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Epidemiology
Original article
Aging of the population may not lead to an increase in the numbers of acute coronary events: a community surveillance study and modelled forecast of the future
  1. Veikko Salomaa1,
  2. Aki S Havulinna1,
  3. Heli Koukkunen2,
  4. Päivi Kärjä-Koskenkari3,
  5. Arto Pietilä1,
  6. Juha Mustonen4,
  7. Matti Ketonen4,
  8. Aapo Lehtonen5,
  9. Pirjo Immonen-Räihä6,
  10. Seppo Lehto2,
  11. Juhani Airaksinen6,
  12. Y Antero Kesäniemi7
  1. 1Department of Chronic Disease Prevention, THL-National Institute for Health and Welfare, Helsinki, Finland
  2. 2Kuopio University Hospital, Kuopio, Finland
  3. 3Oulu University Hospital, Oulu, Finland
  4. 4Central Hospital of North Karelia, Joensuu, Finland
  5. 5Turku City Hospital, Turku, Finland
  6. 6Heart Center, Turku University Hospital, Turku, Finland
  7. 7Clinical Research Center and Department of Medicine, Oulu University Hospital and Institute of Clinical Medicine, University of Oulu, Oulu, Finland
  1. Correspondence to Dr Veikko Salomaa, Department of Chronic Disease Prevention, THL-National Institute for Health and Welfare, PO Box 30, Helsinki FI-00271, Finland; veikko.salomaa{at}thl.fi

Abstract

Objective To examine the incidence, mortality and case fatality of acute coronary syndrome (ACS) in Finland during 1993–2007 and to create forecasts of the absolute numbers of ACS cases in the future, taking into account the aging of the population.

Design Community surveillance study and modelled forecasts of the future.

Setting and methods Two sets of population-based coronary event register data from Finland (FINAMI and the National Cardiovascular Disease Register (CVDR)). Bayesian age–period–cohort (APC) modelling.

Participants 24 905 observed ACS events in the FINAMI register and 364 137 in CVDR.

Main outcome measures Observed trends of ACS events during 1993–2007, forecasted numbers of ACS cases, and the prevalence of ACS survivors until the year 2050.

Results In the FINAMI register, the average annual declines in age-standardised incidence of ACS were 1.6% (p<0.001) in men and 1.8% (p<0.001) in women. For 28-day case fatality of incident ACS, the average annual declines were 4.1% (p<0.001) in men and 6.7% (p<0.001) in women. Findings in the country-wide CVDR data were consistent with the FINAMI register. The APC model, based on the CVDR data, suggested that both the absolute numbers of ACS events and the prevalence of ACS survivors reached their peak in Finland around 1990, have declined since then, and very likely will continue to decline until 2050.

Conclusions The ACS event rates and absolute numbers of cases have declined steeply in Finland. The declining trends are likely to continue in the future despite the aging of the population.

  • CORONARY ARTERY DISEASE

https://doi.org/10.1136/heartjnl-2012-303216

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    Introduction

    Coronary heart disease (CHD) remains the leading cause of mortality and morbidity. In Europe, CHD is responsible for over one in five deaths and many of these deaths are premature.1 Recent statistics from the USA indicated that in 2008 one in every six deaths was caused by CHD.2 Available surveillance data show that the mortality, attack rate and in-hospital case fatality of acute coronary syndrome (ACS) are all declining in Western countries, but the clinical spectrum of the disease has changed considerably.3–7 ST-segment elevation myocardial infarctions (STEMIs) are declining, while the proportion of non-STEMI (NSTEMI) is increasing and NSTEMIs have become the majority of ACS events.3 ,4 ,6 At the same time, the short-term case fatality has declined.

    Besides the changing case mix, another important change is ongoing in population demographics. The post-war baby-boom generation has reached the age where clinically symptomatic CHD is not uncommon. Concerns have been raised that the aging of the population may increase the numbers of ACS events considerably, leading to increased costs.8 Opinions are conflicting, however. It has even been suggested that acute myocardial infarction may be disappearing.9 To better understand the recent developments and to shed more light on future expectations, we have analysed the trends in ACS events using two sets of observed data, complemented with modelled probabilistic projections of the future. First, we analysed the trends in incidence, mortality and 28-day case fatality of ACS, including sudden prehospital coronary deaths, using data from the FINAMI register10 ,11 for the period 1993–2007. Second, we examined whether the observed changes have taken place in the whole CHD category and in the whole country. To this end we carried out a similar trend analysis for all CHD hospitalisations and deaths using data from the National Cardiovascular Disease Register (CVDR).12 ,13 Third, to fully cover the changes in the clinical spectrum of cardiac diseases, we considered separately such acute cardiac events where the primary diagnosis was cardiac disease other than CHD. Fourth, we forecasted the future numbers of all ACS events and the prevalence of ACS survivors until the year 2050, taking the recent trends and the changing population demographics into account.

    Methods

    FINAMI register

    FINAMI has been described previously10 ,11 and is now described in more detail in the online supplementary material. In brief, it is a population-based ACS register, which has operated in four geographical areas since 1993, since the end of the WHO MONICA Project. At the moment, data are available for a 15-year period, 1993–2007. The register aims to evaluate all events suspected of being myocardial infarction or CHD deaths among the permanent residents of the monitored areas.

    National Cardiovascular Disease Register

    The CVDR has been compiled using data from country-wide administrative registers. Cardiovascular parts of the nationwide Causes-of-Death Register and the nationwide Hospital Discharge Register have been linked together on the basis of the personal ID code. The resulting database includes individual-level data on all cardiovascular events that have led to hospitalisation or death in Finland. The register has been described previously12 ,13 and is now described in more detail in the online supplementary material.

    Statistical methods

    Event rates were expressed per 100 000 persons per year and age-standardised by the direct method, using 5-year age groups and the European standard population.14 Population counts for the denominators of the event rates were obtained from the National Population Information System,15 which is updated continuously. The case fatality proportions were age-standardised using weights derived from the combined age distribution of patients with myocardial infarction or stroke in the WHO MONICA Project.16 The trends in event rates were determined using log-linear Poisson regression models, with the year, age, age squared and study area as independent variables. For case fatality trends, similar models were run using logistic regression. Trends for the crude event numbers were determined using negative binomial regression models, deliberately without age adjustment. The 95% confidence intervals of the trend estimates were calculated from the SE of the regression coefficient.

    Finally, we estimated age- and gender-specific population forecasts until the year 2050 on the basis of mortality, birth rate and immigration. The estimation method is described in more detail in the online supplementary material. We then constructed a Bayesian age–period–cohort (APC) model to forecast the numbers of ACS events and the prevalence of ACS survivors from the year 1960 to 2050. Our APC model used autoregressive priors to reduce the uncertainty due to small numbers in the detailed age/period groups. Age, period and birth cohort effects were estimated from the observed CVDR data and then applied to the population forecasts. All models were run separately for men and women. The full Bayesian models were fitted using Markov chain Monte Carlo simulation with programmes written in the C++ programming language. These C++ programmes are available in the online supplementary material.

    Incidence, case fatality and attack rate of ACS were estimated using Bayesian APC models. The prevalence of ACS survivors was then modelled using a modification of the cohort component model, as follows. First, the prevalence was assumed to be 0.0 in 1878. Then, year after year, the prevalence was estimated by first advancing the current prevalent survivors to the next year and aging them by 1 year, and then decreasing their number according to the age-specific death rate in the general population. Finally, the new incident cases were added after the 1st year fatal cases had been subtracted from the estimated number of incident cases.

    The R statistical software package, V.2.15, was used to summarise the results and for presentation. Posterior means (or medians in the case of a skewed posterior density) together with 50% and 95% credible intervals were used to make summaries.

    Results

    Altogether 24 905 ACS events were observed in the FINAMI register during the 15-year period 1993–2007, and 364 137 in CVDR during the period 1991–2009. Their distribution by sex, together with the corresponding numbers of incident (=first ever) events and fatal events, are presented in table 1.

    View this table:
    Table 1

    Numbers of acute coronary syndrome events in the FINAMI and National Cardiovascular Disease Register among persons aged ≥35 years in Finland during the period 1993–2007

    The age-standardised mortality from ACS declined on average by 4.5% (p<0.001) per year among men and 4.7% (p<0.001) per year among women (figure 1A). This was clearly steeper than the decline in incidence, which declined by 1.6% per year (p<0.001) among men and by 1.8% (p<0.001) per year among women (figure 1B).

    Figure 1
    Figure 1

    Trends in age-standardised mortality (A) and incidence (B) of acute coronary syndrome in men (black lines) and women (red lines) aged >35 years in the FINAMI areas. The trend is expressed as the average relative change (%) in event rates per year during the study period 1993–2007. Dotted lines denote the 95% confidence intervals.

    The total 28-day case fatality of incident ACS declined by 4.1% (p<0.001) per year among men and by 6.7% (p<0.001) per year among women (figure 2A). When broken down to prehospital and in-hospital case fatality, the prehospital case fatality declined less, by 2.6% (p<0.001) per year among men and 3.9% (p<0.001) per year among women (figure 2B), whereas the decline in the in-hospital case fatality was steep, 5.7% (p<0.001) per year in men and 7.6% (p<0.001) per year in women (figure 2C).

    Figure 2
    Figure 2

    Trends in age-standardised 28-day case fatality (A), prehospital case fatality (B) and in-hospital case fatality (C) of acute coronary syndrome in men (black lines) and women (red lines) aged >35 years in the FINAMI areas. The trend is expressed as the average relative change (%) in case fatality during the study period 1993–2007. Dotted lines denote the 95% confidence intervals.

    We then used the CVDR to analyse all first hospitalisations and deaths in the country with a CHD code as the primary diagnosis (see online supplementary table S1). The age-standardised rates showed a decline in men, 3.7% (p<0.001) per year, and in women, 4.3% (p<0.001) per year. The absolute numbers also showed declining trends: 0.4% (p=0.018) per year in men and 1.6% (p<0.001) per year in women.

    The analysis of ‘other’ incident cardiac events—that is, hospitalisations or deaths where CHD was not listed as the primary diagnosis—showed declining trends in the age-standardised rates: 2.4% (p<0.001) per year in men and 2.6% (p<0.001) per year in women (table 2). However, the absolute numbers of these events increased significantly among men, +1.1% (p=0.020) per year, and did not change among women, +0.3% (p=0.54) per year.

    View this table:
    Table 2

    Age-standardised rates* (per100 000 inhabitants) and absolute numbers of first hospitalisations and deaths where the primary diagnosis for hospitalisation or the underlying cause of death was cardiac disease† other than coronary heart disease

    The proportion of the population aged >65 years was projected to increase by 54% in men and by 46% in women by the year 2030 and by 74% and 56%, respectively, by the year 2050 (see online supplementary table S2). The modelled forecasts of ACS events in the future suggested that steep declines in the age-standardised event rates will continue in both men and women (figure 3A,B, supplementary figures S1 and S2). Interestingly, the absolute numbers of ACS events seemed to reach their peak around 1990 among men and between 1990 and 2000 among women and have declined since then. The observed data (green lines) for the period 1991–2009 were in good agreement with the results predicted by the model. The model suggested that the decline will continue with a high probability, despite the aging of the population. The estimated numbers of ACS events and their percentage changes from the year 1991 to 2050 are shown in supplementary table S3. Among men, the mean age at the time of the attack will increase from 73.4 years in 2010 to 77.8 (95% credible interval 76.3 to 79.1) years in 2040 (see online supplementary figure S1). Among women, no change in the mean age at the time of the attack is likely to take place (see online supplementary figure S2).

    Figure 3
    Figure 3

    Modelled age-adjusted attack rates and absolute numbers of acute coronary syndrome from 1960 to 2050 based on the Bayesian age–period–cohort model. (A) men; (B) women. Vertical broken lines indicate the period of observed data, and the green line describes the observed rates and numbers. The black line is the modelled trend estimate, and the dotted lines around it indicate 50% and 95% credible intervals.

    The prevalence of ACS survivors reached a peak around 1980–1990, a bit later among women than among men (figure 4). Since then, the prevalence has declined steeply. In 2010 the estimated prevalence of ACS survivors in the population aged >35 years was 5.1% (95% credible interval 4.9% to 5.3%) among men and 2.6% (95% credible interval 2.5% to 2.7%) among women. According to our model, the decline will continue until 2050 among men, but among women, although there is also a declining trend, the long-term development looks more uncertain.

    Figure 4
    Figure 4

    Modelled prevalence of acute coronary syndrome survivors until 2050 in Finland among men (blue line) and women (red line) aged >35 years. To demonstrate the effect of the aging of the population, the prevalence is not age-standardised. The thin dotted lines indicate the 50% and 95% credible intervals.

    Discussion

    Our data show steep declines in CHD mortality, which seem to be mainly due to the decline in case fatality, although the incidence also declined. The main contributor to the case fatality decline was in-hospital case fatality, but prehospital case fatality also declined significantly. The analyses of country-wide CVDR data confirmed that the decline was real and there was no shift to other CHD diagnoses from the usual acute coronary event diagnoses. Furthermore, a decline in the absolute numbers of all hospitalisations and deaths due to CHD was observed during the period 1991–2009. However, the numbers of hospitalisations and deaths due to cardiac diseases other than CHD had not declined. The main diagnoses in this category were heart failure and arrhythmias.

    Our APC modelling showed that the absolute numbers of ACS events reached their peak in Finland around 1990–2000, have declined since then, and, with a high probability, will decline even more in the future. Our modelling results are in good agreement with known historical development from the 1960s to the present day, and, for the period 1991–2009, the modelled rates almost perfectly fit our observed data. The prevalence of ACS survivors peaked around 1980–1990, has declined steeply since then, and will very probably continue to decline, at least among men, in the future. Thus, the aging of the population may not inevitably increase the numbers of acute coronary patients.

    Comparison with other studies

    Few community surveillance studies have been reported from Europe since the end of the WHO MONICA Project and the study protocols have been variable, but declining trends, generally consistent with ours, have been reported, for example, from France,17 Italy18 and Germany.19 In Spain, increasing event rates but decreasing case fatality trends have been reported.20 ,21 In Eastern Europe, the development has been more variable, but there also the trends have recently turned downwards in many countries.22 In the USA, a large study based on Medicare data reported a decline in the hospitalisations of myocardial infarction events by 5.8%/year during the period 2002–2007.5 Another study based on Kaiser Permanente insurance data reported a decline, especially in the incidence of STEMIs during 1999–2008.3 Thirty-day case fatality also declined significantly. These studies did not, however, include out-of-hospital coronary deaths. The Framingham Study reported steady overall rates of myocardial infarction events until 1999, which was partly explained by the increasing sensitivity of biomarkers used for diagnosing myocardial injury.23 A more recent report from the surveillance arm of the ARIC Study showed accelerating declines. The average declines in CHD death rates were 4.7% per year in men and 4.3% per year in women, which are very similar to our figures.7 Declines in our incidence rates may look more modest than those of the ARIC Study, but that may be due to the fact that we did not correct for the adoption of troponins in the present analyses.

    Even though the aging of the population is widely considered a problem, very few studies have tried to project the cardiovascular event rates to the future.24 A recent Policy Statement of the American Heart Association mainly focused on costs, but it did suggest a substantial increase in the prevalence of cardiovascular diseases, including CHD, by the year 2030.8 Its modelling was, however, clearly simpler than ours and mainly based on the changes in population demographics. Odden and coworkers used the CHD Policy Model and predicted an increase in incidence by 26%, prevalence by 47%, and mortality by 56% from the year 2010 to 2040.25 According to their simulations, much of this increase can be attenuated if the risk factor trends continue to be favourable. Their modelling strategy was different from ours and fails to take into account the birth-cohort effect, which in our model was the strongest contributor to the favourable development. Another important reason for the differences between these projections and ours are the differences in the projections of the background population. The US population is projected to grow substantially, which of course increases the absolute numbers of ACS events. The Finnish population is growing only modestly, and merely aging does not seem to increase the numbers of ACS events. An earlier Bayesian APC model from Finland has predicted CHD mortality until 2030 in three geographical areas.26 Assuming that the current trends continue, the analysis predicts strong declines in CHD mortality among middle-aged people, no change in the age group 60–79 years, and an increase in the age group 80–99 years. This study did not consider non-fatal ACS events and did not take migration into account when modelling the background population counts.

    Strengths and limitations

    The strengths of our study include two large population-based ACS registers, which provided observed data on all ACS events, including out-of-hospital deaths. These registers are based on complementary approaches: CVDR covers all cardiac hospitalisations and deaths in the country while FINAMI produces more standardised data from limited geographical areas. The observed data, together with the long time span of accurate population statistics, provided a good basis for sophisticated statistical modelling, which produced novel information on the effects of the aging population on the numbers of patients with ACS in the future.

    Any forecasts 40 years ahead of time include numerous uncertainties and should be viewed with caution. An important limitation of our study is that we were not able to include obesity and diabetes in our models. Obesity and diabetes are very serious public health threats, and concerns have been raised that they may thwart the favourable progress in CHD mortality and morbidity.26–28 Obesity has been increasing in most Western countries for the past 20 years, but it may not be reasonable to assume that a similar development will continue for the next 40 years. In fact, some recent studies have indicated that the obesity epidemic may be levelling off.29 Another limitation of our study is the short period of observed data, 15 years. A longer period would have provided more accurate estimates of period and cohort effects, which might have improved the accuracy of the forecasts.

    Other limitations include the fact that these predictions are based on Finnish data, and their generalisability to other countries should be considered with caution. The aging of the population of Finland is faster than in many other countries30 but, by and large, the phenomena described in the present paper are occurring in most Western countries and we have no reasons to assume that the development would be substantially different. Furthermore, we did not correct for the effects of troponins in the present analyses. We believe that this has kept our analysis conservative and the real decline would have been steeper if we had adjusted for more sensitive biomarkers. The bump in the attack rate curves around the change in the millennium is probably caused by the adoption of troponins, which caused an upward shift in the numbers of myocardial infarctions but in the long run did not alter the declining slope. Finally, it should be noted that we had no opportunity to make predictions on cardiac disease ‘other’ than CHD, but our observed data suggest that the absolute numbers of hospitalisations and deaths in this category may not have declined. In fact, an increase was observed in men. The main diagnoses in this group are heart failure and arrhythmias, which deserve more attention in the future.

    Conclusions

    In conclusion, we observed significant declines in the incidence, mortality and case fatality of ACS during the period 1993–2007. According to our model, the numbers of ACS events reached their peak around 1990 and have declined since then. Likewise, the prevalence of ACS survivors reached its peak around 1980–1990 and has declined since then. It is highly probable that the numbers of both incident and prevalent cases will continue to decline in the future, despite the aging of the population. In the future, cardiologists will very likely see fewer patients with acute manifestations of CHD, but they may see more patients with heart failure and arrhythmias. This may have obvious implications for healthcare planning in the future.

    What is already known on this subject

    • Age-standardised rates of acute coronary syndrome (ACS) events are declining in most industrialised populations.

    • Many industrialised populations are aging rapidly and the occurrence of ACS events increases with increasing age.

    • Concerns have been raised that the aging of the population may increase the numbers of ACS events considerably leading to increased burden to the healthcare system.

    What this study adds

    • The age-standardised event rates and case fatality of ACS continue to decline steeply in Finland.

    • The absolute numbers of ACS events have also declined and, with high probability, will continue to decline in the future, despite the aging of the population.

    • It seems that the peak numbers of ACS events and the peak prevalence of ACS survivors occurred around 1990, and the trends have been declining since then.

    References

    1. ↵
      European Heart Network. European Cardiovascular Disease Statistics 2008. http://www.ehnheart.org/cvd-statistics.html (accessed 2 Jan 2012).
    2. ↵
      1. Roger VL,
      2. Go AS,
      3. Lloyd-Jones DM,
      4. et al
      . Heart disease and stroke statistics–2012 update: a report from the American Heart Association. Circulation 2012;125:e2–e220.
      OpenUrlFREE Full Text
    3. ↵
      1. Yeh RW,
      2. Sidney S,
      3. Chandra M,
      4. et al
      . Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med 2010;362:2155–65.
      OpenUrlCrossRefPubMedWeb of Science
    4. ↵
      1. Roger VL,
      2. Weston SA,
      3. Gerber Y,
      4. et al
      . Trends in incidence, severity, and outcome of hospitalized myocardial infarction. Circulation 2010;121:863–9.
      OpenUrlAbstract/FREE Full Text
    5. ↵
      1. Chen J,
      2. Normand SL,
      3. Wang Y,
      4. et al
      . Recent declines in hospitalizations for acute myocardial infarction for Medicare fee-for-service beneficiaries: progress and continuing challenges. Circulation 2010;121:1322–8.
      OpenUrlAbstract/FREE Full Text
    6. ↵
      1. McManus DD,
      2. Gore J,
      3. Yarzebski J,
      4. et al
      . Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. Am J Med 2011;124:40–7.
      OpenUrlCrossRefPubMed
    7. ↵
      1. Rosamond WD,
      2. Chambless LE,
      3. Heiss G,
      4. et al
      . Twenty-two year trends in incidence of myocardial infarction, CHD mortality, and case-fatality in four US communities, 1987 to 2008. Circulation 2012, 125:1848–57.
      OpenUrlAbstract/FREE Full Text
    8. ↵
      1. Heidenreich PA,
      2. Trogdon JG,
      3. Khavjou OA,
      4. et al
      . Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 2011;123:933–44.
      OpenUrlAbstract/FREE Full Text
    9. ↵
      1. Luepker RV,
      2. Berger AK
      . Is acute myocardial infarction disappearing? Circulation 2010;121:1280–2.
      OpenUrlFREE Full Text
    10. ↵
      1. Salomaa V,
      2. Ketonen M,
      3. Koukkunen H,
      4. et al
      . The effect of correcting for troponins on trends in coronary heart disease events in Finland during 1993–2002: the FINAMI study. Eur Heart J 2006;27:2394–9.
      OpenUrlAbstract/FREE Full Text
    11. ↵
      1. Salomaa V,
      2. Koukkunen H,
      3. Ketonen M,
      4. et al
      . A new definition for myocardial infarction: what difference does it make? Eur Heart J 2005;26:1719–25.
      OpenUrlAbstract/FREE Full Text
    12. ↵
      1. Salomaa V,
      2. Pääkkönen R,
      3. Hämäläinen H,
      4. et al
      . Use of secondary preventive medications after the first attack of acute coronary syndrome. Eur J Cardiovasc Prev Rehabil 2007;14:386–91.
      OpenUrlCrossRefPubMedWeb of Science
    13. ↵
      1. Pajunen P,
      2. Pääkkönen R,
      3. Juolevi A,
      4. et al
      . Trends in fatal and non-fatal coronary heart disease events in Finland during 1991–2001. Scand Cardiovasc J 2004;38:340–4.
      OpenUrlCrossRefPubMedWeb of Science
    14. ↵
      1. Waterhouse J,
      2. Muir C,
      3. Correa P
      , eds. Cancer incidence in five continents. Vol. III. Lyon, France: International Agency for Research on Cancer, 1976;456.
    15. ↵
      Population Register Centre. Population Information System. http://www.vrk.fi/default.aspx?id=39 (2 Jan 2012).
    16. ↵
      1. Tunstall-Pedoe H,
      2. Kuulasmaa K,
      3. Mähönen M,
      4. et al
      . Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease. Lancet 1999;353:1547–57.
      OpenUrlCrossRefPubMedWeb of Science
    17. ↵
      1. Lang T,
      2. Ducimetière P,
      3. Arveiler D,
      4. et al
      . Trends and geographical disparities in coronary heart disease in France: are results concordant when different definitions of events are used? Int J Epidemiol 1999;28:1050–8.
      OpenUrlAbstract/FREE Full Text
    18. ↵
      1. Ferrario M,
      2. Cesana G,
      3. Vanuzzo D,
      4. et al
      . Surveillance of ischaemic heart disease: results from the Italian MONICA populations. Int J Epidemiol 2001;30(Suppl 1):S23–29.
      OpenUrlFREE Full Text
    19. ↵
      1. Löwel H,
      2. Meisinger C,
      3. Heier M,
      4. et al
      . The population-based acute myocardial infarction (AMI) registry of the MONICA/KORA study region of Augsburg. Gesundheitswesen 2005;67(Suppl 1):S31–7.
      OpenUrlCrossRefPubMedWeb of Science
    20. ↵
      1. Gil M,
      2. Marrugat J,
      3. Sala J,
      4. et al
      . Relationship of therapeutic improvements and 28-day case fatality in patients hospitalized with acute myocardial infarction between 1978 and 1993 in the REGICOR study, Gerona, Spain. The REGICOR investigators. Circulation 1999;99:1767–73.
      OpenUrlAbstract/FREE Full Text
    21. ↵
      1. Sans S,
      2. Puigdefábregas A,
      3. Paluzie G,
      4. et al
      . Increasing trends of acute myocardial infarction in Spain: the MONICA-Catalonia study. Eur Hear J 2005;26:505–15.
      OpenUrlAbstract/FREE Full Text
    22. ↵
      1. Laks T,
      2. Jõeste E,
      3. Pullisaar O,
      4. et al
      . Trends in incidence, attack rate, and mortality of acute myocardial infartion in Estonia: The Tallinn AMI registry 1991–2005. Ann Med 2013;45:107–11.
      OpenUrlCrossRefPubMed
    23. ↵
      1. Parikh NI,
      2. Gona P,
      3. Larson MG,
      4. et al
      . Long-term trends in myocardial infarction incidence and case fatality in the national heart, lung, and blood institute's Framingham heart study. Circulation 2009;119:1203–10.
      OpenUrlAbstract/FREE Full Text
    24. ↵
      1. Capewell S,
      2. Allender S,
      3. Critchley J,
      4. et al
      . Modelling the burden of cardiovascular disease to 2020. A research report for the Cardio & Vascular Coalition and the British Heart Foundation. London: British Heart Foundation, 2008.
    25. ↵
      1. Odden MC,
      2. Coxson PG,
      3. Moran A,
      4. et al
      . The impact of the aging population on coronary heart disease in the United States. Am J Med 2011;124:827–33.
      OpenUrlCrossRefPubMed
    26. ↵
      1. Huovinen E,
      2. Härkänen T,
      3. Martelin T,
      4. et al
      . Predicting coronary heart disease mortality -assessing uncertainties in population forecasts and death probabilities by using Bayesian inference. Int J Epidemiol 2006;35:1246–52.
      OpenUrlAbstract/FREE Full Text
    27. ↵
      1. Bibbins-Domingo K,
      2. Coxson PG,
      3. Pletcher MJ,
      4. et al
      . Adolescent overweight and future coronary heart disease. N Engl J Med 2007;357:2371–9.
      OpenUrlCrossRefPubMedWeb of Science
    28. ↵
      1. Wang YC,
      2. McPherson K,
      3. Marsh T,
      4. et al
      . Health and economic burden of the projected obesity trends in the USA and UK. Lancet 2011;378:815–25.
      OpenUrlCrossRefPubMedWeb of Science
    29. ↵
      1. Flegal KM,
      2. Carroll MD,
      3. Kit BK,
      4. et al
      . Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA 2012;307:491–7.
      OpenUrlCrossRefPubMedWeb of Science
    30. ↵
      OECD. Population statistics for OECD member countries. http://stats.oecd.org/index.aspx?queryid=254 (accessed 5 Jun 2012).

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

      Files in this Data Supplement:

    Footnotes

    • Contributors All authors developed the study design, interpreted the data and critically reviewed drafts of the manuscript. ASH performed the statistical analyses. VS drafted the manuscript and is the guarantor.

    • Funding The FINAMI register was supported by the Finnish Foundation for Cardiovascular Research.

    • Competing interests JA has received consultancy fees from Boehringer Ingelheim and Boston Scientific, and lecture fees from St Jude Medical and MSD; YAK owns some stocks in Orion Pharma, is a member of the Lipid Board of Merck, and reports having received a grant and lecture fees from Merck; VS has received a speaker honorarium from Roche Diagnostics. All these financial activities are outside the present paper. No other potential competing interests exist.

    • Ethics approval The ethics committee of the National Institute for Health and Welfare (formerly National Institute for Public Health) has approved the FINAMI project (decision dated 21 January 2004). The ethics committee of Helsinki and Uusimaa Hospital District, epidemiology and public health section, has approved the CVDR project (decision number 563/E3/2002). Informed consent was not required because of the register-based nature of the study. The study complies with the Declaration of Helsinki.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Summary estimates of the National Cardiovascular Disease Register are available at http://www.thl.fi/cvdr/. The C++ code used in the analyses is available at http://urn.fi/URN:NBN:fi-fe201304112732.