Trends in Out-of-Hospital Deaths Due to Coronary Heart Disease in Sweden (1991 to 2006)

Abstract

Background-Case fatality associated with a first coronary event is often underestimated when only those who survive to reach a hospital are considered. Few studies have examined long-term trends in case fatality associated with a major coronary event that occurs out of the hospital. Methods and Results-Record linkage documented all case subjects 35 to 84 years of age in Sweden during 1991 to 2006 with a first major coronary event (out-of-hospital coronary death or hospitalization for acute myocardial infarction). Of the 384 597 cases identified, 111 319 (28.9%) died out of the hospital, and another 36 552 (9.5%) died in the hospital or within 28 days of hospitalization. From 1991 to 2006, out-of hospital deaths as a proportion of all major coronary events declined from 30.5% to 25.6% (adjusted mean annual decrease 2.2%, 95% confidence interval 2.1% to 2.4%), however, with a larger decline in 28-day case fatality in hospitalized cases (adjusted mean annual decrease 5.8%, 95% confidence interval 5.5% to 6.0%). As a result of the faster decline in in-hospital deaths, the relative contribution of out-of-hospital deaths to overall case fatality increased, particularly among younger individuals (eg, among those 35 to 54 years of age, no more than 10.8% of all deaths occurred in hospitalized cases during [2003][2004][2005][2006]. Although female sex (odds ratio 0.85, 95% confidence interval 0.83 to 0.87) and older age (odds ratio 0.972, 95% confidence interval 0.971 to 0.974 per year) were associated with lower risk for initial out-of-hospital death, each successive calendar year was associated with increased risk (odds ratio 1.041, 95% confidence interval 1.038 to 1.044). Conclusions-The great majority of all fatal coronary events occur outside the hospital, and this proportion is increasing, particularly among younger individuals. (Circulation. 2011;123:46-52.)

The disparity between long-term survival in patients with and without diabetes following a first myocardial infarction did not change between 1989 and 2006: an analysis of 6,776 patients in the Northern Sweden MONICA Study

“…An important advantage is the inclusion of all MIs, including prehospital deaths. This reduces the risk of bias due to differential mortality according to sex and diabetes before reaching hospital [11,15]. A long study period and a large number of patients allowed us to observe over 50,000 patientyears, adding further strength.…”

“…Previous studies are limited in different ways. Some are based only on patients treated at hospital [5,7,8], thereby neglecting the large number of prehospital deaths, which influence estimated mortality risk [11]. Some only included patients admitted to coronary care units [6].…”

“…Towards this goal, survival data over periods much longer than 1 year are needed to describe the secular trends over a period that includes the introduction of evidencebased cardiovascular diabetology [10]. In addition, data should include prehospital deaths [11].…”

Comparative trends in hospitalizations for osteoporotic fractures and other frequent diseases between 2000 and 2008

“…On the other hand, as many as 25% of all coronary events are lethal before the patient reaches the hospital, a proportion that continues to increase as a result of the decline in in-hospital deaths observed during the past decades [36]. Therefore, the proposed comparisons across diseases should be considered as restricted to hospitalizations only.…”

We must identify patients at risk for pre-hospital sudden cardiac arrest at the early phase of myocardial infarction

“…Concurrently, effective therapeutic modalities have contributed to reducing further in-hospital fatal events, obtaining a 6-8% reduction (1,2). Meanwhile, out-of-hospital sudden cardiac arrest (SCA) secondary to myocardial infarction remains high, and still represents the majority of all fatal cardiac events (3). Although there is a large amount of literature regarding this sudden and unexpected complication, there is still need for a better understanding of associated risk factors and to identify patients at highest risk for SCA at the pre-hospital phase.…”