Coronary artery disease has been the leading cause of death and disability in Iceland during the past decades although in recent years, malignancy has taken over that position. A steady improvement in the level of major risk factors has been evident since 1980. This trend explains 72% of the decrease in premature mortality from coronary artery disease during the past three decades. However, an opposing trend in increasing obesity and type 2 diabetes has attenuated this decline in premature deaths. Unchanged risk factor trends will lead to increasing cardiovascular mortality in the years to come. This will result from the above mentioned changes in major risk factors as well as an increased ageing of the Icelandic population.  At the same time case fatality after myocardial infarction has declined substantially. This will result in a steadily growing proportion of elderly in the population as well as a high burden of chronic non-communicable diseases among the elderly population. The resulting increase in long term disease and disability will put a major constraint on the health care system and economy alike. According to vital statistics and secular trends the rate of Icelanders in working age for each one reaching retirement age will decrease from the current 5.6 to 2.6 by year 2060. This paper addresses the driving factors of risk factor change in Iceland with previously unpublished data extending to 2013.

Table I: The number of subjects by study and period.

Figure Ia: Age adjusted incidence rates of coronary artery disease according to 2009 age distribution.

Figure Ib: Incidence of coronary artery disease by age categories 1981 and 2009.

Figure Ic: Age adjusted mortality from coronary artery disease among 25 to 74 year olds in 1981-2015.

Figure II: Improved 28 day survival after first myocardial infarction among 25-74 years old 1981-2009.

Figure III: Predicted population distribution in Iceland 2010-2065.  The ratio of 16-66 year olds by 67 years and older.

Figure IV:

a)    Decreasing mean total cholesterol in 50-69 years old Icelanders between 1968 and 2012.  The decrease amounts to 1.33 mmol/l (20.1%) among men and 1.71 mmol/l (23.3%) among women.  No change is evident in total cholesterol during 2006-2012.

b)    Declining prevalence of daily smokers among 50-69 years old Icelanders 1968-2012.  The decline is 72% among men and 66% among women.  The declining prevalence rates continue during 2006-2012.

c)    Decreasing mean systolic blood pressure among 50-69 years old Icelanders 1968-2012.  The decrease is 10% among men and 16.7% among women.  A continuing decrease in mean systolic blood pressure is seen during 2006-2012 both among men and women.

d)    Increasing prevalence of regular physical exercise among 50-69 years old Icelanders 1968-2012. 

e)    Increasing body mass index among 50-69 years old Icelanders 1968-2012.  The increase seems to continue among men but level out among women.

f)     The prevalence of type 2 diabetes has increased substantially among 50-69 years old males in 1968-2012.  During 2006-2012 the prevalence continues to rise among men, but levels off among women.

Figure V: Mean total cholesterol among men and women in total population (solid lines) and among the population not taking statins (dotted lines).

Figure 6.  Mean systolic blood pressure among men and women in total population (solid lines) and among the population not taking blood pressure lowering medication (dotted lines).

Figure VI: Mean systolic blood pressure among men and women in total population (solid lines) and among the population not taking blood pressure lowering medication (dotted lines).

Figure VII: Prevalence of type 2 diabetes in 2010 by age categories.

Figure VIII: Projected coronary artery disease mortality trends in 2010-2040 according to three possible scenarios.  First, if the historical risk factor trends of the last three decades were to continue unchanged, the declining mortality rates would be significantly attenuated, mostly due to the ageing population.  Secondly, if the risk factor trends of the more recent time period of 2006-2010 were to continue, a substantial increase in mortality rates would be seen, mainly caused by increasing rates of obesity and type 2 diabetes in addition to population aging.  Finally, if we accomplish realistic goals in the positive development of major risk factor trends, we could expect declining rates of coronary artery disease mortality up to year 2040.