Trends in the Incidence of Myocardial Infarction and in Mortality Due to Coronary Heart Disease, 1987 to 1994
Wayne D. Rosamond, Ph.D., Lloyd E. Chambless, Ph.D., Aaron R. Folsom, M.D., Lawton S. Cooper, M.D., David E. Conwill, M.D., Limin Clegg, Ph.D., Chin-Hua Wang, Ph.D., and Gerardo Heiss, M.D., Ph.D.
Background and Methods To clarify the determinants of contemporarytrends in mortality from coronary heart disease (CHD), we conductedsurveillance of hospital admissions for myocardial infarctionand of in-hospital and out-of-hospital deaths due to CHD among35-to-74-year-old residents of four communities of varying sizein the United States (a total of 352,481 persons in 1994). Between1987 and 1994, we estimate that there were 11,869 hospitalizationsfor myocardial infarction (on the basis of 8572 hospitalizationssampled) and 3407 fatal coronary events (3023 sampled).
Results The largest average annual decrease in mortality dueto CHD occurred among white men (change in mortality, –4.7percent; 95 percent confidence interval, –2.2 to –7.1percent), followed by white women (–4.5 percent; 95 percentconfidence interval, –0.7 to –8.2 percent), blackwomen (–4.1 percent; 95 percent confidence interval, –10.3to +2.5 percent), and black men (–2.5 percent; 95 percentconfidence interval, –6.9 to +2.2 percent). Overall, in-hospitalmortality from CHD fell by 5.1 percent per year, whereas out-of-hospitalmortality declined by 3.6 percent per year. There was no evidenceof a decline in the incidence of hospitalization for a firstmyocardial infarction among either men or women; in fact, suchhospital admissions increased by 7.4 percent per year (95 percentconfidence interval, 0.5 to 14.8 percent) among black womenand 2.9 percent per year (95 percent confidence interval, –3.6to +9.9 percent) among black men. Rates of recurrent myocardialinfarction decreased, and survival after myocardial infarctionimproved.
Conclusions From 1987 to 1994, we observed a stable or slightlyincreasing incidence of hospitalization for myocardial infarction.Nevertheless, there were significant annual decreases in mortalityfrom CHD. The decline in mortality in the four communities westudied may be due largely to improvements in the treatmentand secondary prevention of myocardial infarction.
Mortality from coronary heart disease (CHD) has declined steadilyin the United States for the past 30 years.1,2 Between 1990and 1994, age-adjusted mortality from CHD among people 35 yearsof age or older in the United States declined by 10.3 percent3;the rate of decline was highest for white men (2.9 percent peryear) and lowest for black women (1.6 percent per year). Nationalvital statistics provide mortality rates for CHD, and nationalhospital-discharge surveys yield rates of hospitalization formyocardial infarction. Neither measure is adequate to evaluatethe incidence of CHD, however, since they are based on unvalidatedcodes from the International Classification of Diseases, 9thRevision, Clinical Modification (ICD-9-CM)4; thus, it may notbe possible to compare rates over time and between communities.5,6,7
The use of accurate measures of the incidence of CHD is particularlyimportant if the effects of primary prevention are to be distinguishedfrom those of treatment. Much of what is known about the incidenceof acute myocardial infarction and fatal CHD in the United Statescomes from isolated community-surveillance studies,8,9,10,11cohort studies of cardiovascular disease,12,13 or studies ofmanaged-care medical programs.14 Although these studies haveprovided valuable insights into recent trends in the occurrenceof CHD, none of them alone provide annual data on the incidenceof CHD in multiple large, geographically and ethnically diversepopulations. Furthermore, data on incidence in the 1990s anddata on out-of-hospital deaths confirmed as due to CHD are largelyunavailable.
We studied population-based trends in mortality from CHD andin the incidence of myocardial infarction from 1987 to 1994.The data come from the Atherosclerosis Risk in Communities (ARIC)study, which examined the incidence of CHD in four areas ofvarying size, referred to in this study as communities, in theUnited States.15,16
Methods
Study Population
The ARIC study used a retrospective surveillance system forthe continuous monitoring and analysis of hospital admissionsfor myocardial infarction and deaths due to CHD that occurredin or out of the hospital among all residents 35 through 74years of age in Forsyth County, North Carolina; the city ofJackson, Mississippi; eight northern suburbs of Minneapolis;and Washington County, Maryland.
Data on Mortality Due to Chd
Death certificates that met criteria based on age, residence,and underlying cause of death (ICD-9-CM codes 250, 401, 402,410 through 414, 427 through 429, 440, 518.4, 798, and 799)were reviewed by trained personnel, who abstracted data forthe study. Few deaths among community residents occurred outof state15; such deaths were omitted. Deaths in nursing homesor emergency rooms and hospital admissions of persons classifiedas dead on arrival were considered to be out-of-hospital deaths.For out-of-hospital deaths, additional information was soughtfrom the next of kin and other informants, the certifying andfamily physicians, and coroners or medical examiners. BecauseMaryland state law prohibited contacting persons listed on deathcertificates, we were unable to use the same method to validatecauses of death for out-of-hospital deaths in Washington County.For this reason, rates of mortality due to confirmed CHD arenot reported for Washington County.
Using standardized criteria,15 the ARIC Mortality and MorbidityClassification Committee reviewed out-of-hospital deaths andassigned a final diagnosis; disagreements were adjudicated bythe committee chairman. In-hospital deaths were classified aftera review of hospital records and death-certificate information.The rate of death due to CHD includes deaths classified as dueto either a definite fatal myocardial infarction or definiteCHD. This category included deaths for which no probable causeother than atherosclerosis was known in patients with a historyof hospitalization for myocardial infarction within 28 daysbefore death, as well as deaths for which there was evidenceof chest pain within 72 hours before death or a history of myocardialinfarction and no known nonatherosclerotic cause.
Rates of mortality due to CHD based only on the ICD-9-CM codesfor the underlying cause of death are also presented in thisreport. A death due to unconfirmed CHD was defined by the presenceof an ICD-9-CM code of 410 through 414 or 429.2 for the underlyingcause of death.
Data on Hospitalization for Myocardial Infarction
Annual lists of eligible hospital discharges were obtained foreach of 28 hospitals serving the four communities in the ARICstudy.15 Eligibility was based on age, residence, date of discharge,and diagnosis codes (ICD-9-CM codes 402, 410 through 414, 427,428, and 518.4). Hospitalizations of community residents outsidethe study area were not identified. Trained staff members recordedthe following information from eligible medical records: symptomson presentation, presence or absence of chest pain, historywith respect to myocardial infarction or other cardiovascular-relatedconditions, and cardiac-enzyme levels on the first four daysafter the event. Copies of up to three electrocardiograms weremade and sent to the University of Minnesota ElectrocardiographicReading Center for classification according to the Minnesotacode.17 A computerized algorithm was applied to data on symptoms,cardiac enzymes, and electrocardiographic evidence to determineeach patient's computer diagnosis.15 Cases with multiple hospitalizationsand those with certain types of discrepancy between the discharge-diagnosiscodes and the computer diagnosis were reviewed by the Mortalityand Morbidity Classification Committee.
Trends in rates of hospitalization for myocardial infarctionwere also calculated on the basis of discharge-diagnosis codesalone. These nonvalidated events were defined by the presenceof an ICD-9-CM discharge-diagnosis code of 410 (acute myocardialinfarction).
Definition of a First Event
A first myocardial infarction was defined as one in a patientfor whom the medical record either stated that there was nohistory of myocardial infarction or did not contain any referenceto a history of myocardial infarction. For patients who diedfrom cardiovascular events outside the hospital, the historywas based on information obtained from the next of kin and otherinformants, the certifying and family physicians, the coroneror medical examiner, or the medical record for any eligiblehospitalization within 28 days before death.
During the eight-year study period, 13 percent of patients hospitalizedfor myocardial infarction had no recorded history of myocardialinfarction; this percentage was generally stable over time.The proportion of medical records in which there was no informationon the history was higher for women (15 percent) and blacks(18 percent) than for men (11 percent) and whites (12 percent).
Statistical Analysis
The types of deaths and discharge diagnoses that are relativelyunlikely to be confirmed as related to CHD were sampled. Samplingwas based on the ICD-9-CM code and the date of discharge ordeath. Hospitalizations were categorized according to four mutuallyexclusive codes or groups of codes (ICD-9-CM codes 410; 411;412 through 414; and 402, 427, 428, and 518.4 — with samplingprobabilities of 1.0, 0.5, 0.25, and 0.1, respectively). Similarly,deaths were categorized according to two code groups (ICD-9-CMcodes 410 through 414 and 429.2; and 250, 401, 402, 427, 428,440, 518.4, 798, and 799 — with sampling probabilitiesof 1.0 and 0.25, respectively). Our analysis was weighted toreflect this sampling.
Rates specific for sex, race, and community were computed onthe basis of dynamic population estimates derived by interpolationfrom U.S. Census data. Rates were adjusted for age by the directmethod, according to the distribution in U.S. population in1990. The logs of the weighted rates were modeled as linearfunctions of year and of age (the midpoints of five-year agegroups), by Poisson regression with SAS Proc Genmod (SAS Institute,Cary, N.C.), using annual projections of the numbers of peoplein each group defined by five-year age group, race, and sexin the 1990 Census. Variances for the estimators of the coefficientsin the model were programmed in SAS IML to account for the additionalvariance, beyond the Poisson variance, due to the sampling ofevents. Seventy-nine coronary events in persons with missingdata on race or in persons who were identified as neither blacknor white were excluded from these analyses.
Results
From 1987 through 1994, there were an estimated 11,869 hospitaladmissions (on the basis of 8572 hospitalizations sampled) forfatal or nonfatal, definite or probable acute myocardial infarctionsamong residents who were from 35 through 74 years old in thefour communities (Table 1). There were an estimated 3407 deathsdue to CHD (3023 sampled), including both in-hospital and out-of-hospitaldeaths. Sixty-one percent of all coronary events occurred inpersons with no recorded history of myocardial infarction (66percent for blacks and 60 percent for whites; 65 percent forwomen and 59 percent for men).
Table 1. Events Confirmed as Due to CHD, 1987 to 1994.
Trends in Mortality Due to Chd
Among men, the age-adjusted mortality from confirmed CHD fellfrom 3.1 per 1000 persons (95 percent confidence interval, 2.7to 3.5) in 1987 to 2.2 per 1000 (95 percent confidence interval,1.9 to 2.6) in 1994 (Figure 1). The decline was observed between1987 and 1991, with no further decline through 1994. Among women,mortality from CHD fell from 1.1 per 1000 (95 percent confidenceinterval, 0.9 to 1.4) in 1987 to 0.90 per 1000 (95 percent confidenceinterval, 0.7 to 1.1) in 1994. Mortality rates based solelyon deaths for which CHD was listed as an underlying cause showeda similar pattern of change (Figure 1). Mortality from confirmedCHD among blacks showed declines similar to the overall trends.For black men, mortality fell from 3.0 per 1000 persons (95percent confidence interval, 2.0 to 3.9) in 1987 to 2.3 per1000 (95 percent confidence interval, 1.4 to 3.2) in 1994, andfor black women, it fell from 2.4 per 1000 (95 percent confidenceinterval, 1.4 to 3.3) in 1987 to 1.9 per 1000 (95 percent confidenceinterval, 1.2 to 2.7). The annual male-to-female rate ratiofor mortality from CHD was consistently greater among whitesthan among blacks, with overall ratios of 3.3 and 1.7, respectively.
Figure 1. Age-Adjusted Mortality from CHD among Men and Women 35 to 74 Years Old, 1987 to 1994.
Expressed as a percentage, age-adjusted mortality from confirmedCHD declined 27.6 percent from 1987 to 1994 (95 percent confidenceinterval, 13.4 to 39.4 percent), an average decline of 4.0 percentper year, for men, and 31.3 percent (95 percent confidence interval,8.8 to 48.3 percent), or 4.6 percent per year, for women (Table 2).The average declines among white men and white women weresimilar and statistically significant. The average declinesof 2.5 percent per year for black men and 4.1 percent per yearfor black women were not significantly different from no decline.
Table 2. Average Annual Change in Mortality Due to Confirmed CHD and Case Fatality Rates, Adjusted for Age, 1987 to 1994.
Among men, 64 percent of all deaths due to CHD occurred outsidethe hospital, with essentially no change in this percentagebetween 1987 and 1994. About half of all deaths due to CHD amongwomen during this period were out-of-hospital deaths, exceptin 1988 and 1994, when this proportion was about a third. Thepercentage of deaths due to CHD that occurred outside the hospitalamong blacks was as high as 74 percent and was generally higherthan among whites.
Both out-of-hospital and in-hospital mortality due to CHD declined(Figure 2). Overall, in-hospital mortality from CHD fell by5.1 percent per year (95 percent confidence interval, 2.1 to8.1 percent), whereas out-of-hospital mortality declined by3.6 percent per year (95 percent confidence interval, 1.3 to5.8 percent). For men, the decline in the rate of in-hospitaldeath from CHD was 5.1 percent (95 percent confidence interval,1.5 to 8.5 percent) per year, and the decline in the rate ofout-of-hospital death was 3.4 percent (95 percent confidenceinterval, 0.7 to 6.0 percent) per year. Trends among women weresimilar. Declines in mortality from CHD were also similar forpersons less than 55 years of age and for those 55 or older.
Figure 2. Age-Adjusted Mortality from CHD among Men and Women 35 to 74 Years Old, 1987 to 1994, According to Whether Death Occurred in or out of the Hospital.
Trends in the Incidence of Hospitalization for Myocardial Infarction
The age-adjusted incidence of hospitalization for myocardialinfarction changed little over the eight-year period (Figure 3).The rate of such hospitalization among women was 1.9 per1000 persons (95 percent confidence interval, 1.6 to 2.2) in1987 and 1.8 per 1000 (95 percent confidence interval, 1.5 to2.1) in 1994. For men, the rate was the same in 1994 as in 1987— 4.1 hospitalizations per 1000. The annual male-to-femalerate ratio for hospitalization for myocardial infarction wasconsistently higher among whites than among blacks, with overallratios of 2.5 and 1.4, respectively.
Figure 3. Age-Adjusted Incidence of Hospitalization for Acute Myocardial Infarction among Men and Women 35 to 74 Years Old, 1987 to 1994.
Expressed as a percentage, the age-adjusted rate of hospitalizationfor myocardial infarction from 1987 to 1994 increased by 1.1percent (95 percent confidence interval, –13.1 to +17.5percent), an average increase of 0.1 percent per year, for men,and declined by 1.7 percent (95 percent confidence interval,20.8 to –22.0 percent [the negative number indicates anincrease]), an average decline of 0.2 percent per year, forwomen (Table 2). When the average annual percent change in incidencewas calculated on the basis of nonvalidated events, the changeswere close to zero both for men (an increase of 1.0 percent[95 percent confidence interval, –0.2 to +2.3 percent])and for women (an increase of 0.6 percent [95 percent confidenceinterval, –1.2 to +2.4]).
Although the incidence of hospitalization for myocardial infarctionwas more variable among blacks, there was evidence of an increasein this rate. The age-adjusted annual incidence increased by2.9 percent per year among black men and by 7.4 percent peryear among black women (the increase among women was statisticallysignificant). The incidence declined an average of 2.5 percentper year among white women, whereas there was essentially nochange in the annual rate among white men (a decrease of 0.3percent per year). In addition, the incidence among men 55 to74 years of age increased significantly, by 4.6 percent peryear (95 percent confidence interval, 2.1 to 7.2), whereas otherage-specific rates for men 35 through 54 years of age and forwomen did not change significantly.
The rate of a combined end point defined as the incidence ofacute myocardial infarction or fatal CHD in patients (withouta history of myocardial infarction) changed little between 1987and 1994 (Table 2), declining by only 1.1 percent annually formen and increasing by only 0.4 percent per year for women (Pnot significant for both comparisons).
Trends in Recurrent Myocardial Infarction
In contrast to the flat trends in the rates of hospitalizationfor myocardial infarction, the annual rates of recurrent myocardialinfarction showed a significant 18.8 percent decline among men(2.6 percent per year) and a nonsignificant 14.5 percent declineamong women (1.9 percent per year) (Table 2).
Trends in the Case Fatality Rate at 28 Days
The 28-day case fatality rate among patients with definite orprobable myocardial infarction who were hospitalized in theperiod from 1987 through 1994, with adjustment for year andage, was 10.6 percent (95 percent confidence interval, 8.7 to13.0 percent) for women and 9.0 percent (95 percent confidenceinterval, 7.8 to 10.4 percent) for men. Overall, the decreasein the age-adjusted case fatality rate was 4.1 percent per yearfor men and 9.8 percent per year for women. This decline wasstatistically significant only among women, primarily becauseof the relatively large decline among white women (Table 2).There was no evidence of a decline in the case fatality rateamong blacks hospitalized for myocardial infarction.
An estimate of the overall case fatality rate from CHD combinesinformation on mortality at 28 days among patients hospitalizedfor myocardial infarction with information on deaths attributedto CHD that did not occur in conjunction with an event for whichthe patient was hospitalized. The overall case fatality ratedeclined among both men (by 3.9 percent per year) and women(by 6.1 percent per year). This decline was significant forwhites but not for blacks.
Discussion
We found that mortality due to CHD declined among 35-to-74-year-oldresidents of four geographically and ethnically diverse communitiesin the United States from 1987 to 1994; the decline was 28 percentfor men and 31 percent for women. The decline was evident amongboth blacks and whites. Among men, most of the decline was observedbetween 1987 and 1991, with stable rates through 1994. The decreasein mortality due to CHD was accompanied by declining case fatalityrates and declining rates of hospitalization for recurrent myocardialinfarction. In contrast, the incidence of hospitalization formyocardial infarction was stable or increased slightly. Thesefindings suggest that the decrease in mortality due to CHD between1987 and 1994 in these communities may be due largely to improvementsin the treatment of myocardial infarction and to secondary prevention(rather than to a decline in new events). The rates of bothin-hospital and out-of-hospital death due to CHD declined; therefore,the percentage of deaths due to CHD that occurred outside thehospital changed little between 1987 and 1994. Future effortsto reduce the burden of mortality from CHD in the communitymust address the prevention of out-of-hospital deaths —a goal that may require better primary prevention as well asmore timely access to medical care.
The downward trend in mortality from CHD was consistent withthat reported from analyses of U.S. vital statistics.3 The overalldecline in age-adjusted mortality from CHD in the study communitiesin the late 1980s and the early 1990s does not bear out theprediction, based on simulation studies, that the increase inthe prevalence of CHD in the pool of patients at risk between1980 and 1990 would cause age-adjusted mortality from CHD torise in the 1990s.18 We did not, however, determine mortalityfrom CHD for persons over 74 years of age, a group in whichthe prevalence could be increasing because the population isliving longer.
The significant improvement in survival after hospitalizationfor myocardial infarction (an increase of 28 to 56 percent)suggests an important contribution of medical care to recenttrends in mortality from CHD. Similarly, the Minnesota HeartSurvey reported that the risk of death within the 28 days aftera myocardial infarction was 15 to 25 percent lower in 1990 thanin 1985.9
Although the declines in mortality due to CHD and in case fatalityrates are encouraging, the lack of change — or, for blackwomen, the increase — in the incidence of acute myocardialinfarction raises several issues. First, this trend representsa departure from previous reports: between 1985 and 1990, theincidence of myocardial infarction declined by approximately1 percent annually in Minneapolis9; between 1975 and 1988, theincidence fell by 2 percent per year in Worcester, Massachusetts8;and between 1965 and 1979, the incidence declined by 1.4 percentper year in Rochester, Minnesota.19 Although the Corpus ChristiHeart Project did not report the percent change in incidence,this group concluded that there were nonsignificant declinesin incidence among Mexican Americans and no appreciable changeamong non-Hispanic whites from 1989 to 1991.20 Second, the differencein trends between blacks and whites suggests that current effortsto prevent CHD may be reaching blacks less effectively thanwhites. Further research is needed to confirm that the increasein the incidence of myocardial infarction among blacks is realand also to identify public health strategies that address thisdiscrepancy.
The conclusion that medical care and secondary prevention havethe most important roles in the observed trends in mortalityfrom CHD is supported by the absence of a decline in the incidenceof CHD and by improvements in the case fatality rate. Thesefindings are consistent with the results of computer-simulationmodeling, which suggested that 25 percent of the decline inCHD in the 1980s was attributable to primary prevention andmore than 70 percent to the effects of reductions in risk factorsor improvements in the treatment of patients with CHD.18 Othersimulation-based estimates suggest that primary prevention accountedfor a greater proportion of the decline in CHD in the late 1960sand 1970s.21,22,23 Although the incidence of myocardial infarctiondid not change in the communities in the ARIC study, primaryprevention may have affected the severity of myocardial infarctionand thereby lowered the case fatality rate. However, preliminaryanalysis of trends in the severity of myocardial infarctionin the study (indicated by hemodynamic, cardiac-enzyme, andelectrocardiographic variables) suggests no decline (unpublisheddata).
Continued community surveillance of trends in CHD is neededto evaluate the effects of new preventive and treatment measuressuch as the use of statin drugs to lower cholesterol,24 sincetheir use was not widespread in 1994. National vital statisticsalone will not be adequate to evaluate the relative effect ofthese and other emerging efforts in prevention and treatment.Further evaluation of the reasons for the change in mortalitydue to CHD in the study communities awaits additional analysesof trends in the severity of disease and detailed investigationsof changes in risk factors.
Supported by contracts (N01-HC-55015, N01-HC-55016, N01-HC-55018,N01-HC-55019, N01-HC-55020, N01-HC-55021, and N01-HC-55022)with the National Heart, Lung, and Blood Institute.
Source Information
From the Departments of Epidemiology (W.D.R., G.H.) and Biostatistics (L.E.C., L.C., C.-H.W.), School of Public Health, University of North Carolina, Chapel Hill; the Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis (A.R.F.); the National Heart, Lung, and Blood Institute, Bethesda, Md. (L.S.C.); and the Division of Epidemiology, Department of Preventive Medicine, University of Mississippi Medical Center, Jackson (D.E.C.).
Address reprint requests to Dr. Rosamond at the Department of Epidemiology, University of North Carolina at Chapel Hill, CB 7400, McGavran-Greenberg Hall, Chapel Hill, NC 27599.
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Appendix
In addition to the authors, the following also participatedin this study: University of North Carolina, Chapel Hill —P. Johnson, M. Knowles, C. Paton; Wake Forest University, Winston-Salem,N.C. — K. Burke, W. Cheeks, R. Cook, S. Cothern; Universityof Mississippi Medical Center, Jackson — B. Warren, D.Washington, M. Watson, N. Wilson; University of Minnesota, Minneapolis— G. Feitl, C. Hunkins, E. Justiniano, L. Kemmis; JohnsHopkins University, Baltimore — J. Chabot, C. Christman,D. Costa, P. Crowley; University of Texas Medical School, Houston— V. Stinson, P. Pfile, H. Pham, T. Trevino; AtherosclerosisClinical Laboratory, Methodist Hospital, Houston — W.Alexander, D. Harper, C. Rhodes, S. Soyal; Ultrasound ReadingCenter, Bowman Gray School of Medicine, Winston-Salem, N.C.— A. Safrit, M. Wilder, L. Allred, C. Bell; CoordinatingCenter, University of North Carolina, Chapel Hill — P.DeSaix, S. Goode, T. Goodwin, S. Hutton.
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