Circulation, Vol 90, 583-612, Copyright © 1994 by American Heart Association
H Tunstall-Pedoe, K Kuulasmaa, P Amouyel, D Arveiler, AM Rajakangas and A Pajak
BACKGROUND: The WHO MONICA Project is a 10-year study that monitors deaths
due to coronary heart disease (CHD), acute myocardial infarction, coronary
care, and risk factors in men and women aged 35 to 64 years in defined
communities. This analysis of methods and results of coronary event
registration in 1985 through 1987 provides data on the relation between CHD
morbidity and mortality. METHODS AND RESULTS: Fatal and nonfatal coronary
events were monitored through population- based registers. Hospital cases
were found by pursuing admissions ("hot pursuit") or by retrospective
analysis of discharges ("cold pursuit"). Availability of diagnostic data on
identified nonfatal myocardial infarction was good. Information on fatal
events (deaths occurring within 28 days) was limited and constrained in
some populations by problems with access to sources such as death
certificates. Age- standardized annual event rates for the main diagnostic
group in men aged 35 to 64 covered a 12-fold range from 915 per 100,000 for
North Karelia, Finland, to 76 per 100,000 for Beijing, China. For women,
rates covered an 8.5-fold range from 256 per 100,000 for Glasgow, UK, to 30
per 100,000 for Catalonia, Spain. Twenty-eight-day case-fatality rates
ranged from 37% to 81% for men (average, 48% to 49%), and from 31% to 91%
for women (average, 54%). There was no significant correlation across
populations for men between coronary event and case- fatality rates (r =
-.04), the percentages of coronary deaths known to have occurred within 1
hour of onset (r = .08), or the percentages of known first events (r =
-.23). Event and case-fatality rates for women correlated strongly with
those for men in the same populations (r = .85, r = .80). Case-fatality
rates for women were not consistently higher than those for men. For women,
there was a significant inverse correlation between event and case-fatality
rates (r = -.33, P < .05), suggesting that nonfatal events were being
missed where event rates were low. Rankings based on MONICA categories of
fatal events placed some middle- and low-mortality populations, such as the
French, systematically higher than they would be based on official CHD
mortality rates. However, rates for nonfatal myocardial infarction
correlated quite well with the official mortality rates for CHD for the
same populations. For men (age 35 to 64 years), approximately 1.5 (at low
event rates) to 1 (at high event rates) episode of hospitalized, nonfatal,
definite myocardial infarction was registered for every death due to CHD.
The problem in categorizing deaths due to CHD was the large proportion of
deaths with no relevant clinical or autopsy information. Unclassifiable
deaths averaged 22% across the 38 populations but represented half of all
registered deaths in 2 populations and a third or more of all deaths in 15
populations. CONCLUSIONS: The WHO MONICA Project, although designed to
study longitudinal trends within populations, provides the opportunity for
relating rates of validated CHD deaths to nonfatal myocardial infarction
across populations. There are major differences between populations in
nonfatal as well as fatal coronary event rates. They refute suggestions
that high CHD mortality rates are associated with high case-fatality rates
or a relative excess of sudden deaths. The high proportion of CHD deaths
for which no diagnostic information is available is a cause for concern.
ARTICLES
Myocardial infarction and coronary deaths in the World Health Organization MONICA Project. Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents
Cardiovascular Epidemiology Unit, University of Dundee, Ninewells Hospital, Scotland, UK.
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