events that may include sudden death. Morbidity from CHD, measured by population-based surveys and hospital records, includes clinical syndromes of myocardial infarction with damage to and scarring of the myocardium; coronary insufficiency, including angina pectoris and other symptoms of inadequate blood supply; complex arrhythmias, which may lead to sudden coronary death; and chronic heart disease characterized by heart failure or arrhythmias. Mortality from CHD is defined as the number or proportion of death certificates that are coded as International Classification of Disease (ICD) categories 410-411 (myocardial infarction) or 412-414 (angina pectoris and other chronic heart disease manifestations).
Figure 5-1 depicts wide differences among countries in the vital statistics on CHD death among 35- to 74-year-old men in the 1970s. The highest reported CHD death rates occurred in Finland and the English-speaking countries, including the United States; the lowest rates were in Japan (Inter-Society Commission for Heart Disease Resources, 1984).
CHD death rates for women in the same year (not shown) were highest in Northern Ireland, Scotland, and the United States and lowest in Japan (Inter-Society Commission for Heart Disease Resources, 1984). These large geographic differences in CHD death rates were confirmed by studies comparing geographic differences in CHD incidence rates, such as the Seven Countries Study, in which the 10-year incidence rate among men 40 to 59 years old at the beginning of the study was about 200 per thousand in Finland as compared to about 40 per thousand in Japan and the Greek Islands (Keys, 1980).
Geographic differences in trends of reported deaths from CHD have been equally dramatic (see Figure 5-2). The largest decline among men from 35 to 74 years old occurred in the United States, followed closely by Australia and Canada, whereas rates rose strongly in Northern Ireland, Poland, and Bulgaria. Similar changes in death rates were also reported for women (not shown)the largest