Are the data on trends in case-fatality in patients with acute myocardial infarction observed in Scotland applicable across Europe?

Short-term fatality of patients admitted with acute coronary syndromes is the end-point followed most often in randomized pharmacological and interventional studies dealing with acute myocardial infarction or unstable angina. Usually, follow-ups in most trials are prolonged up to 1 year. The long-term prognosis beyond 1 year is virtually unknown. Meanwhile short-term (1 month) fatality in patients with acute coronary syndromes depends mainly on acute coronary care, the long-term prognosis concerns adequate secondary prevention. Few studies follow coronary deaths over a long period (1986–1995), as had been done by Capewell et al.. Kloner et al. in Los Angeles County reported on a 12-year population-based analysis of more than 220 000 cases of acute coronary events. Its main focus on monthly variations in death showed that monthly case-fatality was highest in the years 1985–1988 and lowest in 1996, while consistently keeping the U-shaped distribution, with peaks in December– January and troughs in June–September. It is well known from coronary registries that case-fatalities of patients admitted to hospital do not reflect the true burden of acute coronary syndromes: namely, half the cases die from sudden or medically unattended deaths. Therefore medical treatments in the acute phase, in respect of evidencebased guidelines, improve real mortality by only a few percent. Treatment of the acute phase of acute coronary syndromes has changed considerably since 1986. It has developed from monitoring and antiarrhythmic therapies through application of thrombolytics, aspirin and ACE inhibitors to revascularization procedures safely and routinely applied in the acute phase of events in most coronary units in Europe and elsewhere. It is not surprising that the report of Capewell et al. showed that in a series of more than 100 000 patients admitted to hospital with a first myocardial infarction in Scotland between 1986–1995 that the short-term