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In the analysis of mortality statistics high age-specific death rates could be interpreted as meaning more deaths (more disease), but they could equally well be interpreted as meaning earlier deaths (death at younger age). The distinction markedly affects the choice of hypotheses that may be advanced to explain variations in person, time and place and the design of subsequent, more detailed field studies to test the hypotheses. Furthermore, the majority of descriptive papers make no comparisons with a control disease and thereby break one of the ground rules of epidemiology. This paper shows how, in the example of the geographical variations within England and Wales of ischaemic heart disease, a control may be simply introduced and that much of the observed variation is not in the proportion who suffer heart disease deaths but is in the age at which deaths occur.
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BACKGROUND: Limited information is available about recent trends in the incidence and death rates from atrial fibrillation (AF) complicating acute myocardial infarction (AMI). The purpose of this study was to examine the impact and trends over time of AF complicating initial AMI. METHODS: We conducted a longitudinal study of 2596 residents of the Worcester, Massachusetts, metropolitan area with initial AMI and without previous AF who were hospitalized at all area hospitals in 5 annual periods between 1990 and 1997. RESULTS: A total of 13% of hospitalized patients developed AF. There was a marked decrease in the proportion of patients who developed AF over time (18% in 1990; 11% in 1997). Patients hospitalized during the most recent study years remained at significantly lower risk for developing AF than patients hospitalized in 1990 after controlling for factors that might affect the risk of AF. Patients with AF were more likely to die during hospitalization than those without AF even after controlling for other prognostic factors. Despite the adverse impact of AF, we observed trends toward improved hospital survival during the most recent study years in patients developing AF. Patients discharged after developing AF had higher long-term death rates than patients who did not develop AF, although these differences were attenuated after adjusting for other factors. CONCLUSIONS: The results of this community-wide study suggest a significant decline in the incidence of AF complicating AMI. Although patients with AF had higher hospital death rates, we observed trends of improved survival for these patients. AF remains a common complication of AMI to which targeted treatment efforts appear warranted.
Ischaemic heart disease (IHD) in prosperous Western populations rose markedly in the 1940s, peaked between 1970 and 1975 and then fell variably--by about 50% in the USA and Australia. Undoubtedly, decreases in serum cholesterol levels, in the incidence of hypertension and in smoking frequencies are largely responsible. In South Africa, in all population groups other than blacks, IHD rates rose analogously, with Asians and whites attaining very high rates. However, from 1978 to 1989, the total death rate among white males (per 100,000 world population) fell from 1,002 to 631 (37%), and the IHD mortality rate from 312 to 139 (56%). Rates for Asians were 1,306-1,130 (14%) and 355-226 (36%), respectively, and for coloureds 1,691 to 1,392 (18%) and 171 to 110 (36%). For blacks, the total mortality rate remained unchanged; IHD rates were low, but these data are unreliable. Percentage falls in the IHD rate exceed those in the total death rate, especially among whites, indicating true decreases in IHD rate. Understandably, the accuracy of the data, as with such data overseas, is questionable. Local falls are none the less in line with those noted in Western countries. Rates for whites remain very high, and are even higher for Asians. While knowledge of the reasons for the rises and falls in IHD rates remains incomplete, whites have none the less taken some preventive action, although Asians and coloureds apparently little.
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Benefits of the implantable defibrillator on survival were studied in 56 consecutive patients (concomitant coronary bypass or arrythmia surgery in 15) during an 8 year period between 1982 and 1990. During a follow-up period of 29 +/- 25 months, six patients had a sudden death and eight patients had a nonsudden cardiac death. Nonsudden cardiac deaths included three surgical deaths (death within 30 days after the surgery; two in patients without and one in a patient with concomitant cardiac surgery), one arrhythmia-related nonsudden death (death within 24 h after an arrhythmic event despite initial termination of the arrhythmia by the implantable defibrillators) and four nonarrhythmic cardiac deaths. The actuarial survival rate free of events at 1, 2 and 3 years was 96%, 96% and 92%, respectively, for sudden death, 91%, 91% and 87% for sudden death and surgical mortality and 89%, 89% and 85% for total arrhythmic death (sudden death, surgical mortality and arrhythmia-related nonsudden death). Thus, in patients treated with an implantable defibrillator, 1) the rate of sudden death is low (8% at 3 years); 2) 50% of nonsudden cardiac deaths are causally related to arrhythmia (surgical mortality or arrhythmia-related nonsudden death); 3) the total arrhythmic death rate is substantially higher than the sudden death rate; and 4) benefits of an implantable defibrillator are overestimated by reported sudden death and nonsudden cardiac death rates. The benefits may be better represented by the total arrhythmic death and nonarrhythmic cardiac death rates.
Death rates and causes of death among opioid addicts in 52 community treatment programs in a national reporting network were compared for 3 consecutive years. The greatest proportion of patients in the base samples were male, 21 to 25 years old, black, and in MM programs. The 275 patients in the deceased sample presented essentially the same profile, with the exception that the older patients were more highly represented among the deceased. Death rates were particularly high during each year for patients over 30 years old. Over the 3 years, death rates increased for whites, addicts 21 to 25 years old, and patients in outpatient DF programs. Consistent decreases in rates each year were found for blacks, patients in the 26 to 30 age range, and patients in MM programs.
Natural time series and prospective studies are combined to determine the contribution of many causal factors to the business cycle variation of the death rate. The variation of housing and nutrition together accounts for roughly a tenth of the death rate fluctuation. Drug consumption accounts for about one-sixth, with 11 percent of the total variation due to alcohol and 6 percent due to cigarette smoking. Social relationship changes, both as sources of stress and as means of relief, account for the greatest part (72 percent) of the business cycle variation of the death rate.
A cohort of 214 drug addicts with serum hepatitis and a cohort of 193 hepatitis patients without drug addiction were examined in respect of death rates, causes of death and a number of risk factors for reduced survival. The death rate was significantly higher among the drug addicts than among non-addicts. The annual mortality rate was 1.5% in the drug addict group and 0.7% in the non-addict group. The highest relative risk of death was 860 for female drug addicts in age group 15-24 compared to females of the same age in the general population. The most prevalent cause of death in the drug addict group was drug overdose (53%), whereas in the other group 66% died from various somatic diseases. Hepatitis or complications of viral hepatitis played no role as cause of death among the drug addicts, and infections as a whole were also responsible for very few deaths. For male drug addicts, imprisonment before admission and leaving hospital without the doctors' permission were risk factors for early death.
As part of an ongoing epidemiologic study, the death rate and causes of death during 1975 through 1984 were determined in Pima Indians who resided in the Gila River Indian Community (GRIC) in 1965 and later. Death certificates were available for 677 of the 681 deaths. In 78% of the deaths, the underlying cause recorded on the death certificate agreed with the cause determined after review of all available relevant records. The age- and sex-adjusted average annual death rate for the GRIC population (1639/100,000) was 1.9 times (95% CI 1.7-2.0) the 1980 rate for the U.S. all races (878/100,000). In Pima males, whose death rate was substantially higher than that of Pima females, the age-adjusted death rate was 2.3 times that in U.S. males, all races. Moreover among males 25-34 years of age, the Pima death rate was 6.6 times that for the U.S. all races. Diseases of the heart and malignant neoplasms caused 59% of U.S. deaths in 1980, but only 19% of GRIC deaths. By contrast, the age- and sex-adjusted mortality rate in the GRIC Pima was 5.9 times the rate of the U.S. all races for accidents, 6.5 times for cirrhosis, 7.4 times for homicide, 4.3 times for suicide, and 11.9 times for diabetes. Tuberculosis and coccidioidomycosis were important causes of death in the Pima, for whom infectious diseases was the tenth leading cause of death. The findings indicate that programs to improve the adverse mortality experience of the GRIC population should emphasize factors related to fatal accidents, alcoholic cirrhosis, homicide, suicide, diabetes mellitus, and infectious diseases. Young Pimas, especially the males, should be the primary focus of such preventive efforts. These findings and recommendations probably apply to many Native American populations.