OBJECTIVE To assess the impact of incidence, recurrence, and case fatality rates for myocardial infarction on coronary heart disease mortality in southwestern France between 1985 and 1993.

DESIGN Toulouse-MONICA myocardial infarction register.

SETTINGS AND PATIENTS All subjects aged 35 to 64 years living in the French department of Haute-Garonne.

INTERVENTIONS All coronary artery disease events between 1985 and 1993.

MAIN OUTCOME MEASURES 7210 events collected by the register between 1985 and 1993.

RESULTS In men, adjusted attack, total, and out of hospital mortality decreased by 2% (95% confidence interval (CI), −3.8% to −0.1%), 6.2% (95% CI −8.4% to −4.0%), and 4.2% (95% CI −7.0% to −1.5%) a year, respectively (p < 0.05). Incidence and recurrence rates decreased by 2% (95% CI −4.1% to −0.1%, p < 0.05) and 1.9% (95% CI −5.9% to 2.2%) a year (NS). In women, attack, total, and out of hospital mortality decreased by 1.7% (95% CI −5.2% to 1.8%), 4.8% (95% CI −9.6% to 0.1%), and 2.6% (95% CI −9.4% to 4.1%) a year, respectively; incidence decreased by 2% (95% CI −6.5% to 2.5%) and recurrence increased by 1.4% (95% CI −9.8% to 12.6%) a year (all NS). In men, total, incident, and recurrent 28 day case fatality decreased by 3.8% (95% CI −4.8% to −2.8%), 3.2% (95% CI −4.1% to −2.3%), and 6.4% (95% CI −9.5% to −3.3%) a year, respectively (p < 0.05). For women, the corresponding decreases were 3.3% (95% CI −6.1% to −0.6%), 3.3% (95% CI −13.2% to 6.6%), and 11.7% (95% CI −24.6% to 1.3%) a year, but only the decrease in total 28 day case fatality reached significance. In both sexes, the reduction in case fatality contributed nearly 70% of the decrease in myocardial infarction mortality.

CONCLUSIONS In southwestern France, the decrease in myocardial infarction mortality mainly reflects improvements in acute management rather than prevention.