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Aim To investigate the incidence of clinical diabetes as determined by the incidence of diabetes drug reimbursements within a 5-year period after the first myocardial infarction (MI) in patients who were non-diabetic at the time of their first MI. Research design and methods A population-based MI register, FINMONICA/FINAMI, recorded all coronary events in persons of 35–64 years of age between 1988 and 2002 in four study areas in Finland. These records were used to identify subjects sustaining their first MI (n = 2632). Participants of the population-based risk factor survey FINRISK (surveys 1987, 1992, 1997 and 2002), who did not have diabetes or a history of MI, served as the control group (n = 7774). The FINMONICA/FINAMI study records were linked with the National Social Security Institute's drug reimbursement records, which include diabetes medications, using personal identification codes. The records were used to identify subjects who developed diabetes during the 5-year follow-up period (n = 98 in the MI group and n = 79 in the control group). Results Sixteen per cent of men and 20% of women sustaining their first MI were known to have diabetes and thus were excluded from this analysis. Non-diabetic men having a first MI were at more than twofold {hazard ratio (HR) 2.3 [95% confidence interval (CI) 1.6–3.4]}, and women fourfold [HR 4.3 (95% CI 2.4–7.5)], risk of developing diabetes mellitus during the next 5 years compared with the control population without MI. Conclusions Many patients who do not have diabetes at the time of their first MI develop diabetes in the following 5 years.

Background and Purpose— Mortality from stroke has been declining over recent decades in most countries, except in Eastern Europe. In this analysis, based on the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) Project, we explored to what extent these trends are due to changes in stroke event rate and to changes in case fatality. Methods— The WHO MONICA Project collected standardized data from 14 populations in 9 countries. All acute strokes occurring in men and women 35 to 64 years of age were included. Registration was carried out between 1982 and 1995, resulting in time spans from 7 to 13 years. Trends in event rates and case fatality were calculated as average annual percentage change. Results— Up to 6-fold differences were observed in stroke mortality. Mortality declined in 8 of 14 populations in men and in 10 of 14 populations in women. An increase in mortality was observed in Eastern Europe. In the populations with a declining trend, about two thirds of the change could be attributed to a decline in case fatality. In populations with increasing mortality, the rise was explained by an increase in case fatality. Conclusions— In most populations, changes in stroke mortality, whether declining or increasing, were principally attributable to changes in case fatality rather than changes in event rates. Whether this was due to changes in the management of stroke or changes in disease severity cannot be established on the basis of these results.

Aims To analyse the trends in incidence, recurrence, case fatality, and treatments of acute coronary events in Finland during the 15-year period 1983–97. Methods and results Population-based MI registration has been carried out in defined geographical areas, first as a part of the FINMONICA Project and then continued as the FINAMI register. During the study period, 6501 coronary heart disease (CHD) events were recorded among men and 1778 among women aged 35–64 years. The CHD mortality declined on average 6.4%/year (95% confidence interval −5.4, −7.4%) among men and 7.0%/year (−4.7, −9.3%) among women. The mortality from recurrent events declined even more steeply, 9.9%/year (−8.3, −11.4%) among men and 9.3%/year (−5.1, −13.4%) among women. The proportion of recurrent events of all CHD events also declined significantly in both sexes. Of all coronary deaths, 74% among men and 61% among women took place out-of-hospital. The decline in 28-day case fatality was 1.3%/year (−0.3, −2.3%) among men and 3.1%/year (−0.7, −5.5%) among women. Conclusions The study period was characterized by a marked reduction in the occurrence of recurrent CHD events and a relatively modest reduction in the 28-day case fatality. The findings suggest that primary and secondary prevention have played the main roles in the decline in CHD mortality in Finland.

Background Male gender is an established risk factor for first myocardial infarction, but some studies have suggested that among myocardial infarction survivors, women fare worse than men. Therefore, we examined the long-term prognosis of incident myocardial infarction survivors in a large, population-based MI register, addressing gender differences in mortality as well as the number of events and time intervals between recurrent events. Methods and Results Study subjects included 4900 men and women, aged 25–64 years, with definite or probable first myocardial infarctions who were alive 28 days after the onset of symptoms. At first myocardial infarction, women were older and more likely to be hypertensive or diabetic than men, and had a greater proportion of probable vs definite events. After adjustment for age and geographic region, men had 1·74 times the risk of fatal coronary heart disease relative to women (hazard ratio=1·63 and 1·55 for cardiovascular disease and all-cause mortality, respectively) over an average of 5·9 years of follow-up. Number and time intervals between any recurrent event—fatal and non-fatal—did not differ by gender. Conclusion These data suggest that men are far more likely to have a fatal recurrent event than women despite comparable numbers of events.

Summary Background The revolution in coronary care in the mid-1980s to mid-1990s corresponded with monitoring of coronary heart disease (CHD) in 31 populations of the WHO MONICA Project. We studied the impact of this revolution on coronary endpoints. Methods Case fatality, coronary-event rates, and CHD mortality were monitored in men and women aged 35–64 years in two separate 3–4-year periods. In each period, we recorded percentage use of eight treatments: coronary-artery reperfusion before, thrombolytics during, and β-blockers, antiplatelet drugs, and angiotensin-converting-enzyme (ACE) inhibitors before and during non-fatal myocardial infarction. Values were averaged to produce treatment scores. We correlated changes across populations, and regressed changes in coronary endpoints on changes in treatment scores. Findings Treatment changes correlated positively with each other but inversely with change in coronary endpoints. By regression, for the common average treatment change of 20, case fatality fell by 19% (95% Cl 12–26) in men and 16% (5–27) in women; coronary-event rates fell by 25% (16–35) and 23% (7–39); and CHD mortality rates fell by 42% (31–53) and 34% (17–50). The regression model explained an estimated 61% and 41% of variance for men and women in trends for case fatality, 52% and 30% for coronary-event rates, and 72% and 56% for CHD mortality. Interpretation Changes in coronary care and secondary prevention were strongly linked with declining coronary endpoints. Scores and benefits followed a geographical east-to-west gradient. The apparent effects of the treatment might be exaggerated by other changes in economically successful populations, so their specificity needs further assessment.

Validated population-based data on the occurrence of coronary heart disease in Finland have previously been obtained from myocardial infarction (MI) registers. Such registers cannot, however, cover large areas. Therefore, the Finnish Cardiovascular Diseases Registers (CVDR) Project was set up to obtain data for the whole of Finland. The CVDR Project is based on routine mortality and morbidity data linkage. We report here the overall approach used in the project, the results of the feasibility study and the first main results. In Finland, data on all hospitalizations are registered in the nationwide Hospital Discharge Register. Also, data on all deaths are collected in the nationwide Causes of Death Register. The unique personal identification number assigned to all persons residing in Finland was used for data linkage. Data have been validated using the FINMONICA MI registers. Sensitivity analyses showed that the data were robust and consistent between different geographical areas. Coronary heart disease (CHD) mortality as well as the incidence and event rates showed the same very clear geographical pattern, dividing Finland to a southwest area with a lower occurrence and a northeast area with nearly twice higher occurrence. Case fatality did not differ much between the areas and did not follow this Southwest-Northeast division. The differences between northeast and southwest Finland may be related to differences in risk factor levels but also to socioeconomic and genetic differences. The CVDR Project data will be instrumental in further research addressing these issues.

Summary Background The WHO MONICA (monitoring trends and determinants in cardiovascular disease) Project monitored, from the early 1980s, trends over 10 years in coronary heart disease (CHD) across 37 populations in 21 countries. We aimed to validate trends in mortality, partitioning responsibility between changing coronary-event rates and changing survival. Methods Registers identified non-fatal definite myocardial infarction and definite, possible, or unclassifiable coronary deaths in men and women aged 35–64 years, followed up for 28 days in or out of hospital. We calculated rates from population denominators to estimate trends in age-standardised rates and case fatality (percentage of 28-day fatalities=[100-survival percentage]). Findings During 371 population-years, 166 000 events were registered. Official CHD mortality rates, based on death certification, fell (annual changes: men −4·0% [range −10·8 to 3·2]; women −4·0% [-12·7 to 3·0]). By MONICA criteria, CHD mortality rates were higher, but fell less (-2·7% [-8·0 to 4·2] and −2·1% [-8·5 to 4·1]). Changes in non-fatal rates were smaller (-2·1%, [-6·9 to 2·8] and −0·8% [-9·8 to 6·8]). MONICA coronary-event rates (fatal and non-fatal combined) fell more (-2·1% [-6·5 to 2·8] and −1·4% [-6·7 to 2·8]) than case fatality (-0·6% [-4·2 to 3·1] and −0·8% [-4·8 to 2·9]). Contribution to changing CHD mortality varied, but in populations in which mortality decreased, coronary-event rates contributed two thirds and case fatality one third. Interpretation Over the decade studied, the 37 populations in the WHO MONICA Project showed substantial contributions from changes in survival, but the major determinant of decline in CHD mortality is whatever drives changing coronary-event rates.

OBJECTIVE To study diabetic and nondiabetic patients with their first myocardial infarction to determine overall 1-year mortality, out-of-hospital mortality, 28-day mortality of hospitalized patients, and 1-year mortality of 28-day survivors. RESEARCH DESIGN AND METHODS This study—based on the FINMONICA Myocardial Infarction Register, a part of the Finnish contribution to the WHO MONICA Project (World Health Organization Multinational Monitoring of Trends and Determinants of Cardiovascular Disease)—covered coronary heart disease (CHD) deaths and acute CHD events occurring during hospitalization among residents of Finland aged 25–64 years in three geographically defined areas. The study population comprised 620 diabetic and 3,445 nondiabetic patients who had their first myocardial infarction during the years 1988–1992. RESULTS The age- and area-adjusted mortality rates and hazard ratios (HRs) for diabetic versus nondiabetic patients (95% CI) were as follows: The 1-year mortality rate was 44.2% in diabetic men and 32.6% in nondiabetic men (HR, 1.38; 1.18−1.61) and 36.9% in diabetic women and 20.2% in nondiabetic women (HR, 1.86; 1.40−2.46); the out-of-hospital mortality rate was 28.3% in diabetic men and 22.4% in nondiabetic men (HR, 1.25; 1.03−1.52) and 10.4% in diabetic women and 11.0% in nondiabetic women (HR, 0.95; 0.58−1.54); the 28-day mortality rate of hospitalized patients was 14.4% in diabetic men and 8.8% in nondiabetic men (HR, 1.58; 1.15−2.18) and 21.7% in diabetic women and 7.8% in nondiabetic women (HR, 2.60; 1.71−3.95); and the 1-year mortality rate of 28-day survivors was 9.6% in diabetic men and 5.0% in nondiabetic men (HR, 1.97; 1.25−3.12) and 10.7% in diabetic women and 2.5% in nondiabetic women (HR, 4.17; 2.05−8.51). CONCLUSIONS The high mortality rate of diabetic patients after their first myocardial infarction and the high proportion of out-of-hospital deaths in this group imply that vigorous primary and secondary preventive measures should become an integral part of their medical care.

Background The clinical view of case fatality (CF) from acute myocardial infarction (AMI) in those reaching the hospital alive is different from the population view. Registration of both hospitalized AMI cases and out-of-hospital coronary heart disease (CHD) deaths in the WHO MONICA Project allows both views to be reconciled. The WHO MONICA Project provides the largest data set worldwide to explore the relationship between CHD CF and age, sex, coronary event rate, and first versus recurrent event. Methods and Results All 79 669 events of definite AMI or possible coronary death, occurring from 1985 to 90 among 5 725 762 people, 35 to 64 years of age, in 29 MONICA populations are the basis for CF calculations. Age-adjusted CF (percentage of CHD events that were fatal) was calculated across populations, stratified for different time periods, and related to age, sex, and CHD event rate. Median 28-day population CF was 49% (range, 35% to 60%) in men and 51% (range, 34% to 70%) in women and was particularly higher in women than men in populations in which CHD event rates were low. Median 28-day CF for hospitalized events was much lower: in men 22% (range, 15% to 36%) and in women 27% (range, 19% to 46%). Among hospitalized events CF was twice as high for recurrent as for first events. Conclusions Overall 28-day CF is halved for hospitalized events compared with all events and again nearly halved for hospitalized 24-hour survivors. Because approximately two thirds of 28-day CHD deaths in men and women occurred before reaching the hospital, opportunities for reducing CF through improved care in the acute event are limited. Major emphasis should be on primary and secondary prevention.

We studied the validity of the Finnish hospital discharge register data on coronary heart disease (CHD) for the purposes of epidemiologic studies and health services research. The Finnish nationwide hospital discharge register (HDR) was linked with the FINMONICA acute myocardial infarction (AMI) register for the years 1983-1990. The frequency of errors in the HDR was assessed separately. Between 8% and 13% of hospitalized AMI events registered in the AMI Register were not found in the HDR with an ICD code for CHD. Problems with the register linkage and the use of some ICD code other than one of the codes for CHD explained these missing events. The frequency of errors in the personal identification number was about 5% in the early 1980s. After 1986 errors were found only occasionally. The diagnosis recorded in the HDR was the same as that in the discharge sheet in about 95% of hospitalizations. The positive predictive value of the ICD code 410 (AMI), compared with the FINMONICA definite+possible AMI category, was very high and stable, about 90% in all areas and all hospitals, but the sensitivity varied from 50% at local hospitals to 80% at central hospitals. In summary, data on CHD obtained from the Finnish hospital discharge register give, on average, a correct picture on changes in the occurrence of AMI in Finland and can, with necessary caution, be used in epidemiological studies and health services research. However, the classification of individual cases is not standardized in the HDR, but varies over time, between geographical areas and the levels of care. Therefore, these data should not be used without confirmation in studies where correct classification of individual outcomes is of crucial importance, such as follow-up studies and case-control studies.

Background The rate of coronary heart disease (CHD) mortality in eastern Finland has been the highest in the world. The official mortality statistics suggest, however, that it has declined by 60% during the past 20 years. The aim of the present study was to examine the contributions of incidence, recurrence, and case fatality of coronary events to the trends in CHD mortality in three areas of Finland. Methods and Results Population-based myocardial infarction registers have been operating in the provinces of North Karelia and Kuopio in eastern Finland and the Turku/Loimaa area in southwestern Finland from 1983 to 1992. During this 10-year period, each suspected coronary event in persons 35 to 64 years of age was evaluated for registration. Of these, 13 566 fulfilled the criteria of myocardial infarction or coronary death. Almost one fourth (22.4%) of the coronary events were sudden, out-of-hospital deaths. Among men, the average change in mortality was −7.1% per year (95% confidence interval, −8.4% to −5.8%) in North Karelia, −5.0% per year (−7.0% to −3.0%) in Kuopio, and −4.9% per year (−8.2% to −1.6%) in Turku/Loimaa. Among women, the corresponding changes were −5.6% (−11.1% to −0.1%), −4.4% (−8.1% to −0.7%), and −8.1% (−13.0% to −3.2%). In eastern Finland, the decline in CHD mortality was due to a decline in recurrent coronary events but also in the incidence of first coronary events, whereas in southwestern Finland, the decline in case-fatality rate had the major role. Conclusions The decline in CHD mortality rate in Finland appears to be the result of a successful combination of primary and secondary prevention measures and improvements in acute coronary care.

Background WHO has played a leading role in the formulation and promulgation of standard criteria for the diagnosis of coronary heart disease and myocardial infarction since early 1970s. Methods The revised definition takes into consideration the following: well-resourced settings can use the ESC/ACC/AHA/WHF definition, which has new biomarkers as a compulsory feature; in resource-constrained settings, a typical biomarker pattern cannot be made a compulsory feature as the necessary assays may not be available; the definition must also have provision for diagnosing non-fatal events with incomplete information on cardiac biomarkers and the ECG; to facilitate epidemiologic monitoring definition must recognize fatal events with incomplete or no information on cardiac biomarkers and/or ECG and/or autopsy and/or coronary angiography. Results Category A definition is the same as ESC/ACC/AHA/WHF definition of MI, and can be applied to settings with no resource constraints. Category B definition of MI is to be applied whenever there is incomplete information on cardiac bio-markers together with symptoms of ischaemia and the development of unequivocal pathological Q waves. Category C definition (probable MI) is to be applied when individuals with MI may not satisfy Category A or B definitions because of delayed access to medical services and/or unavailability of electrocardiography and/or laboratory assay of cardiac biomarkers. In these situations, the term probable MI should be used when there is either ECG changes suggestive of MI or incomplete information on cardiac biomarkers in a person with symptoms of ischaemia with no evidence of a non-coronary reason. Conclusions This article presents the 2008-09 revision of the World Health Organization (WHO) definition of myocardial infarction (MI) developed at a WHO expert consultation.

Background It is well known that increasing age is the strongest risk factor of stroke. Therefore, it has been a common belief in many countries including Finland that the numbers of stroke patients will increase considerably during the next two decades because the population is rapidly ageing. Methods The FINMONICA and FINSTROKE registers operated in Finland in the Kuopio area and city of Turku from 1983 to 1997. The results showed that the incidence, mortality and case fatality of stroke declined significantly during that period. Importantly, it was established that the trends in incidence and mortality were also declining among the elderly (>74 years). We used these results to create a model for the entire country. The model was based on the trends present in these registers from Turku and Kuopio area and age-specific population projections up to the year 2030 that were obtained from Statistics Finland. Results In the year 2000, the number of new first stroke cases was estimated to be 11500. If the declining trend were to level off totally after the year 2000, the number of new strokes would be 20100 in the year 2030 due to the ageing of the population. It would be 12100 if the trend continued as favourable as during the years 1983–1997. Conclusions Ageing of the population will not inevitably increase the burden of stroke in Finland if the present declining trends are maintained, but the annual number of cases will almost double if the incidence remains at the level of the year 2000.

Objective To analyse the risk of coronary heart disease (CHD) events and total mortality among patients who had coronary artery bypass graft (CABG) surgery during 1988–1992. Methods A population-based myocardial infarction (MI) register included data on invasive cardiac procedures among residents of the study area. The subjects aged 35–64 years were followed-up for 12 years for non-fatal and fatal CHD events and all-cause mortality, excluding events within 30 days of the CABG operation. CABG was performed on 1158 men and 215 women. Results The overall survival of men who underwent CABG was similar to the survival of the corresponding background population for about ten years but started to worsen after that. At twelve years of follow-up, 23% ( n = 266, 95% CI 234–298) of the men who had undergone the operation had died, while the expected proportion, based on mortality in the background population, was 20% ( n = 231, 95% CI 226–237). The CHD mortality of men who had undergone the operation was clearly higher than in the background population. Among women, the mortality after CABG was about twice the expected mortality in the corresponding background population. In Cox proportional hazards models age, smoking, history of MI, body mass index and diabetes were significant predictors of mortality. Conclusions The prognosis of male CABG patients did not differ from the prognosis of the corresponding background population for about ten years, but started to deteriorate after that. History of MI prior to CABG and major cardiovascular risk factors was a predictor of an adverse outcome.

OBJECTIVE—To examine socioeconomic differences in case fatality and prognosis of myocardial infarction (MI) events, and to estimate the contributions of incidence and case fatality to socioeconomic differences in coronary heart disease (CHD) mortality. DESIGN—A population-based MI register study. METHODS—The FINMONICA MI Register recorded all MI events among persons aged 35-64 years in three areas of Finland during 1983-1992. A record linkage of the MI Register data with the files of Statistics Finland was performed to obtain information on socioeconomic indicators for each individual registered. First MI events (n=8427) were included in the analyses. MAIN RESULTS—The adjusted risk ratio of prehospital coronary death was 2.11 (95% CI 1.82, 2.46) among men and 1.68 (1.14, 2.48) among women with low income compared with those with high income. Even among persons hospitalised alive the risk of death during the next 12 months was markedly higher in the low income group than in the high income group. Case fatality explained 51% of the CHD mortality difference between the low and the high income groups among men and 38% among women. Incidence contributed 49% and 62%, respectively. CONCLUSIONS—Considerable socioeconomic differences were observed in the case fatality of first coronary events both before hospitalisation and among patients hospitalised alive. Case fatality explained a half of the CHD mortality difference between the low and the high income groups among men and more than a third among women. Keywords: socioeconomic status; myocardial infarction; case fatality

Background —Low socioeconomic status (SES) is associated with increased coronary heart disease mortality rates. There are, however, very little data on the relation of SES to the incidence, recurrence, and prognosis of myocardial infarction (MI) events. Methods and Results —The FINMONICA MI Register recorded detailed information on all MI events among men and women aged 35 to 64 years in 3 areas of Finland during the period of 1983 to 1992. We carried out a record linkage of the MI register data with files of Statistics Finland to obtain information on indicators of SES, such as taxable income and education, for each individual who is registered. In the analyses, income was grouped into 3 categories (low, middle, and high), and education was grouped into 2 categories (basic and secondary or higher). Among men with their first MI event (n=6485), the adjusted incidence rate ratios were 1.67 (95% CI 1.57 to 1.78) and 1.84 (95% CI 1.73 to 1.95) in the low- and middle-income categories compared with the high-income category. For 28-day mortality rates, the corresponding rate ratios were 3.18 (95% CI 2.82 to 3.58) and 2.33 (95% CI 2.03 to 2.68). Significant differentials were observed for prehospital mortality rates, and they remained similar up to 1 year after the MI. Findings among the women were consistent with those among the men. Conclusions —The excess coronary heart disease mortality and morbidity rates among persons with low SES are considerable in Finland. To bring the mortality rates of low- and middle-SES groups down to the level of that of the high-SES group constitutes a major public health challenge.

Miettinen H, Salomaa V, Ketonen M, Niemela M, Immonen-Raiha P, Mahonen M, of the FINMONICA Myocardial Infarction Register Group (Kuopio University Hospital, Kuopio; National Public Health Institute, Helsinki; North Karelia Central Hospital, Joensuu; Loimaa District Hospital, Loimaa; and Turku University Hospital, Turku, Finland). Trends in the treatment of patients with myocardial infarction and coronary revascularization procedures in Finland during 1986–92: the FINMONICA Myocardial Infarction Register Study. J Intern Med 1999; 245: 11–20. Objectives. To investigate changes in the medical treatment of patients with myocardial infarction and the trends in revascularization procedures in Finland. Design. A population-based myocardial infarction (MI) register study. Setting. Populations, aged 25–64 years, of the three geographical areas of Finland, provinces of North Karelia and Kuopio in eastern Finland and the Turku-Loimaa area in south-western Finland. Main outcome measures. Medical treatment administered prior to the coronary event, during the hospitalization and at discharge from hospital to all patients hospitalized due to suspected myocardial infarction and all CAD deaths occurring during three separate 4-month periods in 1986, 1989 and 1992. Data on coronary bypass surgery and percutaneous coronary angioplasty in the study areas for 1986–92. Results. The most marked change in the medical treatment of hospitalized myocardial infarction patients was the significant increase in the use of thrombolytic treatment (5% of patients in 1986 and 24% in 1992, P