Invited Commentary: Trends in Coronary Heart Disease Mortality--Location, Location, Location

Abstract

The well-documented decline in coronary heart disease (CHD) mortality in the United States of approximately 3 percent per year over the past 30 years is one of the most remarkable developments in improving public health in the modern era. Determining the relative contribution of treatment versus primary prevention in achieving this decline is an important medical and epidemiologic issue. This endeavor is not about assigning credit but is a discovery of ways to accelerate the decline and reach those segments of the population that have not yet benefited from the reduction. In real estate, the maxim “location, location, location” is a commentary on the preeminence that setting has in determining the value of a home. Likewise, the “location” of CHD deaths in the community—in-hospital or out-ofhospital—helps elucidate the role and the potential of medical treatment versus primary prevention in reducing CHD death. Temporal trends in in-hospital deaths often are associated with medical care, whereas trends in out-ofhospital events are best associated with primary prevention. This is helpful thinking, especially when combined with information about prior history of heart disease. For example, the rate of sudden cardiac death (SCD) outside of hospitals among persons with no prior history of heart disease is a target of primary prevention and risk factor management more so than medical treatment. Conversely, preventing a fatal outcome for a hospitalized patient with CHD involves medical and/or surgical intervention in the context of disease severity, which is related to both medical treatment and primary prevention. As such, trends in these types of events are often considered an indication of the success of primary prevention and treatment innovation.