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Better coronary care reduces deaths from heart disease

BMJ 2000; 320 doi: (Published 04 March 2000) Cite this as: BMJ 2000;320:600
  1. Zosia Kmietowicz
  1. London

    Improvements in the care given to people with coronary heart disease have contributed more to reducing deaths from the condition than reduction in risk factors in the general population, the results of a 10 year monitoring study show.

    In May last year the first results of the World Health Organization's MONICA project (which monitors trends in and determinants of cardio-vascular disease) across 21 countries showed that deaths from cardiovascular disease had fallen by more than 20% in men and women between the mid-1980s and the mid-1990s.

    Results released last week relate how changes in certain risk factors and the treatments used during the first days after myocardial infarction influenced this trend.

    In the analysis of risk factors, blood pressure and blood cholesterol concentration were decreasing over the study period, but weight was increasing. Smoking decreased in men, but results were mixed among women. Overall, these factors explained 15-40% of the fall in deaths from coronary heart disease throughout the world—less than the proportion anticipated, commented the investigators (Lancet 2000;355:675-87). They say that there may be other important risk factors driving heart disease in the community, and further research is needed to identify them.

    In contrast, the increased use of modern, evidence based treatment modalities during the study period affected mortality from coronary heart disease more than expected. Overall, 72% of the drop in mortality from coronary heart disease in men and 56% in women could be related to or explained by changes in treatment, such as greater use of aspirin, thrombolytic agents, and b blockers and angiotensin converting enzyme inhibitors for the control of raised blood pressure (Lancet 2000;355:688-700).

    “This is the first evidence of treatment having a major impact on outcomes in a chronic disease,” said Professor Hugh Tunstall-Pedoe of Dundee University's cardiovascular epidemiology unit and a member of the MONICA steering group. “The results also show that looking after one's risk factors is not going to be enough. It is important to follow treatments as well.”

    In an accompanying commentary Steven Grover from the division of clinical epidemiology at Montreal General Hospital said that it was reassuring that “some of the expected benefits associated with evolving clinical care are being realised” and that “some modifiable risk factors that remain important irrespective of the individual's nationality or place of residence have been identified” (Lancet 2000;355:668-9).

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