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SUMMARY To investigate whether the reported 17% decline in the national rates of acute ischemic heart disease mortality between 1973 and-1978 was attributable to decreased in-hospital mortality for patients with acute myocardial infarction (MI), we surveyed all 63 acute care.hospitals in the Boston, Massachusetts, area.Compared with 1973-1974, more [1978][1979] MI patients were admitted to hospitals in metropolitan Boston, and especially to the five university teaching hospitals. Between 1973Between -1974Between and 1978Between -1979, hospital admission rates decreased for younger patients and increased for older patients, but overall admission rates were almost identical. In-hospital mortality rates from acute MI did not change significantly in any age group. Because overall MI mortality was declining while in-hospital MI mortality was unchaniged, the proportion of acute MI deaths that occurred inside the hospital increased from about 30% to. about 40%. Although current hospital care undoubtedly benefits many individual patients, this study suggests that improvements in the in-hospital care of acute MI patients are not a major explanation for nationwide mortality trends between 1973 and 1978. SINCE 1968, the age-adjusted mortality rates for all types of ischemic heart disease and for acute myocardial infarction in the United States have fallen each year.'-" In the 8-year period between 1968 and 1976, the overall decline was 20.7%; preliminary data suggest that this decline has continued at least through 1978, and that between 1973 and 1978, the mortality rate decreased by about 3% per year. [4][5][6] Although this decrease in acute ischemic heart disease mortality is not disputed, the explanations for the decline are not clear. Because the decline began before the popularization of coronary artery bypass surgery or the wide application of prehospital cardiopulmonary resuscitation, neither of these innovations are likely explanations. Some epidemiologists believe that the decline in mortality may be related to dietary changes resulting in falling serum cholesterol levels, to improved hypertension control, to a reduction in cigarette smoking in male adults, and perhaps to increased physical activity.2 8 7 Because recent studies8' 9 also suggest that the prognosis of medically treated patients with angina pectoris may be better than it was a decade or so ago,10 11 such therapy may also be a factor.Coronary care units have also been developed and used during the same period as the decline in acute ischemic heart disease mortality. Although coronary care units have not been shown to benefit the specific MethodsWe identified all 63 acute care hospitals in the geographic area centered on Boston, Massachusetts, and bordered by Interstate 495 to the north and west and by U.S. Route 44 to the south. For all hospitals, we sought data pertaining to all patients hospitalized with acute myocardial infarction during consecutive 12-month periods in both