## 4 Discussion  
This study of IHD mortality, prevalence, incidence, and rates of medical interventions over three decades revealed pronounced differences between new and old Mediterranean EU country members. Female IHD mortality has significantly decreased from 1985 to 2019 in all countries except Croatia (+1.85%). The extent and patterns differ. France had the highest average reduction (AAPC) at \(-\)4.01%, while Italy had the lowest at \(-\)2.76%. Croatia and Slovenia had irregular patterns and upward IHD trends that could have been attributable to massive political, social, and healthcare changes accompanied by war. Nonetheless, potential changes in coding practice also cannot be excluded (Figures 1 and 2). The comparison of mean mortality rates among females over the last ten years showed a significantly higher rate in Croatia (112.92) than in Slovenia (33.66), Italy (32.63), Spain (21.65), and France (17.49). France and Spain had similar rates, as well as Italy and Slovenia, which, as opposed to Croatia, narrowed the gap with old EU country members in female IHD mortality. Male mortality has also significantly decreased in all countries except Croatia, with a negligible and non-significant reduction of \(-\)0.18%. As in the case of female IHD mortality, France had the highest average decrease over the 1985-2019 period of \(-\)3.43%. Within the last decade, Croatian males had a significantly higher mortality (183.38) compared to males in Slovenia (82.46), Italy (66.78), Spain (55.38), and France (46.97). Still, Slovenia managed to reduce the gap but less successfully compared with the reduction in female IHD mortality. Moreover, comparing the IHD mortality data for new country members, Slovenia and Croatia, for 2019 vs. 1991, showed significant between-country differences. While Slovenia considerably reduced mortality for females and males by \(-\)72.85% and \(-\)60.60%, this reduction in Croatia was much lower, at \(-\)29.80% for males and \(-\)20.10% for females. These differences can be explained by unsuccessful Croatian healthcare reforms, which systematically neglected politically sensitive aims. Health efficiency still represents a significant healthcare system problem [17]. Although the EU makes considerable effort to equalize health care across country members, distinctions deep-rooted in their historical, political, socioeconomic, and health traditions remain prominent. Cardioprotective Mediterranean heritage in the form of diet and lifestyle seems lost in transition, and the East-West health gap is still visible. Croatia has 5.6-fold higher IHD mortality for females and 3.3-fold higher IHD mortality for males compared to France. Despite the short coastline, the French paradox most likely contributed to the lowest mortality among all analyzed countries. Yet, the term Croatian paradox was also coined to address high CVD mortality, which is more similar to that in CEE than in Mediterranean countries [18,19] (Figures 1 and 2). The excess of male IHD mortality is expected, and male-to-female ratios ranged from 2.88 in France to 1.70 in Croatia. Male disadvantages can partly explain such variations, but smoking might have a crucial role. More harmful effects of smoking on females narrowed the ratio and often are overlooked. In many European countries, male smoking is declining and/or has reached a plateau, whereas female smoking is increasing [20]. Besides smoking, sex-specific mortality differences also cannot exclude potential health disparities regarding prevention, diagnosis, treatment strategies, and cardiovascular outcomes [21; 22]. Countries with a decline in IHD mortality efficiently control major risk factors and provide better medical care but also address relevant political, economic, and social determinants [23]. Various models consistently indicate that risk factor reduction explains a more significant proportion of mortality decline than medical treatments [24].