• Suggested Citation
  • PDF
    •
  • Full Text
  • Abstract
    • image
    Original Research
    Acute Myocardial Infarction Mortality in Cuba, 1999–2008
    Nurys B. Armas-Rojas MD,
    Yanela Y. Ortega MD,
    Reinaldo de la Noval-García MD,
    Ramón Suarez-Medina MD,
    Lorenzo Llerena MD,
    Alfredo F Dueñas Herrera MD
    Published: November 10, 2012 https://doi.org/10.37757/MR2012V14.N4.6

    INTRODUCTION Acute myocardial infarction is one of the leading causes of death in the world. This is also true in Cuba, where no national-level epidemiologic studies of related mortality have been published in recent years.

    OBJECTIVE Describe acute myocardial infarction mortality in Cuba from 1999 through 2008.

    METHODS A descriptive study was conducted of persons aged ≥25 years with a diagnosis of acute myocardial infarction from 1999 through 2008. Data were obtained from the Ministry of Public Health’s National Statistics Division database for variables: age; sex; site (out of hospital, in hospital or in hospital emergency room) and location (jurisdiction) of death. Proportions, age- and sex-specific rates and age-standardized overall rates per 100,000 population were calculated and compared over time, using the two five-year time frames within the study period.

    RESULTS A total of 145,808 persons who had suffered acute myocardial infarction were recorded, 75,512 of whom died, for a case-fatality rate of 51.8% (55.1% in 1999–2003 and 49.7% in 2004–2008). In the first five-year period, mortality was 98.9 per 100,000 population, falling to 81.8 per 100,000 in the second; most affected were people aged ≥75 years and men. Of Cuba’s 14 provinces and special municipality, Havana, Havana City and Camagüey provinces, and the Isle of Youth Special Municipality showed the highest mortality; Holguín, Ciego de Ávila and Granma provinces the lowest.
    Out-of-hospital deaths accounted for the greatest proportion of deaths in both five-year periods (54.8% and 59.2% in 1999–2003 and 2004–2008, respectively).

    CONCLUSIONS Although risk of death from acute myocardial infarction decreased through the study period, it remains a major health problem in Cuba. A national acute myocardial infarction case registry is needed. Also required is further research to help elucidate possible causes of Cuba’s high acute myocardial infarction mortality: cardiovascular risk studies, studies of out-of-hospital mortality and quality of care assessments for these patients.

    KEYWORDS Acute myocardial infarction, ischemic heart disease, cardiovascular diseases, chronic disease, mortality, case-fatality, epidemiology, surveillance, registries, Cuba

    Related articles

    1. Acute Myocardial Infarction Incidence, Mortality and Case Fatality in Santa Clara, Cuba, 2007–2008
    2. Dementia and Other Chronic Diseases in Older Adults in Havana and Matanzas: The 10/66 Study in Cuba
    3. Trends in Cuba’s Cancer Incidence (1990 to 2003) and Mortality (1990 to 2007)
    4. Neonatal Surgery Case Fatality and Associated Factors in a Cuban Pediatric Hospital, 2005–2015
    image

    ABSTRACT
    INTRODUCTION Acute myocardial infarction is one of the leading causes of death in the world. This is also true in Cuba, where no national-level epidemiologic studies of related mortality have been published in recent years.

    OBJECTIVE Describe acute myocardial infarction mortality in Cuba from 1999 through 2008.

    METHODS A descriptive study was conducted of persons aged ≥25 years with a diagnosis of acute myocardial infarction from 1999 through 2008. Data were obtained from the Ministry of Public Health’s National Statistics Division database for variables: age; sex; site (out of hospital, in hospital or in hospital emergency room) and location (jurisdiction) of death. Proportions, age- and sex-specific rates and age-standardized overall rates per 100,000 population were calculated and compared over time, using the two five-year time frames within the study period.

    RESULTS A total of 145,808 persons who had suffered acute myocardial infarction were recorded, 75,512 of whom died, for a case-fatality rate of 51.8% (55.1% in 1999–2003 and 49.7% in 2004–2008). In the first five-year period, mortality was 98.9 per 100,000 population, falling to 81.8 per 100,000 in the second; most affected were people aged ≥75 years and men. Of Cuba’s 14 provinces and special municipality, Havana, Havana City and Camagüey provinces, and the Isle of Youth Special Municipality showed the highest mortality; Holguín, Ciego de Ávila and Granma provinces the lowest. Out-of-hospital deaths accounted for the greatest proportion of deaths in both five-year periods (54.8% and 59.2% in 1999–2003 and 2004–2008, respectively).

    CONCLUSIONS Although risk of death from acute myocardial infarction decreased through the study period, it remains a major health problem in Cuba. A national acute myocardial infarction case registry is needed. Also required is further research to help elucidate possible causes of Cuba’s high acute myocardial infarction mortality: cardiovascular risk studies, studies of out-of-hospital mortality and quality of care assessments for these patients.

    KEYWORDS Acute myocardial infarction, ischemic heart disease, cardiovascular diseases, chronic disease, mortality, case-fatality, epidemiology, surveillance, registries, Cuba

    INTRODUCTION
    In 2006, WHO estimated 7.2 million deaths—all preventable—from ischemic heart disease (IHD), with acute myocardial infarction (AMI) the major contributor.[1] Mortality rates and trends vary by country[2–9] and even within countries,[9–11] with differences attributed to both medical determinants (health system characteristics and coverage) and non-medical (risk factor distribution, genetics, environment and socioeconomic factors).[10] Risk of death from AMI increases with age and population aging has contributed to rising numbers of deaths in several countries.[12]

    Despite efforts in developed countries, time lag between symptom onset and treatment for AMI continues to be a problem, treatment delay causing further deterioration in myocardial function and more disability and death.[6,8] AMI can be fatal or incapacitate the patient for life, both physically and psychologically. It often occurs in the prime of life and so has serious financial implications, imposing considerable burden not only on individuals and families but also on medical and social services. By 2030, years of potential life lost (YPLL) to cardiovascular diseases (CVD) are expected to increase by 20% over the year 2000 in the United States, 30% in Portugal, 64% in Brazil, 57% in China, and 95% in India.[4]

    Data for Latin America are sparse. CVDs overall were the first cause of death in Mexico until 1997, with IHD the most prevalent type.[13,14] In Costa Rica, CVDs have been the leading cause of death since 1970, accounting for 33% of all deaths, 48% of them from AMI,[15] similar to patterns in other countries of the region.[16] AMI causes some 8% of deaths in Chile, primarily striking men aged ≥45 years and women aged ≥60 years.[17] In Brazil, AMI causes one third of deaths from coronary heart disease, the leading cause of death.[18] In Venezuela, AMI mortality rates have been rising since 1959, and today AMI is the second leading cause of death after violence.[19,20]

    In Cuba, infectious diseases dominated the mortality picture in the 1960s,[21] but between 1970 and 2008 IHD has been the leading cause of death; with AMI the most common underlying cause of IHD deaths.[22] In 2010, it constituted 42.7% of IHD cases and had the highest case-fatality rate.[22] In that year, 7022 people died of AMI, 81.4% of them aged ≥60 years,[21] representing 7.7% of all deaths in Cuba.[23]

    Changes instituted in Cuban health services to address AMI included the 1997 creation of the Integrated Medical Emergency System (SIUM, the Spanish acronym),[24,25] a specialized service at the municipal and provincial level. At the primary care level, SIUM is based in the urgent care polyclinics, a subset of the community-based polyclinics equipped to handle more serious medical emergencies for geographically-defined populations. Each of these has an intensive care unit and an ambulance coordinating center. The provincial subsystem includes a coordinating center for dispatching intensive-care ambulances. A third subsystem operates through hospital emergency services.[24,25]

    SIUM has contributed to a progressive decline in mortality from coronary events: prior to the creation of SIUM, 19.6% of heart attack and angina patients spontaneously presenting at a hospital died. However, only 6.8% of patients die who first have been seen in a community health facility and subsequently transferred to hospital by emergency ambulance.[24,25] In one hospital in Havana, AMI case fatality went from 16.1% before SIUM to 13.1% after.[24] The introduction of thrombolytics in all urgent care polyclinics has also contributed to reducing complications and deaths.[25]

    Despite such improvements, AMI remains the leading specific underlying cause of death in Cuba.[22] AMI epidemiology is complex, and the lack of a national AMI registry makes research challenging, resulting in lack of population-level studies published in the past decade to shed light on Cuba’s AMI mortality.

    Understanding the geographic and demographic distribution of major diseases is important for detecting trends to alert health authorities to situations posing population health risks. Although mortality denotes AMI’s end result, rather than risk of occurrence, it is universally available and so is widely used for geographic comparisons and assessment of temporal trends. Hence this study, whose objective was to describe AMI mortality in Cuba in the decade 1999–2008.

    METHODS
    A descriptive study was conducted of all deaths in persons aged ≥25 years in Cuba from 1999 through 2008, where underlying cause was diagnosed as AMI. AMI was defined according to the 9th revision of the International Classification of Diseases for 1999–2007 and the 10th revision for 2008; there was no difference in classification of AMI between the two revisions.[26,27] Death certificate was issued by a physician in all cases.

    Study variables These included age: as a continuous variable and by group aged 25–34, 35–44, 45–54, 55–64, 65–74, 75–84 and ≥85 years; sex: male or female; place (jurisdiction) of death—all provinces in Cuba (then 14) and the Isle of Youth Special Municipality; site of death—hospital emergency room, hospital (inpatient), out of hospital (another medical facility, home, other and unknown); and time—by year and period (1999–2003 and 2004–2008).

    Data source The mortality database of the Ministry of Public Health’s National Statistics Division (DNE–MINSAP, the Spanish acronym) was used.[28]

    Data processing and analysis Data were processed with SAS 9.1.3 and EViews 2.0.[29] Absolute frequencies were tabulated, and percentages and rates calculated as summary measurements for qualitative variables. Crude and age- and sex-specific annual mortality rates per 100,000 population were calculated for comparisons, as well as five-year provincial rates. All rates were directly standardized to the 1981 Cuban census population.

    Ethical considerations Data were taken from DNE–MINSAP registries and databases without using or divulging identities of the deceased. The study was approved by the Cardiology and Cardiovascular Surgery Institute ethics committee.

    RESULTS
    During the period 1999–2008, 145,808 people aged ≥25 years suffered an AMI, 75,572 of whom died, 44,679 men (59.1%) and 30,893 women (40.9%), for a male: female ratio of 1.45. The age-standardized mortality rate was 100.3 per 100,000 population for the decade studied and the case-fatality rate was 51.8%. AMI mortality rates fell over the decade, from a high of 125.4 per 100,000 population in 1999 to 82.8 per 100,000 population in 2008, a net decline of 34% (Figure 1).

    Average age at death was 71.6 years, with a standard deviation of 13.8. AMI mortality rates increased with age. All age groups followed a pattern of highest mortality rate in the initial year of the series and a steep drop in the early years, leading to a plateau or slighter decline. In all age groups except the one aged 25–34 years, there was a slight increase in the mortality rate in the last year of the series (2008), most pronounced in the group aged ≥85 years (Figure 2).

    Figure 1: Age-adjusted acute myocardial infarction mortality rates in population aged ≥25 years, Cuba (1999–2008)

    Source: National Statistics Division, Ministry of Public Health, Havana

    Figure 2: Acute myocardial infarction mortality rates by age group, Cuba 1999–2008

    Source: National Statistics Division, Ministry of Public Health, Havana

    While overall AMI mortality risk increased with age in both sexes, lower rates were always observed in women. However, the gap between male and female mortality rates grew narrower with age, all but disappearing at the upper limit of life span (Figure 3).

    Figure 3: Acute myocardial infarction mortality rates by sex and age, Cuba, 1999–2013

    Source: National Statistics Division, Ministry of Public Health, Havana

    The AMI age-standardized mortality rate per 100,000 population fell by 17.3% between the two five-year periods considered. All jurisdictions had lower rates in the second period, except the Isle of Youth Special Municipality. In 2004–2008, the provinces of Havana, Havana City and Camagüey and Isle of Youth Special Municipality reported the highest mortality rates, while the provinces of Holguín, Ciego de Ávila and Granma had the lowest (Figure 4).

    There was a shift in distribution of site of death between the two time periods; the majority in both periods were out of hospital, increasing from 54.9% in 1999–2003 to 58.2% in 2004–2008. There was also an increase in the percentage of in-hospital deaths between the same periods (16.9% in 1999–2003, 25.4% in 2004–2008). There was a decrease in the proportion of emergency room deaths (28.3% in 1999–2003, 15.4% in 2004–2008).

    DISCUSSION
    AMI has been the leading specific cause of death in Cuba for over 40 years, responsible for 75% of deaths from CVD, which itself causes more than one in every five deaths in Cuba.[22,28] The situation is similar to that of developed and some developing countries.[30,31]

    The decline in AMI mortality rates in Cuba during the study period may have been influenced by a series of measures instituted from the primary care level up: use of SIUM advanced mobile life support units with personnel trained to manage AMI (providing clear advantages for patients transported, since the majority reach hospital stabilized and with a positive diagnosis of heart attack, saving time); the equipping of selected community-based polyclinics with advanced emergency services; opening of polyclinic intensive care units for early treatment of patients; and expanded use of systemic coronary thrombolysis in primary care, helping reduce lethal complications.[23]

    A 33% reduction in AMI mortality rates was observed in Argentina over 14 years (52 per 100,000 population vs. 35 per 100,000 population in 1990 and 2004, respectively),[32,33] possibly attributable to secondary prevention, along with optimization of resources and deployment of new therapies. However, reduced mortality rates documented by the Argentine Cardiology Society were not accompanied by declines in in-hospital mortality, which remained high and substantially unchanged.[34] Explanations posited for Argentina are also valid for Cuba, where incidence rates have not changed appreciably over the decade we studied, remaining at approximately 1.2 per 100,000 population throughout,[35] strengthening the inference that AMI mortality declines observed are due to improved treatment, with a consequent marked reduction in case fatality rates.[36]

    The fact that achievement of universal, free access to highly qualified medical care—key to Cuba’s public health approach to chronic non-communicable diseases—has reduced AMI case- fatality rates without a corresponding reduction in incidence[37] highlights an important area for increased efforts in primary prevention: incidence can only be reduced by reducing cardiovascular risk factors in the population. We must also keep in mind that reduced case fatalities also means increasing numbers of AMI survivors at high risk of suffering a second event.

    Figure 4: Acute myocardial infarction mortality rates by province*, Cuba, 1999–2008

    * Including Isle of Youth Special Municipality / Source: National Statistics Division, Ministry of Public Health, Havana

    The two principal multicenter collaborative studies, MONICA[38,39] and Atherosclerosis Risk in Communities (ARIC),[40] differ in their conclusions about the importance of changes in treatment and risk factor modification in the observed reduction in AMI mortality rates. MONICA investigators concluded that mortality reductions observed between 1985 and 1994 were fundamentally due to reduced incidence, i.e., better primary prevention,[38,39] while ARIC researchers in the United States attributed these results to improved patient survival due to better treatment.[40] The MONICA project in the United States attributed approximately 25% of reduced heart disease mortality to primary prevention, 29% to secondary prevention and 43% to improved treatment.[41] Clearly, all phases of intervention need to be considered to address the problem of AMI mortality: notwithstanding improvements in AMI treatment and serious efforts at primary prevention, AMI continues to cause millions of deaths worldwide.[3,42,43]

    In our study, as in other countries, men had higher AMI mortality rates then women, a pattern similar to that of European countries such as Greece and Finland.[8,44] In some countries—for example, Spain[45] and areas of the Americas and the Caribbean[15,31]—the male:female ratio is smaller, but male rates are still higher.[2,3] In some developed countries, the ratio is about 4:1.[1] In 2005, AMI accounted for 68.3% of all deaths from heart disease in the United States, the percentage 50% higher in men than in women[4]—values that are not substantially different from those obtained in this study.

    Despite declining mortality rates, absolute numbers of AMI deaths continue to rise because of population aging, one of the most significant demographic and social consequences of declining fertility and increased life expectancy.[12,22] We found that AMI mortality rates increased with age, independent of sex, which may be explained in part by its association with atherosclerosis and numerous age-related risk factors.[45,46] The steep increase in AMI mortality rates with age has been observed previously in Cuba[22] and Spain.[47] The average age at AMI observed here is similar to that seen elsewhere in the Americas and the Caribbean.[15,31]

    In Cuba, heart disease mortality rates in men start to increase steadily from age 35 years,[21] becoming the leading cause of death in men aged ≥45 years (only reaching that status in women two decades later), consistent with international reports.[5,7,15,47] Higher male mortality rates may reflect in part higher incidence because of risk factors that are more common in men, such as tobacco and alcohol use.[46,48]

    Out-of-hospital deaths remain a significant problem. It was observed that in both periods more than half the AMI fatalities occurred before reaching hospital, patients succumbing in places where they could not receive the care needed to survive. There was an increase in the proportion of out-of-hospital mortality in the second five-year period analyzed, exceeding reports from elsewhere in the Americas; in the United States an estimated 47% of AMI deaths occur before the patient reaches emergency services[5] and in Chile, up to 30% of patients with AMI die before receiving medical attention.[17] This could be due to insufficient awareness of AMI symptoms, leading to postponed seeking of medical attention. Research at the primary care level would help focus efforts to educate the public on AMI symptoms and what to do when they occur. Heightened public awareness could help reduce deaths that happen before seeking medical attention, but it is also necessary to understand whether there are access issues that influence this delay.

    Figure 5: Proportion of acute myocardial infarction deaths by site and fi ve-year period, Cuba, 1999–2008

    Source: National Statistics Division, Ministry of Public Health, Havana

    Although overall AMI mortality decreased, the proportion of deaths occurring in-hospital increased; this was primarily due to a halving of the emergency room case fatality rate (21.9% in 1999–2003 to 10.6% in 2004–2008), only partially offset by a slight increase in the in-hospital case fatality rate (from 16.8% in 1999–2003 to 19.7% in 2004–2008).[36] The latter increase is only to be expected with a decrease in emergency room mortality, since whether or not a patient survives depends inter alia on complications arising within the first few hours of the event, extent of infarction, and degree of myocardial dysfunction. The earlier the patient receives medical attention, the more likely such complications will appear after the patient has already been hospitalized.

    In addition, an AMI mortality increase is seen in persons aged >65 years, who have accumulated more life-threatening risk factors. Despite improvements in medical care (early reperfusion, percutaneous thrombolysis and interventions such as coronary angioplasty), treatment delays still occur throughout the country, exacerbating deterioration in myocardial function and hence, disability and death.[49,50]

    In recent years, the Cuban emergency care system has taken steps—both in hospital settings and in the rest of the system—to reduce AMI case-fatality rates and mortality. SIUM mobile acute coronary care units mentioned above have helped speed patients to health centers where they can receive immediate thrombolytic treatment, thereby reducing mortality.[24] Thrombolytic treatment for AMI improves quality of life after an acute episode.[51] Thus, use of domestically-manufactured recombinant streptokinase for AMI has led to a radical change in patient outcomes and opens up new prospects for treatment of other cardiovascular disorders. It is most effective within the first 114 minutes of the ischemic event,[24,51,52] but studies of intravenous thrombolysis in Havana City have found that fewer than 50% of AMI patients receive thrombolytic treatment,[53] revealing scope for more attention to this therapy for improving survival.

    We have encountered two constraints related to information in our study. The first is that, due to the lack of an AMI registry in Cuba, it was impossible to examine sociodemographic and clinical variables in depth. The second is that summary data on death site available from our sources did not permit disaggregation to explore all variables of interest, which would have contributed to a better understanding of this aspect. Nevertheless, the study yielded important data on the extent of AMI mortality in Cuba and the need for continued efforts to reduce its impact. We recommend that further studies be conducted to monitor trends and assess the potential role of primary health care in reducing AMI mortality, as well comparative evaluations of in-hospital protocols and their application.

    CONCLUSIONS
    Acute myocardial infarction remains a critical health problem in Cuba, although mortality rates decreased until the end of the decade analyzed, increasing slightly in 2008. Registration of all AMI cases is needed, as well as cardiovascular risk assessments to identify at-risk individuals and studies of out-of-hospital mortality and quality of medical care for AMI, to help elucidate possible causes of Cuba’s high AMI mortality. Campaigns to raise public awareness of AMI symptoms could also help further reduce AMI mortality.

    Related articles

    1. Acute Myocardial Infarction Incidence, Mortality and Case Fatality in Santa Clara, Cuba, 2007–2008
    2. Dementia and Other Chronic Diseases in Older Adults in Havana and Matanzas: The 10/66 Study in Cuba
    3. Trends in Cuba’s Cancer Incidence (1990 to 2003) and Mortality (1990 to 2007)
    4. Neonatal Surgery Case Fatality and Associated Factors in a Cuban Pediatric Hospital, 2005–2015
    References
    image
    1. Life tables for WHO Member States [Internet]. Geneva: World Health Organization; 2006 [cited 2010 Aug 16]. Available from: http://www.who.int/healthinfo/statistics/mortality_life_tables/en/
    2. Statistical Fact Sheet — Populations 2007 Update International Cardiovascular Disease Statistics [Internet]. Dallas (US): American Heart Association; 2007 [cited 2010 Aug 16]. 10 p. Available from: http://www.heartplus.co.za/downloads/heartworldfactsheet.pdf
    3. Sachs J. A Race against Time. The Challenge of Cardiovascular Disease in Developing Economies [Internet]. New York: Columbia University; 2004 [cited 2012 August 21]. 54 p. Available from: http://www.earth.columbia.edu/news/2004/images/raceagainsttime_FINAL_051104.pdf
    4. Heart and Stroke Foundation of Canada [Internet]. Ontario: Heart and Stroke Foundation of Canada; c2012. 2004 Quick Facts; 2004 [cited 2010 Aug 16]; [about 2 screens]. Available from: http://www.heartandstroke.com/site/apps/nlnet/content2.aspx?c=ikIQLcMWJtE&b=4955951&ct=4512817
    5. CDC. Health, United States, 2007 With Chartbook on Trends in the Health of the Americans. Hyattsville (US): National Center for Health Statistics; 2008 Feb. 572 p.
    6. Smolina K, Wright FL, Rayner M, Goldacre MJ. Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study. BMJ. 2012 Jan 25;344:d8059.
    7. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, DeSimone G, et al. Heart Disease and Stroke Statistics — 2010 Update: A Report from the American Heart Association. Circulation [Internet]. 2010 Feb 23 [cited 2012 Jan 25];121(7):e46–e215. Available from: http://circ.ahajournals.org/content/121/7/e46.full.pdf.html
    8. Levi F, Lucchini F, Negri E, La Vecchia C. Trends in mortality from cardiovascular and cerebrovascular diseases in Europe and other areas of the world. Heart. 2002 Aug;88(2):119–24.
    9. Cardiovascular Disease in England: Opportunities and Challenges Over the Next Ten Years [Internet]. London: British Heart Foundation; 2008 Apr [cited 2010 Aug 16]. 86 p. Available from: http://www.bhf.org.uk/cvc/pdf/CVC_10Years_2008_v2.pdf
    10. Müller-Nordhorn J, Binting S, Roll S, Willich SN. An update on regional variation in cardiovascular mortality within Europe. Eur Heart J. 2008 May;29(10):1316–26.
    11. Boix Martínez R, Aragonés Sanz N, Medrano Albero MJ. Tendencias en la mortalidad por cardiopatía isquémica en 50 provincias españolas. Centro Nacional de Epidemiología. Instituto de Salud Carlos III. Madrid, España. Rev Española Cardiol. 2003;56(9):850–6. Spanish.
    12. American Heart Association. Heart Disease and Stroke Statistics. Our guide to current statistics and the supplement to our Heart & Stroke Facts. 2010 Update At-A-Glance. Circulation [Internet]. 2009 Dec [cited 2011 Feb 2]. Available from: http://circ.ahajournals.org/cgi/reprint/CIR.0b013e3182009701
    13. Velázquez Ó, Barinagarrementería FS, Rubio AF, Verdejo J, Méndez MA, Violante R, et al. Morbilidad y mortalidad de la enfermedad isquémica del corazón y cerebrovascular en México. 2005. Arch Cardiol Méx [Internet]. 2007 Jan–Mar [cited 2010 Aug16];77(1):31–9. Available from: http://www.scielo.org.mx/scielo.php?pid=S1405-99402007000100005&script=sci_arttext. Spanish.
    14. Rosas-Peralta M, Attie F. Enfermedad cardiovascular. Primera causa de muerte en adultos de México y el mundo. Arch Cardiol Mex. 2007 Apr–Jun;77(2):91–3. Spanish.
    15. Roselló M, Guzmán S. Evolución de la mortalidad por enfermedad isquémica del corazón e infarto agudo del miocardio en Costa Rica, 1970–2001. Rev Panamericana Salud Púb. 2004;16(5):295–301. Spanish.
    16. Avezum A, Braga J, Santos I, Guimaraes HP, Marín JA, Piegas LS. Cardiovascular disease in South America: Current status and opportunities for prevention. BMJ. 2009 Feb 17;95:1475–82.
    17. Kauffmann QR. Infarto agudo del miocardio: el factor tiempo. Rev Med Chil. 2008 Sep;136(9):1095–7. Spanish.
    18. Wainstein R, Furtado MV, Polanczyk CA. Prehospital thrombolysis in AMI: a feasible alternative to Brazil. Arq Bras Cardiol. 2008 Feb;90(2):71–3. Spanish, Portuguese.
    19. Montes de Oca ZS. Alfinal.com [Internet]. Venezuela: AlFinal.com; c2012; Comportamiento del Infarto Agudo del Miocardio en el Municipio Pedro María Ureña. Venezuela 07/2005–12/2006; [cited 2011 Jun 10]. Available from: http://www.alfinal.com/Cuba/infartoagudo.shtml. Spanish.
    20. Jorna AR, Véliz PL, Cuéllar R. [Myocardial acute infarction in integral diagnosis centers of Vargas, Venezuela]. Rev Cubana Med Gen Integr [Internet]. 2010 Oct–Dec [cited 2012 Sep 12];26(4):712–20. Available from: http://scielo.sld.cu/pdf/mgi/v26n4/mgi14410.pdf. Spanish
    21. Delgado A, Fagundo F, López E, Valdés C, Salabert I. Transición epidemiológica. Rev Medica Electron [Internet]. 2003 Jan–Feb [cited 2011 Jun 10];25(1). Available from: http://www.revmatanzas.sld.cu/revista%20medica/ano%202003/vol1%202003/tema03.htm. Spanish.
    22. Anuario Estadístico de Salud 2010 [Internet]. Havana: Ministry of Public Health (CU); 2011 Apr [cited 2011 May 28]. 174 p. Available from: http://files.sld.cu/dne/files/2011/04/anuario-2010-e-sin-graficosl.pdf. Spanish.
    23. Fernández A, Gálvez AM, Castillo A. Costo institucional del infarto agudo del miocardio en el Instituto de Cardiología y Cirugía Cardiovascular. Rev Cubana Salud Pública. 2008 Oct–Dec;34(4):27–56. Spanish.
    24. García A, García ME, Quiñones A, Chávez E, Cañedo O. Impacto del sistema integral de urgencias médicas en la mortalidad por infarto miocárdico agudo. Rev Cubana Med Int Emerg. 2006;5(1):312–6. Spanish.
    25. Sosa A. Terapia intensiva. Havana: Editorial Ciencias Médicas; c2006. Volume 1, Chapter 3, Organización y dirección de la urgencia y los cuidados intensivos. Spanish.
    26. International classification of diseases. 9th rev. Geneva: World Health Organization; 1977.
    27. International statistical classification of diseases and related health problems. 10th rev. Geneva: World Health Organization; 1992.
    28. National Bureau of Medical Records and Health Statistics (CU). Estadísticas de Salud [Internet]. Havana: Ministry of Public Health (CU); c2012. Dirección Nacional de Registros Médicos y Estadísticas de Salud del Ministerio de Salud Pública (DNE-MINSAP).1970–2005; 2006 [cited 2010 May 28]. Available from: http://www.sld.cu/sitios/dne/temas.php?idv=4022. Spanish.
    29. Quantitative Micro Software, LLC. EViews 4 User’s Guide [Internet]. 2002 Mar [cited 2010 May 8. p 190–7. Available from: http://www.nek.lu.se/nekded/Teaching/Econometrics_IUsers_Guide_4_0.pdf
    30. Defunciones según la causa de muerte 2002. Madrid: Instituto Nacional de Estadística; 2005. Spanish.
    31. Lanas F, Avezum A, Bautista LE, Díaz R, Luna M, Islam S, et al. INTERHEART Latin American Study Risk Factors for Acute Myocardial Infarction in Latin America. Circulation. 2007 Mar 6;115(9):1067–74.
    32. Buzzi A. Fisiopatología Cardiovascular: Bases racionales para la terapéutica. Rev Argentina Cardiol [Internet]. 2010 Nov–Dec [cited 2011 Sep 6];78(6):521. Available from: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S1850-37482010000600014&lng=es. Spanish.
    33. Blanco P, Gagliardi J, Higa C, Dini A, Guetta J, Di Toro D. Infarto agudo de miocardio. Resultados de la Encuesta SAC 2005 en la República Argentina por los Investigadores del Área de Investigación SAC y el Consejo de Emergencias Cardiovasculares de la SAC. Rev Argent Cardiol. 2007 May–Jun;75(3):29–49. Spanish.
    34. Gagliardi J, Charask A, Higa C, Blanco P, Dini A, Tajer C, et al. Infarto agudo de miocardio en la República Argentina. Análisis comparativo de sus características y conductas terapéuticas en los últimos 18 años. Resultados de las Encuestas SAC. Rev Argent Cardiol. 2007;75(3):125. Spanish.
    35. Ortega Torres Y, Armas Rojas N, de la Noval García R, Castilla Arocha I, Suárez Medina R, Feliciano Dueñas A. Incidencia del infarto agudo de miocardio. Rev Cubana Invest Bioméd. 2011;30(3):345–53. Spanish.
    36. Armas Rojas N, Ortega Torres Y, de la Noval García R, Suárez Medina R, Llerena Rojas L, Dueñas Herrera A. Letalidad por infarto agudo de miocardio en Cuba, 1999–2008. Rev Cubana Cardiol Cir Cardiovasc. 2011;17(1):4–10. Spanish.
    37. Ordúñez P, Cooper RS, Espinosa AD, Iraola MD, Bernal JL, La Rosa Y. Enfermedades cardiovasculares en Cuba: determinantes para una epidemia y desafíos para la prevención y control. Rev Cubana Salud Pública. 2005;31(4):270–84. Spanish.
    38. Truelsen T, Mähönen M, Tolonen H, Asplund K, Bonita R, Vanuzzo D, et al. Trends in Stroke and Coronary Heart Disease in the WHO MONICA Project. Stroke. 2003 Jun;34(6):1346–52.
    39. Sans S, Puigdefábregas A, Paluzie G, Monterde D, Balaguer-Vintró I. Increasing trends of acute myocardial infarction in Spain: the MONICA-Catalonia Study. Eur Heart J. 2005 Mar;26(5):505–15.
    40. Rosamond WD, Folsom AR, Chambless LE, Wang CH; ARIC Investigators. Atherosclerosis Risk in Communities. Coronary heart disease trends in four United States communities. The Atherosclerosis Risk in Communities (ARIC) Study 1987–1996. Int J Epidemiol. 2001 Oct;30 Suppl 1:S17–22.
    41. Tunstall-Pedoe H, Vanuzzo D, Hobbs M, Mähönen M, Cepaitis Z, Kuulasmaa K, et al. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet. 2000 Feb 26;355(9205):688–700.
    42. Buiatti E, Barchielli A, Marchionni N, Balzi D, Carrabba N, Valente S, et al. Determinants of treatment strategies and survival in acute myocardial infarction: a population-based study in the Florence district, Italy: results of the acute myocardial infarction Florence registry (AMI-Florence). Eur Heart J. 2003 Jul;24(13):1195–203.
    43. Spencer FA, Montalescot G, Fox KA, Goodman SG, Granger CB, Goldberg RJ, et al. Delay to reperfusion in patients with acute myocardial infarction presenting to acute care hospitals: an international perspective. Eur Heart J. 2010 Jun;31(11):1328–36.
    44. Kesteloot H, Sans S, Kromhout D. Dynamics of cardiovascular and all-causes mortality in Western and Eastern Europe between 1970–2000. Eur Heart J. 2006 Jun;27(1):107–13.
    45. Vega G, Martínez S, Jiménez PA, Navarro A, Bernad F. Efecto de los factores de riesgo cardiovascular sobre la morbimortalidad a largo plazo después de un infarto agudo de miocardio. Rev Esp Cardiol. 2007 Jul;60(7):703–13. Spanish.
    46. Debs Pérez G, de la Noval García R, Dueñas Herrera A, Debs Pino JG. ¿Aumentan los Factores de Riesgo coronario el riesgo de muerte después de cinco años? Rev Cubana Cardiol Cir Cardiovasc. 2001;15(1):6–13. Spanish.
    47. Medrano MJ, Boix R, Cerrato E, Ramírez M. Incidencia y prevalencia de cardiopatía isquémica y enfermedad cerebrovascular en España: Revisión sistemática de la literatura. Rev Esp Salud Pública. 2006 Jan–Feb;80(1):5–15. Spanish.
    48. II Encuesta Nacional de Factores de Riesgo de Enfermedades Crónicas no Transmisibles en Cuba. Informe de Trabajo. Havana: National Hygiene, Epidemiology and Microbiology Institute (CU); 2002. Spanish.
    49. Gabán AM, Alegrant FL, Cardoso EC. Biblioteca Virtual de Salud [Internet]. Havana: National Medical Sciences Information Center (CU); c2012. Comportamiento del infarto agudo del miocardio en la Unidad de Cuidados Intensivos emergentes; 2005 [cited 2012 Feb 12]; [about 3 screens]. Available from: http://www.bvs.sld.cu/revistas/mciego/vol11_supl2_05/articulos/a8_v11_supl205.htm. Spanish.
    50. Gómez MV, Herrera ML, Ladaga HG, Cabrera I. Trombolisis en el infarto agudo del miocardio. Epidemiología de los tiempos de demora. Rev Cubana Med. 2002 Sep–Oct;41(5):91–5. Spanish.
    51. Cáceres–Lóriga FM. History of Streptokinase use in Acute Myocardial Infarction. Tex Heart Inst J [Internet]. 2008 [cited 2011 Jun 10];35(1):91. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2322881/pdf/20080300s00032p91.pdf
    52. TERIMA Group of Investigators. TERIMA-2: national extension of thrombolytic treatment with recombinant streptokinase in acute myocardial infarct in Cuba. Thromb Haemost. 2000 Dec;84(6):949–54.
    53. Castillo B, Campusano A, Hernández W, Trueba D, López M, Morejón D. Trombolisis: aplicación, posibilidad e inconvenientes. Rev Cub Med Int Emerg. 2007 [cited 2011 Jun 10];6(3):768–78. Available from: http://bvs.sld.cu/revistas/mie/vol6_3_07/mie01307.htm. Spanish.

    THE AUTHORS
    Nurys B. Armas Rojas (Corresponding author: nurysarmas@infomed.sld.cu), physician specializing in epidemiology. Associate professor and adjunct researcher, Cardiology and Cardiovascular Surgery Institute, Havana, Cuba.

    Yanela Y. Ortega Torres, cardiologist, Cardiology and Cardiovascular Surgery Institute, Havana, Cuba.

    Reinaldo de la Noval García, cardiologist, Cardiology and Cardiovascular Surgery Institute, Havana, Cuba.

    Ramón Suárez Medina, physician specializing in biostatistics, National Hygiene, Epidemiology and Microbiology Institute, Havana, Cuba.

    Lorenzo Llerena Rojas, cardiologist. Associate professor and adjunct researcher, Cardiology and Cardiovascular Surgery Institute, Havana, Cuba.

    Alfredo F. Dueñas Herrera, cardiologist. Associate professor and adjunct researcher, Cardiology and Cardiovascular Surgery Institute, Havana, Cuba.

    Related articles

    1. Acute Myocardial Infarction Incidence, Mortality and Case Fatality in Santa Clara, Cuba, 2007–2008
    2. Dementia and Other Chronic Diseases in Older Adults in Havana and Matanzas: The 10/66 Study in Cuba
    3. Trends in Cuba’s Cancer Incidence (1990 to 2003) and Mortality (1990 to 2007)
    4. Neonatal Surgery Case Fatality and Associated Factors in a Cuban Pediatric Hospital, 2005–2015
    image
    Submitted: February 21, 2012
    Approved: August 18, 2012
    Disclosures: None

    Armas NB, et al. Acute Myocardial Infarction Mortality in Cuba, 1999–2008. MEDICC Rev. 2012;14(4):19–25.

    Related articles

    1. Acute Myocardial Infarction Incidence, Mortality and Case Fatality in Santa Clara, Cuba, 2007–2008
    2. Dementia and Other Chronic Diseases in Older Adults in Havana and Matanzas: The 10/66 Study in Cuba
    3. Trends in Cuba’s Cancer Incidence (1990 to 2003) and Mortality (1990 to 2007)
    4. Neonatal Surgery Case Fatality and Associated Factors in a Cuban Pediatric Hospital, 2005–2015
    image
    Loading...
    Loading...
    From the Editors ►