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The decline in coronary heart disease; did it fall or was it pushed?

BMJ 2012; 344 doi: (Published 25 January 2012) Cite this as: BMJ 2012;344:d7809
  1. Hugh Tunstall-Pedoe, emeritus professor of cardiovascular epidemiology
  1. 1Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital, Dundee DD1 9SY, UK
  1. h.tunstallpedoe{at}

Probably both, but we need better data where incidence is increasing

Three linked studies assess the decline in mortality from coronary heart disease and its determinants in three European countries.1 2 3 National comparisons on this subject anticipate the Olympics. Who fell first? Furthest? Fastest? Started late? Why?4

Three decades ago, mortality from coronary heart disease in the United States, which had been high since the second world war, was found to be falling. The reasons were obscure. Cardiovascular risk factors had been studied in circumscribed cohorts, not in populations repeatedly sampled over time. Measurements were inadequately standardised.5 The effect of treatment was unknown, but it seemed unlikely to be so much greater in the US than in countries not experiencing a decline in mortality. In 1978 the US National Heart Lung and Blood Institute convened a conference to clarify what was known.6 Reinforcing existing surveillance, the report also inspired new initiatives: the Atherosclerosis Risk in Communities (ARIC) study in the US and the World Health Organization MONICA project (MONItoring trends and determinants in CArdiovascular disease).7 8

Observing that mortality in the population was the product of coronary event rates and their case fatality, MONICA hypothesised that a decrease in event rates was driven by a commensurate change in cardiovascular …

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