The MONICA project as a pioneer in cardiovascular epidemiology

At present, comparable data on morbidity from ischaemic heart disease are not collected on a country-wide basis across Europe. Over 10 years of surveillance (between the mid-1980s and the mid-1990s), the WHO MONICA project (MONItoring trends and determinants in CArdiovascular disease) examined the incidence of coronary events in 37 different populations in 21 countries (including 29 populations in 16 European countries). These populations were not necessarily representative of the countries in which they were located. However, MONICA data were collected through standardized methodologies. Therefore these data are comparable across Europe and are to this day recognised as the golden standard.

The Rates of coronary events and case-fatality in 13 European countries, over a 10-year period around 1990, as derived from the MONICA project (Tunstall-Pedoe et al., 1999) showed that attack rates for coronary events (myocardial infarction - heart attack) were higher in MONICA project populations in Northern, Central and Eastern Europe than in Southern and Western Europe (with the exception of the United Kingdom). During the project period, attack rates have been falling rapidly in Northern and Western Europe but not as fast in Southern, Central and Eastern Europe and in some countries, such as Lithuania (Kaunas), East Germany and Spain (Catalonia) they have even risen.

Contributions to changing IHD mortality varied, but in populations with decreasing mortality, the decrease in coronary events contributed two thirds and improved case fatality one third (Tunstall-Pedoe et al., 1999). Of all patients who died within 28 days after the onset of symptoms, about two thirds died before reaching the hospital. Therefore, primary prevention seems more effective in preventing IHD mortality than improving care (Chambless et al., 1997).

Current population-based registers are mostly regional

Data collection by the MONICA project ended in 1994-95. After that, some countries continued to collect data, sometimes using simplified procedures, but ensuring the validation of coronary events. An updated inventory of population characteristics and case definitions of AMI/ACS registers in 14 countries or regions was performed by the EUROCISS project (EUROCISS, 2003; Madsen et al., 2007). It appears that these registers cover different age groups (ranging between 25 and 74 years) and use different procedures for event definition. Therefore, data comparison between countries is difficult.

See as an example, data on attack rates and case fatality of coronary events are given from the Italian register. These recent Italian data cannot be directly compared to the MONICA data since the upper age limit was extended to 74, and since not all cases have been validated (the Italian registry validates cases on a sample basis).