Cardiovascular disease and high blood pressure trend analyses from 2002 to 2016 : after the implementation of a salt reduction strategy

RESEARCH ARTICLE Open Access Ca dio ascula disease and high blood p essu e end analyses om 2002 o 2016: a e he implemen a ion o a sal educ ion s a egy D. Ab eu 1* , P. Sousa 1,2 , C. Ma ias-Dias 3 and F. J. Pin o 4,5 Abs ac Backg ound: Ca dio ascula disease (CVD) is he leading cause o dea h a ound he wo ld; howe e , many CVD e en s could be p e en ed i we ocused on modi ica ion o he main isk ac o s. Inc eased sal consump ion is es ima ed o ha e caused millions o dea hs, mos ly ela ed o CVD, pa icula ly s oke, which is he leading cause o dea h in Po ugal. In ou s udy, we aim o assess ends in he p opo ion o high blood p essu e (HBP) in Acu e Co ona y Synd ome (ACS) pa ien s as well as he ends in s oke and ACS in Po ugal, especially a e a se o public heal h ini ia i es we e implemen ed o educe sal in ake. Me hods: The mon hly p opo ion o ACS pa ien s p esen ing wi h p e iously diagnosed HBP and he mon hly a e o CVD admissions in o public hospi als in Po ugal we e calcula ed. CVD a es we e s a i ied in o ACS a e and s oke a es. Da a we e s a i ied by demog aphics a iables. An in e up ed ime-se ies model was used o assess changes o e ime. Resul s: B eakpoin analysis e ealed an es ima ed b eakpoin a ound he yea 2013 o he p opo ion o HBP pa ien s, he ollowing yea he e was a dec easing end, howe e i was no signi ican . Analyses showed he end be o e 2013 was inc easing and s a ed o dec ease a e his yea . This dec eased in p opo ion o HBP pa ien s can be ansla ed in o a educ ion o 555 people pe yea p esen ing wi h HBP in he ACS popula ion. We analysed ends o ACS and s oke and es ed he signi icance o a b eakpoin in he yea 2013. Al hough none o he emaining ends we e signi ican o ACS c ude a es and s oke c ude a e, a dec easing end was obse ed. Conclusions: This esea ch p o ides an indica ion abou he impac a popula ion-wide app oach o CVD isk ac o s has on CVD ends hemsel es. Ou esul s sugges ha popula ion-wide app oaches can ha e an impac on he p e en ion and imp o emen o CVD con ol, educing he numbe o CVD e en s, and e en ually educing p ema u e dea h by CVD. As mo e es ic ions on sal in ake a e being planned in Po ugal in he nex yea s, i is highly ele an o assess wha is he cu en pano ama and wha u he educ ions we can expec . Keywo ds: Ca dio ascula disease, High blood p essu e, Popula ion wide-app oach, Public heal h * Co espondence: [email p o ec ed] 1 Escola Nacional de Saúde Pública, Uni e sidade No a de Lisboa, A enida Pad e C uz, 1600-560 Lisboa, Po ugal Full lis o au ho in o ma ion is a ailable a he end o he a icle © The Au ho (s). 2018 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed. Ab eu e al. BMC Public Heal h (2018) 18:722 h ps://doi.o g/10.1186/s12889-018-5634-z Backg ound Ca dio ascula disease (CVD) is he leading cause o dea h a ound he wo ld [1]. An es ima ed 4 million people in Eu ope die by CVD annually [2]. Howe e , many o he CVD e en s could be p e en ed i we ocused on modi i- ca ion o he main isk ac o s [3]. In 2010, high blood p essu e (HBP) was he leading isk ac o con ibu ing o global disease bu den, accoun ing o mo e han 15% o all heal h loss in adul s [4], and esponsible o 62% o all s okes and 49% o ACS e en s [5]. Al hough sodium is an essen ial nu ien necessa y o main enance o plasma olume, acid-base balance, ans- mission o ne e impulses, and no mal cell unc ion [6], cu en sal consump ion is much g ea e han needed o su i al, c ea ing an o e load on he me abolic sys em [7]. This o e load can inc ease blood p essu e (BP) [8]. Inc eased sal consump ion is es ima ed o ha e caused millions o dea hs, mos ly ela ed o CVD, pa icula ly s oke, which is he leading cause o dea h in Po ugal [9], being one o he coun ies wi h he highes mo ali y a es by s oke among he Wes e n coun ies [10]. The high p e alence o HBP is poin ed o as one o he main easons. Implemen ing bo h popula ion-wide and high- isk ap- p oaches o educe blood p essu e seems almos ine i able due o he la ge bu den o HBP [11,12]. E en small educ- ions o HBP p e alence in he popula ion could lead o g ea heal h gains. Knowing he impo ance o hese app oaches, he Wo ld Heal h O ganiza ion (WHO) c ea ed a se o ecommenda ions o educe die a y sal o 5 g/day, in o de o p e en ch onic disease and imp o e heal h [13]. In he Eu opean Union, 26 ou o he 53 Membe S a es, in- cluding Po ugal, implemen ed ope a ional sal educ ion policies including laws aiming o educe sal in ake. Recen epo s ha e shown ha sal consump ion in Po ugal has been declining in ecen decades o a minimum o 7.3 g/day in 2016 [14]. P ospec i e s udies ha e shown ha educing sal in ake can lead o educ ions in blood p essu e and, e en ually, o a educ ion in CVD e en s [15]. By 2010 a se o public heal h ini ia i es we e imple- men ed in Po ugal, namely a educ ion in sal added o b ead and manda o y sal labelling in p e-packed ood. As hese ini ia i es a e mean o educe sal in ake we hypo h- esized ha i could lead o a educ ion in he p opo ion o HBP and CVD, namely ACS and s oke. The e o e in ou s udy, we aim o assess he ends in he p opo ion o HBP in ACS pa ien s, as well as he ends in s oke and ACS in he coun y, be o e and a e hese ini ia i es we e applied. Fo he sake o cla i y in ou s udy we e e as sal o all sodium da a. Me hods S udy popula ion Two popula ion se s we e used in his s udy. App o al o access da a was ob ained p e iously. Fo bo h se s o da a, pa icipan s included in he s udy we e o e 20 yea s old. Fi s popula ion da ase The Na ional Regis y o Acu e Co ona y Synd ome (NRACS) [16]. All da a om 2002 o 2015 we e ex ac ed o ou s udy. This da ase was used o ob ain he p opo - ion o ACS pa ien s p e iously diagnosed wi h HBP. This egis e collec s in o ma ion o ACS only, no jus o isk ac o s bu also demog aphics. This da ase has he ad an age o being in eg a ed in o he Eu o Hea Su ey pla o m and, consequen ly, uses he Ca diology Audi and Regis a ion Da a S anda ds (CARDS) sys em. This sys em ensu es ha c edible and compa able in o ma ion is collec ed in se e al Eu opean coun ies o e ime as hey use s anda dised in o ma ion, bo h in e ms o he de ini ion and coding o a iables, and in he o m o measu emen and collec ion o da a. As his da a is alida ed and s anda dised, i can be applied o and used o alida e analyses in o he la ge popula ions, hus being able o ob ain mo e obus esul s [17]. HBP in his da ase was de ined as p e iously diagnosed by a physician, o known blood p essu e > 140 mmHg sys olic o > 90 mmHg dias olic on wo o mo e occasions. Second popula ion da ase TheNa ionalda abase ha collec sda a omalladmis- sions in o Po uguese public hospi als (Mainland Po ugal). Da a om 2002 o 2016 we e ex ac ed o ou s udy. This da abase uses he Diagnosis Rela ed G oup (DRG) sys em holding da a on p ima y diagnosis and some demog aphic a iables, such as sex and age, as well as he geog aphic egion o admission [18]. DRG codes o ischemic and haemo hagic s oke we e included in he analysis (ICD 9 h codes o s oke: 43301, 43321, 43311, 43331, 43391, 43401, 43411, 43491, 431, 432, 4320, 4321, 4329, and 43381) as well as codes o ACS (ICD 9 h codes: 410.00–410.xx o iden i y admissions diagnosed as Acu e Myoca dial In a c ion and code 4130 o iden i y uns able angina). The wo da ase s we e analysed sepa a ely as he e is no possible me hod o iden i y he pa icipan s in he da ase , hus he same pa icipan can in ac be egis- e ed in bo h da ase s, howe e as he ou comes s ud- ied a e independen om each o he we do no expec his ac o in luence on he alidi y o he analysis. Simila ly he ac ha he wo da ase s used in ou s udy a e ca e ully moni o ed by he Po uguese Socie y o Ca diology, in he case o he NRACS, and he Di ec o a e o Gene al Heal h, in he case o he DRG da a, ensu es he alidi y o hese da a. Ab eu e al. BMC Public Heal h (2018) 18:722 Page 2 o 9 S a is ical analysis Two main ou comes we e analysed in ou s udy, he mon hly p opo ion o ACS pa ien s p esen ing wi h p e iously diagnosed HBP and he mon hly a e o CVD admission in o public hospi als in he coun y. CVD a es we e s a i ied in o ACS a e and s oke a es. The p opo ion o ACS pa ien s wi h HBP was ob ained by di iding he numbe o mon hly HBP diagnoses by he o al ACS pa ien s egis e ed o mon h. We applied an in e up ed ime se ies design, imple- men ing a segmen ed mul iple linea eg ession model, in which he esponse a iable was he mon hly he p opo - ion o ACS pa ien s wi h HBP. These models a e use ul when he ela ionship be ween he esponse and he inde- penden a iables a e piecewise linea , namely ep esen ed by wo o mo e s aigh lines connec ed a unknown alues, which a e usually e e ed o as b eakpoin s. In ou case, he b eakpoin would be expec ed o any gi en yea whe e he e was a change in he end o he p opo ion o pa ien s wi h HBP. R“segmen ed”package was used o de e mine he p esence o any b eakpoin s in he ends ound. C ude e en a es o ACS and s oke (pe 100,000 adul s) we e compu ed o each mon h, using he popula- ion o he coun y, es ic ed o he popula ion esiden in mainland Po ugal, wi h ages o e 20 yea s as he denomina o . C ude a es we e calcula ed as he numbe o e en s, o each ou come sepa a ely, di ided by he Po uguese popula ion o ha mon h. As he e ec o his ype o popula ion wide app oaches migh no be immedia e [19,20], aking some ime o show e ec s in he popula ion, we used he es ima ed b eakpoin om he mon hly p opo ion o ACS pa ien s wi h HBP as a p oxy o he e ec o he es ima ed b eak- poin in CVD ends. The impac o he b eakpoin es ima ed on he CVD ends, was assessed h ough a mul iple linea eg ession model using s anda d me hods o in e up ed ime se ies. We included one dicho omous a iable ha accoun ed o he main e ec on hospi al admissions o he es ima ed b eakpoin o he p opo ion o HBP pa ien s and an in e ac ion be ween he b eakpoin es ima ed and ime, o e alua e changes o e ime ollowing he b eakpoin . This model was implemen ed in o de o es whe he he e was a signi ican change in he numbe o e en s, and i he e was any change in he p opo ion o HBP pa ien s was obse ed. A mon h indica o co a iable was in oduced o adjus o seasonali y in he ou comes admissions. All analyses we e s a i ied by sex and age. Age was g ouped in o wo ca ego ies < 65 and ≥65 yea s old. Au oco ela ion be ween mon h es ima es was inco po- a ed adequa ely in o he model, wi h he p esence o sho e m au oco ela ion applying a i s o de au o eg essi e - AR (1) - s uc u e o he esiduals. Models we e i ed in R e sion 2.3.2 so wa e. S a is ical signi icance was assessed h ough p- alues, assuming < 5% as signi ican and 95% con idence in e als (CI) we e calcula ed o each o he eg ession coe icien s. Resul s A o al o 43,271 ACS e en s we e egis e ed in he NRACS o e he las 14 yea s. The p opo ion o males p esen ing wi h ACS has been consis en ly highe han women, wi h a ound 69% o ACS e en s occu ing in males. Mean age h ough he yea s o s udy has also been ai ly s eady, anging om 65 o 66 yea s old (Table 1). Male/ emale a io o HBP pa ien s (Fig. 1) has also emained ai ly s eady h ough he yea s in he ACS popula ion. The p opo ions o pa ien s wi h HBP anged om a minimum p opo ion o 50.0% o a maximum o 79.2%. B eakpoin analysis e ealed an es ima ed b eakpoin a ound he yea 2013 o he p opo ion o HBP pa ien s (Fig. 2), he yea a e he e is a dec easing end, howe e i was no signi ican (p- alue = 0.832). Analyses showed he end be o e 2013 was, in ac , inc easing and s a ed o dec ease a e his yea (β be o e = 0.009, CI: 0.007, 0.011; β a e =−0.003, CI: -0.037, 0.0302). Al hough ze o is p esen in he CI o he slope a e 2013, he change be ween bo h slopes (be o e and a e 2013) is nega i e wi h a dec ease o −0.012 in he mon hly p opo ion. Thus, he dec ease es ima ed a e 2013 is highe han he inc ease es ima ed be o e 2013. This dec ease in p opo ion can be ansla ed in o a educ ion o 555 people pe yea p esen ing wi h HBP in he ACS popula ion (Table 2). Figu e 3displays he equency o ACS and s oke admissions om 2002 o 2016. A o al o 115 public hospi als om mainland Po ugal egis e ed ACS ad- missions om2002 o2016and122 egis e eds oke admissions. A maximum age o 99 yea s old was ound in he da abase and he majo i y o admissions we e o bo h ACS and s oke. We analysed ends o ACS and s oke and es ed he signi icance o a b eakpoin in he yea 2013. Table 1 Demog aphic cha ac e iza ion o he da a analysed ACS (DRG da a) S oke (DRG da a) HBP in ACS pa ien s (NRACS da a) Be o e egula ion Female % 26,00% 49,43% 35,33% Age ≥65% 37,93% 77,15% 65,38% A e egula ion Female % 26,36% 49,61% 32,67% Age ≥65% 37,85% 78,26% 64,29% Ab eu e al. BMC Public Heal h (2018) 18:722 Page 3 o 9 Al hough none o he emaining ends we e signi ican (Table 2) o ACS c ude a es (β=−0.057, CI: - 0.154, 0.039) and s oke c ude a e (β=−0.049, CI: -0.128, 0.029), a dec easing end can be obse ed. When u he s a i ied da a by sex and age, al hough no signi ican ends we e obse ed, a dec easing end o ACS was ound in women bu no in men. The la ges dec ease was ound o people o e 65 yea s old o bo h ou comes. Ne e heless, all hese esul s should be in e p e ed wi h cau ion as none o he coe icien s we e signi ican (p- alues > 5%), and ze o was always included in he con idence in e al. The seasonal pa e n obse ed o ACS and s oke was consis en wi h ha epo ed elsewhe e [21], wi h highe a es o admission o e win e , and lowe a es du ing he summe (Fig. 3). Discussion Ou esul s showed inc easing ends in he p opo ion o HBP como bidi y in he ACS popula ion un il 2013, he ollowing yea s he ends appea o dec ease. This yea was used as a b eakpoin o es o di e ences in ends o ACS and s oke. Dec easing ends o bo h ou comes we e also ound, bu we e no signi ican . Al hough ou esul s we e no s a is ically signi ican , and hus mus be in e p e ed wi h cau ion, i is encou - aging o ind dec easing ends, especially in he p opo ion o HBP pa ien s in he ACS popula ion, wi h a educ ion o nea ly 600 people pe yea , a e he implemen a ion o a majo public heal h measu e ha was mean o educe sal in ake. E en a small educ ion in he p opo ion o HBP in he ACS popula ion, as he one obse ed in ou s udy Fig. 1 P opo ion o pa ien s wi h HBP in he ACS popula ion. Female/male a io om yea s 2002 o 2015 Fig. 2 T ends in o e all mon hly p opo ion o HBP in ACS pa ien s om Janua y 2002 o Decembe 2015. Dashed line ep esen s he beginning o 2013, yea associa ed o he es ima ed decline in ends Ab eu e al. BMC Public Heal h (2018) 18:722 Page 4 o 9 Table 2 Resul s om he h ee eg essions applied, segmen ed mul iple linea eg ession model, o he p opo ion o HBP pa ien s, and bo h mul iples linea eg essions using s anda d me hods o in e up ed ime se ies, o he ACS and s oke ou comes β(CI) - alue p- alue HBP p opo ion O e all a P e-b eakpoin end (change pe mon h) 0.004 (0.003;0.006) –– Change in end (pos -b eakpoin s p e-b eakpoin ) −0.006 –< 0.001 Pos -b eakpoin end (change pe mon h) −0.002 (−0.003;-0.001) –– Male a P e-b eakpoin end (change pe mon h) −0.003(−0.022;0.022) –– Change in end (pos -b eakpoin s p e-b eakpoin ) −0.016 –0.215 Pos -b eakpoin end (change pe mon h) −0.019(−0.061;0.023) –– Female a P e-b eakpoin end (change pe mon h) −0.003(−0.028;0.022) –– Change in end (pos -b eakpoin s p e-b eakpoin ) −0.016 –0.215 Pos -b eakpoin end (change pe mon h) −0.018(−0.052;0.014) –– Age < 65 a P e-b eakpoin end (change pe mon h) −0.022(−0.798;0.754) –– Change in end (pos -b eakpoin s p e-b eakpoin ) 0.011 –> 0.05 Pos -b eakpoin end (change pe mon h) −0.011(−0.039;0.017) –– Age ≥65 a P e-b eakpoin end (change pe mon h) 0.029(−0.017;0.075) –– Change in end (pos -b eakpoin s p e-b eakpoin ) −0.018 –> 0.05 Pos -b eakpoin end (change pe mon h) 0.011(−0.017;0.039) –– ACS c ude a es (pe 100,000 adul s) O e all a Time o he b eakpoin −0.112(−2.041;1.817) −0.114 0.909 Time o he b eakpoin a ime in e ac ion −0.031(−0.09;0.036) −0.903 0.368 Male a Time o he b eakpoin 0.289(−2.269;2.848) 0.222 0.825 Time o he b eakpoin a ime in e ac ion −0.018(−0.108;0.072) −0.393 0.695 Female a Time o he b eakpoin −0.497(−1.927;0.932) −0.682 0.496 Time o he b eakpoin a ime in e ac ion 0.013(−0.034;0.060) 0.560 0.576 Age < 65 a Time o he b eakpoin 0.151(−0.723;1.024) 0.338 0.736 Time o he b eakpoin a ime in e ac ion −0.015(−0.044;0.015) −0.986 0.325 Age ≥65 a Time o he b eakpoin 0.151(−5.159;6.721) 0.258 0.7970 Time o he b eakpoin a ime in e ac ion −0.015(−0.358;0.066) −1.349 0.1792 S oke c ude a es (pe 100,000 adul s) O e all a Time o he b eakpoin 0.265(−1.399;1.929) 0.312 0.755 Time o he b eakpoin a ime in e ac ion −0.037(−0.091;0.016) −1.370 0.172 Male a Time o he b eakpoin 0.900(−0.743;2.543) 1.074 0.284 Time o he b eakpoin a ime in e ac ion −0.022(−0.074;0.030) −0.822 0.412 Ab eu e al. BMC Public Heal h (2018) 18:722 Page 5 o 9 o 555 pe sons pe yea achie ed h ough a popula ion-wide app oach, can ha e huge impac s [22,23]. This impac s has e ec i ely slowed down he de elopmen o a he oscle osis in young people, he eby educing he likelihood o u u e epidemics o CVD [24]. The dec easing end o ACS was obse ed o women bu no in men, in ac sal in ake ha e been p e iously link o highe isk o CV e en s in women bu no in men [25], mo e pa icula ly s udies ha e ound ha women could bene i mo e, conce ning s oke educ ion, om die a y sal educ ion han men [26]. As sal sensi i i y is known o be g ea e in he elde ly we hypo hesized ha i he sal educ ion law could ha e some e ec i would be g ea e o he elde ly [27,28]. In ac ou esul s sugges a dec easing end o all ou comes in he olde g oup. Table 2 Resul s om he h ee eg essions applied, segmen ed mul iple linea eg ession model, o he p opo ion o HBP pa ien s, and bo h mul iples linea eg essions using s anda d me hods o in e up ed ime se ies, o he ACS and s oke ou comes (Con inued) β(CI) - alue p- alue Female a Time o he b eakpoin 0.999(−1.204;3.202) 0.888 0.376 Time o he b eakpoin a ime in e ac ion −0.047(−0.121;0.027) −1.244 0.215 Age < 65 a Time o he b eakpoin 0.448(−0.261;1.157) 1.238 0.217 Time o he b eakpoin a ime in e ac ion −0.014(−0.037;0.009) −1.207 0.229 Age ≥65 a Time o he b eakpoin 2.548(−5.351;10.446) 0.632 0.528 Time o he b eakpoin a ime in e ac ion −0.238(−0.502;0.026) −1.764 0.079 Values no p esen ed in he able (−) a e no a ailable o he ype o eg ession β ep esen s he coe icien s in he eg ession HBP High blood p essu e, ACS Acu e co ona y synd ome, CI con idence in e al a All models we e adjus ed o seasonali y Fig. 3 T ends in o e all mon hly c ude a es o CV admissions om Janua y 2002 o Decembe 2016 pe 100,000 adul s. a) T ends o s oke c ude a es admissions. b) T ends o ACS c ude a es admissions. Dashed lines ep esen he beginning o 2013, yea associa ed o he es ima ed decline in ends Ab eu e al. BMC Public Heal h (2018) 18:722 Page 6 o 9 Resul s om his ype o popula ion-wide app oach we e seen in he UK, whe e sal educ ion campaigns showed signi ican esul s, achie ing a 15% sal educ ion om 2003 o 2011, which ansla ed in o abou 6000 ewe dea hs om CVD, sa ing abou 1.5 billion pounds a yea [8]. The dec easing ends o all o ou ou comes was no as g ea as we expec ed, howe e he ac ha he s a ing o he dec ease akes place a e he implemen a ion o hese app oaches, and he end o HBP in ACS pa ien s was s eadily inc easing be o e ha , suppo s ou hypo hesis ha his app oach o educing sal in b ead and making p e-packed sal labelling manda o y can in luence HBP p e alence in ACS pa ien s as well as CVD ends. The ac ha , sal in ake le els ha e been dec easing in Po ugal o he mos ecen alue o 7.3 g/day in 2016 [14] also suppo s ou hypo hesis o he po en ially e ec o he egula ion applied in he coun y. Al hough his alue was ob ained by a 24 h die a y ecall ques ion- nai e [29], hese alues we e alida ed agains u ina y so- dium exc e ion o a sub-sample o 100 subjec s and he alues we e highly co ela ed. In addi ion, BP le els ha e been declining in he Po uguese popula ion, om a mean BP o 134.7/ 80.5 mmHg in 2003 [30] o a mean BP o 127/ 74.6 mmHg in 2012 [10]. Fu he mo e, se e al s udies showed ha b ead is one impo an sou ce o sal in Po ugal [7], and con ibu es o abou one-six h o daily sal in ake [7]. Resul s om he Na ional Food, Nu i ion and Physical Ac i i y Su ey sugges mos o he sal consumed by he popula ion comes di ec ly om b ead and oas , cha cu e ie p oduc s, and soups [14]. I was all his e idence ha led o he c ea ion o he egula ion o educe sal in b ead o a minimum o 1.4 g o sal pe 100 g o inal p oduc [31] and manda o y labelling o p e-packed p oduc s s a ing clea ly he sal con en o he p oduc . Po ugal was, hus, he i s wes e n coun y o c ea e a law o he clea de ini ion o he quan i y o sal con ained in b ead. Besides he legisla ion in 2010, se e al ini ia i es ha e been ca ied in Po ugal o educe sal in ake, such as: elec onic ools, such as websi es included in he Na ional P og am o he P omo ion o Heal hy Ea ing, o ee dis ibu ion o books and b ochu es, by he c ea ion o an anima ed se ies, and he c ea ion o he Na ional Food, Nu i ion and Physical Ac i i y Su ey, aiming o collec na ionwide da a on die a y in ake and physical ac i i y [14]. The e is al eady e idence ha educing sal in ake could educe BP in he Po uguese popula ion. One communi y in e en ion ial conduc ed in Po ugal demons a ed ha educing sal in ake in an en i e illage, including cooking and p ocessed ood, led o a signi ican educ ion in he BP o he popula ion [32]. Policy in e en ions o educe na ional sodium con- sump ion ha e demons a ed o be highly cos e ec i e in nea ly e e y coun y in he wo ld. These in e en ions could educe millions o disabili y adjus ed li e yea s a low cos and be mo e cos -e ec i e han pha macological in e en ions [26,33]. Policy and sys em changes a e c i ical o educe HBP in popula ions, including legisla ion and public educa ion o educe die a y sodium and ood p icing policies, o suppo p e en ion and managemen o CVD [34]. Al e na i e public heal h app oaches, such as educing sal in p ocessed oods and b ead, and labelling o p ocessed ood along wi h he use o mul iple iscal and educa ional policies, ha e al eady been p oposed by he WHO as he i s -line app oach o CVD educ ion, when implemen ed onawidescale[24,34]. In spi e o se e al e o s being made in he coun y o educe sal in ake, he e is s ill oom o imp o emen , namely in ood labelling [35], adjus ing i o he le el o heal h li e acy in he coun y. Once he le el o heal h li e acy in Po ugal was sligh ly lowe han he es o Eu opean coun ies [36], his migh ha e p e en ed he popula ion om ully bene i ing om he labelling, as he in e p e a ion o sal con en in each ood can be di icul . Simple labelling sys ems al eady exis in o he coun ies, such as labels ha ely on he use o on -o -pack in o ma- ion such as logos wi h in o ma ion on he o e all heal hi- ness o he ood and a ic ligh and colou coding sys ems, which migh help ci izens make heal hie choices. Coun ies such as Finland and he UK ha e al eady implemen ed some o hese labelling sys ems. In Finland, ood p oduc s wi h sal con en s below he designa ed le els display a low-sal label o emphasise hei lowe - han-con en ional sal le els [37]. In he UK, a a ic ligh sys em o dis in- guish be ween high, medium, and low sal con en in ood p oduc s was implemen ed. These s a egies p o ed o be e icien in educing sal in ake in he popula ion [38]. The a ic ligh labelling sys em has been p oposed by he Po - uguese Hype ension Socie y o help he popula ion choose p oduc s ega dless o hei le el o li e acy. Mo e es ic ions a e being planned in Po ugal o u - he educe sal in ake, such as a axes on p oduc s wi h mo e han 1 g o sal pe 100 g o inished p oduc such as: p e-packaged c acke s and biscui s; p e-packaged ce eal lakes and p essed ce eals; and p e-packaged, dehyd a ed po a o chips. A a e o 0.80 Eu os pe kilog am o inished p oduc will be applied o hese p oduc s. On he o he hand, u he educ ion o sal con en in b ead, o a minimum o 1 g pe 100 g o inal p oduc , was p oposed o be achie ed by 2020, wi h con inuous educ ions each yea a e 2018. Ou s udy p esen s encou aging indica ions sugges - ing he e ha e been educ ions in he p opo ion o Ab eu e al. BMC Public Heal h (2018) 18:722 Page 7 o 9 hype ensi es among ACS pa ien s a e 2013, along wi h an annual dec ease in he a es o ACS and s oke. Limi a ions Howe e , we ecognise some limi a ions o he s udy. Like any ecological s udy, i is no possible o p o e causal ela ions, i.e. di ec associa ion be ween he ini ia- i es o educe sal implemen in he coun y he educ ion obse ed in he p opo ion o hype ensi es ACS pa ien s. Howe e , ou me hodology was applied, using he same da a o analyse he e ec s o he smoking ban legisla ion on ACS ends, and a signi ican educ ion was ound igh a e he ban [39]. On he o he hand, i migh be oo soon o no ice g ea e ec s om sal educ ion on CVD ends. The ac ha un il 2013, he end o he p opo ion o hype ensi es was con inuously inc easing, and igh a e 2013 a dec ease in end can be obse ed, sugges s ha he lack o s a is ical signi icance could esul om he ime pe iod being analysed being oo sho o cap u e u he educ ions. Mo eo e , ou s udy has some s eng hs, such as he ac ha we used wo well alida ed and s anda dised da abases is a majo s eng h as his allows o an easy compa ison wi h o he in e na ional s udies mainly hose de eloped in o he Eu opean coun ies. As well as he a ailabili y o in o ma ion on gende and age, his allowed us o assess he obus ness o ou indings among di e en subg oups. Also he ime se ies me hod is p e e ed o e he simple p e- and pos -p opo ion compa ison me hod ha does no ake he p e-in e en ion end in o accoun , and also allows co ec ion o au oco ela ion [40]. Conclusions In conclusion, he ac ha we ound dec easing ends o bo h HBP in ACS pa ien s and CVD ou comes a e majo ini ia i es o educe sal in ake we e implemen ed in he coun y, sugges s ha his ype o app oaches, al hough ha d o measu e, can impac he ends o majo public heal h ou comes. Thus, his esea ch is ele an o he public heal h communi y because i p o ides an indica ion abou he impac ha a popula ion-wide app oaches can ha e on CVD isk ac o s, and CVD ends hemsel es. Ou esul s sugges ha popula ion-wide app oaches can ha e an impac on he p e en ion and imp o emen o CVD con ol, educing he numbe o CVD e en s and e en ually educing p ema u e dea h, mo bidi y, and disabili y by CVD. Ou s udy also highligh s he impo ance o measu ing he impac o hese ypes o ini ia i es. These indings s ess he need o public heal h policy in CVD o imp o e he heal h o popula ions add essing, in he i s place, he well iden i ied isk ac o s o CVD. Undoub edly, mo e s udies a e needed o assess he impac o such measu es, no only o o he diseases beside CVD, bu also adding mo e yea s o he s udy would allow analysis o long e ms e ec s o he public heal h ini ia- i es. On he o he hand, as mo e es ic ions on sal in ake a e being planned in Po ugal, in he nex yea s i is e y ele an o assess wha is he cu en pano ama and wha u he educ ions we can expec . Abb e ia ions ACS: Acu e Co ona y Synd ome; BP: Blood p essu e; CI: Con idence in e al; CVD: Ca dio ascula disease; DRG: Diagnosis ela ed g oup; HBP: High blood p essu e; NRACS: Na ional Regis y o Acu e Co ona y Synd ome Acknowledgemen s The au ho s hank he in es iga o s o he Na ional Regis y o Acu e Co ona y Synd ome, Sociedade Po uguesa de Ca diologia. This esea ch did no ecei e any speci ic g an om unding agencies in he public, comme cial, o no - o -p o i sec o s. A ailabili y o da a and ma e ials The da a ha suppo he indings o his s udy a e a ailable om he Minis e o Heal h O ice, (email: [email p o ec ed]) o he DRG da a. Da a om he Na ional Regis y o ACS can be eques ed om he Po uguese Socie y o Ca diology (sand a.co[email p o ec ed]). Howe e es ic ions apply o he a ailabili y o hese da a, which we e used unde license o he cu en s udy, and so a e no publicly a ailable. Da a a e howe e a ailable om he au ho s upon easonable eques and wi h pe mission om bo h he Minis e o Heal h O ice and he Po uguese Socie y o Ca diology. Au ho s’con ibu ions DA was esponsible o all s a is ical analysis and he esul s in e p e a ion, as well as esponsible o w i ing he pape . PS was esponsible o e iew all s a is ical analysis and esul s as well as o scien i ic inpu . CMD was in ol ed in d a ing he manusc ip as well as he inal e ision o he s udy. FP was esponsible o scien i ic inpu and inal e ision o he s udy. All au ho s ead and app o ed he inal manusc ip . E hics app o al and consen o pa icipa e App o al o access da a was ob ained p e iously om he Minis e o Heal h O ice and he Po uguese Socie y o Ca diology. E hics app o al and consen o pa icipa e a e no applicable o his s udy. Compe ing in e es s The au ho s decla e ha hey ha e no compe ing in e es s. Publishe ’sNo e Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a ilia ions. Au ho de ails 1 Escola Nacional de Saúde Pública, Uni e sidade No a de Lisboa, A enida Pad e C uz, 1600-560 Lisboa, Po ugal. 2 Cen o de In es igação em Saúde Pública - ENSP-UNL, A enida Pad e C uz, 1600-560 Lisboa, Po ugal. 3 Depa men o Epidemiology o he Ins i u o Nacional de Saúde Dou o Rica do Jo ge, A enida Pad e C uz, 1649-016 Lisboa, Po ugal. 4 Se iço de Ca diologia, Hospi al de San a Ma ia, Cen o Hospi ala Lisboa No e - EPE, Cen o, Académico Medicina de Lisboa, Lisbon, Po ugal. 5 Cen o Ca dio ascula da Uni e sidade de Lisboa, A . P o . Egas Moniz, 1649-035 Lisboa, Po ugal. Ab eu e al. BMC Public Heal h (2018) 18:722 Page 8 o 9 Recei ed: 8 Decembe 2017 Accep ed: 29 May 2018 Re e ences 1. Yusu S, Hawken S, Ôunpuu S, Dans T, A ezum A, Lanas F, e al. 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