ArticlesAge, sex, and social trends in out-of-hospital cardiac deaths in Scotland 1986–95: a retrospective cohort study
Introduction
Deaths from coronary heart disease have halved in most developed countries in the past three decades,1 and much credit for this fall has been given to modern cardiological treatments.2, 3 However, only a third of the fall is attributed to a decline in case fatality (and hence to secondary prevention and therapies), whereas two-thirds has been attributed to a reduction in event rates (and hence mainly to primary prevention).1, 4, 5 Acute myocardial infarction accounts for roughly three-quarters of all coronary heart deaths and half of all hospital admissions for coronary heart disease.1 Half of all deaths from acute myocardial infarction are sudden deaths that happen within 1 h. Consequently, around 70% of deaths occur outside hospital without any admission.1 Therefore, changes in these out-of-hospital deaths dominate overall trends. Few researchers have been able to examine such trends, because most studies are confined to hospital admissions.6, 7
There are increasing concerns about social, age, and sex inequalities in patients with coronary heart disease, especially in the treatment of hospital patients,6 but much less is known about inequalities in community-based events and trends. Most research comes from the MONICA collaboration1, 5, 8 and from studies in the USA and Scandinavia.9, 10, 11, 12, 13 Little is known about trends in older people,6 because most studies are confined to patients younger than 65 years, although three-quarters of all coronary heart disease events occur in people older than 65 years.1 Crucially, we do not know whether recent falls in death rates out of hospital have happened equally in men and women, rich and poor, and old and young.
The Scottish record linkage system routinely captures all deaths and coronary heart disease events that included hospital admission in the entire Scottish population of 5·1 million.14 This linked database contains good quality detailed information on more than 40010 000 admissions to hospital for coronary heart disease and over 25010 000 coronary heart disease deaths since 1981.15 We have examined all acute myocardial infarction deaths that occurred with and without previous hospital admission, between 1986 and 1995. We aimed to assess trends in death rates out of hospital, stratified by sex, age, and socioeconomic status, to identify any inequalities and enable prioritisation of future interventions.
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Data sources
The information and statistics division of the National Health Service (NHS) in Scotland collects and collates data on all NHS hospital admissions by use of the Scottish morbidity record scheme.14, 15 This database is linked to information held by the General Register Office for Scotland, which includes deaths in and out of hospital. This record linkage system enables data to be analysed at the level of the individual patient, rather than the episode of care.14, 15
We did a nationwide
Results
Between 1986 and 1995, 8310 365 patients (4410 655 men and 3810 710 women) had a first acute myocardial infarction and did not survive to reach hospital. The number of deaths out of hospital per year fell substantially, from 9484 to 6712. Mean age at death increased from 73·0 years (SD 10·5) to 75·3 years (10·4), and the proportion of people older than 75 years correspondingly increased from 35·8% (1904 of 5314, 95% CI 34·6–37·1) to 42·8% in men (1476 of 3452, 41·1–44·4), and from 60·3% (2523
Discussion
Our results show that the striking falls in coronary heart disease mortality conceal serious inequalities. Women, old people, and deprived groups have all been left behind. These are not spurious trends. Our large unselected cohort describes coronary mortality trends in an entire population. Thus, we have avoided selection biases potentially associated with data confined to hospital admissions, survey samples, or younger age groups.1
The substantial yearly falls in population-based mortality
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