Decline in Out-of-Hospital Coronary Heart Disease Deaths
Has Contributed the Main Part to the Overall Decline in
Coronary Heart Disease Mortality Rates Among Persons
35 to 64 Years of Age in Finland
The FINAMI Study
V. Salomaa, MD, PhD; M. Ketonen, MD, PhD; H. Koukkunen, MD; P. Immonen-Räihä, MD, PhD;
T. Jerkkola, MD; P. Kärjä-Koskenkari, MD; M. Mähönen, MD, PhD; M. Niemelä, MD;
K. Kuulasmaa, PhD; P. Palomäki, MD, PhD; J. Mustonen, MD, PhD; M. Arstila, MD, PhD;
T. Vuorenmaa, MD, PhD; A. Lehtonen, MD, PhD; S. Lehto, MD, PhD; H. Miettinen, MD, PhD;
J. Torppa, MSc; J. Tuomilehto, MD, PhD; Y.A. Kesäniemi, MD, PhD; K. Pyörälä, MD, PhD
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Background—Out-of-hospital deaths constitute the majority of all coronary heart disease (CHD) deaths and are therefore
of considerable public health significance.
Methods and Results—We used population-based myocardial infarction register data to examine trends in out-of-hospital
CHD deaths in Finland during 1983 to 1997. We included in out-of-hospital deaths also deaths in the emergency room
and all deaths within 1 hour after the onset of symptoms. Altogether, 3494 such events were included in the analyses.
The proportion of out-of-hospital deaths of all CHD deaths depended on age and gender. In the age group 35 to 64 years,
it was 73% among men and 60% among women. These proportions did not change during the study. The annual average
decline in the age-standardized out-of-hospital CHD death rate was 6.1% (95% CI, ⫺7.3, ⫺5.0%) among men and 7.0%
(⫺10.0, ⫺4.0%) among women. These declines contributed among men 70% and among women 58% to the overall
decline in CHD mortality rate. In all, 58% of the male and 52% of the female victims of out-of-hospital CHD death had
a history of symptomatic CHD. Among men with a prior history of myocardial infarction, the annual average decline
in out-of-hospital CHD deaths was 5.3% (⫺7.2, ⫺3.2%), and among men without such history the decline was 2.9%
(⫺4.4, ⫺1.5%). Among women, the corresponding changes were ⫺7.8% (⫺14.2, ⫺1.5%) and ⫺4.5% (⫺8.0, ⫺1.0%).
Conclusions—The decline in out-of-hospital CHD deaths has contributed the main part to the overall decline in CHD
mortality rates among persons 35 to 64 years of age in Finland. (Circulation. 2003;108:691-696.)
Key Words: coronary disease 䡲 myocardial infarction 䡲 population 䡲 mortality
O
ut-of-hospital deaths constitute the majority of all coronary heart disease (CHD) deaths and are therefore of
considerable public health significance.1–3 During the past 25
years, the CHD mortality rate has declined substantially in
many Western countries, including Finland, due to the successful prevention efforts and improved treatment of both
chronic CHD and acute coronary syndromes.4 Epidemiological studies and clinical trials have shown that the 28-day
case-fatality rate of myocardial infarction (MI) among patients reaching the hospital alive has declined to ⬇10% or
even lower.5,6 It has become apparent, however, that the
population view of the case-fatality rate of MI events is very
different from the view of clinical trials and other hospitalbased studies.7,8
Only few longitudinal studies have analyzed trends in
sudden or out-of-hospital cardiac deaths.2,3,9 Most of these
have been based on vital statistics, not on standardized data
collection procedures, and deal with all sudden cardiac deaths
instead of focusing specifically on sudden deaths caused by
CHD. Accordingly, relatively little is known about time
trends in sudden out-of-hospital CHD deaths during the
recent steep decline in CHD mortality rate.
In the current study, we have analyzed trends in out-ofhospital CHD deaths in 4 geographical areas in Finland
Received December 11, 2002; de novo received March 3, 2003; revision received May 20, 2003; accepted May 21, 2003.
From KTL-National Public Health Institute, Helsinki, Finland (V.S., M.M., K.K., J. Torppa, J. Tuomilehhhto, M.N.); Kuopio University Hospital,
Kuopio, Finland (H.K., S.L., K.P.); Jyväskylä Central Hospital, Jyväskylä, Finland (H.M.); Central Hospital of North Karelia, Joensuu, Finland (M.K.,
P.P., J.M.); Oulu University Hospital and Biocenter Oulu, Oulu, Finland (T.J., P.K.-K., Y.A.K.); Raisio Regional Hospital, Raisio, Finland (P.I.-R.);
Turku Town Hospital (A.L.) and University Hospital of Turku (M.A., T.V.), Turku, Finland.
Correspondence to Veikko Salomaa, KTL-National Public Health Institute, Department of Epidemiology and Health Promotion, Mannerheimintie 166,
FIN-00300 Helsinki, Finland. E-mail [email protected]
© 2003 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
DOI: 10.1161/01.CIR.0000083720.35869.CA
691
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Circulation
August 12, 2003
during the 15-year period 1983 to 1997. To consider the
effects of primary and secondary prevention, we broke these
trends further down to out-of-hospital deaths in persons with
and those without a history of MI. We also calculated the
contribution of the decline in out-of-hospital CHD deaths to
the overall decline in CHD mortality rate. The main analyses
focused on persons 35 to 64 years of age, but for the last
5-year period, 1992 to 1997, we included data on persons
older than 64 years.
Methods
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FINAMI is a population-based MI register aiming to record every
CHD event in the populations of monitored areas.10 It continues the
work of the FINMONICA MI register,11 with comparable data
collection procedures. The geographical areas covered by the register
are the town of Turku in southwestern Finland, the town of Kuopio
in eastern Finland, the town of Joensuu, and some surrounding rural
areas in North Karelia, eastern Finland. Also included is the town of
Oulu in northwestern Finland. Oulu joined in the project at a later
stage and currently has data for the years 1993 and 1997, whereas the
other areas have data for the whole 15-year period of 1983 to 1997.
In 1995, there were 104 014 men and 127 683 women ⱖ35 years of
age living in these areas.
Data for the first 10 years of this report originate from the
FINMONICA MI register and for the last 5 years from the FINAMI
register. The main difference is that during the FINMONICA project,
the upper age limit of registration was 64 years, which was removed
in 1993. Sources of case finding were the hospital admission and
discharge diagnoses and death certificates of each area.10 Trained
nurses collected the information from hospital documents, death
certificates, and autopsy reports. The local registration teams periodically sent their data to the coordinating center at the National
Public Health Institute. The data were annually cross-checked with
the national Causes-of-Death Register and the national Hospital
Discharge Register for completeness. These registers cover all deaths
of Finnish residents and every hospitalization in Finland. International Classification of Diseases (ICD) 9 codes 410 – 414 and 798,
and ICD-10 codes I20-I25, R96, R98, I46.1, and I46.9 were used for
cross-checking with the national Causes-Of-Death register. ICD-9
was used in Finland until the end of 1995 and ICD-10 thereafter.
The suspected CHD events were classified into 5 diagnostic
categories, which have been described.10,11 Four of these categories
were relevant for fatal events. For these, the classification criteria
were the same as in the WHO MONICA Project12: (1) definite MI:
appearance of fresh MI by visual inspection and/or recent coronary
occlusion found at necropsy; (2) possible acute MI or coronary
death: fatal cases, in which there is no good evidence for another
cause of death, (a) with symptoms typical or atypical or inadequately
described, (b) without symptoms but with evidence of chronic
coronary occlusion or stenosis or old myocardial scarring at necropsy, or (c) with a good history of chronic ischemic heart disease in
the absence of significant valvular disease or cardiomyopathy; (3) no
acute MI: fatal cases in which another diagnosis has been made; (4)
fatal unclassifiable events: cases with no autopsy, no history of
symptoms, no previous history of chronic ischemic heart disease, and
no other diagnosis. There were very few fatal unclassifiable events
(n⫽42, which is 0.5% of all CHD events registered during the
15-year period).
We defined out-of-hospital CHD deaths as cases of death that had
occurred out-of-hospital or in the emergency room or within 1 hour
after the onset of symptoms and had been classified into the
diagnostic category definite MI, possible MI, coronary death, or fatal
unclassifiable event. The frequency of autopsies among these cases
was high: 70% among men and 76% among women. According to
the practice of the WHO MONICA Project,12 the time frame for one
event was 28 days. Thus, we did not include in out-of-hospital CHD
deaths those deaths that occurred after hospitalization but within 28
days since the beginning of symptoms. During 1988 to 1997 there
were 31 cases among men and 12 cases among women who died
after discharge from a hospital but within 28 days since the
beginning of the event. The event was considered to be incident (first
for a particular person) if there was no indication of a previous,
clinically recognized MI in the patient’s history; otherwise the event
was considered as recurrent. History of CHD was considered
positive if the review of medical records revealed evidence for (a)
previous clinically recognized MI, or (b) clinically symptomatic
coronary insufficiency or angina pectoris in the absence of a firm
diagnosis of valvular heart disease or cardiomyopathy.
Statistical Methods
Out-of-hospital, in-hospital, and total CHD mortality rates were
expressed per 100 000 persons and age-standardized according to the
direct method using 5-year age groups and the European standard
population.13 The annual population counts for the denominators
were obtained from the National Population Register, which is
updated continuously. For the calculation of out-of-hospital CHD
death rates among persons with and without prior MI, the denominators were derived by using data from the FINRISK population
surveys,14 which have been carried out in the FINAMI areas every 5
years. Surveys for the years 1982, 1987, 1992, and 1997 were used
in the analyses, and the years between these surveys were estimated
by means of regression analysis. We took the proportions of persons
who reported having had an MI for each 5-year age group beginning
from age 45 years and then applied these proportions to the
population counts of the FINAMI areas to establish the proportions
of population with and without a history of prior MI. The age group
35 to 44 years was excluded from this analysis because of small
numbers. Also, these rates were age-standardized to the European
Standard Population. The 95% CIs were calculated assuming Poisson distribution for the annual numbers of deaths.
The proportion of out-of-hospital CHD deaths and the 28-day
case-fatality rate were age-standardized by using weights derived
from the combined age distribution of patients with MI and stroke in
the WHO MONICA Project.15 The trends in event rates and
case-fatality rates were determined by means of log-linear Poisson
regression models, with the year as the independent variable.15
Trends were estimated for the age group 35 to 64 years, because that
was the common age group for the whole 15-year period. Oulu was
excluded from the trend analyses because it had data only for the
years 1993 and 1997. Data for the other areas were pooled because
the results for each area were similar.
The proportion of CHD mortality rate decline due to the decline in
out-of-hospital CHD deaths was estimated using the formula
100⫻(dMs/dMt), where dMs⫽out-of-hospital CHD mortality rate in
1983 minus out-of-hospital CHD mortality rate in 1997, and
dMt⫽total CHD mortality rate in 1983 minus total CHD mortality
rate in 1997. Smoothed mortality rates taken from the log-linear
models were used for these calculations. For the age group–specific
analyses, we included all age groups ⱖ35 years and all FINAMI
areas, but only the last 5-year period 1993 to 1997 for which we had
data on persons older than 64 years.
Results
During the 15-year period, 1622 out-of-hospital CHD deaths
occurred in the FINAMI areas among men and 242 among
women 35 to 64 years of age. Another 853 out-of-hospital
CHD deaths were observed during the period 1993 to 1997
among men and 777 among women ⱖ65 years of age. The
average age-standardized proportion of out-of-hospital CHD
deaths of all CHD deaths in the age group of 35 to 64 years
was 73% among men and 60% among women. These
proportions did not change during the study period (trend,
0.3% per year (95% CI, ⫺0.8, 1.5%) among men and
⫺0.4%/year (⫺3.5, 2.7%) among women).
The out-of-hospital CHD death rate declined on average by
6.1% per year (⫺7.3, ⫺5.0%) among men and by 7.0% per
year (⫺10.0, ⫺4.0%) among women (Table 1). Rates and
Salomaa et al
Out-of-Hospital Coronary Deaths
693
TABLE 1. Age-Standardized Rates and Trends in Out-of-Hospital and In-Hospital CHD Deaths and in Total
CHD Mortality Rate Among Men and Women 35 to 64 Years of Age in FINAMI Areas During 1983 to 1997
Out-of-Hospital CHD Mortality Rate
Time Period
In-Hospital CHD Mortality Rate
CHD Mortality Rate
N
Rate
N
Rate
N
Rate
1983–1987
691
270
261
101
952
371
1988–1992
521
192
195
71
716
263
1993–1997
410
145
139
49
549
Men
Trend, %/y
95% CI
195
⫺6.1
⫺7.3
⫺6.4
⫺7.3 to ⫺5.0
⫺9.2 to ⫺5.3
⫺7.4 to ⫺5.4
Women
1983–1987
105
32
76
22
181
54
1988–1992
88
27
64
19
152
46
1993–1997
49
15
35
11
84
Trend, %/y
95% CI
26
⫺7.0
⫺7.2
⫺7.0
⫺10.0 to ⫺4.0
⫺10.7 to ⫺3.6
⫺9.3 to ⫺4.7
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Rates are expressed as averages for each 5-year period per 100 000 inhabitants and age-standardized to the European Standard
Population.
Trends in total CHD mortality rate have been discussed in more detail in Reference 10.
trends in in-hospital CHD mortality rate and in total CHD
deaths are also shown for comparison. The declining trends
did not differ much, but the rates in in-hospital CHD deaths
were much lower than those in out-of-hospital CHD deaths.
The out-of-hospital CHD death rate was further broken
down to deaths among persons with and without a history of
prior MI (Figure 1). Significant declines were observed in
both, but the rates were much higher in persons with prior MI.
Among the victims of out-of-hospital death from a recurrent
CHD event, the time interval to the previous MI showed an
increasing trend: Among men who died during the 5-year
periods 1983 to 1987, 1988 to 1992, and 1993 to 1997, the
time intervals to the previous MI event were 4.7, 5.6, and 7.1
years, respectively. Among women, the corresponding time
intervals were 3.1, 4.8, and 5.2 years.
Of all men 35 to 64 years of age who died of CHD
out-of-hospital during the 15-year period, 37.1% (35.9% to
38.3%) had a history of MI. Another 20.8% (18.8% to 22.8%)
had a history of symptomatic CHD without MI. Among
women of similar age, 29.0% (26.8% to 31.2%) had a history
of MI, and another 22.6% (17.4% to 27.8%) had a history of
CHD without MI. Thus, for approximately half of the cases,
out-of-hospital death was the first clinical manifestation of
CHD.
The case-fatality rate due to out-of-hospital CHD death
increased with age, in particular among women (Table 2).
However, the proportion of out-of-hospital deaths of all CHD
deaths declined with age. Among persons younger than 75
years, out-of-hospital CHD deaths constituted the majority of
all CHD deaths, but not among persons ⱖ75 years of age.
Likewise, the proportion of out-of-hospital deaths of all CHD
deaths was smaller for recurrent than for first events (66.2%
for recurrent and 77.7% for first events among men and
46.8% and 65.3% among women 35 to 64 years of age).
Figure 2 depicts changes in total CHD mortality rate
partitioned to out-of-hospital and in-hospital CHD deaths
among men and women 35 to 64 years of age. Rates shown
in the figure are smoothed by use of the log-linear model. The
decline in out-of-hospital CHD death rate contributed among
men 70% and among women 58% to the overall decline in
CHD mortality rate.
Discussion
Consistent with other epidemiological studies,1–3 our study
confirmed that the majority of CHD deaths take place
out-of-hospital. The out-of-hospital CHD death rate in
FINAMI areas declined significantly during the 15-year
period. A similar development has recently been reported on
the basis of routine mortality statistics from the United States2
and from Scotland.3 In our study, the proportion of out-ofhospital deaths of all CHD deaths did not change over time,
whereas in the United States, the proportion of sudden cardiac
deaths of all cardiac deaths increased by 12.4% during the
period 1989 to 1998.2 Both in Finland and in the United
States, the proportion of out-of-hospital deaths decreased
with increasing age. In the Scottish study, however, the
proportion of patients with MI who survived to hospital
decreased with age.3 These different findings may reflect
technical differences between the studies but may also reflect
real differences in the behavior of patients and health care
systems.
The decline in CHD mortality rate has been a universal
finding in all Western countries.15 To our knowledge, however, no earlier study has partitioned the mortality rate decline
to the contributions of out-of-hospital and in-hospital CHD
deaths. Our calculations showed that more than two thirds of
the mortality rate decline in men and more than half in
women were due to the decline in out-of-hospital CHD
deaths. In the United States, the Minnesota Heart Survey has
reported a faster decline in in-hospital than in out-of-hospital
mortality rates.16 In our study, the declining trends in out-ofhospital and in-hospital deaths did not differ substantially, but
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August 12, 2003
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Figure 1. Age-standardized rates (3-year
moving averages on a log scale) and
trends in out-of-hospital CHD deaths
from first and recurrent CHD events
among men and women 45 to 64 years
of age in FINAMI areas during 1983 to
1997. Average annual change among
men was ⫺5.3% (⫺7.2, ⫺3.3%) for
deaths caused by recurrent events and
⫺2.9% (⫺4.4, ⫺1.5%) for deaths caused
by first events. Among women, corresponding changes were ⫺7.8% (⫺14.2,
⫺1.5%) and ⫺4.5% (⫺8.0, ⫺1.0%).
the much larger amount of out-of-hospital CHD deaths made
their contribution to the decline in total CHD mortality rate
greater. This supports the importance of the roles that primary
prevention and treatment of chronic CHD have played in the
decline in CHD mortality rate in Finland.
The FINAMI register data allowed us to analyze the
history of prior MI or CHD among the persons who had
out-of-hospital CHD death. We found that for less than half
of these cases, out-of-hospital death was the first manifestation of CHD, whereas more than half were receiving treatment for CHD or previous MI at the time of their fatal event.
The history of clinically manifest CHD among persons who
had out-of-hospital death appears to be of the same order of
magnitude in Finland as in Olmsted County, Minnesota, since
a recent study reported that the proportion of “unexpected”
sudden cardiac deaths of all sudden cardiac deaths was 49%
in the Olmsted county.9 Our results clearly show that for a
substantial proportion of cases, out-of-hospital death does not
come out of the blue, and thus there are possibilities for
prevention with appropriate treatment of chronic CHD.
The declining trends in out-of-hospital CHD deaths tended
to be steeper among persons with a history of MI than among
those without such history, but the 95% CIs were overlapping. A special feature of these analyses was that by using
data from the FINRISK population surveys,14 we were able to
calculate the annual numbers of persons in the population
who had and who had not had a prior MI. Thus, we could use
correct denominators for persons at risk of out-of-hospital
death from first or recurrent MI. Our results also showed that
the time interval between the out-of-hospital death from a
recurrent CHD event and the previous MI event was increasing over time. Furthermore, the proportion of out-of-hospital
deaths was smaller for recurrent than for the first-MI events.
Taken together, these findings suggest that primary prevention and secondary prevention and the treatment of chronic
CHD have all contributed to the reduction of out-of-hospital
CHD deaths. The slightly faster decline in persons with prior
MI than in those without prior MI is consistent with recent
findings from the Olmsted County, Minnesota,9 and emphasizes the need for effective primary prevention measures.
Salomaa et al
Out-of-Hospital Coronary Deaths
695
TABLE 2. Age Group–Specific Case-Fatality Rate (%, 95% CI) due to Out-of-Hospital
CHD Death and Proportion of Out-of-Hospital Deaths (%, 95% CI) of All CHD Deaths
Within 28 Days Since Beginning of Symptoms During 1993 to 1997
n*
Case Fatality Rate due to
Out-of-Hospital Death, %
Proportion of
Out-of-Hospital
Deaths of All CHD Deaths, %
35–54
205
22(19–25)
75(69–82)
55–64
397
26(24–29)
73(69–78)
65–74
801
25(23–27)
59(55–62)
Age Group
Men
75–84
580
24(22–27)
44(40–48)
85⫹
291
30(25–34)
41(36–47)
16
10(4–16)
65(43–86)
55–64
78
12(8–15)
52(41–64)
65–74
429
17(15–19)
52(47–57)
75–84
786
17(15–19)
38(34–41)
85⫹
768
24(22–27)
35(31–38)
Women
35–54
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*n indicates No. of persons who died during the 28-day period after the beginning of symptoms.
A strength of our study is the long period of data collection,
according to a standardized protocol. Completeness of case
finding could be ascertained by using national registers,
causes-of-death register, and the hospital discharge register.
Furthermore, the frequency of autopsies among cases of
out-of-hospital death was high, 70% among men and 76%
among women. Two features of the study limited the representativeness of the results. First, the FINAMI register
covered 4 mainly urban areas, which may not be representative of the country as a whole. Since the out-of-hospital death
rate is higher in rural than in urban areas, our study may give
a slightly too optimistic view on out-of-hospital deaths in
Figure 2. Declines in overall CHD mortality rates (per 100 000 persons) partitioned to out-of-hospital (black area) and
in-hospital (gray area) CHD deaths
among men and women 35 to 64 years
of age in the FINAMI areas during 1983
to 1997. Event rates are agestandardized to the European standard
population and smoothed with the use of
a log-linear model.
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Circulation
August 12, 2003
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Finland. Second, the first 10 years of our study included only
persons younger than 65 years. We were therefore not able to
calculate 15-year trends in out-of-hospital CHD deaths for
persons ⱖ65 years of age, even though the majority of CHD
events occurs in this age group. We have, however, included
all age groups in the FINAMI register since 1993. In the
current study, we show results for the last 5-year period of
1993 to 1997, including also elderly individuals to improve
the coverage of this important segment of patients with CHD.
The third limitation was the composite definition of out-ofhospital CHD deaths used in our study. Clinical studies often
define sudden, out-of-hospital deaths as deaths within 1 hour
after the onset of symptoms. It is, however, the inherent
nature of out-of-hospital deaths that exact information about
the time between the onset of symptoms and the death is often
not available. We agree with the conclusion presented by
Zheng and coworkers2 that this makes the 1-hour definition
impractical for public health surveillance. Therefore, the
wider definition is often the only feasible solution.
In conclusion, out-of-hospital CHD death rates have been
declining in the FINAMI areas, and their decline explains the
main part of the overall decline in CHD mortality rate.
Despite this favorable development, out-of-hospital CHD
deaths continue to constitute the majority of all CHD deaths
in persons younger than 75 years. In almost half of the cases,
out-of-hospital death is the first clinical manifestation of
CHD. The main way to reduce these deaths further is the
primary prevention of CHD at the population level. The other
half of out-of-hospital CHD deaths occurs among persons
who are receiving treatment for symptomatic CHD. For them,
carefully tailored treatment and secondary prevention provides a possibility to reduce the risk of out-of-hospital death.
Acknowledgments
The FINAMI study was supported by the Finnish Foundation for
Cardiovascular Research.
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Circulation. 2003;108:691-696; originally published online July 28, 2003;
doi: 10.1161/01.CIR.0000083720.35869.CA
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