The State of Cardiovascular Health in the European Union

2. The burden of cardiovascular disease

Abstract

Cardiovascular disease (CVD) remains the leading cause of death and disability in the European Union, despite major declines in mortality since the 1970s. In 2022, CVD accounted for one in three deaths (1.7 million) and affected 62 million people, with significant gender, socio‑economic, and geographic disparities. The COVID‑19 pandemic disrupted progress, causing mortality increases in countries with already high CVD burden and widening East – West inequalities. Beyond its health impact, CVD imposes a heavy economic cost – over EUR 282 billion annually – driven by healthcare expenditures, productivity losses, and informal care. Premature mortality shortens working lives, while survivors experience poorer physical, mental, and social well-being compared to those without CVD.

In Brief

• There have been remarkable declines in mortality from cardiovascular disease (CVD) in the European Union (EU) since the 1970s, however, CVD remains the leading cause of morbidity and mortality in the EU, accounting for one‑in-three of all deaths (1.7 million deaths in 2022) and affecting an estimated 62 million people. The circumstances brought about by the COVID‑19 pandemic appear to have led to a deterioration of CVD outcomes in several EU countries, which had been improving in a pre‑pandemic period across all EU. European countries with the highest pre‑pandemic CVD mortality in 2019 showed absolute increases in CVD mortality rates in the years following, whereas those with low pre‑pandemic CVD mortality showed falls or no increase in CVD mortality. The wide geographical inequalities in CVD mortality within the EU show the significant potential there is for reducing the human, social and economic impacts of CVD in the EU. Reducing the rates of CVD, and disparities in them, would increase overall survival and life expectancy in Europe.

• Across EU countries, men consistently experience higher mortality due to CVD than women. In 2022, the average age‑adjusted mortality ratio for CVD was 43% higher among men than women on average. Although men exhibit higher rates of CVD mortality and morbidity overall, in some Eastern and Central EU countries, such as Hungary, Romania and Bulgaria, up to two‑thirds of all female deaths are due to CVD. While both Ischaemic heart disease (IHD) and stroke contribute significantly to CVD mortality, IHD is not only more prevalent but also far more lethal in men, including those at younger ages. Stroke, on the other hand, primarily affects older individuals and displays far less gender disparity.

• The excess of male over female mortality rates for CVD is significantly greater at ages under 65 compared to all ages. During the 2012‑2022-decade, premature mortality from CVD fell by an average for the EU of 20% in males and 23% in females, although there were large variations between countries. Premature CVD mortality increased in several EU countries during 2019‑2021, reflecting the impact of the pandemic, the increases being largest in some Central and Eastern European countries (Lithuania, Latvia, Romania and Bulgaria).

• CVD’s shortens human longevity; it also adds to the economic costs associated with curtailing working lives prematurely. EU countries are impacted on average by 1 301.9 potential years of life lost per 100 000 due to premature deaths as a result of CVD among people younger than 75. Approximately 256 million working days were lost in 2021 due to illness and disability, while 1.3 million working years were lost due to premature deaths. The total workforce impact is 47 billion Euro including lost productivity due to premature mortality and illness.

• CVD negatively effects people’s quality of life, and people living with CVD score lower on a breadth of dimensions of self-reported health and well-being compared to those with other chronic conditions. Using data from the OECD PaRIS survey, primary care users with CVD report lower overall well-being (4.5 percentage point (p.p.) difference), reduced social functioning (5.8 p.p. difference), worse physical health (1.8 p.p. difference), and poorer mental health (1.3 p.p. difference) as compared those without.

• Inequalities in CVD risk factors, prevalence, treatment, morbidity and mortality, between and within EU countries, are wide and an obstacle to improvements in population health and life expectancy. CVD burden is closely linked to socio‑economic status, with rates in people in lower income and education brackets experiencing higher prevalence, mortality, and worse health outcomes. Disparities are particularly pronounced for conditions like stroke and diabetes, where the prevalence among the lower-educated population is more than double that of their higher-educated counterparts. Data from the PaRIS survey show that individuals with lower income or educational attainment report poorer physical and mental well-being, more difficulty in managing their health conditions, and lower use of preventive care. Moreover, CVD, hypertension and diabetes impose a disproportionately heavy burden of ill health and mortality on disadvantaged socio‑economic groups, some ethnic minority groups, and people with serious mental illness and disabilities.

• CVD imposes a heavy economic burden on EU health systems and societies, estimated at over EUR 282 billion in 2021. This includes direct healthcare costs, productivity losses due to premature mortality and morbidity, and long-term disability care. Countries with high CVD prevalence and mortality – especially in Central and Eastern Europe – also bear disproportionately high costs relative to GDP. In 2021, the total societal cost of CVD in the EU was assessed to be higher than that of cancer, largely driven by the greater burden of informal care and higher health and social care costs associated with CVD.

Infographic 2.1. The burden of cardiovascular disease

2.1. Despite remarkable declines in CVD related mortality since the 1970s, it remains the leading cause of mortality and morbidity in the EU

The decline in mortality from CVD in recent decades has been one of the most remarkable successes of public health and modern medicine. Over the past 50 years, there have been significant increases in life expectancy in European countries, largely due to advances in preventing and treating CVD and its risk factors (OECD/The King's Fund, 2020[1]). During this period, the development and implementation of preventive public health strategies, and medical advances in managing and treating CVD, have resulted in significant declines in CVD morbidity and mortality. Between 1980 and 2005, CVD mortality rates as much as halved in several European countries (OECD/The King's Fund, 2020[1]). The Global Burden of Disease study shows that years of life lost to CVD in high-income countries have declined more rapidly than those for other major causes of death (ESC Cardiovascular Realities, 2024[2]) (Chong et al., 2024[3]).

Despite exceptional advances in preventing and managing CVD, it remains the biggest health challenge facing European Union (EU) countries (Table 2.1). It is the leading cause of death in the EU, accounting for one‑in-three of all deaths (1.7 million deaths in 2022) and affecting 62 million people (ESC EU 27 Cardiovascular Realities, 2025[4]). Ischaemic heart disease (IHD) is the largest contributor, responsible for almost one‑third (547 000 deaths) of all deaths from CVD. Cerebrovascular disease (stroke) is the second largest contributor, accounting for just over one‑fifth of all CVD deaths in the EU (350 000 deaths). Although CVD mortality rates are higher in men than in women across EU countries, more women than men die from CVD overall. This is because women live longer, and more of them reach the very old age groups where CVD is the leading cause of death. As a result, CVD accounts for a higher share of total deaths among women than among men.

The slowdown in the rate of decline in CVD mortality in Europe since 2011 has been a key driver of the reductions in life expectancy improvements that followed (OECD/The King's Fund, 2020[1]; Steel et al., 2025[5]). CVD affects all age groups, not just older people. Nearly a quarter (22%) of all premature deaths (before the age of 70) in the EU are caused by CVD (ESC Atlas of Cardiovascular Disease Statistics, 2024[6]). CVD also has a disproportionately heavy impact on some populations. It is a major cause of health inequalities between EU countries, and within EU countries among different geographical, socio‑economic and demographic sub-groups. In addition to the loss of, and impact on, human lives, the economic burden of CVD in EU countries exceeded EUR 282 billion in 2021 and is expected to increase further in the coming decades (ESC Atlas of Cardiovascular Disease Statistics, 2024[6]).

Table 2.1. CVD remains the leading cause of death in the EU over the past two decades

Cause of Death in the EU	Rank – 1990	Rank – 2021	Change
Cardiovascular diseases	1	1
Neoplasms	2	2
Respiratory infections & tuberculosis	8	3	‑5
Neurological disorders	4	4
Diabetes & chronic kidney diseases	6	5	‑1
Chronic respiratory	5	6	1
Digestive diseases	3	7	4
Unintentional injuries	7	8	1
Other non-communicable	11	9	‑2
Other COVID‑19 outcomes		10
Self-harm & Violence	10	11	1
Transport Injuries	9	12	3
Substance Use	12	13	1
Enteric infections	19	14	‑5
Maternal & neonatal	13	19	6
HIV / AIDS & sexually transmitted infections	14	20	6

Source: IHME GBD Compare.

The high burden of CVD in European countries, and its health and economic impacts, have been the topic of previous work by international organisations and research institutes (Health Systems Innovation Lab at Harvard University, 2022[7]; OECD/The King's Fund, 2020[1]; OECD, 2025[8]; OECD/European Commission, 2024[9]). However, better understanding the burden and causes of trends in CVD prevalence and mortality needs to take account of the linkages between CVD and other conditions – e.g. influenza and pneumonia, COVID‑19, diabetes, serious mental illness and drug overdoses – that increase the risk of dying from a CVD (OECD/The King's Fund, 2020[1]). On 3 December 2024, the EU Council of Ministers adopted Council Conclusions on the Improvement of Cardiovascular Health in the EU ,mandating the European Commission to take decisive action on cardiovascular health (Council of the European Union, 2024[10]).

This chapter examines the burden and impact of CVD on European health systems and people’s lives. It begins by providing an overview of how CVD affects population health and health service use across Europe. The chapter then turns to mortality patterns, presenting comparative data at the European level, with a focus on gender and geographic disparities. The analysis covers not only overall CVD mortality but also delves into two key components: ischaemic heart disease (IHD) and stroke (cerebrovascular disease) (see Box 2.1). Subsequent sections explore the social and economic inequalities associated with CVD, with disaggregated data by gender, education, income, and ethnicity wherever available. The chapter concludes with an assessment of the economic impact of CVD on European countries, highlighting the costs to health systems and society overall.

Box 2.1. Definitions of Cardiovascular Disease, Ischaemic Heart Disease and Stroke

Among CVD, the main causes of mortality relate to ischaemic heart diseases (i.e. diseases that involve reduced blood flow to the heart, including acute myocardial infarctions also commonly called heart attacks) and cerebrovascular diseases (strokes), which together accounted for over half of all deaths from circulatory diseases.

Cardiovascular Disease (CVD)

CVD refers to a class of diseases that affect the heart and blood vessels. It includes conditions such as coronary artery disease, cerebrovascular disease, rheumatic heart disease, peripheral arterial disease, and other disorders of the cardiovascular system. CVD is the leading cause of death globally and is largely preventable through lifestyle changes and effective management of risk factors such as hypertension, smoking, diabetes, and high cholesterol. Some data in this report refers to circulatory diseases. Circulatory diseases refer any condition affecting the circulatory system, which comprises the heart, arteries, veins, and capillaries – so it includes all CVDs and blood disorders.

Ischaemic Heart Disease (IHD)

Ischaemic heart disease, also known as coronary artery disease, is a type of CVD caused by narrowed heart arteries, which leads to reduced blood flow to the heart muscle. This can result in chest pain (angina), heart attacks (myocardial infarction), or heart failure. It is one of the most common types of CVD.

Acute myocardial infarction (AMI), generally known as a heart attack, is a serious medical condition that occurs when a plaque suddenly blocks the blood supply in a major branch of the coronary artery.

Stroke/Cerebrovascular Disease

A stroke occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. It can be ischaemic (due to a blocked artery) or haemorrhagic (due to a ruptured blood vessel). Stroke is a major cause of death and disability worldwide.

2.2. CVD related mortality increased in many EU countries during the COVID‑19 pandemic, most significantly in countries with high CVD mortality before pandemic

Between 2012 and 2022, mortality from circulatory diseases fell in every EU member state, with an average decline of 20% among men and 22% among women. Nevertheless, large differences persist while countries like France, Denmark or Spain reported rates below 220 deaths per 100 000 population in 2022, Bulgaria, Romania, Latvia still exceeded 800 deaths per 100 000. As shown in Figure 2.1, countries in Central and Eastern Europe experienced smaller reductions compared to Western and Southern European countries, contributing to a persistent – and in some cases widening – Central/East-West European mortality gap.

Figure 2.1. CVD mortality fell overall between 2012 and 2022, though gains have been slower than in previous decades

2022-2012 change in CVD age‑standardised mortality rates (ASMRs)

Note: EU27 average is weighted.

Source: Eurostat (hlth_cd_asdr2), 2025.

However, this progress was disrupted during the COVID‑19 pandemic. Countries with higher pre‑pandemic CVD mortality in 2019 experienced the largest percentage increases in age‑standardised mortality rates (ASMRs) between 2019 and 2021, with rises ranging from 10% to 21% in countries such as Romania, Bulgaria, and Latvia. By contrast, countries with already lower pre‑pandemic mortality – mostly in Western and Southern Europe – showed smaller increases or even continued declines. This divergence further widened regional inequalities in CVD mortality across the EU. It should be noted that these trends are influenced not only by changes in CVD outcomes, but also by the direct impact of COVID‑19 mortality, possible disruptions to health services, and other competing risks.1 For example, between 2019 and 2021, the mortality gap between Bulgaria and France increased from 6‑fold to 7‑fold among men, and from 6‑fold to 8‑fold among women. This pattern, clearly shown in the left panel of Figure 2.2, a scatter plot comparing pre‑pandemic mortality levels to the percentage change during the pandemic, underscores both persistent inequalities and the disproportionate impact of recent health crises on countries with higher baseline.

The right panel of Figure 2.2 extends this analysis to 2022. While some Central and Eastern European countries, such as Romania and Latvia, still exhibit elevated CVD mortality, the overall increases in 2022 are generally lower than those seen in 2021. Moreover, several Western and Southern European countries – including Portugal, Malta and Luxembourg – now show reductions in CVD mortality relative to 2019. This suggests that, despite the severe disruption experienced in the first two years of the pandemic, health systems across the EU have begun to recover, with improved continuity of care and the resumption of preventive services contributing to better cardiovascular outcomes. The contrast between 2021 and 2022 highlights not only the immediate strain imposed on health systems but also their capacity for adaptation and recovery. Nonetheless, these trends reinforce the need for sustained investment in resilient health systems that can protect vulnerable populations and mitigate the long-term impacts of future health crises.

Figure 2.2. CVD mortality increased between 2019-2021, particularly in countries with higher levels of pre‑pandemic CVD mortality

2022/21‑2019 change in CVD age‑standardised mortality rates (ASMRs) in relation to 2019 rates

Note: EU27 average is weighted.

Source: Eurostat (hlth_cd_asdr2), 2025.

The significant burden and existing inequalities associated with CVD were exacerbated by the COVID‑19 pandemic, as CVD is a major risk factor for severe COVID‑19 infection, hospitalisation and death (Bae et al., 2020[11]; Health Systems Innovation Lab at Harvard University, 2022[7]; Regional Health– Europe, 2021[12]). Furthermore, the pandemic disrupted the delivery of healthcare services for people with non-COVID‑19 conditions, and delays in people seeking care as a result of the pandemic, impacted adversely on health outcomes for people living with CVD (Regional Health– Europe, 2021[12]; OECD, 2021[13]; Khan et al., 2023[14]). For example, during the early months of the pandemic hospital admissions for cardiovascular events, including acute myocardial infarction and stroke, fell by 40% or more in many countries, including Austria, France, Germany, Greece, Spain, the United Kingdom and the United States; there was also evidence of an increase in case fatality and complication rates for myocardial infarction (OECD, 2021[13]). In the United Kingdom almost half a million fewer people initiated antihypertensive treatment from March 2020 to May 2021 compared to 2019 (CVD-COVID-UK Consortium, 2023[15]).

Excess mortality overall during the pandemic was highest in some Central and Eastern European countries (Pizzato et al., 2024[16]), caused largely by COVID‑19, but the concurrent rise in CVD mortality in these countries will have contributed to this. The interactions between COVID‑19 and the cardiovascular system are multiple, with direct and indirect effects on the cardiovascular system leading to numerous and life‑threatening cardiovascular complications e.g. myocardial infarction, heart failure, Takotsubo cardiomyopathy, myocarditis and arrhythmias (Krishna et al., 2024[17]; Regional Health– Europe, 2021[12]). Since 2019, life expectancy in most EU countries has reverted to or is higher than pre‑pandemic levels as of 2023, healthcare systems need to be vigilant and have good surveillance and monitoring systems. COVID‑19 is still claiming lives and the CVD impacts of Long COVID will continue to be felt in the coming years. The interactions between CVD and COVID‑19 and other respiratory diseases including influenza remain an ongoing concern for healthcare systems in the EU, as the severity and spread of these respiratory viruses can vary from year to year, highlighting the need for continued surveillance and monitoring, stronger integration of public health and cardiovascular care strategies, and investment in resilient health systems capable of protecting vulnerable populations during future crises.

2.2.1. CVD mortality rates differ significantly across EU: By seven‑fold for men, and eight‑fold for women

EU countries differ vastly in the magnitude of cardiovascular mortality, with Central and Eastern European countries experiencing both higher rates and younger ages at death; the CVD mortality burden is highest in northeastern Europe (Bugiardini, 2023[18]; Cenko et al., 2023[19]).These countries also have the highest overall burden of CVD (in terms of incidence, mortality, DALYs) among people aged 55 and over (Cenko et al., 2023[19]).

In 2022, the EU average age‑standardised mortality rate (ASMR) for circulatory disease was 404 and 283 per 100 000 population for males and females respectively. The rates ranged from 222 and 135 per 100 000 population in males and females respectively in France to 1 338 and 890 in males and females respectively in Bulgaria, a six to seven‑fold variation (see Figure 2.3). This large gap is characteristic of a more general geographical pattern across the EU, with higher rates in Central and Eastern European countries. For example, male and female ASMRs rates were four times higher in Romania, Latvia and Lithuania than in Norway, Spain and Luxembourg.

In most EU countries, the mortality rate from circulatory diseases is about 26‑60% higher in males than in females (the EU average being 43%) except in Finland, Latvia, Estonia, France and Denmark where it is over 60% higher. Although CVD mortality rates are higher in males than in females in all EU countries, as in most countries globally, in all EU countries CVD claims a larger number of lives in females than in males; it also claims a larger proportion of total deaths in females than in males (ESC EU 27 Cardiovascular Realities, 2025[4]). This may seem counterintuitive at first but is a result of longer life expectancy in women. The proportion of total deaths attributable to CVD is higher in Central and Eastern European countries than in Western European countries, especially among females. In Estonia, Hungary, Lithuania, Latvia, Romania and Bulgaria half to two‑thirds of total deaths among females are attributable to CVD.

Figure 2.3. CVD Age‑Standardised Mortality Rates reveal persistent regional inequalities in Europe

CVD ASMRs per 100 000 population, 2022

Note: EU27 average is weighted.

Source: Eurostat (hlth_cd_asdr2), 2025.

In the EU, mortality from CVD, IHD and stroke is higher in males than in females in each case (OECD/European Commission, 2024[9]; Peters and Woodward, 2022[20]). Mortality rates from IHD showed wider differentials by sex (a 10‑fold variation in males and 16‑fold variation in females) than mortality from circulatory diseases overall. The average mortality rate for males in the EU was almost double the rate in females (Figure 2.4). The sex differential in mortality from IHD was greater in Western and Southern European countries than in Central and Eastern European countries: in the former mortality from IHD was about 2‑2.2 times higher in males than in females, whereas in the latter it was 1.6‑1.8 times higher. Hence Central and Eastern European countries have both higher IHD mortality rates and a smaller differential in mortality rates between males and females compared with Western and Southern EU countries.

Mortality rates from stroke showed smaller differentials by sex than mortality from IHD and circulatory diseases overall, the average for the EU being 24% higher mortality in males than females (Figure 2.5). The male‑female differentials also showed less regional variation, with little or no difference in male and female mortality rates from stroke in Ireland, Iceland and the Netherlands and a moderate excess of male mortality of about 30% or less in most Western European countries. In several Central and Eastern European countries male mortality rates from stroke exceeded female mortality rates by 30‑50%, like the case of Bulgaria.

Higher CVD mortality in Central and Eastern European countries is attributed to the higher prevalence of smoking, obesity, harmful alcohol consumption, physical inactivity and differences in the efficacy of public health policies and quality of care (Sørensen and Bredahl Kristensen, 2023[21]; Wang et al., 2023[22]). Life expectancy in these countries is significantly lower than that in the rest of Europe, largely due to the high burden of CVD (Cenko et al., 2023[19]; Steel et al., 2025[5]). In Western and Southern European countries, there have been substantial declines in CVD mortality rates in recent decades.

Figure 2.4. IHD mortality rates vary 8 to 10‑fold between EU countries for men and women, respectively

IHD ASMRs per 100 000 population, 2022

Note: EU27 average is weighted.

Source: Eurostat (hlth_cd_asdr2), 2025.

Figure 2.5. Stroke mortality rates vary 10‑fold between EU countries for both men and women

Stroke ASMRs per 100 000 population, 2022

Note: EU27 average is weighted.

Source: Eurostat (hlth_cd_asdr2), 2025.

Figure 2.6 plots male‑to-female mortality ratios against 2022 ASMRs for IHD and stroke. For IHD, a clear negative association is observed (R² = 0.52): countries with higher overall IHD mortality tend to show smaller male‑to-female mortality ratios, meaning that the gender gap narrows as total mortality increases. In countries where IHD mortality is relatively low – such as France, Cyprus and Spain – men are disproportionately more affected than women. In contrast, countries with high IHD mortality, such as Hungary, Lithuania and the Slovak Republic, record lower male‑to-female ratios, suggesting that the relative excess mortality among men diminishes as overall mortality rises. This pattern implies that while IHD remains a leading cause of death for both sexes, the relative disadvantage for men is greatest in countries that have already achieved low levels of IHD mortality. This highlights the need to continue reducing male IHD mortality across the EU – particularly in Central and Eastern European countries – while also addressing the persistently high levels of female IHD mortality in those same settings, as reflected in the smaller gender gaps.

For stroke, the association between overall mortality and male‑to-female ratios is weaker and slightly positive (R² = 0.15). Countries with higher stroke mortality, such as Bulgaria, Romania and Latvia, tend to have somewhat larger gender gaps, whereas those with lower mortality, including Norway, Greece and the Netherlands, show narrower differences. However, the range of sex ratios for stroke is small (all below 1.4), indicating that gender disparities are modest and not systematically related to overall mortality levels. This likely reflects differences in the age profile and clinical nature of stroke compared with IHD, where sex-related mortality patterns are more pronounce.

These patterns provide valuable insights for cardiovascular health policy, underscoring the importance of a stronger focus on IHD among men across the EU. This is particularly urgent given that IHD accounts for nearly one‑third of all CVD deaths, many of which are attributable to modifiable and preventable risk factors (Cherla et al., 2024[23]). At the same time, the lower male‑to-female mortality ratios observed in countries with high IHD mortality – such as those in Central and Eastern Europe – suggest that female IHD mortality in these settings is unduly high relative to that of men. This points to the need for prevention and early detection efforts to address both sexes. Furthermore, IHD remains a major contributor to the excess mortality observed in Central and Eastern European countries, highlighting the need for more targeted prevention, early detection, and intervention strategies. Beyond mortality, the broader health consequences of both IHD and stroke should also be considered. Stroke, in particular, can have devastating long-term effects on mental well-being, often leading to behavioural changes, cognitive impairment, and conditions such as memory loss and dementia (Rost et al., 2022[24]).

Figure 2.6. Sex differences in cardiovascular mortality are greater for IHD than for stroke, and show a strong negative association with IHD mortality rates

Note: EU27 average is weighted.

Source: Eurostat (hlth_cd_asdr2), 2025.

2.3. There are large geographical disparities in CVD mortality across EU countries

As highlighted in the previous section, the burden of CVD morbidity and mortality varies significantly between EU countries (ESC Cardiovascular Realities, 2024[2]), with countries in Central and Eastern Europe experiencing significantly higher rates compared with Western European countries (Mensah et al., 2023[25]), with the highest CVD disease burden is reported for countries in Northeastern Europe (Cenko et al., 2023[19]). Mensah et al. note from the GBD study that age‑standardised mortality rates for CVD among countries in Central Europe ranged from 132.6 to 581.4 per 100 000 in 2022; a 4.4‑fold difference (Mensah et al., 2023[25]). They note that the variation among countries in Central and Eastern Europe ranged from 215.0 to 553.0 per 100 000, a 2.6‑fold difference, and among Western European countries the 2.5‑fold difference was similar (ranging from 80.2 to 199.9 per 100 000).

The geographic distribution of CVD mortality across Europe reveals significant regional disparities (Figure 2.7). Western and Southern European regions, including much of France, Spain, and parts of Italy, exhibit the lowest mortality rates, generally falling below 244.43 deaths per 100 000 population. These areas are represented in lighter orange shades, suggesting relatively effective public health interventions, better access to preventive care, and healthier lifestyle patterns. In contrast, Central and Eastern European regions – particularly in countries such as Bulgaria, Romania, and parts of the Baltic states – show significantly higher mortality rates, often exceeding 520.36 deaths per 100 000, as indicated by dark blue shading. These disparities may reflect systemic differences in healthcare infrastructure, socio‑economic conditions, and the prevalence of risk factors such as smoking, poor diet, and limited physical activity. Several countries also display considerable variation between regions and intra-national disparities. For instance, while northern Italy shows relatively low CVD mortality, southern regions tend toward higher rates. Similarly, in Germany, regional differences suggest that national averages may obscure localised cardiovascular health challenges.

Figure 2.7. CVD continues to drive excess mortality in Central and Eastern European countries

Note: Data represent standardised death rates (SDR) per 100 000 inhabitants due to diseases of the circulatory system (ICD‑10 I00–I99) by NUTS 2 region of residence, sourced from Eurostat. The SDRs follow Eurostat’s standard age‑standardisation method using the European Standard Population (2013). Data for Portugal are incomplete due to a mismatch between Eurostat’s NUTS‑2021-based indicator and Portugal’s use of NUTS‑2024 for 2022 data. This affects only regional breakdowns.

Source: Eurostat (hlth_cd_asdr2), 2022.

2.4. Premature and avoidable mortality from CVD shortens working lives

Premature mortality (deaths below a specified age limit) refers to deaths that occur at a younger age than expected and is often used as a measure of the burden of potentially preventable deaths and for assessing the effectiveness of public health and healthcare systems. It also has consequences for economic costs and the loss of productivity because of working lives cut short. The age limit used differs between data sources; for the Eurostat data discussed here the age limit is 65 years (some data sources use 70 or 75 years as the upper limit). Because of the small number of premature deaths in countries with smaller populations, the discussion below is limited to EU countries with larger populations. In 2022, the average mortality rate from CVD at ages under 65 for the EU was 61 and 20 per 100 000 population in males and females respectively (Figure 2.8). Mortality rates showed a 6‑ to 9‑foldvariation in mortality in males between some Central and Eastern European countries (e.g. Bulgaria, Latvia, Romania) and Western European countries (e.g. Norway, the Netherlands, Belgium). The range was more moderate in females at 4‑ to 8‑fold.

Figure 2.8. The CVD mortality rate for men under age 65 is more than three times that for women in the same age category

CVD ASMRs under 65, 2022

Note: EU27 average is weighted.

Source: Eurostat (hlth_cd_asdr2), 2025.

The excess of male over female mortality rates for CVD is significantly greater at ages under 65 compared to all ages. During the 2012‑2022-decade, premature mortality from CVD fell by an average for the EU of 20% in males and 23% in females, although there were large variations between countries. As already mentioned, premature CVD mortality increased in several EU countries during 2019‑2021, reflecting the impact of the pandemic, the increases being largest in some Central and Eastern European countries (Lithuania, Latvia, Romania, Bulgaria) (Cherla et al., 2024[23]).

2.4.1. Over 60 million potential years of life lost are attributable CVD each year in

Deaths from CVD in those aged <70 years, commonly referred to as premature, are a particular concern, with more than 60 million potential years of life lost to CVD in Europe annually (Townsend et al., 2021[26]). Potential years of life lost (PYLL) is a summary measure of premature mortality, providing an explicit way of weighting deaths occurring at younger ages, which may be preventable. The upper limit used for calculating PYLLs varies depending on the data source. Between 1995 and 2020, avoidable deaths from CVD in the European Union declined markedly, though disparities remain. Using WHO mortality data and OECD/Eurostat definitions, 11.4 million avoidable CVD deaths – mainly due to IHD – accounted for over 213 million potential years of life lost. Mortality reductions were substantial (−57%) but uneven across sex, age, and regions, with persistent though narrowing gaps between males and females and between Eastern and Western Europe (Cherla et al., 2024[23]). PYLL from CVD also shows large gender gaps, with men consistently experiencing higher premature mortality than women. On average, men in EU countries lose 1 664 years and women lose 540 years of life annually per 100 000 population due to CVD (Figure 2.9). In Bulgaria, men lose 4 848 years per 100 000 population, more than twice the 1 831 years lost by women. Similar patterns are seen in Latvia (4 262 vs. 1 059), Romania (3 451 vs. 1 132) and Lithuania (2 861 vs. 785).2

Figure 2.9. On average, men in EU countries lose 1 664 years and women lose 540 years of life annually per 100 000 population due to CVD

Note: EU22 average is unweighted. Data from 2023. Countries marked with an asterisk (*) are represented with 2022 data.

Source: OECD, 2025.

2.4.2. CVD mortality is a major factor slowing life expectancy gains

Between 1990 and 2011, reductions in deaths from CVD and cancers led to substantial improvements in life expectancy in European countries and the United Kingdom (Steel et al., 2025[5]). In 2018, OECD reported on the slowdown in improvements in life expectancy in many European countries after 2011 and called for further analysis to better understand the relative contributions of different factors (Raleigh, 2019[27]). Evidence now shows that deaths from CVD were the primary driver of the reduction in life expectancy improvements seen across Europe between 2011‑2019 (OECD/The King's Fund, 2020[1]; Steel et al., 2025[5]).

The COVID‑19 pandemic caused life expectancy to fall between 2019‑2021 in most but not all European countries. Increases in CVD mortality will have contributed to these falls in life expectancy. The countries that best maintained gains in life expectancy after 2011 (Norway, Iceland, Sweden, Denmark and Belgium), maintained or boosted life expectancy even during the pandemic; these countries had fewer heart disease and cancer deaths (Steel et al., 2025[5]). Although by 2023 life expectancy in most EU countries had recovered to or exceeded the pre‑pandemic 2019 level, as a leading cause of death, trends in mortality from CVD will be a significant determinant of trends in life expectancy in EU countries in the foreseeable future. CVD remains one of the leading health challenges for the EU, especially in the wake of the COVID‑19 pandemic.

An analysis of trends in avoidable (preventable and treatable) mortality from CVD at ages under 75 in EU countries between 1995 and 2020 by Cherla et al. found that 11.4 million deaths were avoidable, resulting in 213.1 million potential life years lost (Cherla et al., 2024[23]). Nearly 2 of every 3 deaths were in males and 2 of every 5 deaths were in working age adults (25‑64 years). More CVD deaths were considered treatable (52.3%) than preventable (47.7%). IHD followed by cerebrovascular disease and hypertensive diseases were the leading causes of avoidable CVD mortality, together accounting for 89% of avoidable cardiovascular deaths.

People with CVD face poorer health and well-being outcomes than those with any other chronic disease CVD is a leading cause of disability and premature death, and the results highlight the broader impact it has on people’s lives beyond clinical outcomes. Across all measured dimensions – well-being, social functioning, physical health, and mental health – people with CVD report significantly worse outcomes than their peers without CVD. These findings are consistent with existing literature showing that CVD affects multiple aspects of patients’ lives beyond physical symptoms. Physical limitations caused by CVD – such as fatigue, shortness of breath, and reduced exercise capacity – restrict mobility and hinder participation in social and leisure activities, contributing to feelings of isolation and lower social functioning (Mavaddat et al., 2014[28]). The psychological burden is also substantial: people living with CVD often face increased anxiety and fear of recurrent cardiac events, as well as challenges in adapting to lifestyle changes and long-term medication regimens, all of which can exacerbate depressive symptoms and reduce overall mental health (Borkowski and Borkowska, 2024[29]). Furthermore, multimorbidity is highly prevalent among CVD patients and is strongly associated with poorer self-rated health and lower quality of life, sometimes even more than the presence of CVD alone (Skou et al., 2022[30]) (Dunlay and Chamberlain, 2016[31]). Evidence from OECD also highlights that while improved acute care has reduced mortality, many patients continue to struggle with long-term consequences and ongoing disability (OECD, 2015[32]).

Box 2.2. The OECD Patient-Reported Indicator Survey of People Living with Chronic Health Conditions (PaRIS)

The OECD’s Patient-Reported Indicator Surveys took place in 2023/24 and resulted in a dataset of 107 011 patients linked to 1 816 primary care practices across 19 countries: Australia, Belgium, Canada, Czechia, France, Greece, Iceland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Romania, Saudi Arabia, Slovenia, Spain, Switzerland, the United States and Wales (United Kingdom). The main instrument is a survey among primary care service users aged over 45 years who accessed primary care services in the last six months. An additional survey among their primary care practices collected data on the characteristics of the practices and the primary care services provided.

Source: OECD (2025[8]), Does Healthcare Deliver?: Results from the Patient-Reported Indicator Surveys (PaRIS), https://doi.org/10.1787/c8af05a5-en.

The PaRIS survey uses a multilevel analysis approach, accounting for differences at the country, primary care practice, and patient levels. Among the PaRIS population living with chronic conditions, we examined four different patient-reported outcome measures (PROMs) – well-being, social functioning, physical health, and mental health – in two groups: those who self-reported having cardiovascular or heart disease, and those who did not. Well-being levels (Figure 2.10) are consistently lower (4.5‑point difference for the EU 11 average) among people with CVD. In all countries surveyed, the average well-being score for people with CVD falls below that of people without CVD by several points. This highlights the enduring toll that cardiovascular conditions can take on overall life satisfaction.

Figure 2.10. Living with CVD is associated with lower levels of well-being among people living with chronic conditions

Note: EU11 average is unweighted. WHO‑5 well-being index. Response to five questions measuring well-being. raw scale 0‑25 converted to 0‑100 scale, higher scores represent higher well-being. *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. Sorted by people living with CVD. Differences between people living with CVD and people living without CVD are statistically significant (p<0.05) for all countries, except for Belgium and the United States.

Source: OECD PaRIS Database, 2024.

Social functioning (Figure 2.11) shows a similar pattern, with people with CVD reporting lower ability to participate in social activities or maintain social relationships (5.8 p.p. difference for the EU 11 average). The gap is especially wide in countries such as Spain, Italy and Greece. Countries such as France and Slovenia report narrower differences, suggesting more inclusive health and social environments for people with CVD.

Figure 2.11. CVD widens the social gap among people living with chronic conditions

Note: EU11 average is unweighted. PROMIS® Scale v1.2 – Global Health. Answer to the question: “In general, please rate how well you carry out your usual social activities and roles [further specified in questionnaire]”, “good, very good or excellent” versus “fair or poor”. *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. Sorted by people living with CVD. Differences between people living with CVD and people living without CVD are statistically significant (p<0.05) for Czechia, Greece, the Netherlands, Italy, Spain, Canada, Australia, Wales.

Source: OECD PaRIS Database, 2024.

Physical health (Figure 2.12) is where the gap between those with and without CVD is most marked (1.8‑point difference for the EU 11 average). These findings point to the significant physical limitations and daily life constraints experienced by people living with CVD. Likewise, mental health scores (Figure 2.13) also tend to be lower among people with CVD (1.3‑point difference for the EU 11 average). The lowest absolute mental health scores for people with CVD are observed in countries such as Italy, Romania and Portugal. These results align with broader research showing higher rates of depression and anxiety among people with cardiovascular conditions, as well as the impact of mental ill health as a risk factor for CVD (see Chapter 3).

I sometimes feel more tired than others, both physically and mentally. I am learning to say ‘No’ to social events when I don’t feel up to it, but I am often worried other people won’t understand my point and just think I am lazy and rude. I have decided to ask for a part-time because working 8 hours a day didn’t allow me to save energy for other activities such as walks/yoga which I really need to do.

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

Figure 2.12. People with CVD report the poorest physical health scores among people living with chronic conditions

Note: EU11 average is unweighted. PROMIS® Scale v1.2 – Global Health component for physical health is based on responses to four questions measuring physical function, pain, and fatigue (response options 1‑5). Raw scores (4‑20) are converted to a T-score metric, where 50 represents the mean and 10 the standard deviation of the PROMIS reference population, with a range of 16.2‑67.7. Higher T-scores indicate better physical health..1*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. Sorted by people living with CVD. Differences between people living with CVD and people living without CVD are statistically significant (p<0.05) for all countries, except for the United States. ***Spain had the highest response rate, which may have negatively affected the outcomes due to the broader inclusion of more socially disadvantaged groups.

Source: OECD PaRIS Database, 2024.

Figure 2.13. Mental Health outcomes are slightly worse for people living with chronic conditions who report having CVD

Note: EU11 average is unweighted. PROMIS® Scale v1.2 – Global Health component for mental health is based on responses to four questions on quality of life, emotional distress, and social health (response options 1‑5). Raw scores (4‑20) are converted to a T-score metric, where 50 represents the mean and 10 the standard deviation of the PROMIS reference population, with a range of 21.2‑67.6. Higher T-scores indicate better mental health.*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. Sorted by people living with CVD. Differences between people living with CVD and people living without CVD are statistically significant (p<0.05) for Czechia, Spain, Romania and Wales.

Source: OECD PaRIS Database, 2024.

2.5. CVD leads to over 9.2 million hospital admissions across 22 EU countries each year

2.5.1. CVD are the most common cause of hospitalisation in almost all EU countries

Hospital discharge rates are closely linked to other indicators like disease prevalence, severity, and healthcare system efficiency. Higher prevalence of a condition, such as CVD, often leads to more hospital admissions and, consequently, higher discharge rates. High quality healthcare delivery, including early detection and effective primary care management, can reduce hospital admissions and impact discharge rates. Conversely, areas with limited healthcare access may have lower discharge rates due lower levels of hospital use, higher in-hospital mortality or longer hospital stays.

CVD were the leading cause of hospitalisations across EU Member States in 2023, except for Ireland, Romania and Croatia. In Romania and Croatia, circulatory diseases where the second leading cause of hospitalisation (Eurostat, 2023[33]).3 In 2023, Bulgaria recorded the highest hospital discharge rate for CVD across OECD countries, with 4 094 discharges per 100 000 population, well above the EU average of 2 133 (Figure 2.14). Germany (3 368) Latvia (3 232) and Lithuania (3 144) also reported high discharge rates, with lowest rates observed in Ireland (1 125), Iceland (995) and Portugal (710).

Figure 2.14. There is significant variation in CVD hospital discharge rates across EU

Note: EU22 average is unweighted. Data from 2023. Data for countries with and asterisk (*) refer to the year 2022. Portugal refers to 2024.

Source: OECD, 2025.

Hospital discharge rates for the specific conditions of stroke and acute myocardial infarction (AMI) vary widely across EU countries. Stroke leads to more hospitalisations. In 2023, the EU average stroke discharge rate stood at 387 per 100 000 population – with a five‑fold difference between the highest and lowest discharge rate in countries (Figure 2.15). Bulgaria (822) and Latvia (709) reported the highest rates. In contrast, Iceland (163) and Ireland (179) reported substantially lower stroke discharge rates. For AMI, the EU average for hospital discharges in 2023 was 173 discharges per 100 000 population – a rate that differs 4‑fold between EU countries. Lithuania reported a markedly higher rate than the EU average of 272, followed by Germany (247). These high figures likely indicate elevated AMI incidence, which may be linked to lifestyle‑related risk factors, socio‑economic disparities, and limitations in preventive care or early management. Romania (97) and Portugal (69) reported the lowest discharge rates for AMI.

Figure 2.15. Hospital discharges for stroke are double that of AMI

Discharges per 100 000 persons

Note: EU22 average is unweighted. Data from 2023. Data for countries with and asterisk (*) refer to the year 2022. Portugal refers to 2024.

Source: OECD, 2025.

2.5.2. In addition to being frequent events, hospital stays for CVD are often extended

Prolonged hospital stays place a significant burden on people leaving with CVD through lost income and reduced quality of life, while also straining healthcare systems and national economies due to high treatment costs and resource needs. The average length of stay for patients hospitalised with CVD varies based on factors such as disease severity, treatment type, patient demographics, and health system design, varying significantly across EU countries, averaging eight days in the EU (Figure 2.16). In 2023, countries such as Bulgaria and Norway reported relatively short stays, averaging 4.1 and 4.3 days, respectively. Hungary and Austria recorded notably longer hospital stays, averaging 11.7 and 10.6 days, respectively. Overall, the CVD length of stay is slightly longer than the average length of stay for all causes, which averaged 7.4 days in EU countries in 2023–and the two are highly related ((R²) 0.61).

Differences in CVD length of stay across countries are influenced not only by disease severity but also by variations in care models, discharge planning, rehabilitation services, social support, and even hospital registration practices (Jang et al., 2020[34]) (Moura et al., 2023[35]). The findings from Bulgaria and Norway are particularly interesting: both report short stays, but likely for different reasons – resource constraints in Bulgaria versus strong integrated care and rehabilitation systems in Norway. This highlights that shorter hospital stays should not automatically be interpreted as a sign of greater efficiency. Without adequate post-discharge follow-up and community-based support, shorter stays may increase the risk of readmission and worsen patient outcomes.

Figure 2.16. The EU average for CVD hospital length of stay is eight days

Note: EU22 average is unweighted. Data from 2023. Data for countries with and asterisk (*) refer to the year 2022. Portugal refers to 2024.

Source: OECD, 2025.

Stroke patients generally require longer hospitalisation due to the severity of neurological impairments – such as paralysis or speech loss – and the need for early rehabilitation. In 2023, the EU average for stroke‑related hospital stays was 12.7 days, with an almost 13‑day difference between the longest and shortest average stroke related hospitalisation in countries. The shortest average stays were in Bulgaria (5.4 days) and the Netherlands (6.3 days) (Figure 2.17). Austria (19 days), the United Kingdom (18.7 days) and Czechia (18.6 days) reported the longest stays, indicating more prolonged recovery periods within hospital settings. Hospital stays for AMI have been modestly decreasing on average in OECD countries – by half a day between 2010 and 2022. The EU average length of stay for AMI was 6.3 days in 2022. Sweden led with the shortest hospitalisation time at just 3.8 days – approximately six days less than the countries with the longest average hospital stay for AMI, Germany and Lithuania (9 and 9.6 days respectively). A broad variation in hospitalisation lengths for CVD across countries may reflect systemic differences in population health status, health system efficiency, clinical guideline adherence, and discharge effectiveness (OECD, 2023[36]). Shorter stays in some countries may indicate better management of CVD episodes through integrated care models and early intervention.

Figure 2.17. Stroke patients in the EU typically experience hospital stays twice that of AMI patients

Hospital average length of stay in days

Note: EU22 average is unweighted. Data from 2023. Data for countries with and asterisk (*) refer to the year 2022. Portugal refers to 2024.

Source: OECD, 2025.

2.6. Gender inequalities significantly affect care and, consequently, health outcomes of CVD

Gender inequalities significantly affect awareness, prevention, diagnosis, management, and outcomes of CVD. Research across European countries has demonstrated substantial gender disparities, particularly in awareness and recognition of coronary artery disease (CAD). Women exhibit notably lower levels of awareness regarding CAD compared to men, with social inequalities exacerbating this gender gap, especially among lower socio‑economic groups (Daponte-Codina et al., 2022[37]). Women’s lower awareness of CVD partly reflects their historical exclusion from prevention strategies, research, and the broader cardiovascular health discourse (Burgess et al., 2025[38]). This gap is further compounded by public campaigns and medical education that have predominantly framed male symptom patterns as the norm, leaving women less likely to recognise their own symptoms or seek timely care. For the broader population, strengthening CAD awareness remains crucial to reducing CVD morbidity and mortality. The tendency of women to prioritise other health conditions with lower epidemiological impact underscores the need for gender-responsive and targeted awareness strategies.

In primary care settings, assessment and management of cardiovascular risk factors are markedly influenced by gender. Cardiovascular risk factors are frequently under-assessed and undertreated in women compared to men (Hyun et al., 2017[39]). This discrepancy partly arises from the different symptom patterns often presented by women, which may not align with the traditional – male‑based – clinical descriptions of CVD, complicating timely diagnosis and intervention. Such clinical oversight persists largely due to diagnostic and intervention practices traditionally based on data predominantly derived from male populations, reinforcing gender biases in clinical approaches (BHF, 2019[40]).

Although CVD affects more men than women overall, there are gender differences in the diagnosis and management of CVD.  International evidence shows that women at risk of or with CVD are less likely to be prescribed medication (Zhao et al., 2020[41]), included in randomised clinical trials (Melloni et al., 2010[42]) and more likely to be misdiagnosed, have a worse prognosis and higher mortality than men after acute CVD events (Gao et al., 2019[43]; Wenzl et al., 2022[44]). Data for England also shows gender differences in prescribing for CVD and related conditions (Bostock, 2021[45]; Pinho-Gomes et al., 2020[46]), and lower uptake of cardiac rehabilitation (BHF, 2019[40]).

When I suffered my stroke, I was misdiagnosed. “She’s too young (34) to have a stroke”, “Maybe it’s ‘only’ an anxiety crisis”. Being a woman was against me when I needed emergency care.

Diana, 48, stroke survivor.

A survey of 2 609 people from six European countries (Bulgaria, Croatia, Czechia, Germany, Spain and Sweden) of awareness about heart disease in 2017‑2018 showed that women were approximately one‑fifth as likely as men to consider heart disease as a main health issue or leading cause of death, and were significantly less likely to have ever had a cardiovascular screening test (Daponte-Codina et al., 2022[37]). Only about 16% of respondents were able to identify the symptoms of a heart attack. These findings highlight not a deficit of awareness among women, but the long-standing failure of health systems, research agendas and public communication to address women’s cardiovascular health adequately. Historically, prevention campaigns, clinical training and medical research have been designed primarily around male symptom profiles and experiences, leaving women less likely to be informed, screened or treated in a timely manner. Addressing these systemic and structural gaps requires gender-responsive prevention and education strategies that promote equitable access to information, screening and care (Vogel et al., 2021[47]).

Clinical outcomes following cardiovascular events such as heart attacks further underscore these gender inequalities. Female patients experiencing heart attacks face higher mortality rates when treated by male physicians rather than female physicians (Greenwood, Carnahan and Huang, 2018[48]). This finding highlights the life‑saving benefits of patient – physician gender concordance and emphasises the importance of targeted medical training to address gender biases in clinical practice. Symptom recognition in cardiovascular events differs significantly between genders, affecting women’s timely access to care. Women frequently experience atypical symptoms such as fatigue, shortness of breath, nausea, or back pain, as opposed to the characteristic chest pain often presented by men (American Heart Association, 2021[49]). Similarly, stroke symptoms in women, including fatigue, confusion, and generalised weakness, often lead to delayed recognition and management (American Heart Association, 2019[50]).

Sex-specific biological differences significantly influence pharmacological treatment efficacy and the incidence of adverse drug reactions in women. Women experience higher rates of adverse reactions due to physiological variations affecting drug metabolism and pharmacodynamics (Lacroix et al., 2023[51]). Notably, gender-specific variations are particularly pronounced in statin therapy, where women exhibit variable therapeutic responses and increased sensitivity to side effects, underlining the importance of gender-specific pharmacological guidelines (Raparelli et al., 2017[52]). Addressing gender inequalities in cardiovascular healthcare requires comprehensive integration of gender-specific knowledge into clinical research, healthcare delivery, and public policy. The Lancet Women and Cardiovascular Disease Commission (Vogel et al., 2021[47]) underscores the necessity for global initiatives promoting the integration of sex- and gender-specific data into clinical practice. Policies facilitating the creation of gender-sensitive healthcare frameworks are essential for effectively addressing chronic conditions prevalent among women (Temkin et al., 2023[53]). Furthermore, structural adjustments in healthcare systems to accommodate gender differences are imperative. Integrating gender-specific diagnostic criteria and treatment protocols within healthcare systems would enable earlier diagnosis, improved management strategies, and better patient outcomes for women affected by CVD (Maas and Appelman, 2010[54]).

CVD affects men and women differently across the lifespan, requiring distinct yet equally important policy responses. Men tend to experience a higher CVD burden overall, with elevated mortality and earlier onset of conditions such as ischaemic heart disease. In contrast, women often face disparities in diagnosis and management, which can lead to delays in treatment and poorer outcomes (Patwardhan et al., 2024[55]). Women are also more likely to develop certain types of CVD that are less common in men, such as spontaneous coronary artery dissection (SCAD), which accounts for up to 70% of SCAD cases and predominantly affects younger or middle‑aged women without traditional cardiovascular risk factors (Yang, Offen and Saw, 2024[56]). These are both critical issues that demand targeted approaches: prevention efforts, including addressing modifiable risk factors, would benefit from a stronger focus on men, while improving clinical recognition, diagnosis, and management of CVD in women warrants greater policy attention. (Lock et al., 2021[57]). It is important to maintain a balanced perspective. Placing disproportionate emphasis on one set of disparities can lead to bias; both male and female CVD burdens should be addressed with equal consideration through evidence-based, gender-sensitive policy recommendation.

To mitigate gender disparities, healthcare policies can address structural biases and systemic barriers within healthcare systems. Rather than focussing solely on increasing the representation of women in cardiology, policies can better promote gender-sensitive clinical practice and ensure that all healthcare providers – regardless of gender – are equipped to deliver equitable care. This includes providing targeted training on recognising diverse symptom patterns, addressing implicit bias in diagnosis and treatment, and creating clinical environments that support unbiased decision making (Greenwood, Carnahan and Huang, 2018[48]). To strengthen equity in cardiovascular care, the availability and use of data disaggregated by gender – or at minimum, by sex, can be improved. Robust, disaggregated data are key to uncover disparities, guide targeted interventions, and inform inclusive policy design (Vogel et al., 2021[47]). By targeting the root causes of gender disparities, such approaches can lead to more meaningful and sustainable improvements in cardiovascular outcomes for both women and men.

Box 2.3. Inequalities in primary care in CVD management between men and women in England

CVDPREVENT is a national audit of general practitioner (GP) records in England to support primary care to monitor the prevalence of CVD, or conditions that lead to a higher risk of developing CVD, and clinical care for people with CVD. The data set includes a wide range of process and outcome measures of CVD care. The associated Data & Improvement Tool is designed to support quality improvement in general practice, reduce health inequalities and improve outcomes for individuals and populations. The Tool enables drill down of the national data across various levels, down to individual practice level, to enable teams to understand and improve the performance of their services. The data is available by age, gender, deprivation and ethnic group.

CVDPREVENT clinical audit data up to December 2023 shows inequalities in cholesterol management in secondary prevention by sex:

• among patients with CVD, women were more likely than men to have never been prescribed a lipid lowering therapy (LLT) and were less likely than men to have a recent prescription for a LLT; around 200 000 females with CVD had a record of high cholesterol and no recent LLT prescription;

• women were less likely to achieve target cholesterol levels compared to males;

• women with a recent LLT prescription were much more likely to have achieved target cholesterol levels than females with no recent LLT prescription.

These inequalities were present in all age groups, geographic regions of England, across all ethnic groups and deprivation quintiles, and were consistent over time.

Source: (HQIP, 2023[58]).

2.6.1. Gender inequalities in patient-reported outcomes have been observed in the primary care population

CVD is a common condition among primary care users aged 45 and older with chronic conditions, as captured in the PaRIS survey (Box 2.2) (OECD, 2025[8]). Self-reported data indicate a significant gender disparity, with 26.9% of men reporting CVD compared to 16.8% of women. This pattern extends to other related conditions such as diabetes and high blood pressure, which are key risk factors for CVD (see Figure 2.18). Hypertension is most frequently reported condition among primary care users, affecting 58.5% of men and 49.1% of women. Similarly, diabetes, another major contributor to cardiovascular risk, is more common among men (23%) than women (15.2%). Chronic kidney disease (CKD), often linked to both hypertension and diabetes, is reported by a smaller proportion of the surveyed population, with 4.8% of men and 3.6% of women affected. Although the prevalence is lower compared to other chronic conditions, its impact on cardiovascular health is significant, as CKD can both contribute to and result from CVD.

Figure 2.18. CVD, High blood pressure, diabetes and chronic kidney disease are more prevalent among male primary care users living with chronic conditions

Self-reported conditions among people living with chronic conditions in PaRIS

Note: EHIS-2019 was carried out in all EU Member States, plus Iceland, Norway, Albania, Serbia and Türkiye.

Source: OECD PaRIS Database 2024.

These self-reported patterns are strongly aligned with data from CVDPREVENT, a national audit of GP records in NHS England. CVDPREVENT systematically tracks the prevalence, comorbidities, and clinical management of CVD through anonymised primary care data, offering a robust complement to the PaRIS patient-reported findings. Like PaRIS, CVDPREVENT data confirms that hypertension is highly prevalent among adults (18.9% age‑sex standardised), and CVD is more frequently recorded in men (9.0%) than in women (5.0%). The audit also reveals substantial inequalities, with the prevalence, treatment, and outcomes of CVD varying significantly by deprivation and ethnic group. These insights reinforce the critical role of primary care in both identifying at-risk populations and closing equity gaps in cardiovascular health across England (see Box 2.4).

Women’s symptoms are often labelled as “atypical” simply because they don’t match the male-defined model of cardiovascular disease. My own experience is a clear example of how dangerous that bias can be. When I entered menopause, my cardiac health declined significantly. Yet no one connected this to the well-documented hormonal changes—like the drop in oestrogen and progesterone—that directly affect cardiovascular function. The impact of menopause on women with existing heart conditions is almost entirely ignored. While policymakers and researchers increasingly talk about the post-menopausal rise in CVD risk, no one is asking the critical question: what happens to a heart that is already diseased during this transition? Women like me are invisible in the data, in the risk models, and in the clinical decision-making tools used every day across Europe. Risk calculators for sudden cardiac death still rely almost exclusively on age, not sex—despite clear physiological differences.

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

Box 2.4. CVDPREVENT in England

CVDPREVENT data shows that GP recorded prevalence of CVD among patients aged 18 and over is 6.9% overall, the prevalence in women being 5.0% and in men 9.0% (see table). The prevalence of hypertension in adults is almost 1 in 5 (18.0%). Data for England also shows that hypertension is commonly undiagnosed, and some of the groups that are at the lowest risk of hypertension are the most likely to be undiagnosed (Office for National Statistics, 2023[59]). Adults who were the least likely to have hypertension (such as younger adults, those whose general health was good, and those who were not overweight or obese) were the most likely to be undiagnosed.

Directly age standardised GP recorded prevalence (%) in patients aged 18 and over

 

% prevalence	CVD	Hypertension	CKD	Heart failure
Indicator	CVDP001CVD	CVDP001HYP	CVDP001CKD	CVDP001HF
Female	5.0	18.0	4.7	1.0
Male	9.0	19.7	4.5	1.8
Persons (age‑sex standardised)	6.9	18.9	4.6	1.4

Note: CVD: Directly age standardised prevalence of GP recorded CVD (wide definition) in patients aged 18 and over: 6.51%. The wide definition includes coronary heart disease (CHD), stroke, transient ischaemic attack (TIA), peripheral arterial disease (PAD), heart failure (HF), and abdominal aortic aneurism (AAA).

Source: CVDPREVENT data. For more information please see the following sources: CVD: https://data.cvdprevent.nhs.uk/data-explorer?period=20&level=1&area=1&indicator=12; Hypertension: https://data.cvdprevent.nhs.uk/data-explorer?period=20&level=1&area=‌1&indicator=11; CKD: https://data.cvdprevent.nhs.uk/data-explorer?period=20&level=1&area=1&indicator=8; Heart failure: https://data.cvdprevent.nhs.uk/data-explorer?period=20&level=1&area=1&indicator=46.

2.6.2. There are deep socio‑economic divides in CVD across and within EU countries

Reducing health inequalities between and among EU members remains an important challenge for European health systems and policies, especially as the COVID‑19 pandemic exacerbated health inequalities across Europe (OECD, 2023[60]). Overall excess mortality in Europe during the pandemic was associated with high poverty levels and unequal income distributions (Pizzato et al., 2024[16]). Equity-oriented strategies focussing on both prevention and treatment of CVD have the potential to reduce inequalities in the burden of CVD morbidity and mortality and thereby improve population health and life expectancy.

The prevalence of and mortality from CVD in Europe is higher in more disadvantaged population groups (OECD/The King's Fund, 2020[1]). Lower socio‑economic groups have experienced significant declines in cardiovascular mortality rates over the last 25 years. However, the COVID‑19 pandemic reversed these favourable trends in some countries and widened health inequalities because of its disproportionately higher mortality impact on disadvantaged population sub-groups. Wide socio‑economic inequalities in CVD mortality are characteristic of many European countries, including those with generous social welfare schemes e.g. the Nordic countries. Across Europe, CVD accounts for almost half of the excess deaths among lower socio‑economic groups (OECD/The King's Fund, 2020[1]; ESC EHN Fighting cardiovascular disease, 2020[61]; Mensah et al., 2017[62]).

Major socio‑economic risk factors associated with CVD include lower income and education levels, living in deprived areas, higher unemployment rates, and increased exposure to environmental risk factors. The higher prevalence of risk factors among lower socio‑economic groups is a major driver of poorer cardiovascular outcomes. Lower socio‑economic groups also have poorer access to healthcare, reducing the likelihood of early diagnosis, proper clinical management of risk factors such as hypertension, and receipt of treatments such as cholesterol-lowering medications. It is important to note that higher socio‑economic groups have lower levels of most modifiable CVD risk factors and can serve as benchmarks.

As a male patient with a strong educational background and a supportive professional network, I recognize the privileges that have aided my recovery. My education allowed me to actively engage with my healthcare providers and understand my condition, while my income provided access to quality care. However, I am acutely aware of the disparities faced by others, particularly women, who may experience delayed diagnoses due to atypical symptoms or gender biases. This motivates me to advocate for equitable healthcare policies that address these gaps.

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

National Nordic registries provide strong evidence of disparities in cardiovascular morbidity and mortality between deprived and affluent areas, and by socio‑economic position as defined by occupation, income or education level (Højstrup, Thomsen and Prescott, 2023[63]). For example, cardiovascular mortality risks are between 1.6 and 2.1 times higher for people with a low level of education compared with the highly educated. Likewise, CVD is one of the largest contributors to socio-economic inequalities in life expectancy in England, accounting for 23% of the 9-year life expectancy gap between males in the most and least deprived deciles of the population4, and 19% of the 7-year gap between females in the most and least deprived deciles (OHID, 2023[64]). In 2020, the CVD mortality rate in England in people under 75 was almost four‑times higher in the most deprived 10% of the population compared with the least deprived 10% of the population and showed a clear gradient by deprivation. Mortality rates from chronic ischaemic heart disease and hypertensive disease in people living in the most deprived decile of areas in England are over double the rates in people living in the least deprived decile of areas, and for diabetes the differential is almost three times higher (Cherla et al., 2024[23]).

A study of changes in cardiovascular mortality in 12 European populations by gender, educational level and occupational class found that although absolute declines in cardiovascular mortality (deaths per 100 000 person-years) were larger among lower socio‑economic groups, relative declines (%) were faster among higher socio‑economic groups between the 1990s and the early 2010s (Di Girolamo et al., 2019[65]). However, the COVID‑19 pandemic exacerbated existing health disparities because socio‑economically disadvantaged groups across Europe and beyond faced an increased risk of infection, severe illness and death from the virus (OECD, 2021[13]; McGowan et al., 2021[66]). As noted in Section 2.2, CVD increased the mortality risk from COVID‑19 and in several countries CVD mortality levelled off or increased during the pandemic. Although COVID‑19’s direct effects on health outcomes attenuated as the pandemic passed, its indirect effects could continue to have adverse impacts on inequalities in CVD outcomes.

As a male with higher education and stable income, I have generally had better access to quality healthcare and information than others might. However, I am aware that socioeconomic factors deeply influence outcomes in cardiovascular disease. Men are often at higher risk but also may neglect early symptoms. Women face significant challenges in diagnosis and treatment, which need more awareness and equality in care delivery. Education helps me advocate for my health and navigate complex systems

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

Educational attainment is commonly used as a proxy for socio‑economic position and has been shown to be significantly related to prevalence of CVD and the overall health status among individuals living with chronic conditions. As a result, education level emerges as a critical factor influencing both the likelihood of developing CVD and the quality of life experienced once diagnosed. A longitudinal study in the Netherlands reported that the risks of coronary heart disease (CHD) and stroke were higher in people with lower compared with higher education status (Méjean et al., 2013[67]).

Data from the 2019 European Health Interview Survey (EHIS) reveal a clear inverse relationship between educational attainment and the prevalence of several cardiovascular-related conditions. Figure 2.19 shows that individuals with lower levels of education consistently report higher rates of conditions such as heart attack, coronary heart disease, high blood pressure, stroke, and diabetes. These disparities may partly reflect differences in behavioural risk factors, which tend to be more common among individuals with lower educational attainment (Puka et al., 2022[68]). High blood pressure emerges as the most prevalent condition across all education levels, with nearly 30% of individuals with lower education affected and disparities are particularly pronounced for conditions like stroke and diabetes, where the prevalence among the lower-educated population is more than double that of their higher-educated counterparts (see Figure 2.19). Similarly, data on primary care users from the OECD PaRIS data (see Box 2.2) shows that those with lower educational attainment report higher prevalence of CVD (22.9%) compared to those with higher education (19.9). The same pattern appears for high blood pressure, diabetes, and chronic kidney disease (see Annex 2.A).

Figure 2.19. Educational inequalities in cardiovascular self-reported prevalence

Percentage of self-reported CVD prevalence by education attainment

Note: EHIS-2019 was carried out in all EU Member States, plus Iceland, Norway, Albania, Serbia and Türkiye. Age and sex standardised.

Source: European Health Interview Survey, 2019.

Data from the EHIS 2019 also reveal a clear inverse relationship between income level and the prevalence of several cardiovascular-related conditions. Figure 2.20 shows that individuals in the lowest income groups consistently report higher rates of heart attack, coronary heart disease, high blood pressure, stroke, and diabetes compared to those in higher income groups. Likewise, OECD PaRIS data reveals a clear gradient in CVD prevalence linked to income levels, with higher prevalence observed among lower-income groups (23.3%) compared to mid-income (20.3%) and high-income groups (19.0%). This pattern similarly emerges in high blood pressure (52.2% in low-income groups vs. 49.8% in high-income groups) and diabetes prevalence (23.1% low income vs. 17.0% high income), indicating an inverse relationship between socio‑economic status and chronic cardiovascular conditions (see Annex 2.A).

Figure 2.20. Income inequalities in cardiovascular self-reported prevalence

Percentage of self-reported CVD prevalence by income level

Note: EHIS-2019 was carried out in all EU Member States, plus Iceland, Norway, Albania, Serbia and Türkiye. Age and sex standardised.

Source: European Health Interview Survey, 2019.

2.6.3. Migrant and ethnic minority populations experience higher mortality from CVD

The ethnic diversity of European populations is increasing. For example, in 2020, 1.9 million migrants entered the EU from non-EU countries (ESC Cardiovascular Realities, 2024[2]). Migrants and their descendants now constitute around 8% of the population in Finland, 15% in Denmark, 16% in Iceland, 17% in Norway and as high as 22% in Sweden (Højstrup, Thomsen and Prescott, 2023[63]). The proportions are considerably higher in urban areas. Compared to resident populations, ethnic minorities in Europe are disproportionately affected by CVD and its risk factors including hypertension and type 2 diabetes (Dal Canto, Farukh and Faconti, 2018[69]). This higher incidence seems to be the result of complex interactions between genetic and environmental elements that influence the pathophysiology of CVD, as well as significant barriers to access prevention, diagnosis and treatment services – including socio-economic inequities, limited health-literacy, geographic inaccessibility, financial constraints, insufficient health insurance coverage, shortages of trained personnel, fragmented primary care systems, delays in diagnosis, high out-of-pocket costs, poor adherence, and structural biases in referral and treatment practices.

I have experienced hospitalizations related to my cardiac condition. The care was generally attentive, but coordination of post-discharge rehabilitation and follow-up was sometimes fragmented. Access to cardiac rehabilitation programs was helpful but not always consistent or accessible due to geographic or logistic reasons.

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

Several minority groups experience higher rates of CVD, but there are differences between groups in terms of the relative impacts of different CVDs. Much of the epidemiological evidence relates to people of South Asian and African-Caribbean origin living in the United Kingdom and United States; evidence from Europe is sparse. People of South Asian origin (India, Pakistan, Bangladesh, Nepal, Sri Lanka) comprise a large and growing population in several European countries including the United Kingdom, Italy, France, Germany, Spain, Greece, the Netherlands and the Nordic countries. According to Eurostat, more than 2.5 million first-generation South Asian immigrants lived in Europe as of 2011, the largest population being in the United Kingdom (Cainzos-Achirica et al., 2019[70]). There are large numbers of people of South Asian origin living also in other diaspora countries, such as the United States, Canada, the Middle East, Malaysia, South Africa and Australia.

CVD mortality is high and rising in South Asia, in contrast to the declining trend elsewhere (Goh et al., 2024[71]). There is consistent evidence, from South Asian countries of origin, South Asian migrants living across the globe in Europe, Canada, the United States and elsewhere and from multinational studies, of a higher incidence, prevalence and mortality from CVD and particularly coronary heart disease (CHD) in these groups compared to most other racial/ethnic groups (Cainzos-Achirica et al., 2019[70]; Razieh et al., 2022[72]; Raleigh and Colombo, 2023[73]; Raleigh, Goldblatt and Colombo, 2025[74]). South Asian groups also develop heart disease at a younger age and present higher prevalence of hypertension and type 2 diabetes (Volgan et al.,, 2018[75]), increasing the risk of diabetic renal disease (Hanif and Susarla, 2018[76]) (Goff, 2019[77]). The causes of increased CHD risk among South Asian groups are multifactorial and include genetic and epigenetic factors, central obesity, impaired glucose tolerance and insulin resistance, adverse changes to lifestyle and diet following migration, and environmental determinants such as deprivation (Volgan et al.,, 2018[75]; Ho et al., 2022[78]; Patel et al., 2021[79]).

In contrast to South Asian groups, African-Caribbean groups in the United Kingdom have a significantly lower risk of heart disease compared to other ethnic groups, despite having a high prevalence of hypertension and diabetes (Chaturvedi, 2003[80]). Heart disease rates are low in Africa Region, and rates in the Caribbean also appear low (Yusuf et al., 2001[81]; Yuyun et al., 2020[82]). However, more nuanced patterns emerge when examining migrant populations. For example, West African and Caribbean migrants in the United Kingdom exhibit higher stroke mortality but lower ischaemic heart disease mortality compared with the UK-born population, with generational gaps decreasing over time (Harding, Rosato and Teyhan, 2007[83]). Moreover, migrants often experience worse prognosis after hospitalisation for acute myocardial infarction compared with native populations, with differences across ethnicities (van Oeffelen et al., 2014[84]) (Zhu, Huang and Chen, 2023[85]). Cardiovascular risk may also increase with length of stay in the host country (Lozano Sánchez et al., 2013[86]). Including these findings highlights the complex interaction between ethnicity, migration and cardiovascular outcomes.

There is strong evidence from the United Kingdom and the United States of a higher incidence of and mortality rates from hypertension and stroke in African-Caribbean groups, who are also more prone to develop diabetes and at a younger age (Shah and Kanaya, 2014[87]), compared with the White population, and they develop hypertension and have strokes at a younger age (Fluck et al., 2023[88]). ONS data for England show significantly higher mortality rates for stroke and hypertension among people from Black Caribbean and Black African groups compared with people from the White British group (ONS, 2021[89]; ONS, 2023[90]). However, consistent with the above epidemiological evidence, mortality rates for chronic ischaemic heart disease are lower in people of Black ethnicity.

The prevalence of hypertension is also high in Africa Region and the West Indies (Yusuf et al., 2001[81]) (Minja et al., 2022[91]). Explanations for black-white differences in hypertension prevalence include a myriad of factors such as a complex interaction between socio‑economic factors, environmental responses to diet, stress, genetic/physiological differences, health related behaviours and systematic structural disparities, including economic inequality, racial discrimination, and structural racism. (Brondolo et al., 2011[92]) (Abrahamowicz et al., 2023[93])The American Heart Association’s 2025 Heart Disease and Stroke Statistical Update  reports that while progress has been made in reducing cardiovascular disparities, Black communities in the United States face disproportionately higher risk of heart disease, stroke and hypertension, leading to disproportionately high death rates from these causes (AHA, 2025[94]; AHA, 2025[95]). AHA also notes that:

• CVD prevalence: among people aged 20 and older in the United States, nearly 60% of Black adults have some type of CVD, including coronary heart disease, heart failure, stroke and hypertension, compared with about 49% of all US adults.

• Stroke: the prevalence of stroke among adults in the United States is highest among Black women (5.4%) and Black men (4.8%), compared with all women at 2.9% and all men at 3.6%.

• Hypertension: Black adults in the United States have some of the highest prevalence rates of hypertension in the world: 58.4% in Black women and 57.5% in Black men compared to 50.4% of all US adult men and 43% of all women.

• Heart failure: Black adults account for over 50% of heart failure hospitalisations among US adults under 50.

2.6.4. People with serious mental illness and disabilities experience higher mortality from CVD

Several studies have reported that people living with a severe mental illness (SMI) have a greater risk of developing and dying from CVD, which is a major contributor to their shorter life expectancy. An international study of 3.2 million people with severe mental illness showed a substantially increased risk for developing CVD compared to the general population (Correll et al., 2017[96]; Rødevand et al., 2023[97]; Solmi et al., 2024[98]). It showed that people with SMI, including schizophrenia, bipolar disorder and major depression, have a 53% higher risk of having CVD than healthy controls, with a 78% higher risk of developing CVD over the longer term; their risk of dying from CVD was 85% higher than people of a similar age in the general population. Similar findings are reported for the United Kingdom, and that life expectancy in people with SMI is 15‑20 years lower than the general population (Correll et al., 2017[96]).

Nordic studies have reported that patients with severe mental illness have mortality rates two to three times higher than the general population, with an associated reduction in life expectancy of 15 and 20 years for women and men, respectively (Sørensen and Bredahl Kristensen, 2023[21]). A study from Denmark reported increased risks of CVD in people with intellectual disabilities than in those without, and the risks increased with the severity of intellectual disability (Wang et al., 2023[22]). A study from Norway identified barriers to healthcare for people with intellectual disabilities on an individual and a structural level (Plasil et al., 2024[99]). The underlying reason for the barriers is that health problems, such as CVD, are overlooked as the condition of intellectual disability overshadows other diagnoses. The authors concluded that the focus on intellectual disability leads to shortcomings in the prevention, diagnoses, and treatment of CVD in this group.

A systematic review and meta‑analysis of international studies, including studies in Europe, found that overall mortality was twice as high among people with disabilities than among people without disabilities or the general population, and they have a life expectancy about 14 years shorter (Kuper et al., 2024[100]). People with disabilities were at higher risk of mortality from specific cause including CVD. The Confidential Inquiry into premature deaths of people with intellectual disabilities in the United Kingdom found that 37% of deaths among people with intellectual disabilities were avoidable through better access to high quality healthcare, as opposed to 13% among people without intellectual disability (Plasil et al., 2024[99]).

2.6.5. CVD remains one of the leading health challenges for the EU, especially in the post COVID‑19 pandemic era

Although there have been achievements in reducing the prevalence of some risk factors for CVD some other risk factors are becoming more prevalent (see Chapter 3). Advances in CVD care and management, and progress in reducing CVD mortality, have led to increasing numbers of people living with chronic cardiovascular conditions, including heart failure and vascular dementia. The proportion of older people is rising because of declining fertility rates and longer life expectancies have further accelerated population ageing. As a result of these trends, the burden of CVD and its concurrence with other diseases e.g. diabetes and dementia, leading to multimorbidity, is likely to rise.

Inequalities in CVD risk factors, prevalence, treatment, morbidity and mortality, between and within EU countries, are wide and an obstacle to improvements in population health and life expectancy. The Central and Eastern European EU countries, which already had higher CVD mortality and lower life expectancy than other EU countries, experienced the largest rises in CVD mortality during the pandemic, thereby widening the gaps between EU countries when they had been narrowing pre‑pandemic. The wide geographical inequalities in CVD mortality within the EU show the significant potential there is for reducing the human, social and economic impacts of CVD in the EU.

The pandemic illustrated the risks that CVD can present when there are serious emergent risks to public health. For example, although the pandemic has subsided, COVID‑19 is still claiming lives and the risks of a severe season of influenza or other respiratory infections remain a threat to healt5h, especially in ageing populations. People with CVD are at greater risk of developing serious complications of and dying from flu (OECD/The King's Fund, 2020[1]; Ho and Hendi, 2018[101]). Severe influenza outbreaks, such as the one in 2014‑2015 when life expectancy fell across Europe, can also impact on CVD mortality. As with COVID‑19, influenza and pneumonia can trigger acute cardiovascular events like heart attack and stroke, and in turn, individuals with CVD are more susceptible to dying from influenza or pneumonia (Ho and Hendi BMJ 2018, (OECD/The King's Fund, 2020[1]). The CVD risks from respiratory viruses, such as a severe flu season, remain a public health hazard in ageing populations. CVD is also triggered by other chronic conditions or their therapies including, for example, diabetes, hypertension, chronic kidney disease, pulmonary disease, and cancer. For example, advances in oncological treatment have led to improved cancer survival but have also increased CVD morbidity and mortality due to the cardiotoxicity of cancer treatment.

Extreme ambient temperatures, both heatwaves and cold spells, increasingly pose a threat to cardiovascular health: epidemiological evidence shows that each 1°C rise above optimum temperature increases cardiovascular mortality by about 2.1% (heat effect), and cold spells raise CVD-related mortality by about 32% with morbidity also increasing; overall, both extreme heat and cold are associated with higher risk of death from ischaemic heart disease, stroke and heart failure, especially in older and vulnerable populations (heat effect) (Singh et al., 2024[102]); cold exposure effect (Fan et al., 2023[103]); and extreme‐temperature attribution studies estimate that for every 1 000 cardiovascular deaths, about 2 are attributable to extreme heat days and about 9 to extreme cold days (Alahmad et al., 2023[104])In EU countries, and especially in those with high CVD mortality rates, there is significant scope for further reductions in this leading cause of death given that 80% of the deaths are attributable to modifiable risk factors (ESC Cardiovascular Realities, 2024[2]). Given the heavy burden of CVD on populations and social, economic, and healthcare systems, there is an urgent need for action to reduce its impact by scaling up the deployment of existing cost-effective interventions for prevention and treatment. Reducing the burden of CVD and addressing related inequalities remains a key potential driver of future improvements in life expectancy.

2.7. The Economic burden of CVD in EU continues to increase

CVD has long been a major contributor to healthcare expenditures and economic losses in the European Union (EU). Since the early 2000s, multiple studies have quantified the financial impact of CVD, revealing increasing costs associated with medical care, productivity losses, and informal caregiving. These studies highlight the growing economic challenge posed by CVD and underscore the urgent need for policy interventions focussed on prevention and cost-effective disease management.

One of the earliest comprehensive analyses of CVD-related costs in the EU was conducted in 2003, estimating the total economic burden at EUR 169 billion across 25 member states. Direct healthcare expenditures accounted for EUR 105 billion, representing 12% of total healthcare spending, with hospital care being the largest contributor, followed by medication and outpatient services. Indirect costs, including productivity losses (EUR 35 billion) and informal caregiving (EUR 29 billion), further underscored the widespread financial impact of CVD (Leal et al., 2006[105]).

A follow-up study by Wilkins et al. (2017) provided updated estimates, reporting that the cost of CVD had risen to EUR 210 billion by 2017 across 28 EU countries. This analysis, published by the European Heart Network, detailed cost distribution, with direct healthcare expenses comprising EUR 111 billion (53% of total costs), productivity losses due to mortality and morbidity at EUR 54 billion (26%), and informal care costs at EUR 45 billion (21%). The study also highlighted disparities in spending across EU nations, with Western and Northern European countries incurring higher absolute costs, while Central and Eastern European nations bore a proportionally higher burden relative to their healthcare budgets (Wilkins et al., 2017[106]).

The most recent analysis by Luengo-Fernandez et al., uncover the total economic burden of CVD in the EU at EUR 282 billion annually, amounting to approximately 2% of the region’s gross domestic product (GDP). This substantial financial commitment is distributed across several key components: direct healthcare costs, social care costs, informal care, and productivity losses. On a per capita basis, CVD-related costs averaged EUR 630 per EU citizen, varying from EUR 381 in Cyprus to EUR 903 in Germany.5 Notably, health and social care expenditures for CVD represented 11% of total healthcare spending in the EU, with significant variation among member states – from 6% in Denmark to 19% in Hungary (Luengo-Fernandez et al., 2023[107]).

The 2021 study by Luengo-Fernandez et al. provides the most comprehensive and precise estimate of the economic burden of CVD in the EU, surpassing previous studies in several key ways. It utilises more extensive and up-to-date data sources, covers all EU countries with purchasing power parity adjustments, and offers a more detailed cost breakdown, distinguishing between direct healthcare costs, productivity losses, and informal care. Unlike earlier estimates, it accounts for demographic shifts, such as an ageing population and changing workforce dynamics, and improves the estimation of indirect costs by integrating real-time labour market data and caregiving contributions (see Figure 2.21).

Figure 2.21. Assessments over time reveal an increasing economic and financial burden of CVD across the EU

Note: The graph presents and consolidates findings from three separate studies that estimated the financial burden of CVD. percentage of total EU GDP was calculated using Eurostat data and the GDP of EU member states at the time of each study. Figures are presented in nominal terms and are not adjusted for inflation.

Source: Eurostat ; Leal et al. (2006[105]), “Economic burden of cardiovascular diseases in the enlarged European Union”, https://doi.org/10.1093/eurheartj/ehi733; Wilkins et al. (2017[106]), European Cardiovascular Disease Statistics 2017; Luengo-Fernandez et al. (2023[107]), “Economic burden of cardiovascular diseases in the European Union: a population-based cost study”, https://doi.org/10.1093/eurheartj/ehad583.

In the following paragraphs, we present a more detailed overview of the key findings from Luengo-Fernandez et al., whose work offers the most robust and policy-relevant assessment currently available.

2.7.1. Health system burden: healthcare expenditures (EUR 130 billion, 46% of total costs)

Healthcare‑related costs constitute nearly half of the total economic burden of CVD in the EU. These expenditures encompass hospital admissions, outpatient care, medication, and other direct medical interventions.

Hospital care (EUR 79 billion, 61% of healthcare costs)

Hospital-related expenditures dominate healthcare spending on CVD, driven by the high incidence of acute cardiovascular events, prolonged inpatient stays, and the need for complex surgical and interventional procedures. The cost burden varies across EU countries, reflecting differences in healthcare infrastructure, treatment approaches, and patient demographics. Countries with higher rates of acute myocardial infarctions and stroke admissions show disproportionately high hospital expenditures.

Medications (EUR 31 billion, 24%)

Pharmaceutical costs remain a significant component of healthcare spending, largely due to the long-term nature of CVD treatment. The widespread prescription of lipid-lowering agents (e.g. statins), antihypertensives, anticoagulants, and novel biologic therapies contributes to sustained expenditure growth. Variability in drug pricing policies across EU nations, as well as disparities in access to newer medications, accounts for differences in per capita spending.

Outpatient and primary care (EUR 20 billion, 15%)

Primary and specialist consultations, diagnostic testing, and follow-up care contribute to the remaining healthcare expenditures. The emphasis on early detection, preventive screening, and long-term disease management plays a crucial role in cost mitigation by reducing hospital admissions. Countries with strong primary care systems exhibit lower overall healthcare costs per capita, suggesting potential cost-saving opportunities through enhanced primary care models.

2.7.2. Social Care Expenditures (EUR 25 billion, 9%)

Social care costs, including long-term institutional care and home‑based assistance, represent the smallest but still substantial component of CVD-related spending.

Long-term institutional care (EUR 15 billion, 60%)

Patients with severe CVD-related disabilities, such as stroke‑induced paralysis or advanced heart failure, often require prolonged stays in nursing homes and other assisted-living facilities. The demand for long-term care services is expected to rise due to demographic ageing, placing further strain on national budgets.

Home‑based care (EUR 10 billion, 40%)

Many CVD patients receive formal care at home, including physiotherapy, nursing visits, and personal assistance. Countries with robust home healthcare infrastructure allocate a larger share of social care budgets to community-based services, reducing reliance on institutional care.

2.7.3. Family and Community Contributions: Informal Care Costs (EUR 79 billion, 28%)

The economic burden extends beyond formal healthcare services, with informal caregiving representing the second-largest cost category. An estimated 7.5 billion hours of unpaid care were provided by family members and friends, translating into EUR 79 billion in economic value. The majority of informal care is provided by women, with significant implications for gender equity in labour force participation. The need for constant assistance with daily activities, medication management, and mobility support increases caregiver strain, particularly among older adults caring for spouses with advanced-stage CVD.

Southern and Central and Eastern European nations tend to rely more heavily on informal caregiving due to weaker social care systems and cultural preferences for family-based support. By contrast, Nordic countries, which invest heavily in public healthcare services, report lower informal care costs relative to their total CVD burden.

2.7.4. Workforce Impact: Lost Productivity and Employment (EUR 47 billion, 17%)

CVD significantly impacts economic productivity through absenteeism, premature mortality, and work-related disability. The analysis estimates that 256 million working days were lost in 2021 due to illness and disability, while 1.3 million working years were lost due to premature deaths.

Illness-related productivity losses (EUR 15 billion, 32%)

Employees with CVD frequently require time off for treatment, rehabilitation, and disease‑related complications. Conditions such as heart failure, stroke, and ischemic heart disease contribute to prolonged absences and increased sick leave utilisation. Workplace interventions promoting cardiovascular health could help mitigate these costs.

Premature mortality (EUR 32 billion, 68%)

Productivity losses due to premature CVD-related deaths constitute the majority of this category. Deaths occurring before retirement age (often defined as 65 years) result in substantial economic losses, particularly in high-income countries with ageing workforces. Stroke and coronary artery disease remain leading contributors to mortality-related productivity losses, underscoring the need for targeted prevention programmes.

From Cost to Action: Why Data Matters in CVD Policy

The economic burden of CVD highlights the pressing need for informed and targeted policy responses. Effective strategies – ranging from expanding access to primary care and investing in preventive health programmes to optimising pharmacological treatments – offer significant potential to reduce both incidence and long-term healthcare costs of the disease (see Chapter 4). At the same time, regulatory measures promoting healthier lifestyles, such as taxes on unhealthy foods and incentives for physical activity, can help address key risk factors (see Chapter 6). However, the success of these interventions depends on a foundational element: access to high-quality, up-to-date, and disaggregated data (see Chapter 5). Without reliable information on where resources are spent, which interventions are effective, and where gaps remain, policymaking risks being reactive rather than strategic.

To support this evidence‑based approach, future research could prioritise longitudinal analyses of CVD-related expenditures, particularly considering evolving demographics and emerging treatment options. To address this gap, the latest OECD Policy Survey aimed to assess how national governments track, report, and analyse expenditures related to CVD. The broader objective was to map the capacity of health systems to understand and manage the economic dimensions of CVD, which is essential for effective policy, planning, and resource allocation in public health. The survey results uncovered a considerable variability in how governments track and report expenditures related to CVD. A small portion of countries – such as Canada, Estonia and the Netherlands – reported that their governments do track CVD-related spending, while others (e.g. Austria, Colombia) either do not or are unsure (e.g. Czechia). Among those that do monitor such spending, data sources like insurance claims and provider reporting (e.g. DRGs, fee‑for-service systems) are used inconsistently. Canada and Estonia stand out for leveraging both insurance and provider-based data to track CVD expenditures, suggesting more robust monitoring mechanisms in these contexts.

In terms of institutional responsibility, several countries, such as Israel and Canada, indicated the involvement of their Ministry of Health in monitoring CVD spending, although this too was not universal. The responses show that some countries may rely on broader health finance or insurance bodies or lack clear designation. Regarding expenditure trends over the past five years, there was limited but telling information. Estonia reported a significant increase, while Colombia and Singapore noted a slight increase. Most countries did not provide concrete trend data, possibly due to data gaps or inconsistent reporting systems. Finally, qualitative comments highlight key challenges: Canada noted the absence of recent data, and Estonia mentioned issues with data completeness and underreporting due to diagnostic limitations. These insights underscore the structural and methodological hurdles countries face in capturing the true economic burden of CVD.

The survey results reveal significant variation across countries in how they track and report expenditures related to CVD. This gap significantly limits the ability of policymakers to design targeted, cost-effective interventions. Strengthening national capacities to collect, integrate, and analyse CVD expenditure data is essential for driving smarter investments, improving population health outcomes, and managing the long-term economic burden of CVD. The case of Estonia provides several valuable lessons for other EU countries (Box 2.5).

Box 2.5. Building a clearer picture of CVD expenditures in Estonia

Estonia, a small Baltic nation known for its digital innovation, is emerging as a leader in tracking the economic burden of CVD in Europe. Among the countries surveyed, Estonia stands out for its structured and data‑informed approach to monitoring public spending on CVD-related services.

The Estonian Government actively tracks and reports expenditures on cardiovascular health through its national systems. This tracking is embedded in the administrative flow of data: Estonia makes use of insurance claims and hospital provider data (e.g. diagnostic-related groups (DRGs) and fee‑for-service reporting), enabling it to capture a more detailed and nuanced picture of where resources are being allocated and which areas may require attention. Responsibility for monitoring these expenditures is clearly defined: the Ministry of Health plays a central role in overseeing the collection and use of this information.

Estonia reported that government spending on CVD-related services has increased significantly over the past five years, with a marked emphasis on enhancing prevention and care systems. In more detailed expenditure categories, Estonia noted that around 14% of CVD-related spending is directed toward primary care and outpatient services (including physician costs), while hospitalisation and acute care account for approximately 0.47% of reported expenditures. Other categories, such as long-term care and rehabilitation, were not included in the reported figures, reflecting areas for possible future data improvements.

Despite this encouraging framework, Estonia openly acknowledged data limitations. In the survey’s additional comments, officials noted incomplete coverage of data and underdiagnosis of CVD cases, particularly in primary care, due to fragmented information systems. Estonia’s example shows how countries can build robust expenditure tracking systems with clear institutional leadership and a willingness to confront data limitations. For other European countries seeking to strengthen their understanding of the economic impact of CVD, Estonia offers both inspiration and practical lessons.

Source: OECD 2025 CVD Policy Survey

2.8. Analysing the socio‑economic burden of CVD in EU in a wider context

As health systems confront increasing financial pressures from ageing populations, rising treatment costs, and the growing prevalence of non-communicable diseases (NCDs), a clear understanding of their comparative economic burden is essential. Analysing how different conditions contribute to direct healthcare costs and productivity losses can reveal important insights about the nature of each disease and help identify opportunities for more efficient resource allocation, and improved support systems for affected individuals.

This section provides a comparative analysis of the economic burden associated with CVD and cancer – two of the most prevalent and costly NCDs in high-income countries. Cancer is included in this comparison not only because it is a leading cause of death and disability, but also because of its distinct cost profile: it tends to result in higher productivity losses due to premature mortality and often requires expensive, intensive treatment for a short period of time. Finally, this section situates the economic burden of CVD and cancer within the broader context of government spending in other sectors. This comparison underscores the weight of these health conditions on public finances and reinforces the need for sustained investment in prevention, early detection, and comprehensive care strategies.

2.8.1. Total societal economic burden of CVD exceeds cancer

Comparative analyses indicate that CVD impose a substantial economic burden across the European Union, often exceeding the costs associated with other costly diseases such as cancer. In 2021, the total economic burden of cancer in Europe not including informal care costs was estimated at EUR 203 billion (Manzano et al., 2025[108]),which included EUR 134 billion in healthcare expenditures, compared to EUR 155 billion for CVD and EUR 70.4 billion in productivity losses, compared to EUR 48 billion for CVD. The 2021 estimates for cancer exclude the costs of informal care – that is, unpaid support provided by family members or friends. The most recent available data from 2018 indicate that cancer-related informal care costs, adjusted to 2021 euros, amounted to EUR 27 billion (Hofmarcher et al., 2020[109]), compared to EUR 79 billion for CVD.

In 2021, the total societal cost of CVD – inclusive of direct healthcare costs and losses related to informal caregiving and productivity – was higher than cancer-related costs in most EU countries. In Sweden and Finland, the societal costs of CVD are double that of cancer. Austria reported a total CVD cost of EUR 8.47 billion per year, compared to EUR 5.67 billion for cancer (Figure 2.22). Similarly, Germany⁵ spent EUR 83.4 billion on CVD versus EUR 55.6 billion on cancer, while France allocated EUR 38.1 billion to CVD compared to EUR 37.9 billion for cancer.

This cost differential is largely driven by higher costs of health and social healthcare and informal care associated with CVD. This cost differential is largely driven by higher direct social and healthcare costs and informal care associated with CVD. In 15 out of the 27 countries in Table 2.2 direct healthcare costs for CVD in 2021 are larger than those of Cancer in 2023 (in 2021 euros), with an average difference of 52%. The other 12 countries had on average direct costs of cancer 24% larger than for CVD. In Sweden, higher CVD costs are driven by more intensive formal care, but also productivity losses per capita that are three times higher than for cancer. The differences in informal care costs are even more pronounced, with all EU countries spending significantly more on informal care for CVD – by an average margin of nearly 400% compared to cancer. This is especially prominent in Central and Eastern Europe, where the CVD burden is shaped by higher reliance on informal care (almost 10 times that of cancer), together with earlier onset and higher disease prevalence. This stark contrast reflects not only the differing nature of the two diseases and their impact on morbidity and long-term care needs but also points to a critical challenge in care provision and coverage. The high reliance on informal care in CVD highlights potential gaps in formal support systems and places a considerable burden on families and caregivers.

This is not the case when looking at productivity losses due to morbidity and mortality. Out of the 27 countries in Table 2.2, 14 had larger productivity losses due to cancer for the year 2018 (in 2021 euros) than for CVD in the year 2021 with an average difference of 33%. This notable disparity reflects both the distinct characteristics of the diseases and the varying effectiveness of health systems in mitigating their broader economic impact. Because of indirect costs, in some countries, cancer-related costs exceed or closely match those for CVD. For example, in Belgium, total cancer costs were EUR 7.8 billion – considerably higher than the EUR 6.80 billion spent on CVD. Overall, while absolute CVD costs are highest in larger Western European economies, the relative economic impact is particularly severe in lower-income EU countries, highlighting persistent cross-national disparities and the need for co‑ordinated policy responses targeting prevention, early intervention, and long-term care for cardiovascular conditions.

Figure 2.22. The total societal costs of CVD exceed that of cancer more than two‑fold in some European Countries

Ratio of the economic costs of CVD compared to cancer (CVD to cancer)

Note: All costs expressed in 2021 euros. For Cancer, Health & social care are estimated with 2023 data and Informal care + Productivity losses with 2018 data.

Source: Hofmarcher et al. (2020[109]), “The cost of cancer in Europe 2018”, https://doi.org/10.1016/j.ejca.2020.01.011; Luengo-Fernandez et al. (2023[107]), “Economic burden of cardiovascular diseases in the European Union: a population-based cost study”, https://doi.org/10.1093/eurheartj/ehad583; Manzano et al. (2025[108]), “Comparator Report on Cancer in Europe 2025 - Disease Burden, Costs and Access to Medicines and Molecular Diagnostics”, IHE report.

Table 2.2. CVD average total societal costs nearly double cancer, but direct costs are only 52% higher

Annual costs of CVD and cancer (€ million) in the European Union

	Health & social care total (€)		Productivity losses (€)		Informal care (€)		Total costs (€)		Total costs €/capita PPP
Country	CVD	Cancer	CVD	Cancer	CVD	Cancer	CVD	Cancer	CVD	Cancer
Austria	5 142	3 813	1078	1 432	2 246	419	8 466	5 665	831	556
Belgium	3 940	4 298	1 310	2 789	1 547	729	6 797	7 816	530	609
Bulgaria	839	1024	651	235	493	45	1 983	1 303	525	345
Croatia	406	979	195	650	507	97	1 108	1 727	434	676
Cyprus	186	299	69	52	54	25	309	375	382	463
Czechia	2 487	3 801	929	831	1 813	205	5 229	4 837	666	616
Denmark	2 001	1 355	1 413	1 763	979	806	4 393	3 924	561	501
Estonia	250	130	129	143	188	25	567	299	520	273
Finland	2 479	943	970	750	937	355	4 386	2 048	635	297
France	24 290	22 226	6 697	12 270	7 157	3 461	38 144	37 956	519	517
Germany	44 865	33 486	13 184	16 720	25 352	5 411	83 400	55 617	903	602
Greece	2 237	1 841	1075	806	1003	330	4 315	2978	491	339
Hungary	1 848	1 219	921	554	852	157	3 621	1 930	577	307
Ireland	2 041	1 630	855	673	546	189	3 442	2 492	566	410
Italy	23 747	12 353	4 497	5 481	13 734	5 436	41 978	23 271	725	402
Latvia	252	391	293	138	205	35	750	564	515	387
Lithuania	559	706	473	205	406	36	1 438	947	742	489
Luxembourg	267	288	70	134	75	35	412	456	502	555
Malta	95	170	51	29	37	13	183	212	406	472
Netherlands	8 670	6 750	2 289	4 075	2 100	1034	13 059	11 859	643	584
Poland	6 127	5 807	2 586	2 628	4 466	598	13 179	9 032	590	405
Portugal	1 803	2 172	723	891	1 245	390	3 771	3 454	425	389
Romania	2 220	2 403	1 396	789	2 806	165	6 422	3 357	634	332
Slovak Republic	942	968	459	453	562	76	1 963	1 496	447	341
Slovenia	632	359	124	321	292	81	1048	761	585	425
Spain	13 063	8 188	3 462	4 620	7 434	2 662	23 959	15 470	535	345
Sweden	3 998	2 789	5 903	1 919	1 608	526	11 509	5 234	536	389
Average	5 755	4 459	1 919	2 272	2913	865	10 586	7 596	571	445

Note: All costs expressed in 2021 euros. For Cancer, Health & social care are estimated with 2023 data and Informal care + Productivity losses with 2018 data. Estimates follow a societal cost-of-illness framework that includes health and long-term social care, informal care, and productivity losses. The “health and social care” columns exclude administration/overheads, household or ancillary items (e.g. patient transport), prevention and rehabilitative care, and healthcare retailing; hospital costs cover day cases and overnight admissions with a primary diagnosis. National cost-of-illness series often report complete payer coverage and local coding patterns (e.g. secondary diagnoses that still drive resource use) and hence can be larger than those presented.

Source: Hofmarcher et al. (2020[109]), “The cost of cancer in Europe 2018”, https://doi.org/10.1016/j.ejca.2020.01.011; Luengo-Fernandez et al. (2023[107]), “Economic burden of cardiovascular diseases in the European Union: a population-based cost study”, https://doi.org/10.1093/eurheartj/ehad583; Manzano et al. (2025[108]), “Comparator Report on Cancer in Europe 2025 - Disease Burden, Costs and Access to Medicines and Molecular Diagnostics”, IHE report.

2.8.2. The Global Economic Impact of CVD: A complex and uneven burden

CVD represent a significant and escalating economic burden worldwide. Between 2025 and 2050, cardiovascular prevalence is projected to rise by 90%, with deaths increasing by 73.4%, reaching an estimated 35.6 million cardiovascular deaths in 2050 (up from 20.5 million in 2025) (Chong et al., 2024[3]). However, the scale and composition of this burden differ markedly between countries and regions, reflecting variations in healthcare systems, funding structures, and epidemiological patterns. Additionally, differences in study methodologies make it challenging to directly compare cost estimates across global contexts.

In the EU, the economic burden of CVD is substantial but shaped by the relatively strong foundation of universal healthcare systems. According to the above mentioned study by the European Cardiology Society (Luengo-Fernandez et al., 2023[107]) covering all 27 EU plus Member States plus Norway and Iceland, the total cost of CVD in the EU amounted to EUR 282 billion in 2021, including direct healthcare costs, productivity losses, and informal care costs. Due to universal health coverage, out-of-pocket spending on CVD-related healthcare is lower compared to many non-EU countries, and costs are more equitably distributed. However, indirect costs – especially productivity losses – remain high due to the chronic and disabling nature of CVD, particularly in working-age populations.

In contrast, the United States exhibits significantly higher per-patient CVD costs. A recent study by the American Heart Association (American Heart Association, 2024[110]) projected that total annual costs related to CVD and stroke will exceed $1.8 trillion by 2050, driven by high medical prices, widespread use of advanced interventions, and substantial productivity losses. However, these figures are derived using a different methodology from that used in the EU study: US estimates rely on quasi‑experimental approaches that compare healthcare costs of individuals with CVD to matched statistical twins without CVD. This design captures a broad range of attributable costs, but it also makes direct comparisons with EU estimates challenging, as the latter rely on population-level cost allocations rather than individual-level counterfactuals.

In China, the economic burden of coronary heart disease is increasing rapidly, reflecting rising prevalence, demographic ageing, and persistent inequalities in access to healthcare. A study by Mi et al. (Mi et al., 2023[111]) estimated that total annual costs associated with coronary heart disease exceeded JPY 140 billion (~EUR 18 billion), but the analysis primarily covered hospital expenditures and lacked full accounting of outpatient care, productivity losses, and informal caregiving. Moreover, wide urban – rural disparities limit the generalisability of the findings. These limitations make it difficult to construct a comprehensive and directly comparable picture of CVD costs in China relative to the EU.

Republic of Türkiye presents another illustrative case. The modelling study by Balbay (Balbay, 2018[112]) highlighted the growing cost of CVD in Republic of Türkiye, projected to rise substantially by 2035 due to demographic and behavioural risk factors. While this study accounted for both direct and indirect costs, the analysis was based on national projections and modelling assumptions rather than observed data and excluded informal care costs. Therefore, although the results offer valuable insight into trends, their comparability to empirically derived EU estimates is limited.

Addressing the global burden of CVD requires improved data harmonisation for international comparison. Understanding how cost structures differ between health systems – and how those systems manage or fail to mitigate indirect and informal care costs – can guide policymakers toward more effective strategies.

In 2021, the economic burden of CVD represented a substantial share of overall public expenditure across sectors Comparing CVD expenditure as a percentage of GDP to other government spending priorities further illustrates its economic significance (see Table 2.3). In 2021, general government expenditures in the EU were distributed across key sectors, reflecting the region’s policy priorities. Health spending reached EUR 1 251 billion, or 8.1% of the EU’s GDP, while education accounted for EUR 806 billion (4.8% of GDP), and social protection – the largest expenditure – amounted to EUR 3 309 billion, or 19.2% of GDP. Spending on economic affairs, which includes areas such as transport and energy, amounted to EUR 991 billion (5.8% of GDP). Notably, defence expenditures stood at EUR 227 billion, or 1.3% of GDP. When compared to the estimated EUR 155 billion in direct costs attributed to CVD across the EU (healthcare + long‑term care), the economic burden remains large and in some countries is comparable to major government spending areas. By contrast, when productivity losses and informal care are included, the estimated total societal cost rises to EUR 282 billion (approximately 2% of GDP), which should not be directly compared to government budget functions shown in Table 2.3. This stark comparison underscores the immense financial impact of CVD and highlights the importance of prioritising preventive and treatment strategies within public health policy. For instance, in several European countries, CVD-related spending in 2021 is comparable to or even exceeds defence spending – highlighting its role as a major public expenditure item. In a bivariate regression analysis between CVD spending as a share of GDP and other government functions, Economic Affairs emerges as the strongest correlate, with a Pearson correlation of 49.9%, a linear regression coefficient of 3.5, and an R² of 0.25. This suggests that higher national investments in economic infrastructure and development tend to be accompanied by proportionally higher spending on CVD, potentially reflecting broader fiscal capacity or strategic prioritisation of health as part of economic policy.

Across countries, additional patterns emerge. Higher CVD expenditure often coincides with relatively lower investment in sectors such as education and social protection – particularly in countries like Bulgaria and Hungary, which allocate around 1.38% of GDP to CVD despite generally lower overall public service expenditure. Conversely, countries such as Austria and Italy exhibit high CVD spending alongside substantial investment in social protection, indicating a different dynamic where elevated health expenditures are part of a broader welfare model. This contrast underscores that while CVD imposes a significant economic burden across Europe, its relative weight and policy implications vary considerably depending on each country’s overall public spending capacity, budgetary priorities, and healthcare system structure. Understanding these contextual differences is crucial for designing targeted policy responses that balance health needs with broader fiscal and social objectives.

Table 2.3. Higher CVD burden coincides with relatively lower social investment

Annual direct costs of CVD and selected government expenditure 2021 (in percentage GDP)

Country	CVD	General public services	Economic affairs	Education	Social protection
Austria	1.44%	5.8%	9.4%	4.9%	21.9%
Belgium	0.86%	7.0%	7.0%	6.2%	20.8%
Bulgaria	1.38%	4.9%	6.6%	4.3%	12.9%
Croatia	0.84%	5.1%	7.8%	5.4%	13.9%
Cyprus	1.04%	6.5%	4.8%	5.1%	13.3%
Czechia	1.19%	4.6%	7.3%	4.7%	13.2%
Denmark	0.65%	5.6%	4.1%	5.8%	20.3%
Estonia	0.90%	3.9%	5.6%	5.9%	13.3%
Finland	1.06%	6.7%	5.1%	5.9%	25.0%
France	1.06%	6.1%	7.0%	5.1%	24.8%
Germany	1.34%	6.0%	6.5%	4.5%	20.5%
Greece	1.31%	7.7%	10.6%	4.0%	20.3%
Hungary	1.37%	7.9%	9.2%	5.0%	13.0%
Ireland	0.51%	2.3%	3.1%	2.8%	8.2%
Italy	1.39%	7.7%	6.7%	4.2%	22.6%
Latvia	1.05%	4.0%	8.2%	5.9%	13.9%
Lithuania	1.17%	3.0%	4.1%	4.7%	14.2%
Luxembourg	0.41%	4.6%	5.4%	4.7%	18.4%
Malta	0.71%	5.2%	8.6%	4.6%	10.1%
Netherlands	1.08%	3.8%	6.2%	5.0%	16.4%
Poland	1.15%	4.1%	5.9%	4.9%	17.1%
Portugal	0.94%	6.5%	5.5%	4.7%	18.1%
Romania	1.05%	4.9%	6.0%	3.2%	13.3%
Slovak Republic	1.11%	5.4%	6.7%	4.6%	15.9%
Slovenia	1.35%	5.1%	7.0%	5.8%	17.9%
Spain	1.12%	5.7%	6.4%	4.5%	20.1%
Sweden	0.81%	5.2%	5.3%	7.3%	19.2%
Average	1.05%	5.4%	6.5%	5.0%	17.0%

Note: CVD costs shown here include healthcare and long‑term care costs only and exclude productivity losses and informal (unpaid) care. In 2021, total societal costs of CVD in the EU (including productivity losses and informal care) were estimated at EUR 282 billion, of which ERU 155 billion were health and long‑term care costs.

Source: Eurostat. Hofmarcher et al. (2020[109]), “The cost of cancer in Europe 2018”, https://doi.org/10.1016/j.ejca.2020.01.011; Luengo-Fernandez et al. (2023[107]), “Economic burden of cardiovascular diseases in the European Union: a population-based cost study”, https://doi.org/10.1093/eurheartj/ehad583.

2.8.3. Understanding the drivers of CVD’s economic burden: Key cost factors Investigating the drivers of CVD-related costs

Understanding the drivers of CVD-related healthcare expenditure across EU countries is essential for designing effective policies aimed at controlling escalating healthcare budgets

CVD remains a leading cause of morbidity, mortality, and healthcare expenditure across Europe and globally, as illustrated in previous sections. As policymakers and healthcare systems strive for financial sustainability, it is crucial to understand the factors driving CVD-related costs. Demand-side drivers originate from the characteristics and behaviours of individuals and populations that affect their use of healthcare services. Supply-side drivers stem from the structure, organisation, and incentives of healthcare systems and providers that shape how care is delivered and financed. A clear distinction between these two dimensions helps clarify the complex dynamics behind CVD-related costs and inform targeted interventions to improve health outcomes while managing expenditures.

Demand-side drivers: Demographic changes, disease prevalence, comorbidities, health behaviour

Demographic trends, particularly population ageing, are a major demand-side driver of rising healthcare costs. Older individuals experience higher incidences of chronic diseases, including CVD, and typically require more frequent and intensive medical care. The prevalence and severity of cardiovascular conditions – such as hypertension, stroke, and coronary artery disease – rise with age, contributing to increased healthcare utilisation and associated costs (Salvatore et al., 2021[113]). Furthermore, the prevalence of CVD and its associated comorbidities (e.g. obesity, diabetes, hypertension) significantly impacts healthcare demand. Populations with higher rates of these conditions generate greater expenditures due to more frequent hospitalisations, specialist visits, and medication use. Understanding these prevalence dynamics is critical for designing preventive strategies to reduce disease incidence and mitigate healthcare costs (Maddox et al., 2017[114]).

Direct health and social care expenditures – driven by service prices, care pathways, and treatment intensity – account for the largest share of the economic burden of CVD. These costs are virtually uncorrelated with age‑standardised mortality rates (ASMR) from CVD (Figure 2.23) (Pearson correlation: 18%), suggesting that in the EU there is limited scope to further reduce CVD mortality solely through direct healthcare spending. Conversely, this also implies limited potential to significantly lower the overall economic burden of CVD through the prevention of CVD deaths alone.

Indirect costs show a similar pattern. Productivity losses, while partly linked mechanically to premature deaths, correlate only moderately with ASMR (56%) and explain just 31% of the variation in the total economic burden. Together, these findings help explain why, despite ASMR from CVD varying more than six‑fold across European countries, total CVD-related costs vary by just over three‑fold (Figure 2.23).

This reflects a fundamental shift in the nature of CVD’s economic burden: in most EU countries, CVD is increasingly a chronic condition rather than an acute, fatal event. Advances in prevention, diagnosis, and treatment have extended survival, but have also increased the number of people living for many years with CVD, often requiring long-term medication, regular specialist visits, and repeated hospital interventions. As a result, the primary cost driver is no longer the treatment of acute, life‑threatening episodes, but the ongoing management of chronic disease.

High CVD mortality does not necessarily translate into higher spending, and high spending does not necessarily translate into lower mortality. Health systems with comparatively low mortality rates may still face substantial costs, often due to high service prices, intensive treatment protocols, or costly hospital care. Conversely, countries with higher mortality rates may spend relatively little, reflecting differences in care access, coverage, or resource allocation. This lack of a clear relationship suggests that strategies focussed solely on reducing deaths are unlikely to achieve meaningful cost containment. To manage spending effectively, policy responses can better address service prices, provider payment systems, and the efficiency of care pathways. In particular, investments in prevention and chronic care models – those that improve health outcomes and reduce morbidity – can yield substantial economic returns by preserving the productivity of the working-age population, even when short-term mortality gains are limited.

Figure 2.23. Disease burden (CVD mortality) explains only 18% of the variation in health and social care spending

Source: Eurostat (hlth_cd_asdr2), 2025 ; Hofmarcher et al. (2020[109]), “The cost of cancer in Europe 2018”, https://doi.org/10.1016/j.ejca.2020.01.011; Luengo-Fernandez et al. (2023[107]), “Economic burden of cardiovascular diseases in the European Union: a population-based cost study”, https://doi.org/10.1093/eurheartj/ehad583.

It has been widely documented that patient’s behaviour greatly influences health outcomes and consequentially, disease related costs. More specifically, patient adherence to prescribed medications and treatment protocols has a profound effect on CVD-related costs. Better adherence improves disease control, reduces complications, and ultimately lowers healthcare utilisation and expenditures (Ho, Bryson and Rumsfeld, 2009[115]). Conversely, poor adherence increases the risk of adverse events and hospitalisations. More specifically, modifiable risk factors such as smoking, poor diet, and physical inactivity contribute to the demand for CVD care. Effective public health interventions targeting these factors can reduce the incidence of CVD, prevent disease progression, and substantially lower long-term healthcare costs (Landrigan et al., 2018[116]). Analogously, the extent to which populations utilise preventive healthcare services, such as screening and early detection programmes, directly influences CVD-related expenditures. Gaziano and authors showed that countries that invest in preventive services typically achieve better disease management and long-term cost control by reducing the need for costly acute interventions (Gaziano et al., 2013[117]).

Supply-side drivers: Technological innovation, policy framework, health system structure and incentives

On the supply side, several key factors – technological innovation, policy frameworks, and the structural and financial organisation of health systems – play a pivotal role in shaping the cost dynamics of CVD care and related costs.

Technological innovation has transformed the landscape of CVD treatment, introducing a range of advanced interventions such as minimally invasive surgeries, implantable cardiac devices, and cutting-edge pharmaceuticals. While these innovations hold considerable promise for improving patient outcomes, they often come with high price tags, putting additional pressure on healthcare budgets. Balancing innovation with affordability requires robust mechanisms for evaluating the value of new technologies. In this context, rigorous health technology assessments are essential to determine which innovations provide meaningful health benefits relative to their costs, ensuring that resource allocation remains both effective and sustainable (Salvatore et al., 2021[113]). It is equally important to involve multiple stakeholders – including clinicians, patients and caregivers, payers, and manufacturers – in such assessments, so that evaluation criteria are comprehensive, inclusive and aligned with real-world needs and values (Freitas, Oliveira and Vieira, 2025[118]).

Equally important are the policy and governance frameworks that steer public health priorities and shape health system responses to CVD. Comprehensive and well-enforced public health policies, including tobacco control, nutrition regulation and the promotion of physical activity, can play a crucial role in preventing CVD (see Chapter 6). Countries that invest in such upstream preventive strategies tend to experience lower healthcare expenditures in the long run, highlighting the cost-saving potential of proactive governance (Maddox et al., 2017[114]).

Moreover, the efficiency with which healthcare systems allocate and utilise resources greatly influences the economic burden of CVD. Systems that streamline care delivery, reduce redundancy, and prioritise evidence‑based interventions tend to achieve better outcomes at lower costs. Cross-national comparisons show that countries with more efficient models of care often report fewer avoidable hospital admissions and more sustainable expenditure patterns. Sharing and implementing best practices across systems can therefore play a vital role in enhancing the financial sustainability of CVD care (On behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee, 2021[119]).

Finally, the underlying organisation of health systems and the incentive structures they employ have a direct impact on cost trajectories. In fee‑for-service models, providers may have financial motivations to increase the volume of tests and procedures, which can lead to unnecessary interventions and higher costs. In contrast, integrated care systems or those based on capitation payments tend to encourage care co‑ordination, preventive services, and long-term cost containment. These alternative models can align financial incentives with patient-centred outcomes, fostering a more efficient and sustainable approach to managing cardiovascular health (On behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee, 2021[119]). OECD research shows that weaker PHC systems are associated with higher CVD spending, although the relationship remains modest and not statistically significant. For instance, countries with weak gatekeeping6 reported an average CVD spending of EUR 302 per capita, compared to EUR 285 in those with strong gatekeeping. Similarly, countries with limited comprehensiveness, as defined by having limited incentives for quality, spent EUR 315 per capita on average, versus EUR 271 in countries with strong incentives – a notable difference of EUR 44. In terms of continuity of care,7 countries classified as having moderate continuity spent the most (EUR 309), followed by strong continuity (EUR 294) and limited continuity (EUR 290), although this dimension showed less variation. When combining these three features, countries with limited gatekeeping, weak incentives, and low continuity exhibited the highest average CVD expenditure, at EUR 362 per capita (see Annex 2.B).

2.8.4. Balancing demand and supply: Tackling the complex drivers of cardiovascular healthcare costs

In summary, the healthcare costs associated with CVD are driven by a multifaceted interaction between demand- and supply-side determinants. On the demand side, demographic changes such as population ageing and increased life expectancy contribute to a growing number of individuals at risk of CVD. Rising disease prevalence, often linked to modifiable risk factors like unhealthy diets, physical inactivity, smoking, and obesity, further intensifies healthcare needs. Socio‑economic disparities also play a significant role, as lower-income and less-educated populations tend to experience higher CVD incidence, limited access to preventive care, and delayed treatment, amplifying both the health and economic burdens. Moreover, patient behaviours – including adherence to treatment, health literacy, and engagement with preventive services – critically influence outcomes and costs. On the supply side, variations in healthcare system organisation, financing models, and care delivery efficiency substantially affect how resources are allocated and utilised. The adoption of new technologies and innovations – such as digital health tools, telemedicine, and advanced treatments – can improve outcomes but also drive up short-term costs. Policy frameworks and reimbursement mechanisms further shape provider incentives and influence investment in prevention versus acute care. Efficiency gaps, fragmented care pathways, and uneven access across regions can lead to cost escalation and suboptimal health outcomes.

Addressing these interrelated factors requires a comprehensive and balanced policy approach. Health systems can further strengthen primary and preventive care, promote integrated service delivery, and ensure equitable access to effective interventions. Policymakers have an opportunity to also invest in data-driven planning, cost-effectiveness evaluation, and workforce development to improve efficiency and sustainability. By tackling both demand- and supply-side pressures in tandem, countries can achieve a more resilient, equitable, and cost-effective response to the growing challenge of CVD.

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Annex 2.A. PaRIS analysis of CVD based on social and demographic factors

Annex Figure 2.A.1. CVD, High blood pressure, diabetes and CKD are more prevalent among lower educated primary care users

Self-reported conditions among people living with chronic conditions in PaRIS

Note: The PaRIS survey was implemented in 19 countries: Australia, Belgium, Canada, Czechia, Wales (UK), France, Greece, Iceland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Romania, Saudi Arabia, Slovenia, Spain, Switzerland, the United States. Age and sex standardised.

Source: 2024 OECD PaRIS Database.

Annex Figure 2.A.2. CVD, high blood pressure, diabetes and CKD are more prevalent among low-income primary care users living with chronic conditions

Self-reported conditions among people living with chronic conditions in PaRIS

Note: The PaRIS survey was implemented in 19 countries: Australia, Belgium, Canada, Czechia, Wales (UK), France, Greece, Iceland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Romania, Saudi Arabia, Slovenia, Spain, Switzerland, the United States. Age and sex standardised.

Source: 2024 OECD PaRIS Database.

Annex 2.B. Assessing the role of primary care in CVD-related healthcare costs

Primary care substantially influences CVD related healthcare costs across EU countries

Primary care plays a pivotal role in managing chronic diseases, including cardiovascular conditions, by serving as the foundation of effective, accessible, and continuous healthcare. Effective primary care reduces overall healthcare costs through earlier diagnosis and better disease management, preventing severe cardiovascular complications (Kringos et al., 2013[120]). Integrating primary care with public health services enhances community-level preventive strategies, reducing cardiovascular risks through lifestyle interventions and education programmes, subsequently lowering healthcare expenditures (Laurant et al., 2018[121]). Enhanced patient education within primary care settings improves patient self-management and adherence, significantly lowering hospitalisation rates and associated healthcare costs (Nutting et al., 2010[122]). Primary care teams utilising multidisciplinary approaches, including nurses, pharmacists, and health coaches, effectively manage chronic conditions, reducing healthcare resource use and associated costs (Bodenheimer et al., 2014[123]) Finally, primary care‑based chronic disease management programmes that emphasise proactive patient follow-up, telehealth services, and population health management significantly reduce healthcare expenditures related to cardiovascular diseases (Peikes et al., 2018[124]).

According to Starfield’s 4Cs framework – first-contact access, comprehensiveness, continuity and co‑ordination, high-performing primary care systems are associated with better health outcomes and cost containment (Starfield, Shi and Macinko, 2005[125]). By providing initial and continuous care, primary care practitioners can effectively manage chronic conditions, reducing costly hospitalisations and specialist interventions. First-contact access within primary care systems significantly reduces unnecessary emergency department visits and hospital admissions, directly lowering healthcare costs. Countries with robust primary care services, offering prompt access to healthcare professionals, demonstrate better management of cardiovascular risks, thereby preventing expensive acute interventions (Macinko, Starfield and Shi, 2003[126]).

The comprehensiveness component of primary care ensures effective management of cardiovascular risk factors like hypertension, obesity, and diabetes within the community setting. Comprehensive primary care includes preventive services, lifestyle counseling, and chronic disease management, significantly lowering the need for specialist care and hospital-based interventions, and thus reducing overall healthcare expenditures (Murtagh et al., 2021[127]). Continuity of care within primary care systems strengthens patient-provider relationships, enhancing adherence to treatment plans, medication regimens, and lifestyle modifications. Continuity ensures that cardiovascular conditions are closely monitored, reducing the risk of complications and expensive hospital remissions. Effective continuity reduces fragmentation in healthcare services, thus achieving better cost management (Starfield, Shi and Macinko, 2005[125]). Co‑ordination of care by primary care providers facilitates seamless navigation across healthcare services, reducing unnecessary duplication of tests and procedures, which are significant contributors to healthcare expenditure. Finally, well-co‑ordinated primary care systems minimise fragmentation between specialist care, hospitals, and community services, optimizing resource use and thereby effectively managing healthcare costs related to cardiovascular conditions (WHO/UNICEF, 2018[128]).

In this section we empirically explore the association of different primary care models and CVD economic burden in EU context. In order to do so, we first define operationally four dimensions of Starfiled’s framework described above. First, to proxy first-contact access we use an indicator based on the gatekeeping role of primary care within health systems. Gatekeeping refers to whether primary care physicians act as the initial point of contact and control access to specialist care. This concept is captured through the OECD Health System Characteristics Survey (OECD/The Health Foundation, 2025[129]) classifying countries into three categories: Strong gatekeeping, where referrals from primary care physicians are required for access most specialist services; Moderate gatekeeping, where referrals are not mandatory but incentivised through reduced co-payments or other mechanisms; and Limited gatekeeping, where patients can directly access specialist care without referral or incentives to consult a primary care provider first.

Second, to proxy comprehensiveness in a comparative, policy-relevant manner, we use an indicator based on the presence and scope of incentives for quality improvement in primary care. This proxy, drawn from the OECD Health System Characteristics Survey, assesses whether primary care physicians are incentivised based on performance metrics related to preventive care, chronic disease management, patient satisfaction, population health indicators, and uptake of IT services. Countries receive a base score of 3 if any incentive scheme is in place, with additional points (+0.6 each) added for each specific area covered by the scheme. The total score ranges from 0 to 6 and is then categorised into three groups: Limited incentives (0‑2), Moderate incentives (3‑4), and Strong incentives (5‑6). This framework provides a structured way to assess the comprehensiveness and quality orientation of primary care across countries and its potential role in mitigating the economic burden of cardiovascular disease.

Third, to measure continuity of care in a cross-country context, we rely on a proxy indicator based on the proportion of the population with a regular doctor or usual source of care. This indicator, compiled from the OECD Health System Characteristics Survey, OECD PaRIS Survey (OECD, 2025[8]), and the Commonwealth Fund International Health Policy Survey (Gumas, 2024[130]), classifies countries into three categories: Limited continuity, where only a limited part of the population has a regular doctor; Moderate continuity, where the majority of the population does; and Strong continuity, where almost the entire population reports having a regular source of care.

A suitable proxy to categorise the level of co‑ordination in primary care could not be identified for a substantial number of the 27 EU countries. However, for 11 EU countries, we were able to use data from the OECD PaRIS Survey, specifically the P3ECQ Care Co‑ordination scores at the primary care level. Additionally, five EU countries – Bulgaria, Croatia, Cyprus, Malta, and Romania – did not participate in the OECD Health System Characteristics Survey. For these countries, a qualitative classification was developed based on available published literature. The variables classifying primary healthcare are described in Annex Table 2.B.1. Annex Figure 2.B.1 presents average CVD spending per capita in 2021 (in euros, PPP) across countries grouped by the quality of selected PHC system characteristics – first contact, comprehensiveness, and continuity of care.

Annex Table 2.B.1. Quality measuring in Primary Care

Classification of variables indicating strength in primary healthcare

Country	First contact (Gatekeeping)	Comprehensiveness (Incentives for quality)	Continuity	Coordination (P3ECQ – Co‑ordination)
Austria	Limited	Limited	Moderate
Belgium	Moderate	Limited	Strong	8.8
Bulgaria	Strong	Limited	Moderate
Croatia	Strong	Strong	Strong
Cyprus	Strong	Limited	Strong
Czechia	Limited	Strong	Strong	9.2
Denmark	Moderate
Estonia	Strong	Strong	Strong
Finland	Strong	Limited	Strong
France	Moderate	Strong	Moderate	8.4
Germany	Moderate	Limited	Strong
Greece	Limited	Limited	Limited	7.1
Hungary	Limited	Limited	Strong
Ireland	Strong	Limited	Moderate
Italy	Strong	Limited	Moderate	9.5
Latvia	Moderate	Strong	Strong
Lithuania	Strong	Strong	Strong
Luxembourg	Limited	Limited	Limited	8.5
Malta	Limited	Limited	Strong
Netherlands	Strong	Strong	Strong	7.3
Poland	Strong	Strong	Moderate
Portugal	Strong	Strong	Moderate	7.3
Romania	Strong	Limited	Moderate	10.3
Slovak Republic	Limited	Limited
Slovenia	Strong	Limited	Strong	8.2
Spain	Strong	Strong	Moderate	8.5
Sweden	Moderate	Strong	Moderate

Note: P3CEQ Questionnaire (Care Co‑ordination). Response to five questions measuring care co‑ordination. Scale ranges from 0 to 15, higher scores represent better care co‑ordination.

Source: (OECD/The Health Foundation, 2025[129]; Luengo-Fernandez et al., 2023[107]); Bulgaria (OECD/European Observatory on Health Systems and Policies, 2023[131]; Dimova et al., 2018[132]); Croatia (OECD/European Observatory on Health Systems and Policies, 2023[133]; Džakula et al., 2021[134]), Cyprus (Theodorou, Charalambous and Williams, 2024[135]), Malta (OECD/European Observatory on Health Systems and Policies, 2023[136]), Romania (OECD/European Observatory on Health Systems and Policies, 2023[137]).

A pattern emerges in which weaker PHC systems are associated with higher CVD spending, although the relationship remains modest and not statistically significant. For instance, countries with limited first-contact reported an average CVD spending of EUR 302 per capita, compared to EUR 285 in those with strong gatekeeping. Similarly, countries with limited comprehensiveness spent EUR 315 per capita on average, versus EUR 271 in countries with strong incentives – a notable difference of EUR 44. In terms of continuity of care, countries classified as having moderate continuity spent the most (EUR 309), followed by strong continuity (EUR 294) and limited continuity (EUR 290), although this dimension showed less variation.

When combining these three features, countries with limited gatekeeping, weak incentives, and low continuity exhibited the highest average CVD expenditure, at EUR 362 per capita. In contrast, countries with one strong or moderate characteristic across these dimensions reported significantly lower spending, averaging EUR 286. This substantial difference highlights the importance of primary healthcare system design in managing cardiovascular conditions. It suggests that weaknesses across multiple dimensions of PHC can compound one another, driving up healthcare costs by limiting the system’s ability to manage cardiovascular conditions proactively and efficiently at the primary care level.

Annex Figure 2.B.1. Though weak, there is an association between weaker PHC and higher CVD costs

Average and 95% confidence interval of €/capita PPP spent on CVD in 2021

Source: (OECD/The Health Foundation, 2025[129]; Luengo-Fernandez et al., 2023[107]); Bulgaria (OECD/European Observatory on Health Systems and Policies, 2023[131]; Dimova et al., 2018[132]); Croatia (OECD/European Observatory on Health Systems and Policies, 2023[133]; Džakula et al., 2021[134]), Cyprus (Theodorou, Charalambous and Williams, 2024[135]), Malta (OECD/European Observatory on Health Systems and Policies, 2023[136]), Romania (OECD/European Observatory on Health Systems and Policies, 2023[137]).

To address the higher costs associated with weak primary healthcare (PHC) systems and improve cardiovascular disease (CVD) outcomes, several policy recommendations can be considered. Implementing or reinforcing gatekeeping mechanisms that position primary care providers as the first point of contact in the health system. This approach ensures better care co‑ordination, prevents unnecessary specialist referrals, and promotes early detection and management of CVD risk factors. Second, design provider payment models to reward quality, continuity, and prevention rather than volume of services. For example, adopting blended payment systems that include capitation, pay-for-performance, or bundled payments can encourage primary care teams to manage chronic conditions more effectively and reduce costly hospital-based care. Third. promote long-term patient-provider relationships by supporting team-based care, integrated electronic health records, and patient enrolment with primary care practices. Continuity fosters trust, improves adherence to treatment plans, and allows for better tracking and control of chronic diseases like CVD. Fourth, expand and upskill the primary care workforce to meet growing chronic care demands. This includes training in CVD risk assessment and management, team-based approaches, and culturally competent care to address diverse population needs.

These measures can reinforce the foundation of PHC, leading to better health outcomes, more sustainable healthcare spending, and a more resilient system capable of addressing the rising burden of cardiovascular diseases.

Notes

← 1.  i.e. Some deaths from COVID‑19 reduced the population at risk of CVD death (competing risks).

← 2.  Disability-Adjusted Life Years (DALYs) are a widely used summary measure of population health that combine years of life lost due to premature mortality and years lived with disability. While DALYs provide a comprehensive picture of overall disease burden, we focus on PYLL in this report to specifically underscore premature mortality and highlight prevention opportunities.

← 3.  9 201 753. Data from Austria, Belgium, Bulgaria, Croatia, Czechia, Estonia, Finland, France, Germany, Hungary, Ireland, Italy, Latvia, Lithuania, the Netherlands, Poland, Portugal, Romania, the Slovak Republic, Slovenia, Spain and Sweden.

← 4.  Index of Multiple Deprivation (IMD): IMD is the official measure of relative deprivation in England and is part of a suite of outputs that form the Indices of Deprivation (IoD). It follows an established methodological framework in defining deprivation to encompass a wide range of an individual’s living conditions. People may be considered to be living in poverty if they lack financial resources to meet their needs, whereas people can be regarded as deprived if they lack any kind of resources, not just income. The IMD2 019 is a composite comprising seven domains of deprivation which, when combined and appropriately weighted, form the IMD2 019. They are: – Income (22.5%) – Employment (22.5%) – Health Deprivation and Disability (13.5%) – Education, Skills Training (13.5%) – Crime (9.3%) – Barriers to Housing and Services (9.3%) – Living Environment (9.3%). For further details, see https://assets.publishing.service.gov.uk/media/‌5d8e26f6ed915d5570c6cc55/IoD2019_Statistical_Release.pdf.

← 5.  Germany’s national CVD cost estimates may differ due to methodological variations, as they account only for ongoing healthcare expenditures.

← 6.  Gatekeeping refers to whether primary care physicians act as the initial point of contact and control access to specialist care.

← 7.  The proportion of the population with a regular doctor or usual source of care.