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 M. Gil, MD; J. Marrugat, MD; J. Sala, MD; R. Masia ´, MD; R. Elosua, MD; X. Albert, MD; A. Pena, MD; J. Vila, PhD; M. Pavesi, PhD; G. Pe ´rez, MD; for the REGICOR Investigators Background—The aim of this study was to analyze 28-day case fatality trends between 1978 and 1993 among hospitalized acute myocardial infarction (AMI) patients in the REGICOR registry, Gerona, Spain, and relate them to thrombolytic and antiplatelet drug use and changes in patient characteristics. Methods and Results—A total of 2053 consecutive patients 25 to 74 years of age with a first Q-wave AMI admitted to the reference hospital between 1978 and 1993 were registered. Clinical characteristics and patient management were recorded. Four 4-year periods were considered: 1978 to 1981, 1982 to 1985 (prethrombolytic therapy), 1986 to 1989 (thrombolytic and antiplatelet drugs introduced), and 1990 to 1993 (thrombolytic and antiplatelet drugs used routinely). The end point was death at 28 days. Case fatality at 28 days decreased 6% per year between 1978 and 1993. A logistic model adjusted for comorbidity and severity showed the last 3 periods to present a steep decrease in the OR of death at 28 days: 0.86 (95% CI, 0.52 to 1.41), 0.59 (95% CI, 0.35 to 0.99), and 0.40 (95% CI, 0.24 to 0.69), respectively, compared with the first period. After 1986, 85.7% of the 112 lives saved could be attributed to the use of antiplatelet and thrombolytic drugs. Adjusted relative risk reduction was 56.0% for antiplatelet drugs, 34.1% for thrombolytic drugs, and 77.9% for the 2 combined. Conclusions—Our results strongly suggest that new therapies introduced since 1986 have contributed to the decrease in 28-day case fatality of patients admitted with a first Q-wave AMI. This decrease could be attributable mainly to the use of antiplatelet and thrombolytic drugs. These findings should encourage the routine use of thrombolytic and antiplatelet drugs and particularly their combination in the acute phase of AMI. (Circulation. 1999;99:1767-1773.) Key Words: myocardial infarction  mortality  platelet aggregation inhibitors  thrombolysis C oronary heart disease (CHD) mortality has been declining since 1970 in most developed countries, 1 accounting for 10.7% of deaths in Spain in 1993. 2 This decline has been more evident in countries in which mortality was initially higher. 1 Primary prevention interventions, particularly reduction in mean population cholesterol levels, cigarette smoking, and arterial blood pressure levels, have been judged to be principally responsible for this decline before the mid-1980s. 3,4 Since then, improved medical care appears to have contributed greatly to the decrease in CHD mortality. 5,6 Furthermore, these improvements should result in lower short-term mortality in hospitalized acute myocardial infarction (AMI) patients. In fact, a decline in case fatality has been observed in recent decades. 7 The introduction of different pharmacological treatments and particularly thrombolytic therapy and the widespread use of antiplatelet drugs, anticoagulant drugs, -blockers, and the advent of coro- nary angioplasty in the 1980s reduced in-hospital mortality to 13% to 16%. 8 Therapeutic improvements such as fibrinolytic and antiplatelet agents 9 have proved to reduce early mortality in clinical trial settings in selected groups of patients who do not necessarily reflect a real-life hospital patient case mix. 10,11 More extensive evaluation of effectiveness in a general setting such as population-based registries is required to ascertain the effect of these therapeutic modalities on short- term AMI mortality. The aim of this study was to analyze 28-day case fatality trends between 1978 and 1993 among hospitalized first Q-wave AMI patients in Gerona, Spain, and to relate them to the introduction and use of thrombolytic and antiplatelet drugs and to changes in patient characteristics (age, sex, AMI severity, or comorbidity). Methods The hospital under study is the only reference teaching center with a coronary care unit (CCU) in the area. There are 6 community hospitals that refer their AMI patients to that hospital after emergency treatment. From the Lipids and Cardiovascular Epidemiology Unit, Institut Municipal d’Investigacio ´ Me `dica, Barcelona, Spain (M.G., J.M., R.E., A.P., J.V., M.P., G.P.), and Servei de Cardiologia, Hospital Universitari de Girona “Dr Josep Trueta,” Gerona, Spain (J.S., R.M., X.A.). See the “Appendix” for a list of REGICOR investigators. Correspondence to Dr Jaume Marrugat, Unitat de Lipids i Epidemiologia Cardiovascular, Institut Municipal d’Investigacio ´ Me `dica, Carrer Dr Aiguader 80, 08003 Barcelona, Spain. E-mail JAUME@IMIM.ES © 1999 American Heart Association, Inc. 1767 Current Perspective