Rochester, MN - While there is good news in the fight against cardiovascular disease, with a new report showing that cardiovascular disease deaths have declined in the past 25 years, investigators point out that the magnitude of decline differs greatly. They note there was less improvement in cardiovascular disease mortality observed in older patients and women, as well as a shift toward more deaths in the out-of-hospital setting and more deaths attributable to non-coronary heart disease causes.

"Heart disease mortality overall has decreased," senior investigator Dr Véronique Roger (Mayo Clinic College of Medicine, Rochester, MN) told heartwire. "The person dying from heart disease in the past was often middle-aged, a little overweight, a smoker, didn't exercise enough, and who would drop dead in the street while clutching his chest. What we have seen is that this is no longer the case, which is very fortunate. We have been able to push the occurrence of cardiovascular disease toward older ages and toward different groups. What this means for us as healthcare providers is that we now have a different challenge, which is targeting our efforts toward these other groups rather than toward those who, 20 years ago, were primarily affected."

The results of the study are published online May 9, 2006 in Circulation.

Although age-adjusted cardiovascular disease mortality has been declining for the past couple of decades, the data conflict on possible age and gender disparities in mortality, according to the report. Many previous studies excluded very old patients, the investigators note, and other studies have suggested steeper declines in in-hospital mortality compared with out-of-hospital mortality.

In this recent study, investigators led by Dr Yariv Gerber (Mayo Clinic College of Medicine, Rochester, MN) examined trends in cardiovascular disease mortality in Olmsted County, MN, between 1979 and 2003 using categories defined by the American Heart Association, including coronary heart disease, non-coronary diseases of the heart, and noncardiac circulatory disease. In addition to assessing overall cardiovascular mortality, the investigators assessed variations in mortality by location (in-hospital vs out-of-hospital), age, and gender.

Over the 25-year study period, 6378 cardiovascular deaths were recorded in Olmsted County, with a majority (57%) of these attributable to coronary heart disease. The rate of age- and sex-adjusted cardiovascular disease mortality declined substantially over this period, with an average annual decline of 2.9%, or a 50% reduction since 1979. During this time, the average age of an individual dying from cardiovascular disease increased from 76 to 80 years.

Among the other key findings:

• Cardiovascular disease death rates among men declined 3.3% annually whereas mortality among women declined 2.5% annually.
• Cardiovascular disease mortality for those younger than 75 years declined 3.9% annually compared with a 3.4% annual decline among those aged 75 to 84 years. Among those older than 85 years, the annual decline was just 1.5%.
• Coronary heart disease mortality declined 3.3% per year, whereas non-coronary heart disease deaths decreased 2.1% annually and noncardiac circulatory diseases decreased 2.4% annually.
• Cardiovascular deaths occurring out-of-hospital—in the emergency room, private homes, public places, nursing or boarding care homes—declined just 1.8% annually over the 25-year period, while in-hospital deaths occurring in acute-care or long-term facilities declined 4.8% annually.

Speaking with heartwire, Roger noted that one of the components of out-of-hospital death is the occurrence of sudden death, thus emphasizing the importance of primary prevention. Shorter hospital stays and the tendency to take care of more patients outside of the hospital walls will also require refocused efforts in secondary prevention, she noted. With less death attributable to coronary heart disease and more attributable to other diseases of the heart, Roger said people are probably dying of the sequelae of acute heart attacks rather than immediately dying.

Regarding the findings showing lesser mortality improvements in women, Roger pointed out that awareness among women to be attentive to and seek treatment for cardiac-related symptoms and among physicians to order the right tests remains an issue.

"This is a global awareness issue that permeates the entire healthcare system," said Roger. "This means there are a number of opportunities to intervene." She noted that the recent numbers do not reflect the recent AHA-initiated Go Red for Women campaign seeking to raise the profile of heart disease as the number-one cause of death among women. Future surveys will be able to measure the effect of this campaign on cardiovascular disease mortality, she said.

While the overall findings are positive, Roger said older patients with cardiac issues pose a whole host of new problems for clinicians. In many ways, cardiology, as it deals with some of these end-of-life issues, is really merging with geriatrics, she noted, with clinicians also having to deal with a multiplicity of cardiac problems and comorbid disease.

"As we take care of patients today, we're really dealing with a different group of patients than we were 25 years ago," said Roger.