Relation of socioeconomic position to the case fatality, prognosis and treatment of myocardial infarction events; the FINMONICA MI Register Study

OBJECTIVE: To examine socioeconomic differences in case fatality and prognosis of myocardial infarction (MI) events, and to estimate the contributions of incidence and case fatality to socioeconomic differences in coronary heart disease (CHD) mortality. DESIGN: A population-based MI register study. METHODS: The FINMONICA MI Register recorded all MI events among persons aged 35-64 years in three areas of Finland during 1983-1992. A record linkage of the MI Register data with the files of Statistics Finland was performed to obtain information on socioeconomic indicators for each individual registered. First MI events (n=8427) were included in the analyses. MAIN RESULTS: The adjusted risk ratio of prehospital coronary death was 2.11 (95% CI 1.82, 2.46) among men and 1.68 (1.14, 2.48) among women with low income compared with those with high income. Even among persons hospitalised alive the risk of death during the next 12 months was markedly higher in the low income group than in the high income group. Case fatality explained 51% of the CHD mortality difference between the low and the high income groups among men and 38% among women. Incidence contributed 49% and 62%, respectively. CONCLUSIONS: Considerable socioeconomic differences were observed in the case fatality of first coronary events both before hospitalisation and among patients hospitalised alive. Case fatality explained a half of the CHD mortality difference between the low and the high income groups among men and more than a third among women.     

Trends in the incidence of and mortality from coronary heart disease in Finland, 1983-1988.

Trends in the incidence of and mortality from coronary heart disease during the period 1983-1988 were assessed in the population aged 35-64 years in three areas of Finland. The official mortality statistics and the FINMONICA (Finnish portion of the World Health Organization MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) project) Acute Myocardial Infarction Register were used as data sources. They both showed that coronary heart disease mortality declined steeply in Finnish men and women. This marked decline in coronary heart disease mortality was associated with a decline in the number of out-of-hospital coronary deaths. The changes in the incidence of acute myocardial infarction in men did not parallel the changes in mortality. No decline in incidence was seen in women in any of the study areas. These results suggest that the routine mortality statistics alone may give an overly favorable picture of coronary heart disease trends. Data on incidence are necessary to assess the need for the treatment and prevention of coronary heart disease.     

Validity of diagnoses of major coronary events in national registers of hospital diagnoses and deaths in Finland

We validated diagnoses of acute myocardial infarction (AMI) and death from coronary heart disease (CHD) found in the Finnish National Hospital Discharge Register and the Register of Causes of Death from a sample of the 29,133 men participating in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. The cases were traced to hospitals and institutes performing medico-legal death cause examinations and all relevant information was collected. The cardiac events were re-evaluated according to the diagnostic criteria of the Finnish contribution to the WHO MONICA project, i.e. the FINMONICA criteria. Altogether 408 cases of non-fatal AMI (n = 217) and death from CHD (n = 191) were reviewed. In the re-evaluation 94% of them (95% confidence interval 92--96%) were diagnosed as either definite (57%) or possible (37%) AMI. Non-fatal cases were more often classified definite AMI in the review, whereas fatal cases were more often classified possible AMI. Age or trial supplementation group did not affect classification, and no secular trend was observed. In conclusion, the diagnoses of AMI and death from CHD in the registers were highly predictive of a true major coronary event defined by strict criteria, thus their use in endpoint assessment in epidemiological studies and clinical trials is justified.     

Incidence of myocardial infarction in the Danish MONICA population 1982-1991.

BACKGROUND: Cardiovascular mortality has been declining in Denmark over the past 20 years. Trends in incidence of myocardial infarction (MI) over the period 1982-1991 are described within the framework of the World Health Organization MONICA Project. METHODS: The DAN-MONICA heart register included all cases of MI in 25-74-year-old men and women living in 11 municipalities around Glostrup County Hospital evolving over a period of 10 years. They were identified retrospectively based mainly on relevant ICD diagnoses in death certificates and hospital discharge reports. Cases meeting WHO-MONICA criteria for definite or possible MI, recurrent as well as first-ever MI, were registered. Subsequent tracing of cases through national registers on deaths and hospitalizations by means of the patient's civil registration number ensured the completeness of the registration. RESULTS: A total of 6025 cases of MI occurred in the period, 4532 among men and 1493 among women. A total of 2923 men and 1047 women had a first-ever MI in the period. The age-standardized rates show a definite decline over the registration period for men and a less distinct decline for women. CONCLUSIONS: The DAN-MONICA heart register meets the requirements for completeness and uniformity throughout the registration period. Causes and magnitude of bias are well described. Even when possible sources of bias are taken into account, the incidence of MI decreased significantly over the 10-year-period 1982-1991 by an average of 5.0% per year for men and 3.5% per year for women.     

The effect of revascularization procedures on myocardial infarction incidence rates and time trends: the MONICA-Brianza and CAMUNI MI registries in Northern Italy

PurposeClinical guidelines recommend early reperfusion treatment in myocardial infarction (MI) patients to reduce the cardiac damage. Epidemiologic definitions of MI are often based on the evolution of the cardiac lesion. We aim to study the effect of treatment on the estimates of rates and 20-year time trends of MI.MethodsA Multinational Monitoring of trends and determinants in Cardiovascular disease (MONICA) register was active between 1985 and 2004 to survey 35- to 64-year-old residents in Brianza, Northern Italy. To the well-established MONICA definite MI, we added the MONICA possible nonfatal MI receiving either myocardial revascularization or thrombolysis within 24 hours from onset. The average annual relative changes in incidence rate and 28-day case fatality percentage were estimated from log-linear models.ResultsIn our population, characterized by a monotonic decrease in coronary heart disease (CHD) mortality rates, the incident rate for the standard MONICA definite MI decreased yearly by 3% in both gender groups. The addition of selected revascularizations halved the downward trends in incidence rate in men and women; conversely, the decline in 28-day case fatality became steeper.ConclusionsFrom an epidemiologic perspective, the increasing proportion of acute events efficaciously treated with revascularization therapy affects the estimate and the interpretation of time trends in MI incidence and CHD mortality.     

Trends in coronary heart disease mortality and morbidity in Auckland, New Zealand, 1974-1986

Routine mortality statistics show that coronary heart disease (CHD) death rates have declined consistently in Auckland men since 1968; in women, death rates declined between 1968 and 1986 but since 1981 there may have been a reduction in the rate of decline. Data from CHD registers conducted in Auckland, New Zealand in 1974, 1981, and since 1983 as part of the WHO MONICA Project, have been used to investigate the validity and reasons for the decline in the age group 35-64 years. In Auckland age-standardized sudden coronary death rates in men declined by approximately 2% per year between 1974 and 1986; there was no apparent decline in women. There was also an indication of a decline in age-standardized definite myocardial infarction rates but again only in men; 28 day case fatality in patients with a definite myocardial infarction has not changed significantly in the period 1981-1986. These results validate the mortality trends based on death certificates and in particular the differing recent trends in men and women. The decline in CHD mortality in men without a concomitant change in case fatality and the lack of recent decline in women, suggest that changes in the natural history of the disease rather than treatment are responsible for the mortality trends. Since disease events are rare in absolute numbers, long-term monitoring of coronary heart disease in large population groups will be necessary to usefully study disease trends, particularly in women.     

The feasibility of routine mortality and morbidity register data linkage to study the occurrence of acute coronary heart disease events in Finland

Validated population-based data on the occurrence of coronary heart disease in Finland have previously been obtained from myocardial infarction (MI) registers. Such registers cannot, however, cover large areas. Therefore, the Finnish Cardiovascular Diseases Registers (CVDR) Project was set up to obtain data for the whole of Finland. The CVDR Project is based on routine mortality and morbidity data linkage. We report here the overall approach used in the project, the results of the feasibility study and the first main results. In Finland, data on all hospitalizations are registered in the nationwide Hospital Discharge Register. Also, data on all deaths are collected in the nationwide Causes of Death Register. The unique personal identification number assigned to all persons residing in Finland was used for data linkage. Data have been validated using the FINMONICA MI registers. Sensitivity analyses showed that the data were robust and consistent between different geographical areas. Coronary heart disease (CHD) mortality as well as the incidence and event rates showed the same very clear geographical pattern, dividing Finland to a southwest area with a lower occurrence and a northeast area with nearly twice higher occurrence. Case fatality did not differ much between the areas and did not follow this Southwest–Northeast division. The differences between northeast and southwest Finland may be related to differences in risk factor levels but also to socioeconomic and genetic differences. The CVDR Project data will be instrumental in further research addressing these issues.     

Misclassification of coronary heart disease in mortality statistics. Evidence from the WHO-MONICA Ghent-Charleroi Study in Belgium

STUDY OBJECTIVE: To validate the Belgian vital statistics for coronary heart disease (CHD) on the basis of an independent acute myocardial infarction (AMI) register, carried out as part of the WHO-MONICA project. DESIGN: Records of fatal cases of AMI in the WHO-MONICA register were individually linked to the corresponding death certificates. SETTING: Since 1983, the WHO-MONICA Collaborating Centre Ghent/Charleroi registers all fatal and non-fatal AMI in the age group 25-69 years in two geographical areas, Ghent in the northern Dutch speaking part and Charleroi in the southern French speaking part of Belgium. Registration is done according to the MONICA protocol. The official vital statistics in Belgium are published on a yearly basis. They are essentially a reflection of the "underlying" causes of death, coded according to the 9th revision of the International Classification of Diseases (ICD). The study was undertaken in the period 1983-1991. MAIN RESULTS: Out of a total of 741 (Ghent) and 934 (Charleroi) well documented MONICA fatal cases of AMI, 492 (66.4%) and 641 (68.6%), respectively, were officially labelled as CHD (ICD code 410-414); 438 (59.1%) and 385 (41.2%), respectively, were officially labelled as AMI (ICD code 410). A substantial fraction of the MONICA AMI cases--27.1% in Ghent and 38.2% in Charleroi--was coded as "other forms of CHD" (ICD 411-414) or as "other forms of heart disease" (ICD 420-429). The remaining MONICA AMI cases--13.8% in Ghent and 20.6% in Charleroi--were classified in either very aspecific (for example, atherosclerosis, ICD 440) or totally unrelated ICD codes (for example, neoplasm, ICD 140- 239). CONCLUSIONS: It is concluded from the results in this paper that a substantial part of all deaths caused by CHD in Belgium are labelled with incorrect ICD codes and are therefore misclassified in the official mortality statistics for Belgium. This is partly caused by a "drainage" of cases towards less specific CHD related ICD categories. A considerable fraction, however, seems to be absolutely misclassified.       

Validation of reported myocardial infarction mortality in blacks and whites. A report from the Community Cardiovascular Surveillance Program.

It is widely believed that blacks experience a higher mortality due to coronary heart disease (CHD) than do whites. To determine whether this reported difference in mortality between blacks and whites is real, we studied the question in the context of the Community Cardiovascular Surveillance Program (CCSP). Fatal and nonfatal cases of CHD were reviewed in 12 US communities. Standardized criteria were applied to classify these cases as possible CHD, definite CHD, possible myocardial infarction (MI), or definite MI. The annual age-adjusted mortality rate per 100,000 ascribed to definite MI by the CCSP criteria was higher in blacks than in whites: 47 in white men (95% confidence interval, 36 to 58), 18 in white women (95% confidence interval, 8 to 28), 95 in black men (95% confidence interval, 10 to 180), and 41 for black women (95% confidence interval, 0 to 99). The proportion of definite MI to all fatal CHD events was higher in blacks (16%) than in whites (12%). For nonfatal events, however, the rate of definite MI was higher in whites than in blacks: 322 in white men (95% confidence interval, 293 to 351), 225 in black men (95% confidence interval, 160 to 290), 82 in black women (95% confidence interval, 43 to 121), and 103 in white women (95% confidence interval, 88 to 118). The proportion of definite MI to all nonfatal CHD events was lower in blacks (16%) than in whites (30%). Thus, the overall rate for fatal and nonfatal definite MI was lower in blacks (215/100,000) than in whites (244/100,000). These observations suggest that a combination of high case-fatality ratio and misclassification of cause and death may contribute to the reported higher rate of CHD mortality among blacks.     

Serum ferritin and death from all causes and cardiovascular disease: the NHANES II Mortality Study. National Health and Nutrition Examination Study

PURPOSE: The purpose of this study was to assess the association between serum ferritin and death from all causes, cardiovascular diseases (CVD), CHD and myocardial infarction (MI). Positive body iron stores have been proposed as a risk factor for coronary heart disease (CHD). While most epidemiologic studies using serum ferritin and other measures of body iron stores have not found an association between iron and heart disease risk, the hypothesis remains controversial. As a result, we examined the relationship of serum ferritin, the principle blood measure of body iron stores, to risk of death in a cohort with a standardized exam and long follow-up. METHODS: The baseline data for this prospective cohort study were collected in 1976-1980 as part of the second National Health and Nutrition Examination Study (NHANES II) with mortality follow-up using the National Death Index (NDI) through December 31, 1992. The analytic sample (n = 1604) consisted of 128 black men, 658 white men, 100 black women and 718 white women 45-74 years of age at baseline who, based on self-reported data, were free of coronary heart disease at baseline and had no missing data. The main outcome measures were the relative risk of death for persons with serum ferritin levels: <50 microg/L; or 100-199 microg/L; or > or =200 microg/L was compared to persons with serum ferritin levels of 50-99 microg/L adjusted for possible confounding using the Cox proportional hazards model. RESULTS: Most of the deaths were among white men (n = 254) and women (n = 168). There were relatively few deaths among black men (n = 50) and too few in women (n = 23) to reliably model. The largest number of CVD (n = 119), CHD (n = 82), and MI (n = 49) deaths were in white men while there were 69 CVD, 45 CHD and 13 MI deaths in white women. Black men with a serum ferritin level of <50 microg/L had a significantly higher adjusted risk of death from all causes (RR = 3.1 with 95% confidence limits of 1.5-6.5). There were no other statistically significant associations for all causes mortality for the other three race/sex groups. Additionally, there were no statistically significant associations between serum ferritin and any of the cardiovascular endpoints for any of the groups. There was an apparent but nonsignificant u-shaped association between serum ferritin and all causes mortality in black men and between serum ferritin and CVD death in white women. However, in both cases very wide confidence limits preclude further interpretation. CONCLUSIONS: Overall, the results do not support the hypothesis that positive body iron stores, as measured by serum ferritin, are associated with an increased risk of CVD, CHD or MI death or between serum ferritin and all causes mortality. Most of the research to date with serum ferritin has been conducted in European men or in European American men. Our results are consistent with the primarily negative results for that race/sex group. More research is needed in women and minority groups, including an explanation of why such an association would exist in these groups but not in white men before an association can be established in them.     

Comparison of fatal coronary heart disease occurrence based on population surveys in Japan and the USA

BACKGROUND:Although vital statistics have indicated large Japanese-American differences in mortality rates for coronary heart disease (CHD), the magnitude of difference has not been documented well using comparable validation of cause of death. METHODS:Population-based fatal CHD data were compared between the Oita Cardiac Death Survey, Japan and the Atherosclerosis Risk in Communities (ARIC) Study, USA. Both studies (population: Oita City 198 093; the ARIC comunities 286 820) identified possible fatal CHD events (International Classification of Diseases, Ninth Revision [ICD-9]: 410-414, 250, 401-402, 427-429, 440, and 798-799) among residents aged 35-74 years during 1992-1993. Comparable criteria for classifying cause of death were applied. Sex-specific, age-adjusted mortality rates of CHD were calculated by place of death. RESULTS:In all, 330 deaths in Oita and 1398 in the ARIC communities had eligible ICD-9 death certificate codes; CHD codes (ICD-9 410-414) comprised 30.6% of investigated deaths in Oita and 58.6% in ARIC. For men, the non-validated rate ratio for CHD deaths (ARIC:Oita City) was 5.9 (95% CI : 4.2-8.5), which fell to 4.7 (95% CI : 3.5-6.4) with validation and inclusion of sudden deaths within one hour of onset as fatal CHD. For women, the overall non-validated rate ratio was 4.6 (95% CI : 2.8-7.6), which fell to 3.9 (95% CI : 2.4-6.3) with validation and but there was little further change when the sudden deaths were added. CONCLUSIONS:Our results suggest that differences in fatal CHD rates between Japanese and Americans were not as large as suggested by vital statistics when events were validated and sudden deaths were included.     

Trends in fatal coronary heart disease among people aged 25-74 years in Oita City,Japan, from 1987-1998

Serum cholesterol has been increasing in recent years in Japan. There is concern that risk of coronary heart disease (CHD) may be increasing too, but there is little information on validated fatal CHD trends in the Japanese population. We identified 1,056 deaths from heart disease and other deaths possibly hiding CHD from death certificates of residents aged 25-74 years in Oita City, Japan in 1987-1988, 1992-1993, and 1997-1998 (mean population, 273,000 in 1997-1998). We validated 994 of them by medical record review and physician interviews, classifying them into definite fatal acute myocardial infarction (AMI) and possible fatal AMI or CHD death based on Monitoring Trends and Determinants in Cardiovascular Disease project's criteria. Sudden death was defined to estimate the number of CHD sudden deaths. In men, age-adjusted mortality rates due to validated fatal CHD remained quite stable over 10 years (25.3 per 100,000 [95% CI, 15.0-35.5] in 1987-1988 to 24.2 per 100,000 [95% CI, 16.1-32.3] in 1997-1998). When 50% or all sudden deaths were included as fatal CHD, the rates for men tended to decline. This was due to decreasing out-of-hospital deaths in connection with a declining CHD death rate among men aged 65-74 years, whereas in-hospital CHD deaths were level. In women, the rate of validated fatal CHD was highest in 1992-1993, but the 1997-1998 rate was similar to the 1987-1988 rate. We did not find that fatal CHD rates increased in Oita men and women from 1987-1998. Rather, out-of-hospital fatal CHD tended to decline in Oita men.     

The validity of hospital discharge register data on coronary heart disease in Finland

We studied the validity of the Finnish hospital discharge register data on coronary heart disease (CHD) for the purposes of epidemiologic studies and health services research. The Finnish nationwide hospital discharge register (HDR) was linked with the FINMONICA acute myocardial infarction (AMI) register for the years 1983–1990. The frequency of errors in the HDR was assessed separately. Between 8% and 13% of hospitalized AMI events registered in the AMI Register were not found in the HDR with an ICD code for CHD. Problems with the register linkage and the use of some ICD code other than one of the codes for CHD explained these missing events. The frequency of errors in the personal identification number was about 5% in the early 1980s. After 1986 errors were found only occasionally. The diagnosis recorded in the HDR was the same as that in the discharge sheet in about 95% of hospitalizations. The positive predictive value of the ICD code 410 (AMI), compared with the FINMONICA definite+possible AMI category, was very high and stable, about 90% in all areas and all hospitals, but it sensitivity varied from 50% at local hospitals to 80% at central hospitals. In summary, data on CHD obtained from the Finnish hospital discharge register give, on average, a correct picture on changes in the occurrence of AMI in Finland and can, with necessary caution, be used in epidemiological studies and health services research. However, the classification of individual cases is not standardized in the HDR, but varies over time, between geographical areas and the levels of care. Therefore, these data should not be used without confirmation in studies where correct classification of individual outcomes is of crucial importance, such as follow-up studies and case-control studies.     

Coronary heart disease mortality for six ethnic groups in California, 1990-2000

PURPOSE: To investigate ethnic variations in coronary heart disease death in California, the authors examined total and CHD-specific mortality among non-Hispanic white (white), Hispanic, non-Hispanic black (black), Chinese, Japanese, and Asian Indian Americans. Deaths were identified in the California Mortality Database and population information was derived from the 1990 and 2000 censuses. METHODS: Age-standardized death rates per 100,000 population were calculated for ages 25 to 84 years from 1990 to 2000. Proportional mortality ratios (PMRs) for each sex and age group were calculated by dividing the proportion of deaths due to CHD in each ethnic group by the proportion of deaths due to CHD in the total population. RESULTS: Blacks had the highest all-cause age-standardized death rates among men (1614) and women (1014). Blacks had the highest CHD death rates among men (272) and women (190). PMRs for CHD were highest in Asian Indian men (161) and women (144), reflective of the higher percentage of CHD deaths compared with all cause deaths in this group. All sex-ethnic groups showed a decline in all cause and CHD mortality compared with the period between 1985 and 1990, except Asian Indian women, who experienced a 16% increase in all cause mortality and 5% increase in CHD mortality. CONCLUSIONS: There is considerable heterogeneity in CHD mortality among ethnic subgroups, and additional research is needed to guide treatment and prevention efforts. Blacks and Asian Indians in California are identified as particularly high risk populations.     

Trends in mortality from pulmonary tuberculosis and HIV/AIDS co-infection in rural South Africa (Agincourt)

This study investigates trends and age-and-sex patterns of mortality in pulmonary tuberculosis (PTB) and PTB/HIV co-infection in a rural population of South Africa. The PTB/HIV mortality emerged in 1994, and has been rising ever since (men: P=0.001; women: P=0.020, test for trend). In the last 2 years, for both sexes combined, 63% (95% CI 51-74%) of PTB deaths were attributable to HIV/AIDS. PTB/HIV death rate was higher in men than in women for all ages combined (RR(MH)=2.48, 95% CI 1.53-4.04, P<0.001). PTB/HIV death rate was also higher in younger individuals (<25 years) compared with PTB without HIV/AIDS (P=0.033), and the median age at death from PTB/HIV in women (28 years) was lower than in men (38 years, P=0.002). While mortality from PTB without HIV remained constant over time, HIV/AIDS explained the rise in PTB mortality. In the last 3 years, the HIV/AIDS epidemic has caused the number of persons dying of PTB to increase by +117%, with the mortality excess being higher in women (+164%) than in men (+103%, P=0.001). Combined PTB and HIV programme activities need to be reinforced to respond to the increase in PTB mortality, particularly in women.     

The Worldwide WHO MONICA Project: results and perspectives

After World War II coronary heart disease (CHD) assumed epidemic proportions in western countries. In many countries the peak of the epidemic occurred in 1968. In 1978 the National Heart, Lung and Blood Institute of the NIH organized the Bethesda conference on the decline in CHD mortality. The aim of the conference was to find out whether measures of prevention or improvements in acute coronary care were responsible for the decline in age-specific CHD mortality rates. Because of lack of appropriate data in 1978 these questions remained unanswered. To answer these questions the WHO MONICA (Monitoring trends and determinants in cardiovascular disease) project was organized as a monitoring system to assess trends and determinants of cardiovascular mortality, incidence and case fatality from the mid 1980 s to the mid 1990 s in 38 populations in 21 countries worldwide. Altogether some 13 million people were monitored over a 10 year period. 166,000 myocardial infarction patients were registered and more than 300,000 men and women were sampled and examined for their cardiovascular risk factors and many other health data. In Western countries, where the CHD mortality decline was on average 2-3 % annually, two thirds of this decline could be explained by a decline in CHD incidence and one third by a decline in CHD case fatality. When relating risk factor changes to changes in CHD event rates in men over a time period of 10 years in all MONICA populations it turned out that the greatest contribution to the CHD decline came from a decrease in smoking. On a worldwide scale the Seven Countries Study, the Framingham Heart Study and the WHO MONICA Project have contributed most to the development of epidemiology and prevention of cardiovascular diseases.     

Predicting coronary heart disease mortality--assessing uncertainties in population forecasts and death probabilities by using Bayesian inference

BACKGROUND: Predictions concerning people and their health are influenced by many factors and have many sources of uncertainty. Even so predictions can give useful guidelines for health care planning. We present a Bayesian model based on past observations and prior knowledge to predict coronary heart disease (CHD) mortality in selected areas of Finland until the year 2030. METHODS: CHD mortality data are based on official statistics. The study area consists of one western and two eastern parts of Finland. The modelling of the probability of death follows a Bayesian age-period-cohort model. Two models are used, one assuming that the trend from 1970 to 2002 will continue and the other that mortality will stay at the attained level. RESULTS: If the observed trend in CHD mortality were to continue, death probabilities would decrease significantly among men aged 50-69 and women aged 50-59. In the older age groups (men aged 70 and women 60 years or more) the changes were found to be negligible. If the trend continues, the number of CHD deaths will decrease from 2002 to 2030 significantly among men [81% decrease; 95% credible interval (95% CI) 54-96%] and women (90%; 67-100%) aged 50-59. In the age group 60-79 the changes will be smaller and non-significant. In the oldest age group (80-99 years) the predicted increase in the number of deaths will be great, from 284 to 1297 (95% CI 474-2620) in men and from 722 to 1970 (717-4017) in women. CONCLUSIONS: Our predictions emphasize the significance of maintaining the recent decline of CHD mortality among middle-aged adults. Special attention should be paid to CHD mortality among men and women aged 80 and over. Considerable improvements in prevention and treatment are needed to compensate for the effects of ageing of the population.     

Local increases in coronary heart disease mortality among blacks and whites in the United States, 1985-1995

OBJECTIVES: This study analyzed coronary heart disease (CHD) mortality trends from 1985 to 1995, by race and sex, among Black and White adults 35 years and older to determine whether adverse trends were evident in any US localities. METHODS: Log-linear regression models of annual age-adjusted death rates provided a quantitative measure of local mortality trends. RESULTS: Increasing trends in CHD mortality were observed in 11 of 174 labor market areas for Black women, 23 of 175 areas for Black men, 10 of 394 areas for White women, and 4 of 394 areas for White men. Nationwide, adverse trends affected 1.7% of Black women, 8.0% of Black men, 1.1% of White women, and 0.3% of White men. CONCLUSIONS: From 1985 to 1995, moderate to strong local increases in CHD mortality were observed, predominantly in the southern United States. Black men evidenced the most unfavorable trends and were 25 times as likely as White men to be part of a local population experiencing increases in coronary heart disease mortality.     

Drug-related mortality in Denmark 1970-93

We analysed drug-related mortality in Denmark with respect to secular trends, gender, and regional variations, for the period 1970-93, for all deaths from poisoning and among drug addicts. The study was based on the Register of Causes of Death in Denmark and included 6,229 drug-related deaths, defined by specific combinations of manner of death, underlying cause of death, and contributory cause of death. The main outcome measure is age-specific mortality rate. A total of 63% of the drug-related deaths were registered as unnatural deaths. During the period studied, mortality increased for men in the 25 49 year age group and for women in all age groups over 25 years of age. For both men and women, the youngest birth cohorts from the mid-1950s and 1960s suffered much higher mortality than those born before 1950; however, the three youngest birth cohorts had almost the same mortality. During the entire period, mortality in the capital, Copenhagen, was much higher than in the provinces, but in the last years, a more favourable trend has been seen in Copenhagen.     

Socioeconomic inequities in invasive cardiac procedures after first myocardial infarction in Finland in 1995

OBJECTIVE: We examined socioeconomic disparities in coronary procedure rates after first events among hospitalized myocardial infarction (MI) patients. STUDY DESIGN AND SETTING: Information on MI patients in 1995 in Finland was obtained from the Finnish Cardiovascular Disease Register Project. Data on comorbidity, invasive treatments, hospitalizations, mortality, and socioeconomic status were obtained by linking data from the Finnish Hospital Discharge Register, cause of death register, population census, and the health insurance register using personal identity numbers. RESULTS: In 1995, 5172 patients aged 40 to 74 years were hospitalized for first MI. This corresponds to age-standardized event rates of 354/100,000 for men and 152/100,000 for women. Within 2 years, 33% of men and 21% of women underwent an invasive coronary procedure. Men in the lowest income third underwent 25% (95% confidence interval [CI] 12-36) fewer procedures than men in the highest third. Among women, the corresponding difference was 43% (95% CI 24-57). These disparities persisted throughout the 2-year follow-up, and they were not reduced by adjustment for comorbidity or hospital district. CONCLUSION: Socioeconomic disparities were observed in receipt of invasive cardiac procedures. More attention should be paid to equitable distribution of scarce health care resources.