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Toward explaining the decline in coronary heart disease mortality
Volume
106
Number
4, Part 1
Postischemic
stunned myocardium
11. Bateman T, Gray R, Maddahi J, Rozanski A, Raymond M, Berman D: Transient appearance of Q waves in coronary disease during exercise electrocardiography: Consideration of mechanisms and clinical importance. AM HEART J 104182, 1982. 12. Ortega-Carnicer J, Malillos M, Tascon J: Transient bifascicular block during Prinzmetal’s variant angina. Chest 82:789, 1982. 13. Gotzoyannis S: Q waves disappearance after coronary bypass surgery. Am J Cardiol 39:763, 1977.
14. Kim YI, William JF Jr: Large dose sublingual nitroglycerin in acute myocardial infarction: Relief of chest pain and reduction of Q wave evolution. Am J Cardiol49:842, 1982. 15. Burch GE: Of the Q wave and myocardial infarction. AM HEART J 100:757,1980. 16. Goldberger AL: ECG simulators of myocardial infarction. 1. Pathophysiology and differential diagnosis of pseudo-infarct Q wave patterns. PACE 5:106, 1982.
Toward explaining disease mortality
in coronary
Richard
F. Gillum,
the decline
heart
M.D. Minneapolis, Minn.
Coronary heart disease (CHD) death rates continue to decline in the United States. Since the Conference on the Decline in CHD Mortality in 1978,’ a number of reports have appeared which shed light on the continuing decline in coronary disease mortality. New analyses of mortality data a&m the decline is real and not due to changes in disease classification or to waning influenza epidemics. However, it is not known why the decrease in CHD mortality has been relatively greater for women than for men, and for blacks than for whites.2 Great geographic variation in CHD mortality levels and trends also exists internationally, within the U.S., and even within state~.~ Detailed analyses of these regional variations are lacking. While only the Rochester, Minnesota, report has documented that sudden CHD death incidence has declined, other findings are consistent with it.4 The Minnesota Heart Survey has reported CHD deaths out of hospital declining in the Twin Cities of Minneapolis-St. Paul, from 1968 to 78, accounting for about half the overall decline.5+6 Studies of less than entire communities support these findings. Much less information has appeared about trends in CHD morbidity and incidence. Modest declines in hospitalization for CHD occurred in Rochester, From the Minnesota Heart Survey, Laboratory of Physiological Hygiene, School of Public Health, University of Minnesota. Received for publication Feb. 7, 1983; accepted March 11, 1963. Reprint requests: Richard F. Gillum, M.D., Laboratory of Physiological Hygiene, School of Public Health, Stadium Gate 2’7, 611 Beacon Street SE., Minneapolis, MN 55455.
Minnesota, from 1955 to 75.4 Myocardial infarction (MI) case fatality in hospital declined in several studies: but long-term survivorship failed to improve.4p7 However, inconsistencies among studies exist in the degree, distribution, and timing of change in MI rates. Therefore data from carefully executed, population-based studies using valid methods are needed to resolve questions about change in CHD incidence.s Since morbidity trend data are completely lacking for blacks and other minorities,* study populations should include these groups in substantial numbers. Little communitybased data exist about how medical care of CHD and stroke contributes to the decline in mortality. Emergency medical services may have played a limited role in reducing CHD mortality in certain metropolitan areas and this intervention needs systematic study. Even fewer data are available about the role of changing hospital care. Evidence suggesta that coronary care units have reduced MI hospital mortality: but information on trends in management of acute MI survivors is lacking. Few reports exist on systematic studies of cardiovascular risk factor trends in the U.S. Diagnosis and treatment of hypertension clearly improved during the 1970’s, more for women than for men. Though prevalence of hypertension seemed stable, mean population blood pressure levels may have declined slightly.‘O Mean serum cholesterol levels may have diminished slightly, but adequate trend data are lacking, and there are no trend data on lipoprotein fractions. Preliminary results of a comparison of 783
704
Gillum
American
HANES-I* (1971 to 75) and HANES-II (1976 to 78) indicate no significant trend for cholesterol (personal communication). Cigarette smoking rates have gone down since the 1960’s, but trends have varied by age, sex, and race. Trend data are lacking for other risk factors and are incomplete for the major risk factors among blacks and other minorities.” Minnesota Heart Survey findings indicate favorable trends in the Twin Cities metropolitan area for hypertension, total serum cholesterol, and cigarette smoking. l”*12 Preliminary data from the Minnesota Heart Survey suggest little change in high density lipoprotein (HDL) cholesterol in men and a slight decrease for women, the latter related to less exogenous estrogen use. Hard data are needed on trends in diet and other health behaviors as well as on health knowledge related to cardiovascular disease. Large clinical trials in the U.S. and Europe contributed to the rationale for preventive policy, establishing the efficacy of hypertension treatment and control in reducing stroke and, possibly, coronary disease deaths. While one recent trial in high-risk men was highly suggestive, the efficacy of smoking cessation and lowering of serum cholesterol remains in question for primary and secondary prevention of CHD.13 Several trials have demonstrated the efficacy of beta-adrenergic blocking drugs post MI, but the efficacy of other interventions remains in question.14 The efficacy of coronary bypass surgery is established in reducing mortality in patients with left-main or three-vessel coronary stenosis in angina pectoris.*5 The one published community trial of multiple risk factor intervention failed to demonstrate efficacy in reducing CHD mortality.*6 Those effective interventions which are widely used and whose use has increased are all candidates to affect CHD mortality trends, though hard data are lacking. We recently reviewed the methods available to study the causes of CHD and stroke mortality trends.” Little is known about the validity and reliability of current methods or about new methods for assessing morbidity and risk factor trends. Progress in relating social and ecologic factors to change in CHD and stroke mortality has been slight due to methodologic problems. The Minnesota Heart Survey offers a unique opportunity to examine trends in CHD and stroke mortality concurrently with morbidity and risk factor levels between 1970 and 1987.5Tl7 Having developed the methods needed to examine these community trends, the Minnesota Heart Survey will ‘HANES
= (National)
Health
and Nutrition
Examination
Survey.
October, 1983 Heart Journal
contribute long-term trends (1970 to 1985) in hospitalization rates, in hospital case fatality, and in survivorship for MI and stroke in a large metropolitan area. It will also provide systematic populationbased data on change in all the major cardiovascular risk factors and their related behaviors over time (1980 to 87) by serial standardized surveys. The Minnesota Heart Survey will provide data that can be directly compared to other U.S. studies (Community Cardiovascular Surveillance ProgramCCSP) and international studies (World Health Organization, Multinational Monitoring of Trends and Determinants in Cardiovascular DiseasesMONICA), because they have based their methods on those of the Minnesota Heart Survey and continue close collaboration. The Minnesota Heart Survey will also contribute to the methodology and experience for the dynamic surveillance of cardiovascular disease and its known causal factors, which is essential .to scientific understanding and public health action. REFERENCES
5.
6
7.
8.
9.
10.
11. 12.
13.
Havlik R, Feinleib J: Proceedings of the Conference on the Decline in Coronary Heart Disease Mortality. NIH Publications No. 79-1610. Washington, D.C., 1979, U.S. Government Printing Office. Gillum R: Coronary heart disease in black populations. I. Mortality and morbidity. AM HEART J 104:839, 1982. Gillum RF, Jacobs DJ,. Luepker RV, et al: Coronary heart disease mortality trends in Minnesota 1960-1978: The Minnesota Heart Survey. Am J Pub1 Health (In press, 1983) Elveback LR, Connolly DC, Kurland LT: Coronary heart disease in residents of Rochester, Minnesota. II. Mortality, incidence and survivorship, 1950-1975. Mayo Clin Proc 56:665, 1981. . Gillum RF, Prineas RJ, Luepker RV. et al: Decline in coronary deaths: A search for explanations. Minn Med 65~235, 1982. Gillum R, Folsom A, Luepker R, et al: The decline in sudden death and acute myocardial infarction: Coronary heart disease mortality in a metropolitan area, 1968-1980: The Minnesota Heart Survey. N Engl J Med (In press, 1983) Weinblatt E, Goldberg JD, Ruberman W, Frank CW, Monk MA, Chaudhury, BS: Mortality after first myocardial infarction: Search for a secular trend. JAMA 247:1576, 1982. Gillum RF: Community surveillance for cardiovascular disease. Methods, problems, applications-a review. J Chronic Dis 31:87, 1978. Goldberg R, Szklo M, Taonascia JA, Kennedy HL: Time trends in prognosis of patients with myocardial infarction: A population-based study. Johns Hopkins Med J 144:73, 1979. Folsom AR, Luepker RV, Gillum RF, Jacobs DR, Prineas RJ, Taylor HL, Blackburn H: Improvement in hypertension detection and control in Minneapolis-St. Paul, 1973-74 to 1980-81: The Minnesota Heart Survey. JAMA (In press, 1983) Gillum R, Grant CT: Coronary heart disease in black populations. II. Risk Factors. AM HEART J 104~852, 1982. Luepker RV, Jacobs DR, Folsom A. Gillum RF, Taylor HL, Blackburn H: Trends in cardiovascular disease risk 1973-74 to 1980-81: The Minnesota Heart Survey. Circulation 66(suppl II):II-284, 1982. Multiple Risk Factor Intervention Trial Research Group:
Volume Number
106 4, Part 1
Multiple Risk Factor Intervention Trial. Risk factor changes and mortality results. JAMA 248:1465, 1982. 14. Beta-blocker Heart Attack Trial Research Group: A randomized trial of propranolol in patients with acute myocardial infarction. 1. Mortality results. JAMA 247:1707, 1982. 15. Chaitman BR, Fisher LD, Bourassa MC: Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery @ASS). Am J Cardiol48:765, 1981.
Decline in coronary disease mortality
785
16. Salonen JT, Puska P, Mustaniemi H: Changes in morbidity and mortality during comprehensive community programme to control cardiovascular disease during 1972-77 in North Karelia. Br Med J 3:1178, 1979. 17. Gillum RF, Blackburn H, Feinleib M: Current strategies for explaining the decline in ischemic heart disease mortality. J Chronic Dis 35:467, 1982.
106
Number
4, Part 1
Postischemic
stunned myocardium
11. Bateman T, Gray R, Maddahi J, Rozanski A, Raymond M, Berman D: Transient appearance of Q waves in coronary disease during exercise electrocardiography: Consideration of mechanisms and clinical importance. AM HEART J 104182, 1982. 12. Ortega-Carnicer J, Malillos M, Tascon J: Transient bifascicular block during Prinzmetal’s variant angina. Chest 82:789, 1982. 13. Gotzoyannis S: Q waves disappearance after coronary bypass surgery. Am J Cardiol 39:763, 1977.
14. Kim YI, William JF Jr: Large dose sublingual nitroglycerin in acute myocardial infarction: Relief of chest pain and reduction of Q wave evolution. Am J Cardiol49:842, 1982. 15. Burch GE: Of the Q wave and myocardial infarction. AM HEART J 100:757,1980. 16. Goldberger AL: ECG simulators of myocardial infarction. 1. Pathophysiology and differential diagnosis of pseudo-infarct Q wave patterns. PACE 5:106, 1982.
Toward explaining disease mortality
in coronary
Richard
F. Gillum,
the decline
heart
M.D. Minneapolis, Minn.
Coronary heart disease (CHD) death rates continue to decline in the United States. Since the Conference on the Decline in CHD Mortality in 1978,’ a number of reports have appeared which shed light on the continuing decline in coronary disease mortality. New analyses of mortality data a&m the decline is real and not due to changes in disease classification or to waning influenza epidemics. However, it is not known why the decrease in CHD mortality has been relatively greater for women than for men, and for blacks than for whites.2 Great geographic variation in CHD mortality levels and trends also exists internationally, within the U.S., and even within state~.~ Detailed analyses of these regional variations are lacking. While only the Rochester, Minnesota, report has documented that sudden CHD death incidence has declined, other findings are consistent with it.4 The Minnesota Heart Survey has reported CHD deaths out of hospital declining in the Twin Cities of Minneapolis-St. Paul, from 1968 to 78, accounting for about half the overall decline.5+6 Studies of less than entire communities support these findings. Much less information has appeared about trends in CHD morbidity and incidence. Modest declines in hospitalization for CHD occurred in Rochester, From the Minnesota Heart Survey, Laboratory of Physiological Hygiene, School of Public Health, University of Minnesota. Received for publication Feb. 7, 1983; accepted March 11, 1963. Reprint requests: Richard F. Gillum, M.D., Laboratory of Physiological Hygiene, School of Public Health, Stadium Gate 2’7, 611 Beacon Street SE., Minneapolis, MN 55455.
Minnesota, from 1955 to 75.4 Myocardial infarction (MI) case fatality in hospital declined in several studies: but long-term survivorship failed to improve.4p7 However, inconsistencies among studies exist in the degree, distribution, and timing of change in MI rates. Therefore data from carefully executed, population-based studies using valid methods are needed to resolve questions about change in CHD incidence.s Since morbidity trend data are completely lacking for blacks and other minorities,* study populations should include these groups in substantial numbers. Little communitybased data exist about how medical care of CHD and stroke contributes to the decline in mortality. Emergency medical services may have played a limited role in reducing CHD mortality in certain metropolitan areas and this intervention needs systematic study. Even fewer data are available about the role of changing hospital care. Evidence suggesta that coronary care units have reduced MI hospital mortality: but information on trends in management of acute MI survivors is lacking. Few reports exist on systematic studies of cardiovascular risk factor trends in the U.S. Diagnosis and treatment of hypertension clearly improved during the 1970’s, more for women than for men. Though prevalence of hypertension seemed stable, mean population blood pressure levels may have declined slightly.‘O Mean serum cholesterol levels may have diminished slightly, but adequate trend data are lacking, and there are no trend data on lipoprotein fractions. Preliminary results of a comparison of 783
704
Gillum
American
HANES-I* (1971 to 75) and HANES-II (1976 to 78) indicate no significant trend for cholesterol (personal communication). Cigarette smoking rates have gone down since the 1960’s, but trends have varied by age, sex, and race. Trend data are lacking for other risk factors and are incomplete for the major risk factors among blacks and other minorities.” Minnesota Heart Survey findings indicate favorable trends in the Twin Cities metropolitan area for hypertension, total serum cholesterol, and cigarette smoking. l”*12 Preliminary data from the Minnesota Heart Survey suggest little change in high density lipoprotein (HDL) cholesterol in men and a slight decrease for women, the latter related to less exogenous estrogen use. Hard data are needed on trends in diet and other health behaviors as well as on health knowledge related to cardiovascular disease. Large clinical trials in the U.S. and Europe contributed to the rationale for preventive policy, establishing the efficacy of hypertension treatment and control in reducing stroke and, possibly, coronary disease deaths. While one recent trial in high-risk men was highly suggestive, the efficacy of smoking cessation and lowering of serum cholesterol remains in question for primary and secondary prevention of CHD.13 Several trials have demonstrated the efficacy of beta-adrenergic blocking drugs post MI, but the efficacy of other interventions remains in question.14 The efficacy of coronary bypass surgery is established in reducing mortality in patients with left-main or three-vessel coronary stenosis in angina pectoris.*5 The one published community trial of multiple risk factor intervention failed to demonstrate efficacy in reducing CHD mortality.*6 Those effective interventions which are widely used and whose use has increased are all candidates to affect CHD mortality trends, though hard data are lacking. We recently reviewed the methods available to study the causes of CHD and stroke mortality trends.” Little is known about the validity and reliability of current methods or about new methods for assessing morbidity and risk factor trends. Progress in relating social and ecologic factors to change in CHD and stroke mortality has been slight due to methodologic problems. The Minnesota Heart Survey offers a unique opportunity to examine trends in CHD and stroke mortality concurrently with morbidity and risk factor levels between 1970 and 1987.5Tl7 Having developed the methods needed to examine these community trends, the Minnesota Heart Survey will ‘HANES
= (National)
Health
and Nutrition
Examination
Survey.
October, 1983 Heart Journal
contribute long-term trends (1970 to 1985) in hospitalization rates, in hospital case fatality, and in survivorship for MI and stroke in a large metropolitan area. It will also provide systematic populationbased data on change in all the major cardiovascular risk factors and their related behaviors over time (1980 to 87) by serial standardized surveys. The Minnesota Heart Survey will provide data that can be directly compared to other U.S. studies (Community Cardiovascular Surveillance ProgramCCSP) and international studies (World Health Organization, Multinational Monitoring of Trends and Determinants in Cardiovascular DiseasesMONICA), because they have based their methods on those of the Minnesota Heart Survey and continue close collaboration. The Minnesota Heart Survey will also contribute to the methodology and experience for the dynamic surveillance of cardiovascular disease and its known causal factors, which is essential .to scientific understanding and public health action. REFERENCES
5.
6
7.
8.
9.
10.
11. 12.
13.
Havlik R, Feinleib J: Proceedings of the Conference on the Decline in Coronary Heart Disease Mortality. NIH Publications No. 79-1610. Washington, D.C., 1979, U.S. Government Printing Office. Gillum R: Coronary heart disease in black populations. I. Mortality and morbidity. AM HEART J 104:839, 1982. Gillum RF, Jacobs DJ,. Luepker RV, et al: Coronary heart disease mortality trends in Minnesota 1960-1978: The Minnesota Heart Survey. Am J Pub1 Health (In press, 1983) Elveback LR, Connolly DC, Kurland LT: Coronary heart disease in residents of Rochester, Minnesota. II. Mortality, incidence and survivorship, 1950-1975. Mayo Clin Proc 56:665, 1981. . Gillum RF, Prineas RJ, Luepker RV. et al: Decline in coronary deaths: A search for explanations. Minn Med 65~235, 1982. Gillum R, Folsom A, Luepker R, et al: The decline in sudden death and acute myocardial infarction: Coronary heart disease mortality in a metropolitan area, 1968-1980: The Minnesota Heart Survey. N Engl J Med (In press, 1983) Weinblatt E, Goldberg JD, Ruberman W, Frank CW, Monk MA, Chaudhury, BS: Mortality after first myocardial infarction: Search for a secular trend. JAMA 247:1576, 1982. Gillum RF: Community surveillance for cardiovascular disease. Methods, problems, applications-a review. J Chronic Dis 31:87, 1978. Goldberg R, Szklo M, Taonascia JA, Kennedy HL: Time trends in prognosis of patients with myocardial infarction: A population-based study. Johns Hopkins Med J 144:73, 1979. Folsom AR, Luepker RV, Gillum RF, Jacobs DR, Prineas RJ, Taylor HL, Blackburn H: Improvement in hypertension detection and control in Minneapolis-St. Paul, 1973-74 to 1980-81: The Minnesota Heart Survey. JAMA (In press, 1983) Gillum R, Grant CT: Coronary heart disease in black populations. II. Risk Factors. AM HEART J 104~852, 1982. Luepker RV, Jacobs DR, Folsom A. Gillum RF, Taylor HL, Blackburn H: Trends in cardiovascular disease risk 1973-74 to 1980-81: The Minnesota Heart Survey. Circulation 66(suppl II):II-284, 1982. Multiple Risk Factor Intervention Trial Research Group:
Volume Number
106 4, Part 1
Multiple Risk Factor Intervention Trial. Risk factor changes and mortality results. JAMA 248:1465, 1982. 14. Beta-blocker Heart Attack Trial Research Group: A randomized trial of propranolol in patients with acute myocardial infarction. 1. Mortality results. JAMA 247:1707, 1982. 15. Chaitman BR, Fisher LD, Bourassa MC: Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery @ASS). Am J Cardiol48:765, 1981.
Decline in coronary disease mortality
785
16. Salonen JT, Puska P, Mustaniemi H: Changes in morbidity and mortality during comprehensive community programme to control cardiovascular disease during 1972-77 in North Karelia. Br Med J 3:1178, 1979. 17. Gillum RF, Blackburn H, Feinleib M: Current strategies for explaining the decline in ischemic heart disease mortality. J Chronic Dis 35:467, 1982.