## 4 Discussion
In general, prevention confirmed its effectiveness, and modelling studies suggested that 50-60% of the decrease in IHD mortality in Europe is attributable to prevention strategies at both population and individual levels [25; 26]. Primordial prevention seems incredibly demanding since social determinants extend outside the health sector. Studies suggest that social factors are equally important as traditional risk factors such as smoking, dyslipidemia, and hypertension [27; 28]. In high-income countries, a steady decline in IHD mortality since the 1980s has been attributed to primary and secondary prevention. However, the effects of prevention may hardly be distinguishable within the CV risk continuum [1; 29]. Cardiac rehabilitation, pivotal in secondary prevention, is often neglected, with a fragmented uptake across Europe [30]. Secondary prevention is focused on mortality reduction among cardiac patients as opposed to primary prevention, which largely reduces the incidence of IHD. Hyperfension, increased cholesterol levels, BMI, and high fasting glucose remain the most important metabolic risk factors for the reduction in IHD mortality [29; 31]. High systolic blood pressure mostly contributed to CVD mortality in both genders, more in Central than in Western Europe, at 62% vs. 51% in males and 60% vs. 50% in females, respectively. High total cholesterol levels, positioned second for both genders, contributed 20% to 30%. High BMI and high fasting glucose plasma, each responsible for around 20% or less of the CVD mortality burden, were ranked last [32]. Still, their relative contribution is complex, and significant between-country variations indicate an urgent need for further country-specific studies. Croatia's highest IHD mortality among analyzed countries is most likely also mainly attributable to hypertension. Insufficient awareness and lack of a formal public health policy, inadequate health promotion, failure to invest in prevention, underdiagnosed and undertreated patients made hypertension one of the most urgent public health problems [33]. According to the hypertension prevalence, Croatia is among the top-ranked countries in the world [34; 35]. ratio of 1.74 for males compared to Spain. During the last decade, Croatian and Slovenian females had significantly higher SPRs than females in other analysed countries. Still, Slovenian males had significantly lower rates than Croatian males. As a measure of disease burden, the prevalence is not the most appropriate way to measure the effect of risk factors. Nonetheless, it can help assess healthcare needs and assist with the future planning of healthcare services and interventions [36]. CABG and TCA rates also substantially varied between countries over the 2011-2019 period. Old EU country members, namely Italy, Spain, and France, had negative AAPC of CABG rates by \(-1.8\%\), \(-1.5\%\), and \(-0.2\%\) in contrast to an increase in Slovenia (+0.9%) and Croatia (+3.2%) (Figure 7). Differences in average CABG rate were significant, and the high-to-low ratio for Croatia vs. Spain was 3.5-fold. The Croatian CABG rate, previously reported as one of the highest in the EU, exceeded those of OECD countries [37]. Croatia increased the CABG rate from 1994 to 2002 by as much as 6-fold and reached the Slovenian level in 2002 [38]. Although the number of cardiac surgery centers improved, this cannot solely explain such an increase. Fragmentation of hospital care and lack of mandatory data collection enable the precise evaluation of appropriate indications. All countries had increased TCA rates, and the AAPC ranged from +0.6% (Spain) to +11.4 (Croatia), with a high-to-low ratio 3.19 (Figure 8). Such increased TCA utilization in Europe has been previously described [39]. It is partly attributable to the higher disease burden and worldwide growth of interventional cardiology, as well as broader indications and benefits of TCA, such as less invasiveness and improvements in stent technology.