The huge falls in coronary heart disease (CHD) mortality rates which started in Western countries in the 1960s have continued into the 21st century. They represent profoundly important and much studied epidemiological phenomena. The WHO's Multinational MONItoring of trends and determinants in CArdiovascular disease (MONICA) project, Atherosclerosis Risk in Communities (ARIC) community-wide surveillance and hospital discharge study and IMPACT model studies in diverse populations highlighted the crucial contributions of decreases in both CHD incidence and case fatality to overall trends. However, such favourable trends in CHD mortality have not been universal and absolute numbers of deaths have been generally increasing throughout the world because of population growth and ageing. In their Heart paper, Degano et al1 explore recent myocardial infarction trends in several European countries to provide a much-needed, detailed update to previous trend analyses for the new millennium.

The authors performed a well-conducted analysis, using rigorous and validated protocols in well-run population-based registries in six countries in the European Union. The study was conducted using high-quality MONICA methodology, an exemplar in cardiovascular disease epidemiology. Crucially, they paid particular attention to changing acute myocardial infarction (AMI) definitions, particularly in the era of highly sensitive cardiac biomarkers, and adjusted their estimates accordingly.

Degano et al examined the period 1985–2010, from the start of the MONICA project to a decade into the new century. This period reflects a rapidly changing era in cardiovascular medicine, which spans a period when new evidence-based treatments were progressively adopted. Over the study period, the authors found a consistent decline in AMI incidence and mortality rates, including both total and case fatality rates. However, they importantly …