from Schienkiewitz et al. (2017[2]), and Starker et al (2025[3]).

Depressive symptoms are derived from the percentage of adults aged 45 and older who report at least 4 symptoms on the EURO-D scale. Where 2012 data was unavailable, the closest year available was used: 2011 data for Austria, Belgium, Czechia, Denmark, Estonia, France, Hungary, Italy, the Netherlands, Portugal, Slovenia, Spain and Sweden; and 2013 data for Luxembourg.

Age refers to the percentage of people aged 65 and over.

Source: Diabetes: Eurostat (hlth_ehis_cd1e, 2021); Obesity: Eurostat (ilc_hch10, 2024), from (Schienkiewitz et al., 2017[2]), “Overweight and obesity among adults in Germany”, https://doi.org/10.17886/rki-gbe-2017-038 and 2022 data from Starker et al (2025[3]), “Prevalence of obesity and smoking among adults in Germany - trends from 2003 to 2023”, https://doi.org/10.25646/13038; Depressive symptoms: Source: SHARE‑ERIC (2024) and The Irish Longitudinal Study on Ageing (TILDA) 2025; Age: Eurostat (demo_pjangroup, 2025).

Table 3.2. . Dashboard on cardiovascular risk factors: Behavioural and lifestyle risk factors

Country	Tobacco consumption (%)		Vaping use (%)		Alcohol consumption (L/person)		Fruit consumption (%)		Vegetable consumption (%)
	2023	% change (2013‑2023)	2024	% change (2014‑2024)	2023	% change (2013‑2023)	2022	% change (2017‑2022)	2022	% change (2017‑2022)
EU average	18	‑16 ⬇	4.0	45 ⬆	9.6	‑7 ⬇	61	‑4 ⬇	60	‑6 ⬇
Austria	21	‑15 ⬇	0.7	NA	11.3	‑5 ⬇	56	‑7 ⬇	55	‑2 ⬇
Belgium	15	‑19 ⬇	4.1	NA	8.4	‑18 ⬇	61	‑3 ⬇	80	‑5 ⬇
Bulgaria	29	3 ⬆	0.6	NA	11.1	6 ⬆	34	‑6 ⬇	43	‑5 ⬇
Croatia	22	‑12 ⬇	0.8	NA	9.0	‑15 ⬇	53	16 ⬆	57	4 ⬆
Cyprus	NA	NA	NA	NA	NA	NA	68	‑1 ⬇	65	2 ⬆
Czechia	16	‑28 ⬇	11.1	113 ⬆	11.2	‑3 ⬇	52	‑9 ⬇	50	‑1 ⬇
Denmark	11	‑35 ⬇	6.0	140 ⬆	7.5	‑25 ⬇	48	‑12 ⬇	55	‑5 ⬇
Estonia	13	‑40 ⬇	11.8	883 ⬆	10.9	‑8 ⬇	49	‑12 ⬇	50	‑17 ⬇
Finland	11	‑28 ⬇	2.4	‑63 ⬇	7.4	‑19 ⬇	50	‑8 ⬇	61	‑8 ⬇
France	23	‑19 ⬇	6.1	110 ⬆	10.4	‑10 ⬇	58	‑7 ⬇	65	‑8 ⬇
Germany	15	‑30 ⬇	3.3	NA	10.7	‑4 ⬇	NA	NA	NA	NA
Greece	25	‑9 ⬇	1.8	NA	5.3	‑30 ⬇	55	9 ⬆	59	‑1 ⬇
Hungary	25	‑3 ⬇	2.0	233 ⬆	10.3	‑3 ⬇	41	4 ⬆	33	8 ⬆
Ireland	14	‑26 ⬇	8.0	167 ⬆	9.4	‑11 ⬇	65	‑13 ⬇	72	‑14 ⬇
Italy	20	‑8 ⬇	4.8	220 ⬆	6.6	‑12 ⬇	84	‑1 ⬇	76	‑6 ⬇
Latvia	23	‑8 ⬇	3.0	NA	11.7	13 ⬆	36	2 ⬆	43	‑3 ⬇
Lithuania	19	‑7 ⬇	1.6	NA	11.0	‑24 ⬇	37	‑2 ⬇	43	‑4 ⬇
Luxembourg	15	‑4 ⬇	12.3	NA	10.4	‑9 ⬇	55	‑23 ⬇	58	‑22 ⬇
Malta	NA	NA	NA	NA	NA	NA	62	‑12 ⬇	44	‑13 ⬇
Netherlands	13	‑29 ⬇	4.1	17 ⬆	7.8	‑10 ⬇	64	11 ⬆	71	21 ⬆
Poland	17	‑25 ⬇	NA	NA	10.0	‑7 ⬇	56	‑3 ⬇	59	‑2 ⬇
Portugal	14	‑15 ⬇	1.6	60 ⬆	8.6	‑12 ⬇	80	0 ⬇	63	‑19 ⬇
Romania	19	‑6 ⬇	1.7	NA	12.3	28 ⬆	38	‑9 ⬇	37	‑11 ⬇
Slovak Republic	21	‑8 ⬇	1.2	NA	9.4	‑5 ⬇	51	‑5 ⬇	48	‑8 ⬇
Slovenia	17	‑8 ⬇	1.7	NA	9.7	2 ⬆	68	‑1 ⬇	70	0 ⬆
Spain	20	‑14 ⬇	4.6	NA	11.1	21 ⬆	67	‑13 ⬇	51	‑21 ⬇
Sweden	9	‑21 ⬇	1.7	NA	7.4	1 ⬆	48	‑20 ⬇	59	‑17 ⬇
Iceland¹	6	‑51 ⬇	5.0	79 ⬆	7.7	10 ⬆	NA	NA	NA	NA
Norway¹	8	‑47 ⬇	5.0	25 ⬆	6.2	0 ➡	56	‑12 ⬇	65	‑4 ⬇

1. non-EU European Economic Area countries. Dark blue: Lower than the 25th percentile; Light blue: Between the 25th and 50th percentile; Light red: Between the 50th and 75th percentile; Dark red: Above the 75th percentile. (inverse colour coding for fruit and vegetable consumption).

Tobacco consumption refers to the share of the population aged 15 and over who are daily tobacco smokers except for Luxembourg (16+). Where 2023 data was unavailable, the closest year available was used: 2024 data for: Denmark, Estonia, Ireland, Luxembourg, Iceland, Norway; 2022 data for: Finland; 2021 data for Germany; 2020 data for: Spain, Ukraine; 2019 data for: Austria, Bulgaria, Croatia, Greece, Hungary, Latvia, Lithuania, Poland, Portugal, Romania, the Slovak Republic, Slovenia; 2018 data for: Belgium. Where 2013 data was unavailable, the closest year available was used: 2014 data for Austria, Bulgaria, Croatia, Estonia, France, Greece, Hungary, Latvia, Lithuania, Poland, Portugal, Romania, the Slovak Republic, Slovenia, Spain; and 2015 data for Ireland.

Vaping use refers to the share of the population aged 15 and over who are regular vaping product users except for Luxembourg (16+). Where 2024 data was unavailable, the closet year available was used: 2018 data for Belgium; 2019 data for Austria, Bulgaria, Croatia, Germany, Greece, Hungary, Latvia, Lithuania, Portugal, Romania, the Slovak Republic and Slovenia; 2022 data for Finland and Sweden; 2023 data for Czechia, France, Italy, and the Netherlands. Where 2014 data was unavailable, the closet year available was used: 2012 data for Estonia; 2015 data for Ireland and Norway; 2016 data for Finland, the Netherlands, and Iceland; 2017 data for Czechia and Denmark.

Source: OECD (2025).

Alcohol consumption is measured in litres per person among individuals aged 15 and over. Where 2023 data was unavailable, the closet year available was used: 2024 data for Ireland and Norway; 2020 data for Belgium, Bulgaria, Croatia, Germany, Greece, Italy, Luxembourg, and Portugal.

Fruit and vegetable consumption refers to the share of the total population who consume fruits/vegetables at least daily.

Source: Fruit and vegetable consumption: Eurostat (ilc_hch11, 2024); Tobacco consumption: OECD (2025), https://data-explorer.oecd.org/s/3kk; Vaping use: OECD (2025), https://data-explorer.oecd.org/s/3kj; Alcohol consumption: OECD (2025), https://data-explorer.oecd.org/s/3kl.

Table 3.3. . Dashboard on cardiovascular risk factors: Behavioural and lifestyle risk factors (continued) and environmental risk factors

	Insufficient physical activity (%)		Sleep problems (%)		Work-related stress, depression, anxiety (%)		Heat exposure (%)		Air pollution (µg/m³)
	2022	% change (2012‑2022)	2022	% change (2012‑2022)	2025	% change (2022‑2025)	2023	% change (2000‑2023)	2020	% change (2010‑2020)
EU average	28	‑3 ⬇	34	‑5 ⬇	29	7 ⬆	34	9 ⬆	11	‑30 ⬇
Austria	23	‑26 ⬇	35	13 ⬆	25	4 ⬆	48	21 ⬆	11	‑32 ⬇
Belgium	29	‑31 ⬇	39	3 ⬆	32	7 ⬆	0	0% ➡	11	‑34 ⬇
Bulgaria	37	29 ⬆	27	NA	21	11 ⬆	66	‑31 ⬇	17	‑25 ⬇
Croatia	33	53 ⬆	30	NA	32	14 ⬆	72	‑2 ⬇	16	‑25 ⬇
Cyprus	43	‑4 ⬇	22	NA	41	3 ⬆	90	2 ⬆	13	‑27 ⬇
Czechia	27	1 ⬆	39	7 ⬆	24	0 ➡	35	207 ⬆	14	‑32 ⬇
Denmark	14	‑37 ⬇	33	15 ⬆	19	6 ⬆	0	0% ➡	9	‑31 ⬇
Estonia	20	12 ⬆	47	1 ⬆	35	17 ⬆	0	0% ➡	6	‑31 ⬇
Finland	12	‑46 ⬇	34	NA	45	7 ⬆	0	0% ➡	5	‑30 ⬇
France	27	‑28 ⬇	39	0 ➡	25	0 ➡	40	469 ⬆	9	‑30 ⬇
Germany	15	‑28 ⬇	43	43 ⬆	20	11 ⬆	15	74 ⬆	10	‑36 ⬇
Greece	40	10 ⬆	15	NA	49	32 ⬆	90	0 ⬇	14	‑29 ⬇
Hungary	33	30 ⬆	27	‑30 ⬇	32	10 ⬆	86	‑14 ⬇	14	‑31 ⬇
Ireland	24	‑30 ⬇	36	NA	27	0 ➡	0	0% ➡	8	‑21 ⬇
Italy	45	‑6 ⬇	29	‑3 ⬇	29	‑3 ⬇	82	128 ⬆	14	‑27 ⬇
Latvia	18	‑19 ⬇	36	NA	32	19 ⬆	0	0% ➡	12	‑35 ⬇
Lithuania	24	‑9 ⬇	45	NA	27	‑4 ⬇	0	0% ➡	9	‑33 ⬇
Luxembourg	15	‑33 ⬇	37	0 ➡	29	0 ➡	0	0% ➡	9	‑33 ⬇
Malta	44	‑17 ⬇	30	NA	23	0 ➡	0	0% ➡	12	‑31 ⬇
Netherlands	11	‑36 ⬇	28	8 ⬆	30	7 ⬆	0	0% ➡	11	‑33 ⬇
Poland	40	31 ⬆	36	‑19 ⬇	41	11 ⬆	8	‑64 ⬇	18	‑33 ⬇
Portugal	56	11 ⬆	50	22 ⬆	34	3 ⬆	87	142 ⬆	8	‑21 ⬇
Romania	40	44 ⬆	39	NA	24	26 ⬆	77	‑12 ⬇	14	‑30 ⬇
Slovak Republic	26	‑6 ⬇	19	NA	28	17 ⬆	29	‑49 ⬇	15	‑28 ⬇
Slovenia	23	1 ⬆	33	‑16 ⬇	21	‑16 ⬇	9	‑73 ⬇	14	‑25 ⬇
Spain	25	‑33 ⬇	36	1 ⬆	40	8 ⬆	80	49 ⬆	10	‑22 ⬇
Sweden	11	‑53 ⬇	32	12 ⬆	30	‑6 ⬇	0	0% ➡	6	‑28 ⬇
Iceland¹	28	‑12 ⬇	NA	NA	32	7 ⬆	0	0% ➡	5	‑22 ⬇
Norway¹	38	4 ⬆	NA	NA	24	0 ➡	0	0% ➡	6	‑23 ⬇

1. non-EU European Economic Area countries. Dark blue: Lower than the 25th percentile; Light blue: Between the 25th and 50th percentile; Light red: Between the 50th and 75th percentile; Dark red: Above the 75th percentile.

Insufficient physical activity (crude estimate) is the per cent of adults aged 18+ years attaining less than 150 minutes of moderate‑intensity physical activity per week, or less than 75 minutes of vigorous-intensity physical activity per week, or equivalent.

Sleep problems are derived from the percentage of adults aged 45 and older who report trouble sleeping. Where 2012 data was unavailable, the closest year available was used: 2011 data for Austria, Belgium, Czechia, Denmark, Estonia, France, Hungary, Italy, the Netherlands, Portugal, Slovenia, Spain and Sweden; and 2013 data for Luxembourg.

Work-related stress, depression or anxiety refers to the percentage of employed workers (employees and self-employed) aged 16 and over who reported experiencing stress, depression, or anxiety in the past 12 months that was caused or made worse by their work.

Extreme heat refers to the percentage of people who are exposed to at least one hot day (>35°C).

Air pollution refers to the mean population-weighted exposure to fine particulate matter (PM2.5), measured in microgrammes per cubic metre (µg/m³).

Source: Insufficient physical activity: WHO (2024), WHO Global Health Observatory 2024, https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-insufficient-physical-activity-among-adults-aged-18-years-(crude-estimate)-(-); Sleep problems: SHARE‑ERIC (2024); Healthy Ireland Survey 2024; Work-related stress, depression or anxiety: OSH Pulse 2025; Air pollution: OECD (2025), https://data-explorer.oecd.org/s/3kz, Extreme heat: OECD (2025), https://data-explorer.oecd.org/s/3l0.

3.1. Clinical and intermediate factors are driving cardiovascular burden

3.1.1. Diabetes prevalence in Europe has been steadily increasing over the past decades

Diabetes mellitus is a common condition worldwide, involving the abnormal glucose metabolism. The most common types are Type 1 diabetes, which develops at an early age is highly linked to genetic and non-modifiable factors, and Type 2 diabetes, which predominates in adults and is linked to lifestyle and behavioural risk factors. Less common types include gestational diabetes, medically-induced diabetes, among others. In 2022, almost one‑in-ten adults had diabetes in the EU, totalling to 45.4 million affected adults (WHO Global Health Observatory, 2024[4]). Symptoms suggestive of diabetes include frequent urination (i.e. polyuria), excessive thirst (i.e. polydipsia), fatigue, blurry vision, unintended weight loss, slow-healing wounds, and recurring infections. Yet in 40% of adults worldwide, diabetes can go unnoticed, silently damaging organs such as the heart, the kidneys, and the eyes (ESC Guidelines, 2023[5]). In the absence of symptoms, diabetes can be detected by screening for fasting blood glucose, a repeated measure of 126mg/dL or greater (≥ 7.0 mmol/L) confirms the diagnosis of diabetes (ESC Guidelines, 2023[5]).

In the EU, the prevalence of diabetes in adults aged 18 years and over has increased by 22% from 6.4% in 2012 to 7.8% in 2022 (Figure 3.3), and it is estimated to rise to 8.6% in 2050 (IDF, 2025[6]). Within the EU in 2022, the prevalence rate varied from as low as 2.3% in Denmark to 10% or higher in Bulgaria, Poland, Slovenia, Hungary, Lithuania and Romania; among non-EU countries, such as Bosnia and Herzegovina, Mexico and Türkiye, the prevalence surpasses 13%. Within the EU, between 2012 and 2022, the prevalence decreased or remained similar in Denmark, France, Spain and Germany, while it almost doubled in Romania. Among non-EU countries between 2012 and 2022, the prevalence increased by more than 35% in Australia, Albania, Montenegro, Serbia and North Macedonia. Most EU countries (23 out of 27) between 2012 and 2022 have increased the prevalence of diabetes (Figure 3.3). The burden of diabetes-related CVD in Europe is substantial with CVD 30 million DALYs attributable to this condition in the EU (IHME, 2024[7]).

Diabetes mellitus is a major risk factor for CVD, including coronary artery disease, stroke and heart failure. Diabetes is not only associated with high blood glucose levels but also with elevated insulin levels and insulin resistance, which induce and promote the progression of atherosclerosis – the leading cause of cardiovascular conditions such as heart attack and stroke (Dal Canto et al., 2019[8]). This atherosclerotic process can progress faster and earlier in people with diabetes and can even generate “silent” damage to the heart. In a study of adults without established heart disease, high-grade atherosclerosis was found in nearly 75% of those with diabetes or diabetes-related conditions (such as elevated blood glucose, impaired glucose tolerance, or a history of diabetic nephropathy), compared with 55% of those without diabetes (Goraya et al., 2002[9]).

Figure 3.3. Diabetes prevalence among adults has increased by 22% in the EU, 2012 and 2022

Type I and II diabetes prevalence

Note: Percentage of people aged 18 years and over with fasting plasma glucose ≥ 126 mg/dl, or glycated haemoglobin ≥ 6.5%, or on glucose‑lowering medication for diabetes. EU27 average is unweighted. Age‑standardisation to WHO world population, therefore crude rates and percentage change from national sources may differ. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries.

Source: WHO Global Health Observatory 2024.

Cardiovascular conditions are the main cause of morbidity and mortality in patients with diabetes, accounting for 44% of deaths in individuals with type 1 diabetes and 52% in those with type 2​ diabetes (Siam et al., 2024[10]). Patients with diabetes have a two‑ to four‑fold increased risk of CVD compared with patients without diabetes (Siam et al., 2024[10]; Dal Canto et al., 2019[8]). The increased cardiovascular risk is present even at glucose levels below the diagnostic threshold for diabetes, with a continuous relationship between glycemia and CVD incidence.

Diabetes significantly increases the risk of CVD in both men and women, but the risk is greater in women. Women with diabetes are 2.5 times more likely to have acute coronary syndrome compared to those without diabetes, while for men with diabetes the risk is 1.7 compared to those without diabetes (Dong et al., 2017[11]). Similarly, diabetes increases the risk of stroke by 2.3 in women and 1.8 in men compared to people without diabetes, even after adjusting for other cardiovascular risk factors such as blood pressure, smoking status, body mass index an total cholesterol (multiple‑risk adjusted model: RR 2.45 in women, and 1.96 in men) (Peters, Huxley and Woodward, 2014[12]). Furthermore, following an initial myocardial infarction, the risks of subsequent myocardial infarction, heart failure, and early and late death are higher in people with diabetes than in those without diabetes (Peterson, McKenzie and Schaffer, 2012[13]). Diabetes increases the risk of heart failure after a myocardial infarction by 50‑60% compared to those without diabetes (Ritsinger et al., 2020[14]). Detection and treatment of prediabetes and insulin resistance remains a true challenge.

Results from PaRIS, the international survey of people living with chronic conditions, demonstrate that gender and socio-economic status impact diabetes rates. Among primary care users 45 years and over men (23%) report higher rates of diabetes than women (15%), and lower educated patients report higher rates of both diabetes and CVD compared to those with higher education (see Chapter 2). Ethnicity also plays a role, people from South Asia have a higher risk of developing diabetes and CVD compared to other ethnic groups (see Chapter 2). Both CVD and diabetes can go unnoticed in people with high blood glucose levels. This underscores the need for early detection – both of diabetes and of CVD in people with established diabetes (see Section 3.5 on prevention) – for effective management of lifestyle and behavioural risk factors that can lead to both diabetes and CVD (see Section 3.2), and for care that is tailored to the sociodemographic and clinical profile of the patient (see Chapter 4).

3.1.2. Hypertension has stabilised in most countries – but still impacts a significant proportion of the population

Blood pressure results from the combination of environmental, behavioural, genetic and hormonal factors interacting with multiple organ such as the kidneys, heart, blood vessels, and brain (ESC, 2024[15]). Maintaining an adequate blood pressure keeps organs well-functioning. When blood pressure is not adequately regulated it can lead to hypertension – defined as a sustained elevation in arterial blood pressure (≥140/90 mmHg) – which can damage the heart, kidneys and brain (ESC, 2024[15]).

Behavioural factors that can increase blood pressure include high salt intake, low vegetable and fruit consumption, sedentary behaviour, harmful alcohol consumption, obesity and the use of drugs or substances that increase blood pressure (ESC, 2024[15]). This makes hypertension, or high blood pressure, one of the most important and prevalent modifiable risk factors for CVD worldwide. It is a major contributor to ischaemic heart disease, stroke, heart failure, peripheral artery disease, and chronic kidney disease (Forouzanfar et al., 2017[16]). Cardiovascular risk associated with hypertension is continuous and log-linear, meaning there is higher risk of CVD as systolic blood pressure rises (Lawes et al., 2004[17]). For every 10‑mm Hg increase in systolic blood pressure, there was a 53% higher risk for atherosclerotic CVD (Whelton et al., 2020[18]).

Across the EU, 22% of people 15 years and older, on average, report having high blood pressure (Figure 3.4). Over 30% of people report having high blood pressure in Hungary, Latvia and Croatia, while less than 15% report having high blood pressure in Ireland. Differences in the prevalence of high blood pressure by gender tend to become more pronounced among countries reporting higher levels of high blood pressure overall. In Bulgaria, Lithuania and Latvia, there is more than a 6 percentage point (p.p.) difference in reported levels of high blood pressure between men and women, with higher levels observed in women partially linked to the higher screening rates among women compared to men in these countries.1 Early detection and treatment of hypertension can reduce complications to the heart, brain, kidneys, eyes and vessels, thus prevent premature deaths and improve quality of life (ESC, 2024[15]).

Figure 3.4. 22% of people 15 years and older in the EU have high blood pressure, 2019

Note: EU27 average is weighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries.

Source: Eurostat (2021), Persons reporting a chronic disease, by disease, sex, age and educational attainment level (hlth_ehis_cd1e), https://ec.europa.eu/eurostat/web/products-datasets/-/hlth_ehis_cd1e (accessed 8, July 2025).

The prevalence of high blood pressure is age dependent. In the EU, on average, half of the people aged 65 or older have high blood pressure compared to less than 10% in those 44 or younger. In younger age groups women tend to have slightly lower prevalence rates than men, but in the age group 65 and over, this pattern reverses, with higher rates women than men (Figure 3.5).

Figure 3.5. High blood pressure predominates in people 65+ in the EU, the group in which the women to men ratio inverts, 2019

EU27 average of people with high blood pressure by age group

Note: EU is the weighted average of the 27 EU countries.

Source: Eurostat (2021), Persons reporting a chronic disease, by disease, sex, age and educational attainment level (hlth_ehis_cd1e), Persons reporting a chronic disease, by disease, sex, age and educational attainment level, https://ec.europa.eu/eurostat/web/products-datasets/-/hlth_ehis_cd1e (accessed 8, July 2025).

Hypertension is the primary risk factor for ischaemic and haemorrhagic stroke – and has been attributed to approximately 60% of cases (Silva et al., 2024[19]). Antihypertensive pharmacologic treatment within the first 24‑hours of onset of acute CVD events has been found to reduce mortality in as little as 10 days (Perez, Musini and Wright, 2009[20]; Galea et al., 2025[21]). Meta‑analyses show that lowering blood pressure decreases the risk of stroke by approximately 40%, with even modest reductions of 5 mmHg (Law, Morris and Wald, 2009[22]). Moreover, poorly controlled blood pressure after an initial cerebrovascular event is strongly associated with recurrence and mortality (Lindley, 2018[23]). Hypertension is also a major cause of heart failure and it precedes its onset in up to 91% of people, particularly in older adults (Vasan et al., 2001[24]). In the EU, countries with the highest prevalence of high blood pressure among people aged 65 and over tend to have higher age‑adjusted mortality rates due to ischaemic heart disease compared with younger people (Annex Figure 3.B.1).

My experience with preventive medicine has been limited and largely unsatisfactory. Despite leading a generally healthy lifestyle – without significant addictions and with a strong commitment to self-care – I received very little information or guidance on prevention throughout my adult life. Most of the medical attention I received was reactive, focussed on managing symptoms rather than preventing the progression or onset of disease.

Angela, 53, mother, in menopause and living with multiple chronic conditions.

Globally, raised blood pressure is the leading contributor to DALYs from non-communicable diseases. In 2019, raised blood pressure was responsible for an estimated 10.8 million deaths and 235 million DALYs (IHME, 2024[7]). In the EU27, ischaemic heart disease and stroke – the two primary outcomes of uncontrolled hypertension – rank among the top causes of DALYs and premature mortality. The mechanisms underlying the development of hypertension shed light on addressing modifiable risk factors – such as targeting lifestyle and behaviour – to prevent the development of hypertension and its cardiovascular complications. Section 3.2 gives more insight into the behavioural and lifestyle factors, and Section 3.5 on early detection and management of hypertension.

3.1.3. There has been a significant decline in the prevalence of high cholesterol, but recent data suggest a plateau

Dyslipidaemia, typically defined by elevated low-density lipoprotein cholesterol (LDL-C), reduced high-density lipoprotein cholesterol (HDL-C), and/or elevated triglycerides, is a primary modifiable risk factor for atherosclerotic CVD, including coronary artery disease, stroke and peripheral arterial disease. Abnormal lipid profiles are responsible for a substantial proportion of global cardiovascular morbidity and mortality.2 It is estimated to contribute to over 50% of coronary heart disease cases globally (Ference et al., 2017[25]) and in 2021, high levels of LDL-C were estimated to have contributed to 3.8 million cardiovascular deaths worldwide (IHME, 2024[7]).

Box 3.1. Best practices for advancing cardiovascular health: Know Your Numbers!

Description: Know Your Numbers! (KYN) is a UK-based public health campaign that raises awareness of high blood pressure and encourages adults to check their blood pressure. The strategy focusses primarily on partnerships and extensive media engagement (radio, print and TV). One of its central activities is the Know Your Numbers! Week, an annual event each September during which KYN kits are sent to pharmacies, workplaces, schools, sport centres, car parks and supermarkets to offer blood pressure checks in public spaces. Initially, the campaign received significant funding, including from Public Health England, NHS and charities; however, the KYN kit has since become chargeable for all participants wishing to set up a blood pressure testing station. Resource packs to run a pressure station now range is cost from GBP 17.50 plus VAT (suitable to test up to 50 people) to GBP 135 plus VAT (for up to 800 people).

Best practice assessment:

 

Enhancement options: To enhance effectiveness, KYN could expand data collection to include socio-economic status, clinical and behaviour risk factors (e.g. diabetes, obesity, high blood sugar, smoking) as well as health literacy indicators. Establishing follow-up for individuals with high blood pressure would enable assessment of improvements in health literacy, changes in self-monitoring behaviours, and treatment uptake.

Transferability: Campaigns encouraging blood pressure checks have been implemented in other countries, including Ireland (Know your Numbers and Farmers Have Hearts), Australia (Biggest Blood Pressure Check and Know Your Numbers) and the global May Measurement Month (MMM). It is currently being piloted in France as part of JACARDI. KYN’s approach of using partnerships, community settings, and media to raise awareness and offer testing is highly transferable to other countries aiming to increase blood pressure monitoring and awareness.

Conclusion: KYN shows that community-based partnerships and accessible testing can increase public awareness of high blood pressure and promote early detection. Its wide reach and sustained delivery over more than 20 years positions it as a strong example of best practice in raising awareness and encouraging blood pressure testing.

Source: (Blood Pressure UK[26]; NHS Gloucestershire, 2024[27]; NHS England, 2025[28]).

Total cholesterol is a measure that includes “bad” (e.g. LDL-C) and “good” cholesterol (HDL-C) in the blood. A level lower than 5.17 mmol/L (i.e. 200mg/dL) is considered desirable for adults, although lower targets may apply for patients with higher CVD risk. In the EU, 14% of adults report having been diagnosed with high blood lipids cholesterol (Eurostat, 2021[29]). Although the references for diagnosing dyslipidaemia have changed over time – which may influence the assessment of trends in diagnosed high blood lipids – non-HDL and total cholesterol levels have markedly decreased in high-income European countries. This trend is mainly attributed to dietary improvements and expanded use of statins from the late 1990s onward (NCD-RisC, 2020[30]). However, regional disparities persist, with countries like Latvia, Lithuania and Serbia showing higher than optimal average cholesterol levels, which are associated with higher mortality rates due to ischaemic heart disease (Annex Figure 3.B.1). Total cholesterol measures also vary slightly between countries in Europe, with values ranging from 4.6 mmol/L to 5.2 mmol/L (the desirable cutoff is 5.17 mmol/L) (Figure 3.6).

The risk of cardiovascular events is strongly linked to LDL-C. Individuals with familial hypercholesterolemia, whose LDL-C level is double those of their unaffected siblings, face a ten‑fold increased risk of premature coronary events (Drouin-Chartier et al., 2021[31]; ESC/EAS, 2011[32]). Conversely, reducing LDL-C substantially lowers the risk of cardiovascular events, with a 22% reduction in risk for every 1 mmol/L decrease in LDL-C (Patel and Giugliano, 2020[33]). The treatment goal of LDL-C for cardiovascular prevention is less than 3.0 mmol/L (<116 mg/L) in people at low risk, less than 2.6 mmol/L (<100mg/L) for people at moderate risk, less than 1.8 mmol/L (<70 mg/dL) for people at high risk, and less than 1.4 mmol/L (<55 mg/dL) for people at very high risk (ESC, 2019[34]).

Figure 3.6. Average total cholesterol varies within European countries, 2018

Note: EU27 average is unweighted. Desirable total cholesterol below 5.17 mmol/L. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries.

Source: NCD RisC 2018a.

Timely diagnosis and adequate management of dyslipidaemia with pharmacologic therapy along with healthy diet and exercise are key to preventing CVD. See Section 3.2 for more insight into the behavioural and lifestyle factors, and Section 3.5 on early detection and management of dyslipidaemia.

3.1.4. Obesity prevalence is high and continues to pose a challenge for cardiovascular health

Obesity, particularly central or visceral obesity, is a major independent risk factor for CVD and a critical driver of the global burden of noncommunicable diseases. Defined by a body mass index (BMI) ≥30 kg/m², obesity is associated with increased risk of cardiovascular events such as heart failure (HF), arrhythmias, stroke and myocardial infarction (American Heart Association, 2021[35]). Excess weight in childhood further increases the risk of AMI in early adulthood (Chrissini and Panagiotakos, 2022[36]; WHF, 2025[37]). One study found that children with a high BMI are 40% more likely to have CVD in midlife than those with a low BMI (WHF, 2025[37]). Recent evidence also highlights the added value of incorporating metrics of abdominal adiposity (waist circumference, waist-to-height ratio, waist-to-hip ratio) to refine cardiometabolic risk stratification beyond BMI. However, these metrics are not routinely measured in clinical practice (Ross et al., 2020[38]).

Obesity and overweight are widespread across Europe. In 2022, 51% of adults aged 18 and over were overweight (BMI ≥25 kg/m²) and 15% were obese (BMI ≥30 kg/m²) (Figure 3.7). Prevalence rates in obesity vary significantly across Europe, ranging from 7% in Italy to above 20% in Lithuania, Finland, Estonia, Hungary, Latvia and Malta. Men consistently show higher rates of obesity than women. On average, 16% of men live with obesity in the EU compared to 14% of women. Lower socio-economic groups – and in particular women with low income – are more likely to live with obesity. On average, women with high income are 41% less likely to live with obesity than women with low income, while men with high income are 16% less likely to do so (WHO Global Health Observatory, 2025[39]). Childhood overweight and obesity remain a major concern in Europe, with around one‑in-ten children (9%) aged 5 to 19 living with obesity across EU countries and one‑in-four (25%) living with overweight (WHO Global Health Observatory, 2025[40]).

Figure 3.7. Nearly one‑in-seven adults were living with obesity in 2022, with rates consistently higher among men than women

Notes: EU27 average is weighted. Data for Germany are based on a different study (Starker et al., 2025[3]). 2017 data is used for Iceland. 1. Non-EU European Economic Area countries.

Source: Eurostat (2024), Person distribution by body mass index, educational attainment level, sex and age (ilc_hch10), https://ec.europa.eu/eurostat/databrowser/view/ilc_hch10/default/table?lang=en (accessed 10, July 2025).

The prevalence of obesity in Europe remained stable in recent years. Between 2017 and 2022, obesity rates among adults aged 18 and over in the EU decreased slightly from 14.9% to 14.8%. However, projections indicate that by 2050, more than half of the population in all EU countries will be overweight or obese (Ng et al., 2025[41]). Particularly high rates are expected in Croatia, Hungary, Latvia, Lithuania and Slovenia.

While obesity rates remain high in Europe, progress in obesity prevention has been limited. In this context, Glucagon-Like Reptide‑1 Receptor Antagonists (GLP‑1 RAs) have gained attention as an effective therapy for weight reduction. Evidence indicates that GLP‑1 RAs significantly reduces BMI in the short term (Moiz et al., 2025[42]; Gudzune and Kushner, 2024[43]), and reduce the risk of cardiovascular events (Badve et al., 2025[44]; Xie, Choi and Al-Aly, 2025[45]). Despite reducing bodyweight and comorbidities in the short term, evidence indicates that patients tend to regain weight when treatment is stopped. Furthermore, access to GLP‑1RAs is limited due to high prices, limited public insurance coverage, frequent shortages, and strict eligibility criteria (such as age and BMI thresholds). Ensuring long-term efficacy, availability, generous coverage for low-income groups, and accompanying treatment with behavioural and lifestyle changes will be critical for improving the effectiveness of GLP‑1 RAs obesity treatments (Mathieu-Bolh, forthcoming[46]).

Meanwhile, evidence‑based prevention strategies remain central to tackling obesity at the population level. Legislative measures on food advertising, nutrition labelling, and fiscal policies to discourage the consumption of high-fat, high-salt and high-sugar products, together with interventions to reduce calorie intake and increase physical activity, are key components of prevention. School- and nursery-based initiatives – including teaching healthy cooking, promoting physical activity, providing nutritious meals, and involving families in fostering healthy habits – are important targets for early detection and sustainable lifestyle change. Public procurement also offers an important policy lever for promoting healthy diets. The JRC’s criteria for Sustainable Public Procurement (SPP) for food encompass the three dimensions of sustainability – environmental, social and economic – and identify nutrition as a crucial component, as healthier food choices help prevent obesity, especially among children and people in vulnerable situation (Garcia Herrero et al., 2025[47]). Results from the SWEDEHEART registry show that at 1‑year follow-up after a myocardial infarction, central obesity increased from 51% to 57%, as did diabetes (18% to 27%) and insufficient physical activity (57% to 62%) in the cohort (Leosdottir et al., 2023[48]). Management of obesity and clinical risk factors is necessary even after having had a CVD event to prevent further CVD events and complications.

3.1.5. Metabolic syndrome prevalence in Europe has been increasing, with significant variation between countries

Metabolic syndrome (MetS) is usually defined as a cluster of interconnected metabolic abnormalities that increase the risk of CVD, type 2 diabetes mellitus, and all-cause mortality. Various criteria have been proposed to define this syndrome, but no general consensus on the specific markers and the respective cut-offs has been achieved yet. It can commonly be defined by the presence of at least three of the following components: abdominal obesity, elevated blood pressure, hyperglycaemia, high triglycerides, and low high-density lipoprotein cholesterol (HDL-C).

MetS significantly increases the risk of cardiovascular events. It has been found that MetS was associated with a twofold increase in risk for CVD and cardiovascular mortality and strongly associated with the development of heart failure, ischaemic stroke and transient ischaemic attack (Mottillo et al., 2010[49]). The global prevalence of MetS is estimated at around 30% of the global population (Zila-Velasque et al., 2024[50]) and at around 25% in Europe (for the Metabolic Syndrome and Arteries Research (MARE) Consortium, 2014[51]). The increasing burden of obesity and sedentary lifestyles has led to a steady rise in MetS prevalence, particularly among older adults and socio-economically disadvantaged groups (Rus et al., 2023[52]).

3.1.6. Depressive symptoms are prevalent, and highly associated with CVD

Mental illness is a leading cause of ill health and disability in Europe, and a key risk factor for CVD. Depression and severe mental illness – including schizophrenia or bipolar disorder – are associated with increased risk of myocardial infarction, stroke, angina and coronary heart disease (Honigberg et al., 2022[53]; Kwapong et al., 2023[54]; Emerging Risk Factors Collaboration, 2020[55]; Nielsen, Banner and Jensen, 2020[56]). This link is partly explained by the physiological changes associated with depression – including elevated cortisol and adrenaline levels that raise the blood pressure, glucose and heart – as well as the higher level of socio-economic disadvantage and unhealthy behaviours among people with mental illness – such as smoking, diets high in calories, salt and saturated fats, lack of exercise, and lower medication compliance (Nielsen, Banner and Jensen, 2020[56]; Chaddha et al., 2016[57]; Kwapong et al., 2023[54]; Henking, Reeves and Chrisinger, 2023[58]). Some psychotropic medications, particularly first-generation antipsychotics and high-dose prescriptions, also pose cardiac risks, including obesity and QTc prolongation with risk of ventricular tachyarrhythmia (Nielsen, Banner and Jensen, 2020[56]).

I've been medicated for anxiety and depression since my stroke… I stopped working (I was a journalist), had to learn how to do everything only with one side of my body (I have hemiparesis) and it’s very difficult to manage my self-esteem.

Diana, 48, stroke survivor.

Depression is widespread in Europe. In 2022, 27% of adults aged 45 and over reported at least four depressive symptoms on the EURO-D scale (Figure 3.8). Women consistently report higher rates of depressive symptoms than men (32% and 20% respectively) (see Annex 3.E). The higher burden of reported depressive symptoms among women may be explained by hormonal changes, caregiving responsibilities, socio-economic disadvantage and gender-based violence (Kwapong et al., 2023[59]; Karami et al., 2023[60]). Further, under-diagnosis and lower help-seeking behaviour among men may lead to an underestimation of their symptom prevalence, thereby contributing to the observed gender gap (Kwapong et al., 2023[54]; Buffel, Van de Velde and Bracke, 2014[61]).

While depressive symptoms among older adults declined on average across the EU between 2012 and 2022, they remain high across Europe. In many countries, depressive symptoms have increased among older adults, including the Netherlands, Denmark, Austria, Sweden, Germany, Czechia, Belgium and Portugal (Figure 3.8). One contributing factor has been the pandemic, which drove up depression rates by increasing social isolation, loneliness, uncertainty, bereavement and financial stress (Frankenthal, Keinan-Boker and Bromberg, 2022[62]). Further drivers include rising chronic disease burdens, inequality, social media use, and loneliness, as well as increased public awareness and improved diagnosis of mental health conditions (Hidaka, 2012[63]; Twenge et al., 2018[64]).

Living with congenital heart disease has had a significant impact on my physical and mental wellbeing. There have been times of anxiety and stress related to health uncertainties and hospitalizations. Physically, my activity is limited compared to before diagnosis, and fatigue can be a challenge. Workwise, I have had to adapt my responsibilities and pace, while maintaining a sense of purpose. Socially, I strive to stay connected, but sometimes health issues reduce my participation in social events. Overall, I have learned resilience and the importance of strong support networks.

Antonis, 58, congenital heart disease patient and advocate for digital health and patient empowerment.

Figure 3.8. Nearly one‑in-three Europeans report depressive symptoms, with rates rising in several EU countries, 2012 and 2022 (or nearest year)

Note: Respondents aged 45 and older. The EURO-D depression scale is a composite index of 12 items (depressed mood, pessimism, suicidality, guilt, sleep, interest, irritability, appetite, fatigue, concentration, enjoyment and tearfulness). The scale ranges from 0 “not depressed” to 12 “very depressed”. Ireland was excluded due to data availability. 2011 data (instead of 2012 data) was used for Austria, Belgium, Czechia, Denmark, Estonia, France, Hungary, Italy, the Netherlands, Portugal, Slovenia, Spain and Sweden; and 2013 data (instead of 2012 data) was used for Luxembourg.

Source: SHARE‑ERIC (2024); The Irish Longitudinal Study on Ageing (TILDA) 2025.

Mental health problems are common among people with cardiovascular conditions. In 2022, 31% of people with CVD and related clinical risk factors (including high blood pressure, hypertension, high blood cholesterol, diabetes and high blood sugar) reported depressive symptoms, compared to 20% of those without (Figure 3.9). Previous OECD analysis found that stroke survivors faced a 23% higher risk of depression (Everard et al., 2025[65]). This elevated risk may reflect both the physical and psychological burden of living with CVD. Symptoms such as pain, fatigue and sleep disturbance can limit daily functioning and reduce social and economic participation, contributing to isolation and poorer quality of life. At the same time, fear of disease progression, disability or death can have a direct impact on anxiety and depression (Karami et al., 2023[60]).

Cardiovascular disease has profoundly impacted every aspect of my life. Initially, it left me physically incapacitated, unable to walk or see properly, and struggling with panic attacks. Mentally, the fear of another cardiac event weighed heavily on me, requiring significant emotional resilience. Socially, my ability to engage in daily activities and connect with others was limited. However, this experience also inspired me to channel my energy into helping others, both through my professional work and patient advocacy. It has been a journey of rebuilding not just my health, but also my confidence and purpose.

Caius, artist, researcher, patient advocate, and heart attack survivor.

Figure 3.9. People with CVD and related clinical risk factors report more depressive symptoms than those without in all EU countries (2022)

Note: Respondents aged 45 and older. The EURO-D depression scale is a composite index of 12 items (depressed mood, pessimism, suicidality, guilt, sleep, interest, irritability, appetite, fatigue, concentration, enjoyment and tearfulness). The scale ranges from 0 “not depressed” to 12 “very depressed”. CVD includes heart attack, stroke and cerebral vascular disease. Clinical risk factors include high blood pressure, hypertension, high blood cholesterol, diabetes and high blood sugar. Ireland is excluded due to data availability.

Source: SHARE‑ERIC (2024).

3.1.7. Viral infections can increase the risk of cardiac events

Seasonal influenza epidemics and respiratory tract infections have been associated with acute myocardial infarction and excess CVD mortality (Kwong et al., 2018[66]; de Boer et al., 2024[67]). For example, Kwong et al. (2018) found that within 7 days of infection, incidence ratios for acute myocardial infarction were 10.1 (95% CI, 4.4 to 23.4) for influenza B, 5.2 (95% CI, 3.0 to 8.8) for influenza A, 3.5 (95% CI, 1.1 to 11.1) for respiratory syncytial virus, and 2.8 (95% CI, 1.2 to 6.2) for other viruses (such as adenovirus or metapneumovirus) (Figure 3.10). Several mechanisms link respiratory infections to cardiovascular events, including inflammation, endothelial dysfunction, increased plasma viscosity, dehydration and psychological distress (Golabchi, 2010[68]).

Figure 3.10. Respiratory viruses increase the risk of myocardial infarction

Source: Kwong et al. (2018[66]), “Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection”, https://doi.org/10.1056/nejmoa1702090.

There is growing evidence that acute illness from pandemic viruses, such as H1N1 influenza and COVID‑19, is linked to myocardial infarction, stroke and cardiac death. H1N1 infections have been associated with acute myocarditis, myocardial inflammation and cardiomyopathy (Bratincsák et al., 2010[69]; Ananth et al., 2024[70]). More recently, studies on the COVID‑19 pandemic have identified a wide range of cardiovascular complications associated with acute COVID‑19 illness, including acute myocardial injury, myocarditis, stress cardiomyopathy, myocardial infarction, stroke, deep vein thrombosis, pulmonary embolism, vasospasm, arrhythmias and heart failure (Chilazi et al., 2021[71]; Hendren et al., 2020[72]; Vassiliou et al., 2025[73]). Acute cardiac injury is the most commonly reported cardiovascular complication, affecting approximately 8‑12% of COVID‑19 patients (Li et al., 2020[74]; Lippi and Plebani, 2020[75]; Bansal, 2020[76]). In addition to acute COVID‑19 illness, a growing body of research suggests that Long COVID condition can have lasting effects on cardiovascular health (Box 3.2).

Vaccinations provide cardioprotective benefits against respiratory viral infections. A recent clinical consensus statement, developed by associations of the European Society of Cardiology (ESC), emphasises that COVID‑19 vaccinations are a cornerstone of prevention, reducing the cardiac risks of acute COVID‑19 illness and lowering the risk of developing Long COVID and its cardiac complications (Vassiliou et al., 2025[73]). In line with this, a retrospective cohort study of hospitalised COVID‑19 patients found that patients who had received a COVID‑19 vaccine experienced fewer acute cardiac events (17%) compared to non-vaccinated patients (29%), and had a significantly reduced relative risk for acute cardiac events (RR: 0.3, 95% CI [0.1; 0.8])  (Figure 3.11) (Madrid et al., 2024[77]). While this study does not establish a causal relationship, it does report a significant association between vaccination and lower risk of cardiac events, after controlling for confounders, including age, type 2 diabetes, hypertension, cardiac, and pulmonary diseases. Similarly, influenza vaccinations have been associated with a 26% lower risk of CVD, an 18% lower risk in respiratory disease, and a 43% lower risk for all-cause mortality (Cheng et al., 2020[78]). This suggests that vaccinations not only protect against acute infections but also reduce the risk of cardiovascular events, including stroke, myocardial infarction, acute coronary syndrome, heart failure, ischaemic heart disease, major adverse cardiovascular events, and cardiovascular mortality (Omidi et al., 2023[79]; Behrouzi et al., 2022[80]; Cheng et al., 2020[78]).

Box 3.2. Post COVID‑19 condition (Long COVID) and cardiovascular health

Long COVID is defined as the continuation or development of new symptoms three months after SARS‑CoV‑2 infection, persisting for over two months with no alternative explanation (WHO, 2022[81]). Emerging evidence suggests that Long COVID has lasting effects on cardiovascular health. Reported cardiac symptoms include chest pain, palpitations, dyspnoea (shortness of breath) and postural orthostatic tachycardia syndrome (POTS) (Vassiliou et al., 2025[73]; Tsampasian et al., 2024[82]). Long COVID has been associated with the development of CVD events (e.g. heart failure, cardiac arrest and cardiogenic shock). Estimates indicate that one‑in-five patients with Long COVID experience cardiac symptoms, and around 2‑5% of all individuals with COVID‑19 illness develop cardiac Long COVID (Vassiliou et al., 2025[73]).

A recent clinical consensus statement from the ESC provides a comprehensive overview of CVD prevention and management strategies for Long COVID (Vassiliou et al., 2025[73]). Key recommendations include early patient education after acute COVID‑19 illness on potential cardiac symptoms to support timely reporting and early diagnosis, as well as lifestyle interventions such as healthy nutrition, regular physical activity and smoking cessation. COVID‑19 vaccination and boosters are also highlighted as important preventive measures, reducing the risk of developing both Long COVID and COVID‑19 related cardiovascular complications (Xie, Choi and Al-Aly, 2024[83]; ECDC, 2022[84]). For cardiac Long COVID patients, recommendations emphasise evidence‑based pharmacotherapy, timely identification and close follow-up of high-risk individuals, and access to individualised cardiac rehabilitation programmes tailored to the needs of COVID‑19 survivors.

To strengthen the evidence base on Long COVID, the OECD is jointly leading the initiative of the EC on Long COVID “Supporting Long-COVID patients: insights and action”. This work includes preparing a policy paper using data from the Patient-Reported Indicator Survey (PaRIS) on the prevalence and health impacts of Long COVID, developing training for healthcare workers to improve knowledge, recognition and management of the condition, and modelling economic costs (OECD, 2025[85]).

Figure 3.11. Vaccinations have cardio-protective benefits for hospitalised COVID‑19 patients

Source: Madrid et al. (2024[77]), “Cardioprotective effects of vaccination in hospitalized patients with COVID-19”, https://doi.org/10.1007/s10238-024-01367-3.

3.2. Trends in many behavioural and lifestyle factors impacting cardiovascular health have been showing signs of improvement

3.2.1. Tobacco smoking is decreasing in most EU +2 countries

Smoking is a major cause of CVD and the leading cause of preventable mortality in the EU in 2021 (Brauer et al., 2024[86]). Every year, approximately 21% of the deaths due to coronary heart diseases are attributable to tobacco use and exposure to second-hand smoke (WHO, 2020[87]). This behaviour has multiple implications in the human body such as raising the triglycerides, lowering HDL cholesterol, modifying key characteristics of the blood that can lead to higher blood pressure, heart rate and reduced blood flow from the heart (notably to the brain), and ultimately lead to adverse cardiovascular outcomes (U.S. Department of Health and Human Services, 2010[88]). The harmful effects of tobacco use extend beyond the individual, placing a significant burden on healthcare systems and society, with the cost of smoking-attributable diseases estimated at 2.5% of Europe’s annual GDP (Goodchild, Nargis and Tursan d’Espaignet, 2017[89]). In France, a study showed that 21% of the hospital stays related to CVD could be attributable to smoking (Santé Publique France, 2022[90]).

In 2023, an average of 17.8% of adults aged 15 and over smoked daily across EU countries (Figure 3.12). The proportion of daily smokers varied more than three‑fold, ranging from 23% or more in Bulgaria, Greece, Hungary and France to below 12% in Denmark, Finland and Sweden (Figure 3.12). Over the last decade, smoking rates declined in all EU countries except Bulgaria, with an average 16% reduction since 2013. Progress, however, has been uneven, with the largest reductions observed in Denmark, Estonia and Germany (over 6 p.p.), and slight increases seen in Bulgaria (about 1 p.p.) (Figure 3.12) (OECD/European Commission, 2024[91]).

The implementation of more stringent tobacco control policies at the national level, such as smoke‑free environments and tax increases, has contributed to the reduction of smoking rates across many EU countries. These efforts have been supported and complemented by the Tobacco Products Directive 2014/40/EU, the Tobacco Advertising Directive 2003/33/EC and the Tobacco Taxation Directive 2011/64/EU, which introduced EU-wide measures concerning the manufacture, presentation, advertising, sale, and taxation of tobacco products. These measures include combined health warnings, a ban on characterising flavours, advertising and sponsorship bans, and a requirement for a minimum rate of excise duties on tobacco products (European Commission, 2021[92]), see Chapter 6 on designing and implementing effective policies for CVD prevention and control.

It has also been shown that smoking fewer cigarettes per day for longer duration is more dangerous than smoking more cigarettes per day for shorter duration (Lubin et al., 2016[93]). These observations strengthen the need for smoking cessation rather than smoking reduction. While tobacco smoking among adolescents has continued to decline in most EU countries in the last decade, too many adolescents still smoke. On average in EU countries, more than one‑in-six (17%) 15‑year‑olds reported smoking cigarettes at least once in the past month in 2022. This proportion reached more than one‑in-four in Bulgaria, Hungary, Italy and Croatia, whereas less than one‑in-ten reported to have smoked cigarettes in the past month in Ireland, Portugal and Malta. It has been found that tobacco smoking from age 10 to 24 years was associated with 33% to 52% odds of premature structural and functional cardiac injury, causing early and lasting damage to the heart (Agbaje, 2025[94]).

Figure 3.12. Changes in daily smoking rates among adults aged 15 and over, 2013 and 2023 (or nearest years)

Note: The EU25 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries. Tobacco consumption refers to the share of the population aged 15 and over who are daily tobacco smokers except for Luxembourg (16+). Where 2023 data was unavailable, the closest year available was used: 2024 data for: Denmark, Estonia, Ireland, Luxembourg, Iceland, Norway; 2022 data for: Finland, Australia, Türkiye; 2021 data for: Germany; 2020 data for: Spain, Ukraine; 2019 data for: Austria, Bulgaria, Croatia, Greece, Hungary, Latvia, Lithuania, Poland, Portugal, Romania, the Slovak Republic, Slovenia; 2018 data for: Belgium. Where 2013 data was unavailable, the closest year available was used: 2014 data for Austria, Bulgaria, Croatia, Estonia, France, Greece, Hungary, Latvia, Lithuania, Poland, Portugal, Romania, the Slovak Republic, Slovenia, Spain, Türkiye; and 2015 data for Ireland and Ukraine; 2011 data for Mexico.

Source: OECD (2025), Tobacco consumption (database), OECD Data Explorer, http://data-explorer.oecd.org/s/2hb (accessed 8, July 2025).

Only half of the people who currently smoke report having received advice on quitting

Tobacco use is often cited as one of the most modifiable behavioural interventions, and reducing it can substantially lower the risk of CVD and other health conditions (OECD, 2024[95]). According to OECD PaRIS survey results,3 over one‑in-ten (15%) of healthcare users aged 45 and older report currently smoking, and one‑in-ten (10%) report smoking daily (see Annex 3.D). Among people who report having a cardiovascular condition, 15% report currently smoking and 10% report smoking daily. Although primary care users are expected to be more exposed to more and promotion interventions, surprisingly, their smoking rate is only slightly lower than the 18% rate reported for adults in 2022 for the EU (see Section 3.2.1). The provision of counselling by primary healthcare providers on the risks associated with tobacco smoking and sharing information regarding cessation methods has been found to reduce tobacco use. Yet, PaRIS data show that less than a third (28%) of healthcare users 45 and older who previously or currently smoke report that a healthcare professional talked to them about the health risks of smoking or using tobacco and ways to quit; however, this figure goes up to 35% among those reporting CVD. Among healthcare users that report currently smoking, only about half (49%) report that a healthcare professional talked to them about the health risks of smoking and ways to quit – ranging from 29% in the Netherlands to 68% in Italy (Figure 3.13). Surprisingly, in Greece, where 22% of healthcare users report currently smoking, only 43% of them received advice on quitting.

I stopped smoking after my stroke, but no one asked me if I needed help to quit. It wasn’t easy, but I felt that I had no option! I have high cholesterol, the medication interferes with my muscle tension, and it has not been easy to deal with this and with the spasticity (a sequel of the stroke) ... Health professionals are more present in the acute phase, but in the chronic phase I’ve felt a little bit abandoned.

Diana, 48, stroke survivor.

Figure 3.13. Only half of the people who currently smoke report having received advice on quitting

Percentage of primary care user aged 45 and older who self-reported having received advice on the risks of smoking by smoking status

Note: The EU11 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Smoking status is based on the questions: “Do you smoke any tobacco products (excluding electronic cigarettes or similar electronic devices)?” Yes, daily and yes, occasionally compared to No. Having received advice on tobacco refers to those that currently smoke or have previously smoked daily and responded “yes” to the question: “In the past 12 months has any healthcare professional talked with you about health risks of smoking or using tobacco and ways to quit”. * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions.

Source: OECD PaRIS 2024 Database.

Second hand smoke exposure has seen notable shifts

Tobacco smoke contains many dangerous chemicals that affect air quality and for which there is no safe level of exposure. Cardiovascular problems caused by second-hand smoke in adults who do not smoke include coronary artery disease and stroke (Fischer and Kraemer, 2015[96]). Second-hand smoke can increase the risk of ischaemic heart disease and stroke by at least 8% and 5%, respectively (Flor et al., 2024[97]), this association is dose dependent and can increase up to 30% for stroke (Oono, Mackay and Pell, 2011[98]; U.S. Dept of Health and Human Services, 2014[99]). In 2019, second-hand smoke accounted for 1.30 million deaths and 37.0 million DALYs globally, with 11.2% of the burden seen among children under the age of 5 years (The Lancet, 2020[100]).

Data from the Global Youth Tobacco Survey (GYTS) from 2010 to 2018, show that in Europe out of 24 countries included, 11 had downward trend in second-hand smoke exposure, 8 had no change, and 5 had upward change such as Italy and Ukraine (Ma et al., 2021[101]). Multivariate analysis showed that nicotine concentrations from second-hand smoke are higher in countries with greater smoking prevalence and less comprehensive tobacco control policies (Henderson et al., 2021[102]).

The use of e‑cigarettes is on the rise

Electronic cigarettes – handheld electronic vaping devices which produce an aerosol by heating a liquid, usually nicotine and other potentially toxic chemicals, but not tobacco – were introduced in the market in the early 2000s and their consumption has increased globally since4 (Feeney, Rossetti and Terrien, 2022[103]) (WHO Europe, 2024[104]). Information from the Global Tobacco Surveillance System shows that current e‑cigarette used by children aged 13‑15 years old often exceeds those of older age groups (WHO, 2023[105]). Likewise, vaping product consumption remains high at the ages 15‑24 compared with the overall population (Figure 3.14). In 2024, 4% of individuals aged over 15 were regular users of vaping products across EU countries. Luxembourg, Estonia and Czechia reported the highest vaping rates (over 10%), while Bulgaria, Austria and Croatia had the lowest (less than 1%). Among young adults, the average vaping rate was 8.1% in 2024 – ages 15‑24 in most countries, and ages 16‑24 in Luxembourg – with particularly high rates in Czechia (30%), Estonia (28%) and Luxembourg (26%). Countries are increasingly documenting higher rates of e‑cigarette use than of cigarette smoking among young people. In Estonia, for example, 28% of young adults use vaping products – almost double the share of the adult population smoking tobacco in Estonia.

Figure 3.14. Regular use of vaping products, by age group, 2024 (or nearest year)

Note: The EU24 average is unweighted 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Vaping consumption refers to the share of the population aged 15 and over who are regular vaping product users. Where 2024 data was unavailable, the closet year available was used: 2018 data for Belgium; 2019 data for Austria, Bulgaria, Croatia, Germany, Greece, Hungary, Latvia, Lithuania, Portugal, Romania, the Slovak Republic and Slovenia; 2022 data for Australia and Sweden; 2023 data for Canada, Czechia, France, Italy, the Netherlands, the United Kingdom and the United States. For Finland, the percentage of all adults using vapes is based on 2022 EHIS data, while the figure for young adults comes from the 2019. For young adults in Luxembourg, the age range is 16‑24.

Source: OECD (2025), Use of vaping products (database), OECD Data Explorer, http://data-explorer.oecd.org/s/2hd (accessed 8, July 2025).

Before diagnosis, preventive advice on lifestyle was limited; after diagnosis, I received more detailed guidance about managing heart disease risk factors. Healthcare professionals encouraged me to quit smoking and adopt a healthier diet, but support for sustained behavioral change could be improved. I felt more supported in managing medications than in lifestyle counseling, which often depended on the provider and setting.

Antonis, 58, congenital heart disease patient and advocate for digital health and patient empowerment.

E‑cigarette use has been linked to significant increases in heart rate, systolic and diastolic blood pressure, and mean arterial pressure (Izquierdo-Condoy et al., 2024[106]). Nevertheless, an acute decrease in systolic blood pressure and resting heart rate was observed in tobacco users that switched to e‑cigarettes (D’Ruiz et al., 2017[107]), though this effect was not observed beyond one month (Veldheer et al., 2019[108]). Evidence suggests that long-term e‑cigarette use may impair endothelial function (Biondi‐Zoccai et al., 2019[109]), which is a precursor to CVD, but no available evidence exists on whether e‑cigarettes increase the risk of heart attacks, strokes, or cardiovascular mortality in the long term (Banks et al., 2023[110]). Furthermore, the switch from tobacco to e‑cigarettes may have the opposite effect, with studies finding improved arterial stiffness in this population (George et al., 2019[111]), but insufficient evidence on whether switching from smoking to e‑cigarettes reduces overall CVD risk (Banks et al., 2023[110]). The impact of e‑cigarette exposure on non-users is also unclear. There is conclusive evidence that vaping increases airborne particulate matter indoors, which may pose respiratory risks, though the extent of harm remains uncertain (Banks et al., 2023[110]). Nicotine is a toxic and highly addictive substance that poses serious health and safety risks, evidence shows that flavours in e‑cigarettes contribute to their attractiveness and initiation, and nicotine in e‑cigarettes can generate dependence, becoming a gateway for non-smokers who use e‑cigarettes to start smoking (SCHEER, 2021[112]) (Banks et al., 2023[110]).

Substance use also increases CVD risk

Recreational drug use, particularly cannabis, has been increasingly linked to adverse cardiovascular outcomes – especially among younger people (Sebastian et al., 2025[113]; Jouanjus et al., 2017[114]; CDC, 2024[115]). Cannabis is the most commonly used recreational drug among young adults in Europe, with approximately 12% (11.8 million) of individuals aged 15 to 34 in EU countries reporting cannabis use in the last year. The highest rates of cannabis consumption are found in Italy and Croatia, where 20% or more of people in this age group have used cannabis in the past year (Figure 3.15). It is estimated that around 1.3% of European adults – primarily males under 35 years old – are daily or almost daily cannabis users.

Cannabis can lead to arrhythmias and impact blood pressure – and recent large‑scale studies have shown that individuals under 50 who use cannabis are over six times more likely to experience a heart attack compared to non-users (Kamel et al., 2025[116]; Paulraj et al., 2025[117]; Chandy, Jimenez-Tellez and Wu, 2025[118]). Additionally, cannabis use has been associated with over 40% higher odds of stroke (Anderer, 2024[119]). Recent metanalysis found that cannabis use is associated with a two‑fold increase in the risk of death from CVD (Storck et al., 2025[120]).

Figure 3.15. Cannabis use over last 12 months among people aged 15 to 34, 2024 (or nearest year)

Source: EMCCDA (2025), https://www.euda.europa.eu/media-library/prevalence-cannabis-use-europe-2023-or-most-recent-data_en.

Note: The EU26 average is unweighted 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Where 2024 data were unavailable, the closest year available was used: 2015 data for Greece; 2017 data for Türkiye; 2018 data for Belgium; 2019 data for Croatia, Ireland, Luxembourg, Romania and Hungary; 2020 data for Austria, Latvia and Bulgaria; 2021 data for Germany and Lithuania; 2022 data for Italy, Finland, Cyprus, Sweden and Portugal; 2023 data for France, Czechia, the Netherlands, Denmark, Estonia, Slovenia, the Slovak Republic and Norway; 2024 data for Spain and Poland.

3.2.2. Harmful alcohol consumption is falling across EU countries

Harmful alcohol consumption is a major public health concern in the EU, contributing to premature mortality and disability, being a causal factor for various chronic diseases including CVD (WHO, 2024[121]). Harmful use of alcohol increases the risk for hypertensive heart disease, cardiomyopathy, atrial fibrillation, flutter and strokes. Harmful alcohol consumption (100g/ week)5 is linearly associated with a higher risk of stroke, heart failure, fatal hypertensive disease and fatal aortic aneurysm, and has a borderline elevation in the risk of coronary heart disease, as compared to those consuming between 0‑25g/ week (Wood et al., 2018[122]).

OECD modelling estimates that between 2020 and 2050, harmful alcohol consumption exceeding one drink per day for women and 1.5 drinks per day for men will lead to over 125 000 premature deaths annually in the EU. Between 2020 and 2050, the mortality impact of harmful alcohol consumption is projected to reduce average life expectancy in the EU by one year compared to what it would have been without such consumption. The economic burden of harmful alcohol consumption is also large, with estimates for EU countries for which data are available ranging between 0.4% and 1.5% of GDP, see Annex 3.C (OECD, 2021[123]).

Alcohol consumption levels vary considerably across EU countries, with significant differences in drinking patterns. Measured through sales data, overall alcohol consumption averaged 10.0 litres per adult aged 15 and over across EU countries in 2022 (Figure 3.16). The average alcohol consumption in the EU saw a modest decline of 0.3 litres (‑3%) between 2010 and 2022. Notable changes have occurred in several countries, with nine EU countries reporting a decrease of at least 10% in their average consumption per capita, having achieved the target from the European framework for action on alcohol 2022‑2025 of a relative reduction in alcohol per capita consumption of 10% by 2025 compared to 2010 (WHO, 2022[124]). In 2023, heavy episodic drinking – the share of people aged 15 and over who reported consuming ≥48 g of alcohol for women and ≥64 g for men (about 5+ drinks for women and 6+ for men) on one single occasion at least monthly in the past year – was reported higher in men (34%) than women (18%) in the EU (ESS, 2025[125]).

Figure 3.16. Overall alcohol consumption among the population aged 15 and over, 2013 and 2023

Note: The EU25 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Alcohol consumption is measured in litres per person among individuals aged 15 and over. Where 2023 data were unavailable, the closet year available was used: 2024 data for Ireland, Norway, and Mexico; 2022 data for Australia, Canada, and the United States; 2020 data for Belgium, Bulgaria, Croatia, Germany, Greece, Italy, Luxembourg, Portugal, and Ukraine. In Spain the source of information on annual wine sales varied between 2010 and 2023, which affects the time‑trend comparison, see country-specific sources at https://data-explorer.oecd.org/s/32f.

Source: OECD Health Statistics 2025.

Only 13% of healthcare users aged 45 and over report having received advice on alcohol although most report drinking alcohol

In EU countries that participated in PaRIS, most (80%) healthcare users aged 45 and over report drinking alcohol – including more than three out of four (76%) of those that report cardiovascular conditions. However, counselling on alcohol use is uncommon and falls below that of tobacco use – with only about a tenth (13%) of PaRIS respondents reporting that a healthcare professional consulted them in the past 12 months on alcohol use (Figure 3.17). This figure rises to 17% among people who report living with CVD.

Figure 3.17. Less than one‑in-five people aged 45 and older received advice on alcohol use

Percentage of primary care user aged 45 and older that self-reported having received advice on alcohol use

Note: The EU11 average is unweighted.1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Having received advice on alcohol use refers to those that have drank in the past 12 months or no longer drink alcohol and responded “yes” to the question: “In the past 12 months has any healthcare professional talked with you about alcohol use”. * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions.

Source: OECD PaRIS 2024 Database.

3.2.3. Physical activity remains below recommended levels in most of Europe

Although the benefits of maintaining an active lifestyle are well-documented, many adults and children across Europe still do not engage in enough physical activity. Physical activity can significantly reduce systolic blood pressure, one of the predominant risk factors for CVD, by a minimum of 3 mmHg depending on the frequency and duration of the physical activity (Masmoum et al., 2024[126]). Higher sedentary rates (median of 10h/day or more) are associated with higher mortality (Ekelund et al., 2020[127]). In 2022, over one‑in-four adults (28.0%) across EU countries were not sufficiently active, not meeting the WHO’s recommended activity levels of 150 minutes of moderate‑intensity or 75 minutes of vigorous-intensity physical activity per week for adults (Figure 3.18) (OECD/WHO, 2023[128]). Rates of inactivity were especially high in several Southern European countries, while Nordic countries reported comparatively lower levels. Strategies to promote physical activity are most effective when they start early in life, at school and at home, and are adapted to the context and needs of the individual.

Figure 3.18. More than one‑in-four adults in the 27 EU Member States are insufficiently active, 2022 

Prevalence of insufficient physical activity among adults aged 18+ years (crude estimate) (%)

Note: The EU27 average is unweighted.1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries Insufficient physical activity is defined as not meeting the WHO’s recommended activity levels for adults: 150 minutes of moderate‑intensity or 75 minutes of vigorous-intensity physical activity per week.

Source: WHO Global Health Observatory 2024, https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-insufficient-physical-activity-among-adults-aged-18-years-(crude-estimate)-(-); OECD/WHO (2023[128]), Step Up! Tackling the Burden of Insufficient Physical Activity in Europe, https://doi.org/10.1787/500a9601-en.

The physical limitations associated with these illnesses prevent me from engaging in regular physical activity due to the constant fear of stroke or cardiac events. I also experience chronic leg swelling and fatigue, making it impossible to sit for extended periods or work full-time in a traditional office setting... These constraints have significantly reduced my professional capacity and limited my social participation, often leading to isolation. The cumulative effect of these challenges has contributed to clinical anxiety and depression, further impacting my quality of life. Managing such a complex health profile requires ongoing medical care and personal adaptation, and has deeply affected my mental, emotional, and social wellbeing as I am always thinking about my health and worrying that I am not doing enough to help myself.

Angela, 53, mother, in menopause and living with multiple chronic conditions.

Lack of physical activity contributes to almost 130 000 new cases of CVD in Europe annually (Figure 3.19). For people between 60 and 79 years old, CVD accounts for 40% of all diseases due to insufficient physical activity, and nearly three‑quarters of the burden for people over 80 years old (OECD/WHO, 2023[128]). Analysis from the OECD finds that if everyone were to meet the WHO recommended activity levels for adults – 150 minutes of moderate‑intensity or 75 minutes of vigorous‑intensity physical activity per week – more than 10 000 premature deaths per year (among people aged 30 to 70) could be prevented; and EU member states could save, on average, 0.6% of their healthcare budget (OECD/WHO, 2023[128]).

Figure 3.19. Lack of physical activity leads to CVD directly, but also to CVD risk factors – including diabetes and depression

Number of new disease cases per year by age group due to insufficient physical activity (defined as less than the WHO recommended activity levels for adults: 150 minutes of moderate‑intensity or 75 minutes of vigorous‑intensity physical activity per week), averaged over 2022‑2050 and covering all the 27 EU Member States

Source: OECD/WHO (2023[128]), Step Up! Tackling the Burden of Insufficient Physical Activity in Europe, https://doi.org/10.1787/500a9601-en.

Less than half of healthcare users aged 45 and over report having talked with a healthcare professional about physical activity

Among OECD PaRIS survey respondents, less than half (45%) of healthcare users aged 45 and over reported engaging in moderate‑vigorous exercise for at least 30 minutes three or more times a week (≥90 min a week), and only one‑quarter (25%) reported doing physical activity for at least 30 minutes five or more times a week (≥ 150 min a week) (Annex Figure 3.D.2). Physical activity counselling in primary care has been found to be a cost-effective intervention to reduce the impact of CVD – and can demonstrate effects in as little as four weeks (Galea et al., 2025[129]). Less than half (49%) of healthcare users aged 45 and over report that a healthcare professional talked to them about their physical activity according to data from the OECD PaRIS survey (Figure 3.20). The rate is slightly higher (58%) among people reporting CVD (see Chapter 4).

I notice that when I do exercise and follow a good diet my symptoms get better. On the other side, when I spend too much time sitting down and eat too much, they get worse. When I was first diagnosed, I was told to avoid high impact sports, but I wasn’t guided very well in what I was and what I was not allowed to do.

Francesca, 34, female living with hypertrophic cardiomyopathy and an implantable cardioverter-defibrillator.

Figure 3.20. Only about half of people aged 45 and older received advice on physical activity

Percentage of primary care user aged 45 and older that self-reported having received advice on physical activity

Note: The EU11 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Having received advice on physical activity refers to those that responded “yes” to the question: “In the past 12 months, has any healthcare professional talked with you about your physical activity?”. * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** the United States sample only includes people aged 65 years or older.

Source: OECD PaRIS 2024 Database.

3.2.4. Dietary risk factors are prevalent among adults and adolescents in EU countries

Healthy dietary habits – including high intakes of vegetables, fruits, legumes, wholegrains and lean protein sources (i.e. fish and poultry) and low intakes of sugar, saturated fats and salt – promote cardiovascular health by reducing key metabolic risk factors such as diabetes, hypertension, dyslipidaemia and obesity (Diab et al., 2023[130]). A Mediterranean diet – characterised by high intakes of vegetables, fruits, wholegrains, pulses, nuts, extra-virgin olive oil and fish and low intakes of (red) meats, sweets and saturated fats – has cardioprotective benefits and is recommended by the ESC guidelines on CVD prevention and clinical practice (ESC, 2021[131]). Diets high in sodium and low in wholegrains, fruits, nuts and seeds, vegetables and omega‑3 fatty acids are the leading diet-related causes of CVD deaths (Afshin et al, 2019[132]).

Only about 60% of adults in the EU consume fresh vegetables and fruits daily

Fruit and vegetables are important components of a healthy diet, supplying important vitamins, minerals, and antioxidants. Consuming them regularly has been linked to a lower risk of chronic illnesses, including cardiovascular and metabolic diseases. A DASH (Dietary Approaches to Stop Hypertension) diet and a fruit and vegetable diet can reduce the 10‑year CVD risk by about 10% in over 8 weeks (Jeong et al., 2023[133]). Additionally, their low-calorie density, high water content, and fibre contribute to weight management by enhancing satiety and regulating overall calorie intake – reducing obesity. However, people in the EU struggle to access quality meals, including fruit and vegetables, due to financial limitations. The number of people in the EU who cannot afford a proper meal every other day has risen from 33 million in 2018 to nearly 43 million in 2023, meaning that almost one‑in-ten individuals in the EU are unable to access nutritious meals regularly (Eurostat, 2024[134]).

Box 3.3. Policy to promote healthy and sustainable eating in educational settings: An example from Spain

Spain’s Royal Decree 315/2025, issued on 15 April, sets out the regulatory framework for implementing Law 17/2011 on Food Safety and Nutrition, with a specific focus on promoting healthy and sustainable eating in schools. It applies to all types of educational institutions – both public and private – covering early childhood, primary, secondary, and vocational education. The decree establishes minimum nutritional standards for school meals, emphasising the inclusion of fresh, seasonal, and locally sourced foods while limiting processed items high in sugar, salt, and saturated fats. The decree explicitly prohibits the sale of foods with high salt content in school environments (i.e. more than 0.5 grammes of salt (0.2 grammes of sodium) per packaged portion) and provides standards for the reduction of the use of iodised salt in school cafeterias. More broadly, it integrates sustainability principles, such as reducing food and packaging waste and encouraging short supply chains, in line with Spain’s climate and circular economy goals.

Source: (Ministerio de la Presidencia, Justicia y Relaciones con las Cortes, 2025[135]).

On average, across the EU in 2022, 60% of the population consumed fresh vegetables and 61% consumed fresh fruit at least daily. Belgium and Italy led in fresh vegetable consumption, with over three‑quarters of their adult populations consuming vegetables daily. Italy and Portugal lead in fruit consumption, with over 80% of adults consuming them daily. In contrast, daily fresh vegetable consumption is below 40% in Hungary and Romania, and daily fresh fruit consumption is lowest in Bulgaria, Latvia, Lithuania and Romania (Figure 3.21).

Figure 3.21. Share of population reporting daily consumption of fruit and vegetables, 2022

Note: The EU average is weighted. Data for Germany, Iceland, the United Kingdom and North Macedonia pertain to 2017. Low data reliability for the United Kingdom.

Source: Eurostat (2024), Persons eating fruit, vegetables or salad by educational attainment level, risk of poverty threshold, most frequent activity status and sex (ilc_hch11), https://ec.europa.eu/eurostat/web/products-datasets/-/ilc_hch11 (accessed 8, July 2025).

Between 2017 and 2022, the percentage of adults in the EU who consumed fruit and vegetables at least daily dropped by 4% and 6% respectively. This decrease in 2022 may be partly linked to rising prices. During the early and final months of the year, vegetable prices in the EU surged beyond the overall increase in the food price index, potentially prompting consumers to reduce their purchases or opt for more affordable alternatives (Eurostat, 2024[136]). Socio-economic status has a significant impact on people’s eating habits. In 2022, 67% of adults with higher education levels in the EU reported regular consumption of fruits or vegetables daily, compared to 60% among those with lower education levels. OECD analysis has also shown that countries with lower overall consumption of fruit and vegetables also typically see larger differences in healthy diets across socio-economic groups (OECD/European Commission, 2024[137]).

Most EU countries report having a salt intake above the WHO recommended level

Excess salt consumption raises the risk of hypertension, which, in turn, increases the likelihood of heart attacks, strokes and heart failure. Reducing salt intake helps lower blood pressure, improving overall cardiovascular health. A study of average salt intake found that 96% of EU countries reported salt intake above WHO recommended maximum levels, and that the average salt intake in EU countries was approximately 9.2 g per day – almost double the value of salt consumption that the WHO recommends not to reach or exceed6 (Kwong et al., 2022[138]; WHO, 2025[139]). Population average daily salt intake in Czechia and Romania exceed 12 g per day, almost two and a half times the daily recommended maximum (Figure 3.22).

Studies suggests that a 25% reduction in salt intake through public health policies could prevent up to 900 000 deaths from CVD in the WHO European Region7 (WHO, 2025[140]). To achieve this, countries need better data on dietary habits and the nutritional content of processed foods, which account for over 70% of salt intake (ibid.). Effective strategies include international collaboration to share best practices for overcoming barriers such as limited will to implement regulatory salt reduction measures and using public food procurement to promote healthy food consumption.

Box 3.4. Best practices for advancing cardiovascular health: Activa Tu Salud

Description: Programa Activa Tu Salud (formerly “Activa Murcia”) is a community-based initiative in a Spanish region aimed at promoting physical activity among sedentary individuals with chronic conditions. The programme targets patients with cardiovascular risk factors such as high cholesterol and overweight/obesity, type 2 diabetes and pre‑diabetes, and mental health conditions. Launched as part of the 2010-2015 Health Plan, the programme includes the prescription of physical exercise by a primary care professional, with a duration of 6 months, in one of the community sport centres. It involves sports science experts and is conducted in co‑ordination with the Departments of Sports and Health of the municipalities. Its primary goal is to foster healthy lifestyles and improve the physical and psychological well-being of participants through structured exercise regimens. The regional government subsidises the programme, notably recently offering activities within the framework of the Youth Plan “Opportunities” 2024-2027.

Best practice assessment:

 

Enhancement options: To further enhance Activa Tu Salud expanding digital tools for virtual support could increase accessibility, especially for rural populations. Additionally, developing mechanisms to ensure and monitor whether participants continue performing physical exercise after the 6‑month period of the programme could enhance the programme’s impact.

Transferability: The programme’s structured methodology, multi-sectoral collaboration, and use of existing infrastructure make it highly transferable to other regions. Its reliance on primary care and community resources allows for adaptation in diverse healthcare systems, provided there is institutional support and trained personnel.

Conclusion: Programa Activa Tu Salud exemplifies a successful, evidence‑based approach to CVD prevention through community engagement, offering structured physical activity to high-risk populations. Its demonstrated outcomes and sustainable model offer valuable insights for replication in other settings. Continued investment and innovation will ensure its long-term success and broader impact.

Source: (Programa Activa[141]; European Commission[142]; Region de Murcia, 2025[143]).

Figure 3.22. Daily salt intake is almost double the WHO recommendation on average in EU countries

Mean population salt intake, grammes per day, among people aged 12 years or more, most-recent salt intake data for adults between 2000-2022

Note: The EU27 average is unweighted. The reference line at 5 g represents the WHO-recommended maximum daily salt intake (equivalent to 2 000 mg of sodium).1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries.

Source: Kwong et al. (2022[138]), “Population-level salt intake in the WHO European Region in 2022: a systematic review”, https://doi.org/10.1017/s136898002200218x.

About 14% of 15‑year‑olds drink sugared soft drinks daily

Excess sugar consumption can impact vascular function, contributing to unhealthy blood lipid levels and hypertension – and is also a concern as major risk factor for intermediate clinical risk factors for CVD such as diabetes, obesity, and other metabolic disorders. On average across EU countries, 14% of 15‑year‑olds reported drinking sugared soft drinks daily in 2022 (Figure 3.23). The daily consumption of sugared soft drinks among 15‑year‑olds declined by about 2 p.p. on average across EU countries between 2018 and 2022. The most notable reductions of above 5 p.p. were observed in Malta, the Slovak Republic, France and Poland. In contrast, Estonia and Bulgaria experienced some increases, with other countries maintaining relatively stable rates. Children’s dietary behaviours are increasingly shaped by a food environment saturated with ultra-processed products, where digital marketing strategies target young audiences with persuasive, often unhealthy food messaging. Addressing the commercial factors that influence health is essential to counteract these influences and promote equitable access to nutritious, culturally appropriate food (see Chapter 6 for more on policy actions being taken in this area, including fiscal policies).

Figure 3.23. Share of people aged 15 who consume sugared soft drinks each day, 2018‑2022

Note: The EU27 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries. *Data for Belgium (2018) refer to the average of the Dutch-speaking and French-speaking communities; data for Belgium (2022) refer to the Dutch-speaking community only.

Source: HBSC Data Browser, https://data-browser.hbsc.org/.

Fat consumption has decreased in four EU countries, but further efforts are needed in other countries

Trans-fats (i.e. trans-fatty acids) and saturated fats (i.e. saturated fatty acids) contribute to the build-up of plaque in arteries by increasing LDL-C, increasing risk of dyslipidaemia and therefore increasing the risk for CVD (see Section 3.1.3). Evidence shows that reducing both trans- and saturated fat intake lowers LDL-C, which reduces the risk of all-cause mortality and CVD mortality (Reynolds et al., 2022[144]; WHO, 2023[145]). It is recommended to replace saturated fats with unsaturated fats to lower the risk of ischaemic heart disease and stroke (ESC, 2021[131]). Consumption of saturated fats is recommended to remain below 10% of total daily energy intake; and 5‑6% of total energy intake for patients with hypercholesterolemia (Maki, Dicklin and Kirkpatrick, 2021[146]). Similarly, consuming 1% or less of the total energy intake as trans-fats reduces LDL-C and the risk of CVD (Reynolds et al., 2022[144]; WHO, 2023[145]).

Although most food products in the EU have less than 2 grammes of trans fat per 100 grammes of fat, there are products with high levels of trans fats (i.e. 40‑50g/100g of fats), such as biscuits, cakes and wafers. Products with high industrial fat were mainly found in Sweden, Croatia, Poland, Bulgaria and Slovenia (EU, 2019[147]). Data from 2021 show that saturated fat intake across EU (Belgium, Denmark, Ireland, Greece, France, Italy, Hungary, the Netherlands, Austria, Finland, Portugal, Sweden) and Norway, surpassed 10% of the total daily energy intake, with an average consumption in adults ranging from 11% of the total energy intake in Italy to more than 14% in France and Austria (EU, 2021[148]). Trans-fatty acid intake, however, was below 1% for Belgium, Denmark, the Netherlands and Finland (EU, 2021[149]). The goals achieved in trans-fatty acid consumption can be associated with the EC’s 2019 regulation limiting the content of trans fat, other than from animal origin, in food intended for the final consumer and to supply to retail to not exceed 2g/100g of fat (EU, 2019[150]).

Only a third of healthcare users aged 45 and over reported receiving advice on healthy eating

A healthy diet can contribute to lowering the risk of CVD, as well as reducing the burden of clinical risk factors, such as metabolic disorders (see Section 3.2.4). The ESC Prevention Guidelines recommend a healthy diet to reduce the risk of CVD, including the daily consumption of fruits and vegetables, with 2‑3 servings of each group per day (200g or more per day) (ESC, 2021[131]). Only about one‑in-five (20%) of PaRIS respondents report consuming vegetables more than once a day, and about one‑in-three (29%) report fruit consumption more than once a day (see Annex 3.D). Despite generally low levels of patients reporting having a healthy diet, only (34%) of healthcare users aged 45 and over report that a healthcare professional talked to them about healthy eating – increasing to 41% among people reporting CVD (Figure 3.24).

Figure 3.24. Only a third of people in the EU aged 45 and older received advice on healthy eating

Percentage of primary care user aged 45 and older that self-reported having received advice on healthy eating

Note: The EU11 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Having received advice on healthy eating refers to those that responded “yes” to the question: “In the past 12 months, has any healthcare professional talked with you about healthy eating?”. * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** the United States sample only includes people aged 65 years or older.

Source: OECD PaRIS 2024 Database.

3.2.5. Sleep problems are widespread in Europe, posing a significant risk for developing CVD

Sleep is increasingly recognised as a key component of cardiovascular health (Ramar et al., 2021[151]; Jaspan et al., 2024[152]). In 2022, the American Heart Association added sleep to its core metrics for promoting cardiovascular health (American Heart Association, 2022[153]). Poor sleep quality and sleep duration (both too short and too long), have been linked to higher stroke incidence (Ungvari et al., 2025[154]) and increased all-cause mortality (Quan, 2009[155]; Cappuccio et al., 2010[156]). Poor sleep quality and duration contribute to high blood pressure, inflammation, and metabolic imbalances that strain the heart and blood vessels – key pathways leading to increased CVD risk (Lao et al., 2018[157]). Poor sleep quality and duration also worsens major clinical risk factors such as obesity, diabetes, hypertension, and mental health (Kuehn, 2019[158]; Poon et al., 2024[159]).

Sleep problems are widespread in Europe. In 2022, 34% of adults aged 45 and over reported sleep problems in Europe, with rates particularly high in Portugal, Estonia, Lithuania and Germany (Figure 3.25). Women are disproportionately affected: 39% of women reported sleep problems compared to 26% of men (see Annex 3.E). While sleep problems among older adults declined on average across the EU between 2012 and 2022, they remain high in Europe. In many countries, sleep problems have increased among older adults, including the Netherlands, Sweden, Denmark, Austria, Spain, Luxembourg, Belgium, Czechia, Germany, Estonia and Portugal. Contributing factors include growing use of technology, declining mental health, precarious work (those in certain roles as well as those engage in shift work) (Matricciani et al., 2017[160]) and more recently rising temperatures due to climate change – particularly affecting older adults, people with obesity, and those living in high-humidity environments (Li et al., 2025[161]).

Figure 3.25. One‑in-three Europeans report sleep problems, with rates rising in several countries, 2012 and 2022 (or nearest years)

Note: Respondents aged 45 and older. Respondents were asked “Have you had trouble sleeping recently?”. Responses included “Trouble with sleep or recent change in pattern” and “No trouble sleeping”. 2011 data (instead of 2012 data) was used for Austria, Belgium, Czechia, Denmark, Estonia, France, Hungary, Italy, the Netherlands, Portugal, Slovenia, Spain and Sweden; and 2013 data (instead of 2012 data) was used for Luxembourg.

Source: SHARE‑ERIC (2024); Healthy Ireland Survey 2024.

People aged 45 and over with CVD and related clinical risk factors consistently report more sleep problems across all EU countries than those without (Figure 3.26). In 2022, 37% of those with CVD reported sleep problems, compared to 27% without CVD. Poor sleep can elevate nocturnal catecholamine levels and contribute to CVD (Nagai, Hoshide and Kario, 2010[162]). Studies have also shown that low physical activity further exacerbate the negative association between inadequate sleep duration and all-cause and CVD mortality risk (Huang et al., 2021[163]). Conversely, CVD can worsen sleep quality and duration. Heart failure may cause fluid buildup in the lungs, leading to breathing issues and reduced restorative sleep (Jaspan et al., 2024[152]). In addition, the psychological burden of living with CVD and fear of future cardiac events, can also impair sleep quality and contribute to chronic insomnia (Jaspan et al., 2024[152]).

Figure 3.26. People with CVD and related clinical risk factors report more sleep problems than those without in all EU countries (2022)

Note: Respondents aged 45 and older. Respondents were asked “Have you had trouble sleeping recently?”. Responses included “Trouble with sleep or recent change in pattern” and “No trouble sleeping”. CVD includes heart attack, stroke and cerebral vascular disease. Clinical risk factors include high blood pressure, hypertension, high blood cholesterol, diabetes and high blood sugar. Ireland is excluded due to data availability.

Source: SHARE‑ERIC (2024).

3.3. Environmental and occupational risk factors

3.3.1. Work-stressors pose significant risks to cardiovascular health

While workplaces can offer important sources of social connection that help protect cardiovascular health, work-related stressors – including job strain, long working hours and job insecurity – pose significant risk factors to CVD. One meta‑analysis found that individuals exposed to work stress have a 10‑40% higher risk of CVD compared to those without work stress (Kivimäki and Kawachi, 2015[164]). This is supported by further studies which have also found that work stress increases the risk of coronary heart diseases, strokes and cardiovascular mortality (Eller et al., 2009[165]; Kivimäki et al., 2006[166]; Dong et al., 2025[167]; Slopen et al., 2012[168]; Vahtera et al., 2004[169]). Plausible mechanisms include that work stress is associated with the thickening of arterial walls, increases in blood pressure, disturbances in metabolic processes, and unhealthy behaviours such as physical inactivity and smoking, all of which contribute to cardiovascular risk (Kivimäki and Kawachi, 2015[164]).

Fatigue and physical limitations [after returning to work after health setbacks] required workplace adaptations and flexible schedules, which were sometimes difficult to obtain. Supportive employers and understanding colleagues made a significant positive difference. Emotional stress related to balancing health and job demands is ongoing.

Antonis, 58, congenital heart disease patient and advocate for digital health and patient empowerment.

The share of workers reporting work-related stress, depression or anxiety is high. According to OSH Pulse 2025 survey data, 29% of workers in the EU experienced stress, depression or anxiety caused or made worse by work in the last 12 months (Figure 3.27). Country differences are pronounced, ranging from 19% of workers in Denmark to over 40% in Spain, Cyprus, Poland, Finland and Greece. While these large variations may reflect differences in working conditions and economic structures, they may also indicate cultural differences in how people perceive their health and their willingness to report it (Eurostat, 2021a[170]).

Returning to work after my cardiac events was both a necessity and a challenge. As a co-owner of multiple businesses, I had to balance my health with professional responsibilities. Support from my colleagues and a flexible work environment played a crucial role in my recovery. However, not all patients have access to such support, highlighting the need for workplace policies that accommodate individuals recovering from cardiovascular events.

Caius, artist, researcher, patient advocate, and heart attack survivor.

Figure 3.27. Almost one‑in-three Europeans report work-related stress, depression or anxiety (2025)

1. Non-EU European Economic Area countries.

Source: OSH Pulse 2025; OSH Pulse 2023.

Work-related stress, depression or anxiety has increased in most EU countries, rising from 27% in 2022 to 29% in 2025. Exceptions include Slovenia, Lithuania, Italy and Sweden, where rates decreased over this period. These trends should be interpreted with caution, as the 2022 data were collected in April-May 2022, when the effects of the COVID‑19 pandemic on working life were still significant.

According to Eurostat data, women reported higher levels of work-related stress, depression or anxiety than men (EU27 average is 1.5% among men and 2.2% among women in 2020) (Eurostat, 2023[171]). One possible explanation is the double burden of paid and unpaid work, whereby women have increased their participation in paid employment but continue to carry a disproportionate share of family and caring responsibilities, which may contribute to higher levels of work-related stress (Mensah, 2021[172]).

Fortunately, the Spanish healthcare and social security system allows me to receive my full salary while on medical leave, which has been essential—without it, I would not be able to support myself. However, the process to obtain official disability status is very slow and complex, even for patients with multiple chronic conditions. What makes it harder is that I don’t “look” sick. People often say, “You don’t look ill,” which, although well-intentioned, makes me feel even worse. It invalidates my experience and adds to the emotional burden of living with invisible illnesses—conditions that are serious, but not always visible from the outside.

Angela, 53, mother, in menopause and living with multiple chronic conditions.

Given the well-documented impact of work-related stress on cardiovascular health and the widespread country variation in work stress across Europe, mitigating work stressors and promoting health at the workplace is crucial for the primary prevention of CVD. Workplace‑based programmes – including de‑stigmatising mental health issues, integrated health and employment services, return-to work programmes for employees recovering from health illness, tailored support or dialogue initiatives for employees experiencing frequent health issues, health insurance coverage and disability pensions, as well as the promotion of healthy lifestyle behaviours such as physical exercise during working hours – can support employee health. Government policies – such as occupational safety and health regulations, working hour and break regulations, preventative care services such as employee health checks, and smoking regulation – also play a key role in promoting well-being at the workplace and cardiovascular health (OECD, 2022[173]).

3.3.2. There have been improvements on some environmental risk factors, but climate change poses an ongoing risk to cardiovascular health, particularly for lower socio-economic groups

Despite notable declines in air pollution over the last decade, it continues to be the leading environmental health risk in Europe (European Environment Agency, 2024[174]). In 2022, 96% of the EU’s urban population was exposed to levels of fine particulate matter (PM_2.5) above the latest WHO guideline levels (European Environment Agency, 2024[174]). Both short and long-term exposure to PM_2.5 are linked to increased cardiovascular risk, including myocardial infarction, stroke, heart failure, hypertension and cardiovascular mortality (Rajagopalan, Al-Kindi and Brook, 2018[175]; Franchini and Mannucci, 2012[176]; Sun, Hong and Wold, 2010[177]; Krismanuel, 2025[178]). Lower socio-economic groups are disproportionately exposed to higher pollution levels, further concentrating cardiovascular risks in lower socio-economic groups (Krismanuel, 2025[178]). Mechanisms through which air pollution increases cardiovascular risk include oxidative stress, inflammation, endothelia dysfunction and autonomic nervous system imbalance, which increase the likelihood of cardiac events (European Environment Agency, 2023[179]; Krismanuel, 2025[178]). Evidence from the COVID‑19 pandemic further suggests that PM_2.5 functions as a carrier, or transport vector, for many viruses, facilitating their inhalation into the respiratory tract (Comunian et al., 2020[180]). Higher particulate concentration may therefore drive greater infection risk and worsen respiratory and cardiovascular complications in exposed populations.

Climate change is increasing the frequency, intensity and duration of extreme temperature events, particularly heatwaves which contribute to the growing burden of CVD (Du et al., 2022[181]). In 2023, one‑in-three Europeans (34%) experienced at least one hot day (>35°C) (Figure 3.28) and two in three Europeans (67%) experienced at least one icy day (<0°C) (Annex Figure 3.G.1). While climate change is driving the rise in extreme heat, both extreme hot and cold temperatures are associated with higher cardiovascular mortality (Alahmad et al., 2023[182]; De Vita et al., 2024[183]; Weilnhammer et al., 2021[184]; Kazi et al., 2024[185]). For example, Alahmad et al. (2023) found that hot days (above 97.5th percentile) and cold days (below 2.5th percentile) accounted for 2.2 (95% empirical CI [eCI], 2.1‑2.3) and 9.1 (95% eCI, 8.9‑9.2) excess deaths for every 1 000 cardiovascular deaths, respectively. Heat exposure can lead to vasodilation, increasing heart rate and cardiac output, thereby increasing the risk of heart attack and stroke (De Vita et al., 2024[183]). In contrast, cold exposure can trigger vasoconstriction and activate the renin-angiotensin system, raising blood pressure and myocardial oxygen demand, thereby also increasing the risk of heart attacks and stroke (De Vita et al., 2024[183]). The impact of extreme temperatures on cardiovascular health is particularly pronounced among lower socio-economic groups, who are more likely to live in poor-quality housing, have limited access to cooling or heating (such as fans, air conditioning and radiators), and live in neighbourhoods with urban heat islands and fewer cool public spaces (Gronlund, 2014[186]).

Figure 3.28. Nearly one‑in-three people in the EU were exposed to at least one hot day (>35°C) in 2023

Note: This indicator presents the annual percentage of population exposed to n number of hot days (above 35°C). This temperature threshold for hot days (above 35 °C) follows the IPCC AR6 definition of “hot summer days” and corresponds to levels linked with severe health impacts (Maes et al., 2022[187]). Countries with zero values experienced no days exceeding 35 °C in 2023. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries.

Source: OECD (2025), Exposure to extreme temperature (database), OECD Data Explorer, http://data-explorer.oecd.org/s/2f7 (accessed 8, July 2025).

Noise pollution – including road, rail and air traffic, construction public work, neighbourhood, police and emergency sirens – is an important environmental risk factor as urban populations grow (Murphy and King, 2022[188]). According to the WHO, traffic noise accounts for at least 1.6 million healthy life years lost in Western Europe alone (WHO, 2018[189]). Exposure to environmental noise increases the risk of cardiovascular morbidity and mortality (Münzel, Sørensen and Daiber, 2021[190]), with exposure typically being higher in areas of greater socio-economic deprivation (Havard et al., 2011[191]; Bocquier et al., 2012[192]; Dale et al., 2015[193]). Pathways through which noise pollution affect cardiovascular health include sleep duration and quality disturbances, elevated stress hormone levels, and increased oxidative stress in the vasculature and brain – all of which can contribute to vascular dysfunction, inflammation, and hypertension, thereby increasing the risk of CVD (Münzel, Sørensen and Daiber, 2021[190]).

Despite improvements on some environmental risk factors, air pollution, extreme temperatures and noise pollution continue to pose significant risks to cardiovascular health, particularly among lower socio-economic groups. Addressing these risks through, for example, cleaner transport and energy systems, urban planning to reduce heat islands, and improved housing quality can help protect cardiovascular health while also promoting environmental sustainability.

3.4. Non-modifiable risk factors can still be mitigated

3.4.1. Europe’s ageing population puts people at risk

Older adults are especially vulnerable to CVD. As individuals age, the cardiovascular system undergoes structural and functional changes that increase the likelihood of CVD (Jensen, 2024[194]). These include increased arterial stiffness, reduced elasticity, and reduced capacity of the heart to pump blood efficiently. At the same time, exposure to age‑related risk factors, such as diabetes, obesity, hypertension and hyperlipidaemia, reduced physical activity, cognitive decline and depression, further contribute to the growing burden of CVD in older adults.

The share of older adults is growing, contributing to the rising burden of CVD. In the EU, between 2000 and 2024, the share of adults aged 65 and over grew from 18% to 22% of the population and is projected to reach 29% by 2050 (Figure 3.29). While all EU countries are ageing, the pace and extent differ. In 2024, Italy, Portugal and Bulgaria had the highest shares of older adults (24%), while Ireland and Luxembourg had the lowest (15%). By 2050, the highest shares of older adults are expected in Greece, Italy, Portugal, Spain, Lithuania, Bulgaria, Croatia, Latvia and Slovenia (over 30%), while the lowest shares are projected in Luxembourg, Malta, Sweden and Iceland (below 23%) (Figure 3.29). This demographic shift is expected to increase the burden of CVD, with estimates suggesting a 90% rise in CVD prevalence in Europe between 2025 and 2050 (Chong et al., 2024[195]).

Figure 3.29. Nearly three in ten people in the EU will be over age 65 in 2050, up from two in ten in 2024

Note: EU27 average is weighted. 1. non-EU European Economic Area countries.

Source: Eurostat (2023), Population on 1 January by age, sex and type of projection (proj_23np), https://ec.europa.eu/eurostat/web/products-datasets/product?code=proj_23np (accessed 8, July 2025); Eurostat (2025), Population on 1 January by age group and sex (demo_pjangroup), https://ec.europa.eu/eurostat/en/web/products-datasets/-/DEMO_PJANGROUP (accessed 8, July 2025).Source: Eurostat (2023), Population on 1 January by age, sex and type of projection (proj_23np), https://ec.europa.eu/eurostat/web/products-datasets/product?code=proj_23np (accessed 8, July 2025); Eurostat (2025), Population on 1 January by age group and sex (demo_pjangroup), https://ec.europa.eu/eurostat/en/web/products-datasets/-/DEMO_PJANGROUP (accessed 8, July 2025).

While middle‑aged and older adults are more likely to experience cardiovascular events, the incidence of CVD is increasing among younger age groups (15‑39 years) (Sun et al., 2023[196]). A key contributor is the high and rising rate of childhood obesity: in 2022, the average prevalence of obesity among children in EU countries was 8.8% (WHO Global Health Observatory, 2025[39]). Increased exposure to other CVD risk factors in younger people – such as diabetes, hypertension, poor diet and physical inactivity – also contribute to the growing burden in CVD in young people, especially heart failure (Andersson and Vasan, 2017[197]). These developments underscore the need for primary prevention strategies that address cardiovascular risk factors throughout the life course.

3.4.2. Sex plays a significant role as a risk factor due to biological, hormonal, and lifestyle differences between men and women

As seen in Chapter 2, men have higher age‑standardised mortality rates (ASMRs) from circulatory diseases than women – 412 per 100 000 population for men versus 289 for women. This pattern holds across most cardiovascular conditions, though the size of the sex gap varies. For instance, the difference is most pronounced in ischaemic heart disease (155 for men versus 83 for women per 100 000), while it is narrower for cerebrovascular disease (80 for men versus 64 for women per 100 000).

However, these averages mask important gender and sex-specific differences in cardiovascular risk across the life course. Currently, men are more likely to engage in unhealthy behaviours – such as smoking, harmful alcohol consumption, and poor diet – and have higher rates of obesity, all of which contribute to CVD risk. In addition, low testosterone levels represent a sex-specific cardiovascular risk in men (Hanna, Wabnitz and Grewal, 2024[198]). Conversely, women generally have lower activity levels than men, are at higher risk of inflammatory diseases such as rheumatoid arthritis and systemic lupus erythematosus, and are exposed to a range of sex-specific risks across the life course – including early and late menarche, polycystic ovary syndrome (PCOS), infertility, assisted reproductive technology, adverse pregnancy outcomes, hormonal contraceptives and transitions to menopause – all of which increase their CVD risk (Figure 3.30) (O’Kelly et al., 2022[199]; Vogel et al., 2021[200]).

Figure 3.30. Cardiovascular risk factors for women across the life course

Source: Adapted from O’Kelly et al. (2022[199]), “Pregnancy and Reproductive Risk Factors for Cardiovascular Disease in Women”, https://doi.org/10.1161/circresaha.121.319895.

Several early-life and reproductive health conditions are linked to increased cardiovascular risk. Studies suggest that the relationship between the age of the first menstrual period and future CVD is U-shaped, where both early menarche (before age 12) and late menarche (after age 17) are associated with increased CVD risk (Canoy et al., 2015[201]). Genetic predisposition and elevated childhood BMI have been associated with the timing of menarche – key underlying risk factors for developing CVD (O’Kelly et al., 2022[199]). Furthermore, polycystic ovary syndrome (PCOS), which affects 5% to 13% of women, is associated with an increased risk of developing CVD and its associated risk factors, such as BMI, dyslipidaemia, hypertension, insulin resistance and deficiencies in insulin secretion (O’Kelly et al., 2022[199]; Okoth et al., 2020[202]). At the same time, infertility – particularly among women whose infertility was attributed to ovulatory disorders or endometriosis – has also been associated with increased CVD risk (Farland et al., 2023[203]).

Adverse pregnancy outcomes – such as hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm births, placental abruption, low birth weight and small for gestational age – are associated with increased risk of CVD and mortality (Parikh et al., 2021[204]; O’Kelly et al., 2022[199]; Okoth et al., 2020[202]). For example, studies have found a two-fold risk of CVD among women with a history of gestational hypertension or preeclampsia (O’Kelly et al., 2022[199]). Assisted reproductive technologies (ART) have also been linked with elevated CVD risk. For example, one meta‑analysis found that in vitro fertilisation (IVF) and intracytoplasmic sperm fertilisation (ICSI) pregnancies are at higher odds of hypertensive disorders of pregnancy than spontaneous conception (SC) (OR 1.70; 95% CI 1.60‑1.80; I² = 80%)  (Chih et al., 2021[205]).

Hormonal contraceptives – including oestrogen-progestin and progestin-only contraceptives – are associated with an increased risk of cardiovascular events, including ischaemic stroke and myocardial infarction (Yonis et al., 2025[206]). Studies have shown that the presence of oestrogen and progesterone receptors throughout the vascular system increases the risk of thrombosis and hypertension, key risk factors for developing CVD (Trinh et al., 2023[207]). Furthermore, studies show that CVD risk is mediated by type and dose of hormonal components, where lower oestrogen doses and certain progestogens appear to carry lower CVD risks (Asubiaro, 2024[208]). Therefore, it is recommended that healthcare providers consider the type and dose of hormonal components, as well as women’s age, personal and family medical history, and lifestyle factors when prescribing hormonal contraceptives (Shufelt and Bairey Merz, 2009[209]; Asubiaro, 2024[208]).

The transition to menopause is a key risk factor for CVD in women. While the burden of CVD is higher in men in earlier life, women experience similar or greater self-reported rates from midlife onwards (Figure 3.31).8 Figure 3.31 shows men report higher rates of CVD events before the age of 54 than women. However, from age 55 onwards, the gender gap in CVD narrows and even reverses, with women reporting similar or even higher rates of CVD events than men. This pattern aligns with previous research finding that women typically experience CVD 7‑10 years later than men. The increase in incidence among women after midlife is attributed largely to the loss of the cardioprotective effects of the endogenous female sex hormone oestrogen following menopause, as well as the cumulative impact of psychosocial stressors such as caregiving responsibilities during this life stage (Williams et al., 2024[210]). Hormone replacement therapy (HRT) is used to recover the loss of endogenous oestrogen and has been suggested to improve cardiovascular health, although studies have reported conflicting results (Johansson et al., 2022[211]).

Box 3.5. Best Practices for Advancing Cardiovascular Health: Heart Health 4 Moms (HH4M): case study overview

Description: Heart Health 4 Moms (HH4M) is an online intervention aimed at reducing cardiovascular risk in women who experienced preeclampsia, a pregnancy complication associated with increased cardiovascular risk after pregnancy. The programme targeted US women with a medically confirmed diagnosis of preeclampsia within the five past years. The intervention was co-designed with preeclampsia survivors. It provided online educational modules, personalised lifestyle coaching from a registered dietician, a community forum to enable women to communicate with each other and the lifestyle coach, and a “toolbox” of additional resources such as meal plans, recipes, and exercise videos.

Best practice assessment:

 

Enhancement options: To enhance effectiveness, the programme could be expanded to engage a more diverse population, particularly women from ethnic minority groups and lower socio-economic backgrounds. Engagement with HH4M could be strengthened by developing a mobile application for easier access and by integrating HH4M within clinical care systems to support sustained participation. Evaluating the long-term outcomes beyond the 9‑month trial period and conducting cost-effectiveness analyses would further strengthen the evidence base for this programme.

Transferability: Similar postpartum literacy and lifestyle interventions for women who experienced preeclampsia have been tested through randomised trials in the United Sates and Australia, demonstrating transferability across health systems. In Europe, interventions are also in development; France is currently developing a trial to improve the health literacy of women about their increased cardiovascular risk after hypertensive disorders of pregnancy, with a particular focus on socio-economically disadvantaged women. As these interventions require few resources, they could be implemented in further maternity clinics in and become standard practice in other EU and OECD countries.

Conclusion: The HH4M web-based intervention improved the knowledge of CVD risk after preeclampsia, increased self-efficacy for healthy eating, and reduced physical inactivity. The programme placed a strong emphasis on building self-efficacy – an important strategy for effectively managing a wide spectrum of chronic diseases. Its patient-centred approach, developed in collaboration with preeclampsia survivors, ensured that the intervention was tailored to participants’ needs. By combining online education, peer support and personalised counselling, HH4M lowers access barriers and offers a scalable model for secondary prevention in a high-risk population.

Source: Rich-Edwards et al. (2019[212]), “Randomized Trial to Reduce Cardiovascular Risk in Women with Recent Preeclampsia”, https://doi.org/10.1089/jwh.2018.7523.

Figure 3.31. The gender gap in CVD narrows and even reverses after age 55

Note: Respondents aged 45 and older. CVD includes heart attack, stroke and cerebral vascular disease.

Source: SHARE‑ERIC (2024).

As a woman in menopause living with multiple chronic illnesses, I face a large gap in both medical understanding and clinical data relevant to my profile. There is little to no guidance for managing menopause in patients with complex cardiovascular, autoimmune, and metabolic conditions. Despite clear evidence that hormone replacement therapy (HRT) could potentially improve my quality of life, it remains a taboo subject. No healthcare provider has proactively discussed it with me, and when I bring it up, I’m met with vague responses like “better not,” often based on assumptions rather than evidence. This reflects a broader issue: the intersection of chronic disease, menopause, and gender remains understudied and under-addressed.

The fact that I am educated and financially stable has allowed me to research options independently and pursue private or alternative care. However, this is a privilege not shared by many others in similar situations. Without health literacy or financial means, many women are left without access to appropriate support or treatment, further deepening inequalities in healthcare.

Angela, 53, mother, in menopause and living with multiple chronic conditions.

Lifestyle factors are not evenly distributed by gender. While women generally report lower levels of harmful alcohol consumption compared to men, the cardiovascular consequences of excessive drinking are more severe for women. One study found that women who exceeded the recommended weekly alcohol limit had a 43% higher risk of coronary heart disease (CHD) compared to those who drank less (adjusted hazard ratio (aHR), 1.4; 95% CI, 1.2‑1.7), whereas for men, the increased risk was 19% (aHR, 1.2; 95% CI, 1.0‑1.4) (Rai, 2025[213]).

Adverse Drug Reactions (ADR) can also contribute to the differences in mortality due to poor adherence to drug treatments, yet evidence reporting sex differences is limited. A systematic review showed how only four out of eleven studies reported sex-differences in ADR for heart failure, showing in three studies higher risk of ADR in women due to angiotensin-enzyme inhibitor, one with higher mortality due to digoxin in women, and one study with higher risk of ADR in men due to mineralocorticoid receptor antagonist (Bots et al., 2019[214]).

3.4.3. Genetics and family history require a targeted approach

Family history of premature CVD is a risk factor for CVD, and is associated with both genetic factors (i.e. CAD polygenic risk score and heterozygous familial hypercholesterolemia) and clinical factors (e.g. morbid obesity, hypertension, dyslipidaemia). Around 25% of family history of heart disease is explained by genetic factors alone, and 34% by the combined impact of genetic and clinical factors (Jowell et al., 2022[215]; ESC, 2021[131]). Heterozygous familial hypercholesterolemia (FH) is a significant risk factor for CVD that can be targeted for prevention and management. Among the factors that increase the risk of CVD in patients with heterozygous familiar hypercholesterolemia are: age, male sex, hypertension, diabetes, high body mass index, smoking, elevated lipoprotein a, low high-density lipoprotein cholesterol, and family history of CVD; with smoking, hypertension, and diabetes accounting for more than a quarter of the risk of CVD in people with FH (Akioyamen et al., 2019[216]). Family history of coronary heart disease in first degree relatives, after adjusting for other risk factors, has a hazard ratio9 of 1.72 (95% CI: 1.69 – 1.75) in men, and 1.58 (95% CI: 1.54 – 1.61) in women (Hippisley-Cox, Coupland and Brindle, 2017[217]).

Ethnicity, likewise, has genetic and environmental factors associated with the risk of CVD. The impact of ethnicity on CVD risk can vary by region. For instance, in the United Kingdom, immigrants from South Asia have a markedly higher CVD risk, with QRISK3 algorithm applying a 1.3‑fold multiplier for individuals of Indian and Bangladeshi origin, and a 1.7‑multiplier for those of Pakistani origin when estimating 10‑year CVD risk (Cainzos-Achirica et al., 2019[218]). In addition to genetic factors, the risk factor profiles – such as prevalence of physical inactivity – can vary across ethnic and racial groups, further impacting CVD risk (Cruz-Flores et al., 2011[219]; Patel et al., 2022[220]). See Chapter 2 for additional discussion of CVD related disparities related to race and ethnicity.

Genetic factors contribute to the development of CVD and advances have been made on polygenic risk scores for risk prediction and risk stratification (Samani et al., 2024[221]). Adding polygenic risk scores modestly improves prediction of CVD risk, meaning it could help prevent one additional CVD event for every 5 750 individual screened, yet more evidence and economic assessment is needed to assess its clinical utility and cost-effectiveness (Sun et al., 2021[222]). A targeted, personalised approach – now increasingly powered by AI – can analyse complex genetic data to guide early interventions and optimise treatment strategies for CVD (see Chapter 5).

3.5. Clinical practice guidelines for CVD prevention exist, but recommendations are not entirely followed

3.5.1. Clinical practice guidelines exist, but management of risk factors is lacking

Clinical practice guidelines help healthcare professionals to standardise the diagnostic, management and follow-up process of patients based on the highest level of evidence available for a specific chronic condition (e.g. diabetes, hypertension, among others). Commonly known evidence‑based clinical practice guidelines have been developed by organisations such as the European Society of Cardiology (ESC), the European Stroke Organisation (ESO) and the American Heart Association (AHA). These guidelines are commonly implemented by countries with adaptation to their national context. According to the OECD Policy and Data Questionnaire for the OECD Report on the State of Cardiovascular Health – answered by 17 countries – most countries (15) use ESC guidelines to influence their national clinical practice guidelines on CVD, followed by ESO guidelines (10) and the AHA guidelines (10). 11 out of 17 countries report adapting these clinical practice guidelines to their national context based on affordability and coverage regulations, new clinical evidence and patient or provider preferences.

Most OECD countries (15 out of 17) reported having a clinical practice guideline for the management of diabetes, followed by hypertension (12 out of 17), and high cholesterol in only 11 out of the 17 countries (Figure 3.32).

Figure 3.32. Countries with clinical practice guidelines for the management of CVD risk factors

Note: N=18 EU+2 and OECD G20 countries (Austria, Canada, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).

Source: OECD Policy and Data Questionnaire for the OECD Report on the State of Cardiovascular Health, 2025.

Clinical practice guidelines, such as the ESC guidelines on CVD prevention in clinical practice, call for clinicians to encourage lifestyle changes and support adherence to drug therapy, but these guideline recommendations face challenges (ESC, 2021[131]). As seen in Section 3.2.1, just over a quarter (28%) of primary care users aged 45 years and older report that a health professional talked to them about the risks of tobacco use, and from those that currently smoke only half (49%) report that a healthcare professional has talked to them about the risks of tobacco and quitting. A Cochrane systematic review has shown that simple advice on quitting significantly increases quitting rates (Relative Risk: 1.66, Confidence Interval: 1.42 to 1.94) (Stead et al., 2013[223]). Related to alcohol use, only 13% of healthcare users report that a healthcare professional has talked to them about their alcohol use. Regarding healthy eating, only a third report that they have received advice on healthy eating. Given the importance of managing risk factors to prevent and manage CVD, prevention and promotion strategies in primary care need to be strengthened.

Before my diagnosis, I was largely unaware of the risk factors contributing to my condition. Post-diagnosis, I received excellent medical care, but the guidance on lifestyle changes was limited. It was through my own research and determination that I adopted a healthier lifestyle, including regular exercise and dietary changes. I believe primary care providers need to play a more proactive role in educating patients about prevention and supporting them in addressing modifiable risk factors.

Caius, artist, researcher, patient advocate, and heart attack survivor.

Considering that about a third (31%) of people with CVD and related clinical risk factors in Europe reported at least four depressive symptoms on the EURO-D scale in 2022, it is important to adequately manage mental health conditions as a management strategy to reduce CVD risk. Depression and anxiety can increase the risk of CVD as well as increase the challenges of adequately managing behavioural risk factors (Section 3.1.6). Among PaRIS respondents, having a mental health condition, such as anxiety or depression, is associated with worse perceived well-being, underscoring the need for stronger support within primary care. Figure 3.33 shows a 20 point higher reported well-being among people aged 45 and older with CVD or hypertension compared to those with CVD or hypertension that also report a mental health condition. There is a need for a targeted approach for people with CVD and mental health conditions, to provide better support to improve well-being and thus improve adherence to lifestyle changes and drug treatments.

Figure 3.33. People with CVD or hypertension and mental health conditions have 20‑points lower well-being than those with only CVD or hypertension

Average well-being score of primary care user aged 45 and older

Note: The EU11 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. WHO‑5 well-being index with a range of 0‑100. A cutoff of 50, below which suggests poor mental well-being. All within country differences are statistically significant (p<0.05). * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. HTA: Hypertension.

Source: OECD PaRIS 2024 Database.

3.5.2. Early detection through primary care and screening programmes improves outcomes

The ESC recommends a CVD risk assessment to be systematically done in individuals with vascular risk factors (i.e. family history of premature CVD, familial hypercholesterolemia, CVD risk factors such as smoking, arterial hypertension, diabetes mellitus, raised lipid level, obesity, or comorbidities increasing CVD risk). Women younger than 50 years of age and men younger than 40 years of age with no vascular risk factors have low risk of cardiovascular events, therefore a systematic CVD risk assessment in these groups is not recommended. Conversely, women over 75 years of age and men over 65 years of age usually have a high 10‑year CVD risk. Given that the risk varies between these age groups a systematic or opportunistic CVD risk assessment in men 40 years and older and women 50 years and older may be considered and can be repeated every five years if there is low risk of CVD (ESC, 2021[131]). Risk assessment can be done using the Systematic Coronary Risk Estimation 2 (SCORE2) which consider the age, sex, smoking status, systolic blood pressure, non-HDL cholesterol, and the population group to estimate the 10‑year risk of fatal and non-fatal CV events.

Systolic blood pressure measurement is one of the first steps for CVD risk assessment. Although a blood pressure measurement can be considered a readily accessible screening tool, on average 94% of people aged 45 to 54 (age range where systematic CVD screening is recommended) report having had a blood pressure measurement by a health professional within the five years before the survey (Figure 3.34), this goes down to 68% reporting having had the blood pressure measurement within the year preceding the survey (Figure 3.35). ESC guidelines for elevated blood pressure recommend a blood pressure measurement in adults aged 40 and over at least annually (ESC, 2024[15]). This means that about 30% of people aged 45 to 54 in the EU did not have their blood pressure measured within the year preceding the survey or have never had their blood pressure measured. Although screening for CVD in men is recommended to begin at age 40 and for women at age 50, among those aged 45 to 54, men report lower rates (65%) than women (70%) of having had their blood pressure measured within the year preceding the survey. Given that the age‑standardised prevalence of hypertension in the EU ranges from 30‑45%, and hypertension is one of the main risk factors for CVD, scaling up screening for hypertension for timely diagnosis and management is key (Section 3.1.2). Further discussion of risk assessment policies can be found in Chapter 6.

Figure 3.34. Blood pressure measurement in the EU is lacking most among those aged 45 to 54

Percentage of population reporting having had their blood pressure measured by a health professional, 2019

Note: EU27 is the weighted average.

Source: Eurostat (2022), Self-reported screening of CVD and diabetes risks by sex, age and educational attainment level (hlth_ehis_pa2e), https://ec.europa.eu/eurostat/web/products-datasets/product?code=hlth_ehis_pa2e (accessed 17 October 2025).

Figure 3.35. Around two thirds of adults aged 45 to 54 reported having had their blood pressure measured within a year

Percentage of population aged 45 to 54 reporting having had their blood pressure measured by a health professional within the year preceding the survey, 2019

Note: EU27 is the weighted average. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries.

Source: Eurostat (2022), Self-reported screening of CVD and diabetes risks by sex, age and educational attainment level (hlth_ehis_pa2e), https://ec.europa.eu/eurostat/web/products-datasets/product?code=hlth_ehis_pa2e (accessed 17 October 2025).

A measurement of the blood cholesterol and blood glucose is essential to assess the risk of CVD. While more than 90% of men and women over the age of 55 report having had a blood glucose and cholesterol measurement in the five years preceding the survey, rates are lower among those aged 45‑54 (Figure 3.36). Among those aged 45‑54, men report lower rates than women for both blood cholesterol measurement (87% vs. 89%) and blood sugar measurement (86% vs. 88%) in the past five years. Improving blood cholesterol and blood glucose measurements to assess CVD risk, especially in men aged 40 and over, remains a priority.

Figure 3.36. Screening for blood cholesterol and blood sugar in the EU is lacking most among those aged 45 to 54

Percentage of population, by age group, reporting having had a blood cholesterol or blood sugar measured by a health professional in less than 5 years from the time of the survey, 2019

Note: EU27 is the weighted average.

Source: Eurostat (2022), Self-reported screening of CVD and diabetes risks by sex, age and educational attainment level (hlth_ehis_pa2e), https://ec.europa.eu/eurostat/web/products-datasets/product?code=hlth_ehis_pa2e (accessed 17 October 2025).

High cholesterol levels, more specifically LDL-C, play an important role in the development of CVD. Lowering LDL-C reduces the risk of CVD, therefore it is important to detect the level of cholesterol to be able assess the risk of CVD and initiate timely treatment (Section 3.1.2). In the EU most adults aged 45‑54 (88%) report having had their blood cholesterol measured in the past five years (Figure 3.37), this aligns with current guidelines which consider 5‑year intervals for cholesterol measurement if levels are normal and there are no other CVD risk factors (ESC, 2021[131]). This is consistent with most EU countries where 80% or more of adults aged 45‑54 report having had their blood cholesterol measured in the previous five years, only Denmark (66%), the Netherlands (63%) and Sweden (61%) report values lower than 80%, this is also seen in Norway (79%), Iceland (71%) and Türkiye (76%).

As seen in Section 3.1.1, diabetes increases the incidence of CVD by 2.6 in women and 1.8 in men compared to those without diabetes. This is why within the CVD risk assessment it is important to measure blood glucose levels. There is a direct relationship between blood glucose level and the risk for CVD (3.1.1). In the EU, most adults aged 45‑54 (87%) report having had their blood glucose level measure in the previous five years (Figure 3.38); this ranges from below 70% in the Netherlands, Sweden and Denmark to over 95% in Greece, Czechia and Cyprus.

Figure 3.37. Most adults aged 45 to 54 reported having had their blood cholesterol level measured

Percentage of population aged 45 to 54 reporting having had their blood cholesterol measured by a health professional within 5 years preceding the survey, 2019

Note: EU27 is the weighted average. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries.

Source: Eurostat (2022), Self-reported screening of CVD and diabetes risks by sex, age and educational attainment level (hlth_ehis_pa2e), https://ec.europa.eu/eurostat/web/products-datasets/product?code=hlth_ehis_pa2e (accessed 17 October 2025).

Figure 3.38. Most adults aged 45 to 54 reported having had their blood sugar level measured

Percentage of population aged 45 to 54 reporting having had a blood sugar level measured by a health professional less than 5 years from the time of the survey, 2019

Note: EU27 is the weighted average. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries.

Source: Eurostat (2022), Self-reported screening of CVD and diabetes risks by sex, age and educational attainment level (hlth_ehis_pa2e), https://ec.europa.eu/eurostat/web/products-datasets/product?code=hlth_ehis_pa2e (accessed 17 October 2025).

Screening for metabolic risk factors is key to control underlying conditions such as hypertension, diabetes and dyslipidaemia, which if not control can lead to a CVD event with greater complications to the patients. Screening through CVD risk assessment also helps primary care identify higher risk patients to provide support on self-management and information on signs of alarm to identify a CVD event.

Despite the accessibility of blood pressure screening, more than 30% of adults aged 45‑54 in the EU have not had a measurement in the last year, and about 6% have not had a measurement in the past five years, despite hypertension being a major CVD risk factor. Cholesterol and blood glucose screening is also lacking, with over 10% of adults aged 45‑54 in the EU not having had a test in the past five years. These screenings are essential for identifying and managing metabolic risk factors – hypertension, diabetes, and dyslipidaemia – thereby enabling timely interventions and supporting self-management in primary care settings. However, screening alone is not sufficient – timely follow-up care, including diagnosis, treatment, and patient support, is essential to translate early detection into improved outcomes. Effective management of metabolic risk factors and patient engagement in self-care are critical components of a comprehensive CVD prevention strategy. These concepts are further discussed in Chapter 4.

3.6. Conclusion

This chapter outlines the risk factors associated with CVD, many of which are amenable to policy action, see Chapter 6 for a description of prevention and promotion policies addressing CVD. Although many of these indicators on protective and risk factors can be further broken by sex, education level, income status, the scope of this chapter focusses on the general view of risk factors. See Chapter 2 for an analysis of the burden of CVD by disaggregated by socio-economic characteristics.

References

[8] Aboyans, V. and F. Cosentino (eds.) (2019), “Diabetes as a cardiovascular risk factor: An overview of global trends of macro and micro vascular complications”, European Journal of Preventive Cardiology, Vol. 26/2_suppl, pp. 25-32, https://doi.org/10.1177/2047487319878371.

[132] Afshin et al (2019), “Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017”, The Lancet, Vol. 393/10184, pp. 1958 - 1972.

[94] Agbaje, A. (2025), “Incidental and Progressive Tobacco Smoking in Childhood and Subsequent Risk of Premature Cardiac Damage”, Journal of the American College of Cardiology, Vol. 85/5, pp. 546-549, https://doi.org/10.1016/j.jacc.2024.09.1229.

[216] Akioyamen, L. et al. (2019), “Risk factors for cardiovascular disease in heterozygous familial hypercholesterolemia: A systematic review and meta-analysis”, Journal of Clinical Lipidology, Vol. 13/1, pp. 15-30, https://doi.org/10.1016/j.jacl.2018.10.012.

[182] Alahmad, B. et al. (2023), “Associations Between Extreme Temperatures and Cardiovascular Cause-Specific Mortality: Results From 27 Countries”, Circulation, Vol. 147/1, pp. 35-46, https://doi.org/10.1161/circulationaha.122.061832.

[153] American Heart Association (2022), “Life’s Essential 8: Updating and Enhancing the American Heart Association’s Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association”, Circulation, Vol. 146/5, https://doi.org/10.1161/cir.0000000000001078.

[35] American Heart Association (2021), “Obesity and Cardiovascular Disease”, PMC, Vol. 143/21, https://doi.org/10.1161/cir.0000000000000973.

[70] Ananth, P. et al. (2024), “H1N1-associated Cardiomyopathy: A Case Series”, Journal of Association of Pulmonologist of Tamil Nadu, Vol. 7/1, pp. 24-26, https://doi.org/10.4103/japt.japt_40_23.

[119] Anderer, S. (2024), “Cannabis Use Linked to Elevated Myocardial Infarction and Stroke Risk”, JAMA, Vol. 331/14, p. 1172, https://doi.org/10.1001/jama.2024.2075.

[197] Andersson, C. and R. Vasan (2017), “Epidemiology of cardiovascular disease in young individuals”, Nature Reviews Cardiology, Vol. 15/4, pp. 230-240, https://doi.org/10.1038/nrcardio.2017.154.

[208] Asubiaro, J. (2024), “The Impact of Hormonal Contraceptives on the Incidence and Progression of Cardiovascular Diseases in Women: A Systematic Review”, Cureus, https://doi.org/10.7759/cureus.65366.

[44] Badve, S. et al. (2025), “Effects of GLP-1 receptor agonists on kidney and cardiovascular disease outcomes: a meta-analysis of randomised controlled trials”, The Lancet Diabetes & Endocrinology, Vol. 13/1, pp. 15-28, https://doi.org/10.1016/s2213-8587(24)00271-7.

[110] Banks, E. et al. (2023), “Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence”, Medical Journal of Australia, Vol. 218/6, pp. 267-275, https://doi.org/10.5694/mja2.51890.

[76] Bansal, M. (2020), “Cardiovascular disease and COVID-19”, Diabetes & Metabolic Syndrome: Clinical Research & Reviews, Vol. 14/3, pp. 247-250, https://doi.org/10.1016/j.dsx.2020.03.013.

[168] Behrens, T. (ed.) (2012), “Job Strain, Job Insecurity, and Incident Cardiovascular Disease in the Women’s Health Study: Results from a 10-Year Prospective Study”, PLoS ONE, Vol. 7/7, p. e40512, https://doi.org/10.1371/journal.pone.0040512.

[80] Behrouzi, B. et al. (2022), “Association of Influenza Vaccination With Cardiovascular Risk”, JAMA Network Open, Vol. 5/4, p. e228873, https://doi.org/10.1001/jamanetworkopen.2022.8873.

[109] Biondi‐Zoccai, G. et al. (2019), “Acute Effects of Heat‐Not‐Burn, Electronic Vaping, and Traditional Tobacco Combustion Cigarettes: The Sapienza University of Rome‐Vascular Assessment of Proatherosclerotic Effects of Smoking (SUR‐VAPES) 2 Randomized Trial”, Journal of the American Heart Association, Vol. 8/6, https://doi.org/10.1161/jaha.118.010455.

[26] Blood Pressure UK (n.d.), Know Your Numbers!, https://www.bloodpressureuk.org/know-your-numbers/ (accessed on 16 July 2025).

[192] Bocquier, A. et al. (2012), “Small-area analysis of social inequalities in residential exposure to road traffic noise in Marseilles, France”, European Journal of Public Health, Vol. 23/4, pp. 540-546, https://doi.org/10.1093/eurpub/cks059.

[214] Bots, S. et al. (2019), “Adverse Drug Reactions to Guideline-Recommended Heart Failure Drugs in Women”, JACC: Heart Failure, Vol. 7/3, pp. 258-266, https://doi.org/10.1016/j.jchf.2019.01.009.

[69] Bratincsák, A. et al. (2010), “Fulminant Myocarditis Associated With Pandemic H1N1 Influenza A Virus in Children”, Journal of the American College of Cardiology, Vol. 55/9, pp. 928-929, https://doi.org/10.1016/j.jacc.2010.01.004.

[86] Brauer, M. et al. (2024), “Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021”, The Lancet, Vol. 403/10440, pp. 2162-2203, https://doi.org/10.1016/s0140-6736(24)00933-4.

[61] Buffel, V., S. Van de Velde and P. Bracke (2014), “Professional care seeking for mental health problems among women and men in Europe: the role of socioeconomic, family-related and mental health status factors in explaining gender differences”, Social Psychiatry and Psychiatric Epidemiology, Vol. 49/10, pp. 1641-1653, https://doi.org/10.1007/s00127-014-0879-z.

[218] Cainzos-Achirica, M. et al. (2019), “Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe”, Atherosclerosis, Vol. 286, pp. 105-113, https://doi.org/10.1016/j.atherosclerosis.2019.05.014.

[201] Canoy, D. et al. (2015), “Age at Menarche and Risks of Coronary Heart and Other Vascular Diseases in a Large UK Cohort”, Circulation, Vol. 131/3, pp. 237-244, https://doi.org/10.1161/circulationaha.114.010070.

[156] Cappuccio, F. et al. (2010), “Sleep Duration and All-Cause Mortality: A Systematic Review and Meta-Analysis of Prospective Studies”, Sleep, Vol. 33/5, pp. 585-592, https://doi.org/10.1093/sleep/33.5.585.

[115] CDC (2024), Cannabis and Heart Health, https://www.cdc.gov/cannabis/health-effects/heart-health.html.

[57] Chaddha, A. et al. (2016), “Mental Health and Cardiovascular Disease”, The American Journal of Medicine, Vol. 129/11, pp. 1145-1148, https://doi.org/10.1016/j.amjmed.2016.05.018.

[118] Chandy, M., N. Jimenez-Tellez and J. Wu (2025), “The relationship between cannabis and cardiovascular disease: clearing the haze”, Nature Reviews Cardiology, Vol. 22/7, pp. 467-481, https://doi.org/10.1038/s41569-025-01121-6.

[78] Cheng, Y. et al. (2020), “Effects of influenza vaccination on the risk of cardiovascular and respiratory diseases and all-cause mortality”, Ageing Research Reviews, Vol. 62, p. 101124, https://doi.org/10.1016/j.arr.2020.101124.

[205] Chih, H. et al. (2021), “Assisted reproductive technology and hypertensive disorders of pregnancy: systematic review and meta-analyses”, BMC Pregnancy and Childbirth, Vol. 21/1, https://doi.org/10.1186/s12884-021-03938-8.

[71] Chilazi, M. et al. (2021), “COVID and Cardiovascular Disease: What We Know in 2021”, Current Atherosclerosis Reports, Vol. 23/7, https://doi.org/10.1007/s11883-021-00935-2.

[195] Chong, B. et al. (2024), “Global burden of cardiovascular diseases: projections from 2025 to 2050”, European Journal of Preventive Cardiology, https://doi.org/10.1093/eurjpc/zwae281.

[36] Chrissini, M. and D. Panagiotakos (2022), “Acute Myocardial Infarction in Young Patients and its Correlation with Obesity Status at Pre-adolescent Stage: A Narrative Review”, The Open Cardiovascular Medicine Journal, Vol. 16/1, https://doi.org/10.2174/18741924-v16-e2206200.

[180] Comunian, S. et al. (2020), “Air Pollution and COVID-19: The Role of Particulate Matter in the Spread and Increase of COVID-19’s Morbidity and Mortality”, International Journal of Environmental Research and Public Health, Vol. 17/12, p. 4487, https://doi.org/10.3390/ijerph17124487.

[219] Cruz-Flores, S. et al. (2011), “Racial-Ethnic Disparities in Stroke Care: The American Experience”, Stroke, Vol. 42/7, pp. 2091-2116, https://doi.org/10.1161/str.0b013e3182213e24.

[193] Dale, L. et al. (2015), “Socioeconomic status and environmental noise exposure in Montreal, Canada”, BMC Public Health, Vol. 15/1, https://doi.org/10.1186/s12889-015-1571-2.

[67] de Boer, A. et al. (2024), “Influenza Infection and Acute Myocardial Infarction”, NEJM Evidence, Vol. 3/7, https://doi.org/10.1056/evidoa2300361.

[183] De Vita, A. et al. (2024), “The Impact of Climate Change and Extreme Weather Conditions on Cardiovascular Health and Acute Cardiovascular Diseases”, Journal of Clinical Medicine, Vol. 13/3, p. 759, https://doi.org/10.3390/jcm13030759.

[130] Diab, A. et al. (2023), “A Heart-Healthy Diet for Cardiovascular Disease Prevention: Where Are We Now?”, Vascular Health and Risk Management, Vol. Volume 19, pp. 237-253, https://doi.org/10.2147/vhrm.s379874.

[167] Dong, H. et al. (2025), “Work Stress and Its Association with Cardiovascular Events in Occupational Populations: A Systematic Review and Meta-analysis”, Asian Journal of Social Health and Behavior, Vol. 8/2, pp. 47-58, https://doi.org/10.4103/shb.shb_286_24.

[11] Dong, X. et al. (2017), “Diabetes as a risk factor for acute coronary syndrome in women compared with men: a meta‐analysis, including 10 856 279 individuals and 106 703 acute coronary syndrome events”, Diabetes/Metabolism Research and Reviews, Vol. 33/5, https://doi.org/10.1002/dmrr.2887.

[31] Drouin-Chartier, J. et al. (2021), “Correlates of Coronary Artery Calcification Prevalence and Severity in Patients With Heterozygous Familial Hypercholesterolemia”, CJC Open, Vol. 3/1, pp. 62-70, https://doi.org/10.1016/j.cjco.2020.09.010.

[107] D’Ruiz, C. et al. (2017), “Measurement of cardiovascular and pulmonary function endpoints and other physiological effects following partial or complete substitution of cigarettes with electronic cigarettes in adult smokers”, Regulatory Toxicology and Pharmacology, Vol. 87, pp. 36-53, https://doi.org/10.1016/j.yrtph.2017.05.002.

[181] Du, Y. et al. (2022), “Global Population Exposure to Extreme Temperatures and Disease Burden”, International Journal of Environmental Research and Public Health, Vol. 19/20, p. 13288, https://doi.org/10.3390/ijerph192013288.

[227] EC (2024), National low-risk drinking recommendations (or drinking guidelines) and standard units, https://knowledge4policy.ec.europa.eu/health-promotion-knowledge-gateway/national-low-risk-drinking-recommendations-drinking-guidelines_en.

[84] ECDC (2022), Prevalence of post COVID-19 condition symptoms: A systematic review and meta-analysis of cohort study data stratified by recruitment setting, https://www.ecdc.europa.eu/en/publications-data/prevalence-post-covid-19-condition-symptoms-systematic-review-and-meta-analysis.

[127] Ekelund, U. et al. (2020), “Joint associations of accelerometer-measured physical activity and sedentary time with all-cause mortality: a harmonised meta-analysis in more than 44 000 middle-aged and older individuals”, British Journal of Sports Medicine, Vol. 54/24, pp. 1499-1506, https://doi.org/10.1136/bjsports-2020-103270.

[165] Eller, N. et al. (2009), “Work-Related Psychosocial Factors and the Development of Ischemic Heart Disease”, Cardiology in Review, Vol. 17/2, pp. 83-97, https://doi.org/10.1097/crd.0b013e318198c8e9.

[55] Emerging Risk Factors Collaboration (2020), “Association Between Depressive Symptoms and Incident Cardiovascular Diseases”, JAMA, Vol. 324/23, p. 2396, https://doi.org/10.1001/jama.2020.23068.

[15] ESC (2024), “2024 ESC Guidelines for the management of elevated blood pressure and hypertension”, European Heart Journal, Vol. 45/38, pp. 3912-4018, https://doi.org/10.1093/eurheartj/ehae178.

[131] ESC (2021), “2021 ESC Guidelines on cardiovascular disease prevention in clinical practice”, European Heart Journal, Vol. 42/34, pp. 3227-3337, https://doi.org/10.1093/eurheartj/ehab484.

[34] ESC (2019), “2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk”, European Heart Journal, Vol. 41/1, pp. 111-188, https://doi.org/10.1093/eurheartj/ehz455.

[5] ESC Guidelines (2023), “2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes”, European Heart Journal, Vol. 44/39, pp. 4043-4140, https://doi.org/10.1093/eurheartj/ehad192.

[32] ESC/EAS (2011), “ESC/EAS Guidelines for the management of dyslipidaemias: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS)”, European Heart Journal, Vol. 32/14, pp. 1769-1818, https://doi.org/10.1093/eurheartj/ehr158.

[125] ESS (2025), European Social Survey European Research Infrastructure.

[148] EU (2021), Saturated fat intake across the EU, Norway and the United Kingdom, https://knowledge4policy.ec.europa.eu/health-promotion-knowledge-gateway/dietary-fats-5b_en.

[225] EU (2021), Special Eurobarometer 506: Attitudes of Europeans towards tobacco and electronic cigarettes [Internet], http://data.europa.eu/88u/dataset/S2240_506_ENG (accessed on 7 August 2025).

[149] EU (2021), Trans Fatty Acid intake across the EU, Norway and the United Kingdom, https://knowledge4policy.ec.europa.eu/health-promotion-knowledge-gateway/dietary-fats-5e_en.

[150] EU (2019), Commission Regulation (EU) 2019/649 of 24 April 2019 amending Annex III to Regulation (EC) No 1925/2006 of the European Parliament and of the Council as regards trans fat, other than trans fat naturally occurring in fat of animal origin.

[147] EU (2019), Trans-fat factsheet, https://food.ec.europa.eu/document/download/ee6db065-4ccf-4a66-9c99-8adfaff25c0f_en?filename=fs_labelling-nutrition_trans-fats-factsheet_en.pdf.

[228] European Commission (2024), Standard drink, standard unit, https://knowledge4policy.ec.europa.eu/glossary-item/standard-drink-standard-unit_en.

[92] European Commission (2021), Report on the application of the Tobacco Products Directive.

[142] European Commission (n.d.), Best practices Portal, https://webgate.ec.europa.eu/dyna/bp-portal/ (accessed on 12 July 2025).

[174] European Environment Agency (2024), Europe’s air quality status 2024, https://www.eea.europa.eu//publications/europes-air-quality-status-2024.

[179] European Environment Agency (2023), Air pollution, https://www.eea.europa.eu/publications/beating-cardiovascular-disease/air-pollution.

[134] Eurostat (2024), Almost 1 out of 10 in the EU could not afford a proper meal,, https://ec.europa.eu/eurostat/web/products-eurostat-news/w/ddn-20240712-1.

[136] Eurostat (2024), Food price monitoring tool, Eurostat Database, https://ec.europa.eu/eurostat/cache/website/economy/food-price-monitoring/.

[171] Eurostat (2023), Persons reporting a work-related health problem by type of diagnose, https://doi.org/10.2908/hsw_pb5.

[29] Eurostat (2021), Persons reporting a chronic disease, by disease, sex, age and educational attainment level.

[170] Eurostat (2021a), Self-reported work-related health problems and risk factors - key statistics, https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Self-reported_work-related_health_problems_and_risk_factors_-_key_statistics (accessed on 8 July 2025).

[65] Everard, C. et al. (2025), “Exploring the relationship between non-communicable diseases and depression”, OECD Health Working Papers, No. 178, OECD Publishing, Paris, https://doi.org/10.1787/02a1cfc5-en.

[203] Farland, L. et al. (2023), “Infertility and Risk of Cardiovascular Disease: A Prospective Cohort Study”, Journal of the American Heart Association, Vol. 12/5, https://doi.org/10.1161/jaha.122.027755.

[103] Feeney, S., V. Rossetti and J. Terrien (2022), “E-Cigarettes—a review of the evidence—harm versus harm reduction”, Tobacco Use Insights, Vol. 15, https://doi.org/10.1177/1179173x221087524.

[25] Ference, B. et al. (2017), “Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel”, European Heart Journal, Vol. 38/32, pp. 2459-2472, https://doi.org/10.1093/eurheartj/ehx144.

[96] Fischer, F. and A. Kraemer (2015), “Meta-analysis of the association between second-hand smoke exposure and ischaemic heart diseases, COPD and stroke”, BMC Public Health, Vol. 15/1, https://doi.org/10.1186/s12889-015-2489-4.

[97] Flor, L. et al. (2024), “Health effects associated with exposure to secondhand smoke: a Burden of Proof study”, Nature Medicine, Vol. 30/1, pp. 149-167, https://doi.org/10.1038/s41591-023-02743-4.

[51] for the Metabolic Syndrome and Arteries Research (MARE) Consortium (2014), “Metabolic syndrome across Europe: Different clusters of risk factors”, European Journal of Preventive Cardiology, Vol. 22/4, pp. 486-491, https://doi.org/10.1177/2047487314525529.

[16] Forouzanfar, M. et al. (2017), “Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015”, JAMA, Vol. 317/2, p. 165, https://doi.org/10.1001/jama.2016.19043.

[176] Franchini, M. and P. Mannucci (2012), “Air pollution and cardiovascular disease”, Thrombosis Research, Vol. 129/3, pp. 230-234, https://doi.org/10.1016/j.thromres.2011.10.030.

[62] Frankenthal, D., L. Keinan-Boker and M. Bromberg (2022), “Rise in depression and anxiety during the COVID-19 pandemic: results from a cross-sectional national survey”, Psychology, Health & Medicine, Vol. 28/1, pp. 139-147, https://doi.org/10.1080/13548506.2022.2057558.

[129] Galea, G. et al. (2025), “Quick buys for prevention and control of noncommunicable diseases”, The Lancet Regional Health - Europe, p. 101281, https://doi.org/10.1016/j.lanepe.2025.101281.

[21] Galea, G. et al. (2025), “Quick buys for prevention and control of noncommunicable diseases”, The Lancet Regional Health - Europe, Vol. 52, p. 101281, https://doi.org/10.1016/j.lanepe.2025.101281.

[47] Garcia Herrero, L. et al. (2025), “Criteria for Sustainable Public Procurement (SPP) for Food, Food services, and Vending machines”, Office of the European Union, https://doi.org/10.2760/0895877.

[111] George, J. et al. (2019), “Cardiovascular Effects of Switching From Tobacco Cigarettes to Electronic Cigarettes”, Journal of the American College of Cardiology, Vol. 74/25, pp. 3112-3120, https://doi.org/10.1016/j.jacc.2019.09.067.

[68] Golabchi, A. (2010), “What Every Cardiologist Should Know about H1N1?”, ARYA Atheroscler, Vol. 6/3, pp. 118-21, https://pmc.ncbi.nlm.nih.gov/articles/PMC3347827/.

[89] Goodchild, M., N. Nargis and E. Tursan d’Espaignet (2017), “Global economic cost of smoking-attributable diseases”, Tobacco Control, Vol. 27/1, pp. 58-64, https://doi.org/10.1136/tobaccocontrol-2016-053305.

[9] Goraya, T. et al. (2002), “Coronary atherosclerosis in diabetes mellitus”, Journal of the American College of Cardiology, Vol. 40/5, pp. 946-953, https://doi.org/10.1016/s0735-1097(02)02065-x.

[186] Gronlund, C. (2014), “Racial and Socioeconomic Disparities in Heat-Related Health Effects and Their Mechanisms: a Review”, Current Epidemiology Reports, Vol. 1/3, pp. 165-173, https://doi.org/10.1007/s40471-014-0014-4.

[43] Gudzune, K. and R. Kushner (2024), “Medications for Obesity”, JAMA, Vol. 332/7, p. 571, https://doi.org/10.1001/jama.2024.10816.

[198] Hanna, M., A. Wabnitz and P. Grewal (2024), “Sex and stroke risk factors: A review of differences and impact”, Journal of Stroke and Cerebrovascular Diseases, Vol. 33/4, p. 107624, https://doi.org/10.1016/j.jstrokecerebrovasdis.2024.107624.

[191] Havard, S. et al. (2011), “Social inequalities in residential exposure to road traffic noise: An environmental justice analysis based on the RECORD Cohort Study”, Occupational and Environmental Medicine, Vol. 68/5, pp. 366-374, https://doi.org/10.1136/oem.2010.060640.

[102] Henderson, E. et al. (2021), “Secondhand smoke exposure assessment in outdoor hospitality venues across 11 European countries”, Environmental Research, Vol. 200, p. 111355, https://doi.org/10.1016/j.envres.2021.111355.

[72] Hendren, N. et al. (2020), “Description and Proposed Management of the Acute COVID-19 Cardiovascular Syndrome”, Circulation, Vol. 141/23, pp. 1903-1914, https://doi.org/10.1161/circulationaha.120.047349.

[58] Henking, C., A. Reeves and B. Chrisinger (2023), “Global inequalities in mental health problems: understanding the predictors of lifetime prevalence, treatment utilisation and perceived helpfulness across 111 countries”, Preventive Medicine, Vol. 177, p. 107769, https://doi.org/10.1016/j.ypmed.2023.107769.

[63] Hidaka, B. (2012), “Depression as a disease of modernity: Explanations for increasing prevalence”, Journal of Affective Disorders, Vol. 140/3, pp. 205-214, https://doi.org/10.1016/j.jad.2011.12.036.

[222] Hindy, G. (ed.) (2021), “Polygenic risk scores in cardiovascular risk prediction: A cohort study and modelling analyses”, PLOS Medicine, Vol. 18/1, p. e1003498, https://doi.org/10.1371/journal.pmed.1003498.

[217] Hippisley-Cox, J., C. Coupland and P. Brindle (2017), “Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study”, BMJ, p. j2099, https://doi.org/10.1136/bmj.j2099.

[53] Honigberg, M. et al. (2022), “Low depression frequency is associated with decreased risk of cardiometabolic disease”, Nature Cardiovascular Research, Vol. 1/2, pp. 125-131, https://doi.org/10.1038/s44161-021-00011-7.

[163] Huang, B. et al. (2021), “Sleep and physical activity in relation to all-cause, cardiovascular disease and cancer mortality risk”, British Journal of Sports Medicine, Vol. 56/13, pp. 718-724, https://doi.org/10.1136/bjsports-2021-104046.

[6] IDF (2025), IDF Diabetes Atlas 11th edition 2025.

[7] IHME (2024), GBD 2021 Cause and Risk Summary.

[1] IHME (2021), GDB Compare, https://healthdata-digex.healthdata.org/data-tools-practices/interactive-data-visuals (accessed on 16 June 2025).

[106] Izquierdo-Condoy, J. et al. (2024), “Direct health implications of e-cigarette use: a systematic scoping review with evidence assessment”, Frontiers in Public Health, Vol. 12, https://doi.org/10.3389/fpubh.2024.1427752.

[152] Jaspan, V. et al. (2024), “The Role of Sleep in Cardiovascular Disease”, Current Atherosclerosis Reports, Vol. 26/7, pp. 249-262, https://doi.org/10.1007/s11883-024-01207-5.

[194] Jensen, C. (2024), “Cardiovascular Disease in the Aging Population: Addressing Challenges and Management Approaches”, J Cardiovasc Disc Diagn, Vol. 12, p. 629, https://doi.org/10.37421/2329-9517.2024.12.629.

[133] Jeong, S. et al. (2023), “Effects of Diet on 10-Year Atherosclerotic Cardiovascular Disease Risk (from the DASH Trial)”, The American Journal of Cardiology, Vol. 187, pp. 10-17, https://doi.org/10.1016/j.amjcard.2022.10.019.

[211] Johansson, T. et al. (2022), “Oral Contraceptives, Hormone Replacement Therapy, and Stroke Risk”, Stroke, Vol. 53/10, pp. 3107-3115, https://doi.org/10.1161/strokeaha.121.038659.

[114] Jouanjus, E. et al. (2017), “What is the Current Knowledge About the Cardiovascular Risk for Users of Cannabis-Based Products? A Systematic Review”, Current Atherosclerosis Reports, Vol. 19/6, https://doi.org/10.1007/s11883-017-0663-0.

[215] Jowell, A. et al. (2022), “Abstract 462: Clinical And Genetic Risk Factors Underlying Family History Of Heart Disease”, Arteriosclerosis, Thrombosis, and Vascular Biology, Vol. 42/Suppl_1, https://doi.org/10.1161/atvb.42.suppl_1.462.

[116] Kamel, I. et al. (2025), “Myocardial Infarction and Cardiovascular Risks Associated With Cannabis Use”, JACC: Advances, Vol. 4/5, p. 101698, https://doi.org/10.1016/j.jacadv.2025.101698.

[60] Karami, N. et al. (2023), “Global prevalence of depression, anxiety, and stress in cardiac patients: A systematic review and meta-analysis”, Journal of Affective Disorders, Vol. 324, pp. 175-189, https://doi.org/10.1016/j.jad.2022.12.055.

[185] Kazi, D. et al. (2024), “Climate Change and Cardiovascular Health”, JAMA Cardiology, Vol. 9/8, p. 748, https://doi.org/10.1001/jamacardio.2024.1321.

[164] Kivimäki, M. and I. Kawachi (2015), “Work Stress as a Risk Factor for Cardiovascular Disease”, Current Cardiology Reports, Vol. 17/9, https://doi.org/10.1007/s11886-015-0630-8.

[166] Kivimäki, M. et al. (2006), “Work stress in the etiology of coronary heart disease—a meta-analysis”, Scandinavian Journal of Work, Environment &; Health, Vol. 32/6, pp. 431-442, https://doi.org/10.5271/sjweh.1049.

[178] Krismanuel, H. (2025), “Air pollution and cardiovascular diseases: mechanisms, evidence, and mitigation strategies”, Journal of Medicine and Life, Vol. 18/5, pp. 411-427, https://doi.org/10.25122/jml-2025-0018.

[158] Kuehn, B. (2019), “Sleep Duration Linked to Cardiovascular Disease”, Circulation, Vol. 139/21, pp. 2483-2484, https://doi.org/10.1161/circulationaha.119.041278.

[59] Kwapong, Y. et al. (2023), “Association of Depression and Poor Mental Health With Cardiovascular Disease and Suboptimal Cardiovascular Health Among Young Adults in the United States”, Journal of the American Heart Association, Vol. 12/3, https://doi.org/10.1161/jaha.122.028332.

[54] Kwapong, Y. et al. (2023), “Association of Depression and Poor Mental Health With Cardiovascular Disease and Suboptimal Cardiovascular Health Among Young Adults in the United States”, Journal of the American Heart Association, Vol. 12/3, https://doi.org/10.1161/jaha.122.028332.

[138] Kwong, E. et al. (2022), “Population-level salt intake in the WHO European Region in 2022: a systematic review”, Public Health Nutrition, Vol. 26/S1, pp. s6-s19, https://doi.org/10.1017/s136898002200218x.

[66] Kwong, J. et al. (2018), “Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection”, New England Journal of Medicine, Vol. 378/4, pp. 345-353, https://doi.org/10.1056/nejmoa1702090.

[157] Lao, X. et al. (2018), “Sleep Quality, Sleep Duration, and the Risk of Coronary Heart Disease: A Prospective Cohort Study With 60,586 Adults”, Journal of Clinical Sleep Medicine, Vol. 14/01, pp. 109-117, https://doi.org/10.5664/jcsm.6894.

[17] Lawes, C. et al. (2004), “Blood Pressure and Stroke”, Stroke, Vol. 35/3, pp. 776-785, https://doi.org/10.1161/01.str.0000116869.64771.5a.

[22] Law, M., J. Morris and N. Wald (2009), “Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies”, BMJ, Vol. 338/may19 1, pp. b1665-b1665, https://doi.org/10.1136/bmj.b1665.

[48] Leosdottir, M. et al. (2023), “Temporal trends in cardiovascular risk factors, lifestyle and secondary preventive medication for patients with myocardial infarction attending cardiac rehabilitation in Sweden 2006–2019: a registry-based cohort study”, BMJ Open, Vol. 13/5, p. e069770, https://doi.org/10.1136/bmjopen-2022-069770.

[161] Li, A. et al. (2025), “Climate warming may undermine sleep duration and quality in repeated-measure study of 23 million records”, Nature Communications, Vol. 16/1, https://doi.org/10.1038/s41467-025-57781-y.

[74] Li, B. et al. (2020), “Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in China”, Clinical Research in Cardiology, Vol. 109/5, pp. 531-538, https://doi.org/10.1007/s00392-020-01626-9.

[23] Lindley, R. (2018), “Stroke Prevention in the Very Elderly”, Stroke, Vol. 49/3, pp. 796-802, https://doi.org/10.1161/strokeaha.117.017952.

[75] Lippi, G. and M. Plebani (2020), “Laboratory abnormalities in patients with COVID-2019 infection”, Clinical Chemistry and Laboratory Medicine (CCLM), Vol. 58/7, pp. 1131-1134, https://doi.org/10.1515/cclm-2020-0198.

[93] Lubin, J. et al. (2016), “Risk of Cardiovascular Disease from Cumulative Cigarette Use and the Impact of Smoking Intensity”, Epidemiology, Vol. 27/3, pp. 395-404, https://doi.org/10.1097/ede.0000000000000437.

[101] Ma, C. et al. (2021), “Global trends in the prevalence of secondhand smoke exposure among adolescents aged 12–16 years from 1999 to 2018: an analysis of repeated cross-sectional surveys”, The Lancet Global Health, Vol. 9/12, pp. e1667-e1678, https://doi.org/10.1016/s2214-109x(21)00365-x.

[77] Madrid, J. et al. (2024), “Cardioprotective effects of vaccination in hospitalized patients with COVID-19”, Clinical and Experimental Medicine, Vol. 24/1, https://doi.org/10.1007/s10238-024-01367-3.

[187] Maes, M. et al. (2022), “Monitoring exposure to climate-related hazards: Indicator methodology and key results”, OECD Environment Working Papers, No. 201, OECD Publishing, Paris, https://doi.org/10.1787/da074cb6-en.

[146] Maki, K., M. Dicklin and C. Kirkpatrick (2021), “Saturated fats and cardiovascular health: Current evidence and controversies”, Journal of Clinical Lipidology, Vol. 15/6, pp. 765-772, https://doi.org/10.1016/j.jacl.2021.09.049.

[126] Masmoum, M. et al. (2024), “The Effectiveness of Exercise in Reducing Cardiovascular Risk Factors Among Adults: A Systematic Review and Meta-Analysis”, Cureus, https://doi.org/10.7759/cureus.68928.

[46] Mathieu-Bolh, N. (forthcoming), “Economic and policy implications of breakthrough obesity treatment”.

[160] Matricciani, L. et al. (2017), “Past, present, and future: trends in sleep duration and implications for public health”, Sleep Health, Vol. 3/5, pp. 317-323, https://doi.org/10.1016/j.sleh.2017.07.006.

[172] Mensah, A. (2021), “Job Stress and Mental Well-Being among Working Men and Women in Europe: The Mediating Role of Social Support”, International Journal of Environmental Research and Public Health, Vol. 18/5, p. 2494, https://doi.org/10.3390/ijerph18052494.

[135] Ministerio de la Presidencia, Justicia y Relaciones con las Cortes (2025), Real Decreto 315/2025, https://www.boe.es/diario_boe/txt.php?id=BOE-A-2025-7659.

[42] Moiz, A. et al. (2025), “Efficacy and Safety of Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss Among Adults Without Diabetes”, Annals of Internal Medicine, Vol. 178/2, pp. 199-217, https://doi.org/10.7326/annals-24-01590.

[49] Mottillo, S. et al. (2010), “The Metabolic Syndrome and Cardiovascular Risk”, Journal of the American College of Cardiology, Vol. 56/14, pp. 1113-1132, https://doi.org/10.1016/j.jacc.2010.05.034.

[190] Münzel, T., M. Sørensen and A. Daiber (2021), “Transportation noise pollution and cardiovascular disease”, Nature Reviews Cardiology, Vol. 18/9, pp. 619-636, https://doi.org/10.1038/s41569-021-00532-5.

[188] Murphy, E. and E. King (2022), Environmental noise pollution: Noise mapping, public health, and policy, Elsevier, https://doi.org/10.1016/C2012-0-13587-0.

[162] Nagai, M., S. Hoshide and K. Kario (2010), “Sleep Duration as a Risk Factor for Cardiovascular Disease- a Review of the Recent Literature”, Current Cardiology Reviews, Vol. 6/1, pp. 54-61, https://doi.org/10.2174/157340310790231635.

[30] NCD-RisC (2020), “Repositioning of the global epicentre of non-optimal cholesterol”, Nature, Vol. 582/7810, pp. 73-77, https://doi.org/10.1038/s41586-020-2338-1.

[41] Ng, M. et al. (2025), “Global, regional, and national prevalence of adult overweight and obesity, 1990–2021, with forecasts to 2050: a forecasting study for the Global Burden of Disease Study 2021”, The Lancet, Vol. 405/10481, pp. 813-838, https://doi.org/10.1016/s0140-6736(25)00355-1.

[28] NHS England (2025), This May Measure Month get your blood pressure checked to help avoid the number one cause of preventable death worldwide, https://www.england.nhs.uk/north-west/2025/05/06/this-may-measure-month-get-your-blood-pressure-checked-to-help-avoid-the-number-one-cause-of-preventable-death-worldwide.

[27] NHS Gloucestershire (2024), Know Your Numbers: more than 1,250 people so far take up the offer of blood pressure checks at community drop-in events, https://www.nhsglos.nhs.uk/news/know-your-numbers-more-than-1250-people-so-far-take-up-the-offer-of-blood-pressure-checks-at-community-drop-in-events/.

[56] Nielsen, R., J. Banner and S. Jensen (2020), “Cardiovascular disease in patients with severe mental illness”, Nature Reviews Cardiology, Vol. 18/2, pp. 136-145, https://doi.org/10.1038/s41569-020-00463-7.

[199] O’Kelly, A. et al. (2022), “Pregnancy and Reproductive Risk Factors for Cardiovascular Disease in Women”, Circulation Research, Vol. 130/4, pp. 652-672, https://doi.org/10.1161/circresaha.121.319895.

[224] OECD (2025), Does Healthcare Deliver?: Results from the Patient-Reported Indicator Surveys (PaRIS), OECD Publishing, Paris, https://doi.org/10.1787/c8af05a5-en.

[85] OECD (2025), “The prevalence and impact of Long COVID in the primary care population: Findings from the OECD PaRIS survey”, OECD Publishing, Paris, https://doi.org/10.1787/119b0e8f-en.

[95] OECD (2024), Tobacco Taxation in Latin America and the Caribbean: A Call for Tobacco Tax Reform, OECD Publishing, Paris, https://doi.org/10.1787/080cd662-en.

[173] OECD (2022), Promoting Health and Well-being at Work: Policy and Practices, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/e179b2a5-en.

[123] OECD (2021), Preventing Harmful Alcohol Use, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/6e4b4ffb-en.

[137] OECD/European Commission (2024), Health at a Glance: Europe 2024: State of Health in the EU Cycle, OECD Publishing, Paris, https://doi.org/10.1787/b3704e14-en.

[91] OECD/European Commission (2024), Health at a Glance: Europe 2024: State of Health in the EU Cycle, OECD Publishing, Paris, https://doi.org/10.1787/b3704e14-en.

[128] OECD/WHO (2023), Step Up! Tackling the Burden of Insufficient Physical Activity in Europe, OECD Publishing, Paris, https://doi.org/10.1787/500a9601-en.

[202] Okoth, K. et al. (2020), “Association between the reproductive health of young women and cardiovascular disease in later life: umbrella review”, BMJ, p. m3502, https://doi.org/10.1136/bmj.m3502.

[79] Omidi, F. et al. (2023), “Influenza vaccination and major cardiovascular risk: a systematic review and meta-analysis of clinical trials studies”, Scientific Reports, Vol. 13/1, https://doi.org/10.1038/s41598-023-47690-9.

[98] Oono, I., D. Mackay and J. Pell (2011), “Meta-analysis of the association between secondhand smoke exposure and stroke”, Journal of Public Health, Vol. 33/4, pp. 496-502, https://doi.org/10.1093/pubmed/fdr025.

[204] Parikh, N. et al. (2021), “Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association”, Circulation, Vol. 143/18, pp. e902-e916, https://doi.org/10.1161/CIR.0000000000000961.

[220] Patel, N. et al. (2022), “Racial/Ethnic Disparities and Determinants of Sufficient Physical Activity Levels”, Kansas Journal of Medicine, Vol. 15/2, pp. 267-272, https://doi.org/10.17161/kjm.vol15.17592.

[33] Patel, P. and R. Giugliano (2020), “Low-density lipoprotein cholesterol lowering therapy for the secondary prevention of atherosclerotic cardiovascular disease”, Global Cardiology Science and Practice, Vol. 2020/3, https://doi.org/10.21542/gcsp.2020.39.

[117] Paulraj, S. et al. (2025), “Arrhythmias and cannabis use: A comprehensive overview”, Heart Rhythm O2, Vol. 6/1, pp. 78-85, https://doi.org/10.1016/j.hroo.2024.10.020.

[20] Perez, M., V. Musini and J. Wright (2009), “Effect of early treatment with anti-hypertensive drugs on short and long-term mortality in patients with an acute cardiovascular event”, Cochrane Database of Systematic Reviews, https://doi.org/10.1002/14651858.cd006743.pub2.

[13] Peterson, L., C. McKenzie and J. Schaffer (2012), “Diabetic Cardiovascular Disease: Getting to the Heart of the Matter”, Journal of Cardiovascular Translational Research, Vol. 5/4, pp. 436-445, https://doi.org/10.1007/s12265-012-9374-7.

[12] Peters, S., R. Huxley and M. Woodward (2014), “Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775 385 individuals and 12 539 strokes”, The Lancet, Vol. 383/9933, pp. 1973-1980, https://doi.org/10.1016/s0140-6736(14)60040-4.

[159] Poon, K. et al. (2024), “Mediating roles of sleep quality and resilience in the relationships between chronotypes and mental health symptoms”, Scientific Reports, Vol. 14/1, https://doi.org/10.1038/s41598-024-56688-w.

[141] Programa Activa (n.d.), Programa Activa – Gobierno de Murcia, https://activamurcia.com/ (accessed on 12 July 2025).

[155] Quan, S. (2009), “Sleep Disturbances and Their Relationship to Cardiovascular Disease”, American Journal of Lifestyle Medicine, Vol. 3/1_suppl, pp. 55S-59S, https://doi.org/10.1177/1559827609331709.

[213] Rai, A. (2025), “Excessive Drinking Raises Heart Disease Risk”, Medscape, https://www.medscape.com/viewarticle/excessive-drinking-raises-heart-disease-risk-2025a10004es?form=fpf.

[175] Rajagopalan, S., S. Al-Kindi and R. Brook (2018), “Air Pollution and Cardiovascular Disease”, Journal of the American College of Cardiology, Vol. 72/17, pp. 2054-2070, https://doi.org/10.1016/j.jacc.2018.07.099.

[151] Ramar, K. et al. (2021), “Sleep is essential to health: an American Academy of Sleep Medicine position statement”, Journal of Clinical Sleep Medicine, Vol. 17/10, pp. 2115-2119, https://doi.org/10.5664/jcsm.9476.

[143] Region de Murcia (2025), CARM.es - El Gobierno regional subvenciona el programa ’Activa tu ocio’ con una amplia oferta de actividades inclusivas para el tiempo libre, https://www.carm.es/web/pagina?IDCONTENIDO=121011&IDTIPO=10&RASTRO=c54$s3$m (accessed on 12 July 2025).

[144] Reynolds, A. et al. (2022), “Saturated fat and trans-fat intakes and their replacement with other macronutrients A systematic review and meta-analysis of prospective observational studies”.

[212] Rich-Edwards, J. et al. (2019), “Randomized Trial to Reduce Cardiovascular Risk in Women with Recent Preeclampsia”, Journal of Women’s Health, Vol. 28/11, pp. 1493-1504, https://doi.org/10.1089/jwh.2018.7523.

[14] Ritsinger, V. et al. (2020), “Heart failure is a common complication after acute myocardial infarction in patients with diabetes: A nationwide study in the SWEDEHEART registry”, European Journal of Preventive Cardiology, Vol. 27/17, pp. 1890-1901, https://doi.org/10.1177/2047487319901063.

[38] Ross, R. et al. (2020), “Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR Working Group on Visceral Obesity”, Nature Reviews Endocrinology, Vol. 16/3, pp. 177-189, https://doi.org/10.1038/s41574-019-0310-7.

[52] Rus, M. et al. (2023), “Prevalence and Risk Factors of Metabolic Syndrome: A Prospective Study on Cardiovascular Health”, Medicina, Vol. 59/10, p. 1711, https://doi.org/10.3390/medicina59101711.

[221] Samani, N. et al. (2024), “Polygenic risk score adds to a clinical risk score in the prediction of cardiovascular disease in a clinical setting”, European Heart Journal, Vol. 45/34, pp. 3152-3160, https://doi.org/10.1093/eurheartj/ehae342.

[90] Santé Publique France (2022), Hospitalizations for cardiovascular diseases attributable to tobacco smoking in France in 2015.

[112] SCHEER (2021), Scientific Committe on Health, Environmental and Emerging Risks (SCHEER) Opinion on electronic cigarettes, European Commission, https://doi.org/10.2875/457545.

[2] Schienkiewitz, A. et al. (2017), “Overweight and obesity among adults in Germany”, Health Monit, Vol. 2/2, pp. 20-27, https://doi.org/10.17886/RKI-GBE-2017-038.

[113] Sebastian, S. et al. (2025), “Cannabis use and atherosclerotic cardiovascular disease outcomes: A meta-analysis of multinational cohort data”, Disease-a-Month, Vol. 71/3, p. 101849, https://doi.org/10.1016/j.disamonth.2024.101849.

[209] Shufelt, C. and C. Bairey Merz (2009), “Contraceptive Hormone Use and Cardiovascular Disease”, Journal of the American College of Cardiology, Vol. 53/3, pp. 221-231, https://doi.org/10.1016/j.jacc.2008.09.042.

[10] Siam, N. et al. (2024), “Diabetes Mellitus and Cardiovascular Disease: Exploring Epidemiology, Pathophysiology, and Treatment Strategies”, Reviews in Cardiovascular Medicine, Vol. 25/12, https://doi.org/10.31083/j.rcm2512436.

[19] Silva, G. et al. (2024), “Blood pressure management to prevent recurrent stroke: current evidence and perspectives”, npj Cardiovascular Health, Vol. 1/1, https://doi.org/10.1038/s44325-024-00021-x.

[3] Starker, A. et al. (2025), “Prevalence of obesity and smoking among adults in Germany - trends from 2003 to 2023”, J Health Monit, Vol. 10/1, https://doi.org/10.25646/13038.

[223] Stead, L. et al. (2013), “Physician advice for smoking cessation”, Cochrane Database of Systematic Reviews, Vol. 2013/5, https://doi.org/10.1002/14651858.cd000165.pub4.

[120] Storck, W. et al. (2025), “Cardiovascular risk associated with the use of cannabis and cannabinoids: a systematic review and meta-analysis”, Heart, pp. heartjnl-2024-325429, https://doi.org/10.1136/heartjnl-2024-325429.

[196] Sun, J. et al. (2023), “Global, regional, and national burden of cardiovascular diseases in youths and young adults aged 15–39 years in 204 countries/territories, 1990–2019: a systematic analysis of Global Burden of Disease Study 2019”, BMC Medicine, Vol. 21/1, https://doi.org/10.1186/s12916-023-02925-4.

[177] Sun, Q., X. Hong and L. Wold (2010), “Cardiovascular Effects of Ambient Particulate Air Pollution Exposure”, Circulation, Vol. 121/25, pp. 2755-2765, https://doi.org/10.1161/circulationaha.109.893461.

[100] The Lancet (2020), https://www.thelancet.com/pb-assets/Lancet/gbd/summaries/risks/second-hand-smoke.pdf.

[207] Trinh, A. et al. (2023), “Contraception and Cardiovascular Effects: What Should the Cardiologist Know?”, Current Cardiology Reports, Vol. 25/11, pp. 1489-1498, https://doi.org/10.1007/s11886-023-01981-9.

[82] Tsampasian, V. et al. (2024), “Cardiovascular disease as part of Long COVID: a systematic review”, European Journal of Preventive Cardiology, Vol. 32/6, pp. 485-498, https://doi.org/10.1093/eurjpc/zwae070.

[64] Twenge, J. et al. (2018), “Digital Media May Explain a Substantial Portion of the Rise in Depressive Symptoms Among Adolescent Girls: Response to Daly”, Clinical Psychological Science, Vol. 6/3, pp. 296-297, https://doi.org/10.1177/2167702618759321.

[88] U.S. Department of Health and Human Services (2010), How Tobacco Smoke Causes Disease.

[99] U.S. Dept of Health and Human Services (2014), The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General..

[154] Ungvari, Z. et al. (2025), “Inadequate sleep increases stroke risk: evidence from a comprehensive meta-analysis of incidence and mortality”, GeroScience, https://doi.org/10.1007/s11357-025-01593-x.

[169] Vahtera, J. et al. (2004), “Organisational downsizing, sickness absence, and mortality: 10-town prospective cohort study”, BMJ, Vol. 328/7439, p. 555, https://doi.org/10.1136/bmj.37972.496262.0d.

[24] Vasan, R. et al. (2001), “Impact of High-Normal Blood Pressure on the Risk of Cardiovascular Disease”, New England Journal of Medicine, Vol. 345/18, pp. 1291-1297, https://doi.org/10.1056/nejmoa003417.

[73] Vassiliou, V. et al. (2025), “Cardiovascular disease prevention and management in COVID-19: a clinical consensus statement of the European Association of Preventive Cardiology, the European Association of Cardiovascular Imaging, the Association of Cardiovascular Nursing & Allied Professions, the European Association of Percutaneous Cardiovascular Interventions, and the Heart Failure Association of the ESC”, European Journal of Preventive Cardiology, https://doi.org/10.1093/eurjpc/zwaf540.

[108] Veldheer, S. et al. (2019), “Pulmonary and other health effects of electronic cigarette use among adult smokers participating in a randomized controlled smoking reduction trial”, Addictive Behaviors, Vol. 91, pp. 95-101, https://doi.org/10.1016/j.addbeh.2018.10.041.

[200] Vogel, B. et al. (2021), “The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030”, The Lancet, Vol. 397/10292, pp. 2385-2438, https://doi.org/10.1016/S0140-6736(21)00684-X/ASSET/F41BEF47-0EB8-460A-B7CB-D9C370907872/MAIN.ASSETS/GR4.JPG.

[184] Weilnhammer, V. et al. (2021), “Extreme weather events in europe and their health consequences – A systematic review”, International Journal of Hygiene and Environmental Health, Vol. 233, p. 113688, https://doi.org/10.1016/j.ijheh.2021.113688.

[18] Whelton, S. et al. (2020), “Association of Normal Systolic Blood Pressure Level With Cardiovascular Disease in the Absence of Risk Factors”, JAMA Cardiology, Vol. 5/9, p. 1011, https://doi.org/10.1001/jamacardio.2020.1731.

[37] WHF (2025), World Heart Report 2025 - World Heart Report 2025, https://world-heart-federation.org/report2025/ (accessed on 12 July 2025).

[140] WHO (2025), From policy to plate: how countries can reduce salt intake and protect people’s health, https://www.who.int/europe/news/item/15-05-2025-from-policy-to-plate--how-countries-can-reduce-salt-intake-and-protect-people-s-health.

[139] WHO (2025), Sodium reduction, https://www.who.int/news-room/fact-sheets/detail/sodium-reduction.

[121] WHO (2024), Global status report on alcohol and health and treatment of substance use disorders, World Health, World Health Organization.

[105] WHO (2023), Global Tobacco Surveillance System (GTSS).

[145] WHO (2023), “Saturated fatty acid and trans-fatty acid intake for adults and children WHO guideline”.

[124] WHO (2022), European framework for action on alcohol 2022–2025, World Health Organization.

[81] WHO (2022), Post COVID-19 condition (Long COVID), https://www.who.int/europe/news-room/fact-sheets/item/post-covid-19-condition.

[87] WHO (2020), Tobacco use and exposure to second-hand smoke linked to more than 20% of deaths from coronary heart disease, World Health Organization, https://www.who.int/europe/news/item/29-09-2020-tobacco-use-and-exposure-to-second-hand-smoke-linked-to-more-than-20-of-deaths-from-coronary-heart-disease.

[189] WHO (2018), Environmental Noise Guidelines for the European Region, World Health Organization, https://www.who.int/europe/publications/i/item/9789289053563.

[226] WHO (2013), Global action plan for the prevention and control of noncommunicable diseases 2013-2020., https://iris.who.int/server/api/core/bitstreams/15f51d0a-bfbd-43ad-a637-73778feb57e3/content.

[104] WHO Europe (2024), Prevalence of tobacco and e-cigarette use by young people in the HWO European region.

[39] WHO Global Health Observatory (2025), Body mass index among adults, https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-group-details/GHO/bmi-among-adults.

[40] WHO Global Health Observatory (2025), Body mass index among children, https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-group-details/GHO/bmi-among-children.

[4] WHO Global Health Observatory (2024), Diabetes, prevalence (%), https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-diabetes-age-standardized.

[210] Williams, J. et al. (2024), “Differences in cardiovascular risk factors associated with sex and gender identity, but not gender expression, in young, healthy cisgender adults”, Frontiers in Cardiovascular Medicine, Vol. 11, https://doi.org/10.3389/fcvm.2024.1374765.

[122] Wood, A. et al. (2018), Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599912 current drinkers in 83 prospective studies.

[45] Xie, Y., T. Choi and Z. Al-Aly (2025), “Author Correction: Mapping the effectiveness and risks of GLP-1 receptor agonists”, Nature Medicine, Vol. 31/3, pp. 1038-1038, https://doi.org/10.1038/s41591-025-03542-9.

[83] Xie, Y., T. Choi and Z. Al-Aly (2024), “Postacute Sequelae of SARS-CoV-2 Infection in the Pre-Delta, Delta, and Omicron Eras”, New England Journal of Medicine, Vol. 391/6, pp. 515-525, https://doi.org/10.1056/nejmoa2403211.

[206] Yonis, H. et al. (2025), “Stroke and myocardial infarction with contemporary hormonal contraception: real-world, nationwide, prospective cohort study”, BMJ, p. e082801, https://doi.org/10.1136/bmj-2024-082801.

[50] Zila-Velasque, J. et al. (2024), “Prevalence of metabolic syndrome and its components according to altitude levels: a systematic review and meta-analysis”, Scientific Reports, Vol. 14/1, https://doi.org/10.1038/s41598-024-77928-z.

Annex 3.A. DALY Definitions

Disability Adjusted Life Year (DALY)

DALYs are a measure of overall disease burden, one DALY is equivalent to the loss of one year of full health, combining Years of Life Lost (YLLs), due to premature mortality, and Years Lived with Disability (YLDs).

Attributable burden is the reduction in current disease burden that would have been possible if past population exposure had shifted to an alternative or counter-factual distribution of risk exposure. Deaths and DALYs can be attributed to several risk factors at once and are not summative.

Risk factor estimates defined by the Institute for Health Metrics and Evaluation (IHME) model the risk factor attributions

Metabolic risks

• High systolic blood pressure – estimation of brachial systolic blood pressure, using a theoretical minimum risk exposure level (TMREL) ranging from 105 to 115 mmHg.

• High low-density lipoprotein cholesterol (LDL-c) – is the estimated blood concentration of LDL-c in units of mmol/L with a TMREL of 0.9 and 1.4 mmol/L.

• High body-mass index (BMI) – is defined for adults ages 20 and older as BMI greater than 20‑23kg/m².

• High blood sugar – called “high fasting plasma glucose” (levels recorded after no eating or drinking for 8 hours) is defined as any level above the theoretical minimum risk exposure level of 4.9‑5.3 mmol/L.

• Kidney dysfunction – is defined as estimated glomerular filtration rate (eGFR) less than 60ml/min/1.73m² or albumin to creatinine ratio (ACR) ≤ 30mg/g. The TMREL value used is ACR < 30mg/g and eGFR ≥ 60ml/min/1.73m²

Behavioural risks

• Dietary risk includes factors associated with CVD such as diets low in fruit, vegetables, whole grains, milk and fiber, and high in sodium, trans fatty acids, sugar-sweetened beverages, red meat and processed meat.

• Tobacco use includes estimates about smoking (current and former), second-hand smoke (at home, at work and in other public places) and chewing tobacco (use of primary chewing tobacco, non-chew smokeless tobacco and all other smokeless tobacco).

• Harmful use of alcohol is defined as the excess of the region-, age‑, sex-, and year-specific theoretical minimum risk exposure level (TMREL). Current drinkers are defined as individuals consuming at least one alcoholic beverage in the past year. The estimate level of alcohol exposure for current drinkers is the reported average grammes of pure alcohol consumed per day (g/day).

• Physical inactivity measured in total metabolic equivalent (MET)-minutes per week and defined as objectively measured, average weekly physical activity (at work, home, transport-related, and recreational) of less than 3 600‑4 400 MET-minutes per week.

Environmental/occupational risks

• Air pollution includes exposure to particulate matter that are 2.5 microns or less in diameter (PM2.5), including ambient (outdoor) and household (indoor) exposure.

• Non-optimal temperature – aggregate of the burden attributable to low and high temperatures. The population-weighted mean TMREL used was 25.6 °C.

For more detail methodology refer to Brauer et al. (2024[86]).

Annex 3.B. Relationship between hypertension and cardiovascular conditions

Annex Figure 3.B.1. Countries with higher prevalence of high blood pressure have higher mortality due to ischaemic heart disease in people 65 and over

Note: ASMR: Age‑adjusted mortality rate.

Source: Eurostat (2021), https://ec.europa.eu/eurostat/databrowser/bookmark/46974e2c-13e5-4ff4-a1de-4b68019a87bf?lang=en, and Eurostat (2025), https://doi.org/10.2908/HLTH_CD_ASDR2.

Annex 3.C. The healthcare expenditure associated with diseases caused by harmful alcohol consumption

Annex Figure 3.C.1. Annual health expenditure due to diseases caused by harmful alcohol consumption above 1 drink per day for women and 1.5 drinks per day for men, in USD PPP per capita and as a percentage of total health expenditure, average 2020‑50

Source: EU26 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. OECD analyses based on the OECD SPHeP-NCDs model, 2020; OECD (2021[123]), Preventing Harmful Alcohol Use, https://doi.org/10.1787/6e4b4ffb-en.

Annex 3.D. Additional analysis of risk factor prevalence among PaRIS respondents

Annex Figure 3.D.1. More than a tenth of primary care users aged 45 and older report currently smoking

Percentage of primary care user aged 45 and older reporting their smoking status

Note: EU11 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Response to question: “Do you smoke any tobacco products (excluding electronic cigarettes or similar electronic devices)?”. * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions.

Source: OECD PaRIS Database 2024.

Annex Figure 3.D.2. More than half of primary care users aged 45 and older do not exercise regularly (less than 60 minutes or less per week)

Percentage of primary care users aged 45 and older reporting how often they exercise weekly

Note: EU11 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Response to question: “In the past week, on how many days did you do at least 30 minutes of either vigorous or moderate activity (such as running, swimming, riding a bike, brisk walking, or dancing)? Vigorous physical activities typically make you breathe much harder than normal, whereas moderate activities make you breathe somewhat harder than normal.” * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** the United States sample only includes people aged 65 years or older.

Source: OECD PaRIS Database 2024.

Annex Figure 3.D.3. Almost two out of three primary care users aged 45 and older consume vegetables daily

Percentage of primary care users aged 45 and older reporting how often they consume vegetables

Note: EU11 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Response to question: “How often do you eat vegetables or salad, excluding potatoes and fresh juice or juice made from concentrate?” * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** the United States sample only includes people aged 65 years or older.

Source: OECD PaRIS Database 2024.

Annex Figure 3.D.4. Two out of three primary care users aged 45 and older consume fruits daily

Percentage of primary care users aged 45 and older reporting how often they consume fruits

Note: EU11 average is unweighted. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Response to question: “How often do you eat fruit, excluding juice squeezed from fresh fruit or made from concentrate?” * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** the United States sample only includes people aged 65 years or older.

Source: OECD PaRIS Database 2024.

Annex 3.E. Sleep quality among men and women

Annex Figure 3.E.1. Women report more sleep problems than men in all EU countries (2022)

Note: EU26 average is unweighted. Respondents aged 45 and older. Respondents were asked “Have you had trouble sleeping recently?”. Responses included “Trouble with sleep or recent change in pattern” and “No trouble sleeping”. Ireland is excluded due to data availability.

Source: SHARE‑ERIC (2024)

Note: Respondents were asked “Have you had trouble sleeping recently?”. Responses included “Trouble with sleep or recent change in pattern” and “No trouble sleeping”. Ireland is excluded due to data availability.

Annex 3.F. Levels of depression among men and women

Annex Figure 3.F.1. Women report more depressive symptoms than men in all EU countries (2022)

Note: EU26 average is unweighted. Respondents aged 45 and older. The EURO-D depression scale is a composite index of 12 items (depressed mood, pessimism, suicidality, guilt, sleep, interest, irritability, appetite, fatigue, concentration, enjoyment and tearfulness). The scale ranges from 0 “not depressed” to 12 “very depressed”. Ireland is excluded due to data availability.

Source: SHARE‑ERIC (2024).

Annex 3.G. Exposure to extreme cold

Annex Figure 3.G.1. Nearly 7 in 10 people in the EU were exposed to at least one icing day (<0°C) in 2023

Note: EU27 average is unweighted. This indicator presents the annual percentage of population exposed to n number of icing days (below 0°C). 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries.

Source: OECD (2025), Exposure to extreme temperature (database), OECD Data Explorer, http://data-explorer.oecd.org/s/2f7 (accessed 8, July 2025).

Notes

← 1.  Blood pressure screening rates (Figure 3.34) in Latvia are 30 p.p. higher in women than men, in Lithuania and Bulgaria differences are only about 5 p.p. higher for women than men.

← 2.  Lipoproteins transport lipids in the body to produce energy, hormones, bile acid and for deposit. In excess, small lipoproteins, such as low-density lipoprotein cholesterol (LDL-C), can accumulate in the arterial walls generating an atheroma. This process can lead to an atherosclerotic plaques that can limit blood flow to vital organs, such as the heart and brain, giving rise to the CVD (ESC, 2019[34]).

← 3.  respondents are people aged 45 and older that have used primary care services in the 6‑months prior to the survey (OECD, 2025[224]).

← 4.  14% of respondents to the Special Eurobarometer 506: Attitudes of Europeans towards tobacco and electronic cigarettes report having at least tried e‑cigarettes once or twice (EU, 2021[225]).

← 5.  A standard drink refers to a volume of beverage alcohol (e.g. glass of wine, can of beer, or mixed drink containing distilled spirits) that contains approximately the same amounts (in grammes or mL) of pure ethanol regardless of the type of beverage (European Commission, 2024[228]). In most EU countries, a standard drink is defined as containing 10 grammes of pure alcohol. Therefore, 100g of alcohol per week is equivalent to approximately 10 standard drinks (EC, 2024[227]).

← 6.  A standard drink refers to a volume of beverage alcohol (e.g. glass of wine, can of beer, or mixed drink containing distilled spirits) that contains approximately the same amounts (in grammes or mL) of pure ethanol regardless of the type of beverage (European Commission, 2024[228]). In most EU countries, a standard drink is defined as containing 10 grammes of pure alcohol. Therefore, 100g of alcohol per week is equivalent to approximately 10 standard drinks (EC, 2024[227]).

← 7.  The WHO has also recommended a 30% relative reduction in mean population intake of salt/sodium as part of the Global Action plan for the Prevention and Control of Non-Communicable Diseases (WHO, 2013[226]).

← 8.  See Figure 3.5 observing the same trend for hypertension specifically.

← 9.  A hazard ratio is a statistical measure used to compare the risk of a specific event occurring at any given time point between two groups; for example, a hazard ratio of 2.0 means the event is twice as likely to happen in one group compared to the other.