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(Circulation. 1996;93:2033-2036.)
© 1996 American Heart Association, Inc.

Articles

Comparison of Sudden and Nonsudden Coronary Deaths in the United States

Luis G. Escobedo, MD, MPH; Matthew M. Zack, MD

From the Office on Smoking and Health (L.G.E.) and the Division of Chronic Disease Control and Community Intervention (M.M.Z.), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, Ga.

Correspondence to Luis G. Escobedo, MD, Mail Stop K-50, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30333.

	Abstract

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Background The present study was designed to compare risk factor prevalences in coronary heart disease deaths in persons dying within 1 hour of onset of cardiovascular symptoms (sudden coronary death), those dying without such sudden symptoms (nonsudden coronary death), and those with unknown duration of symptoms before death (other coronary death).

Methods and Results Data from the 1986 National Mortality Followback Survey and the US Bureau of the Census were examined to assess death rates for sudden, nonsudden, and other coronary deaths. Multivariate logistic regression methods were used to calculate the odds ratio (OR), compared with nonsudden and other coronary deaths, for sudden coronary death associated with socioeconomic status variables, the person's location at death, and coronary heart disease risk factors. Mortality rates for all coronary deaths increased with age, were higher for men than women, and increased with decreasing years of schooling. The rate of sudden coronary death was highest for Hispanics. In 1986, an estimated 251 000 sudden coronary deaths (95% CI=238 000 to 263 000) occurred in the United States. Sudden coronary deaths were less likely than nonsudden coronary deaths to occur at home (OR=0.5, 95% CI=0.4 to 0.6), but individuals who died of sudden coronary death were more likely to have been current cigarette smokers (OR=1.3, 95% CI=1.0 to 1.8). No other modifiable risk factors for coronary heart disease distinguished sudden coronary deaths from nonsudden coronary deaths.

Conclusions Contrary to the commonly held view, coronary deaths in the home are more likely to be nonsudden than sudden. Cigarette smoking more likely results in sudden than nonsudden coronary death, perhaps because of nicotine-induced ventricular arrhythmias.

Key Words: coronary disease • mortality • smoking • death, sudden

	Introduction

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Data about the incidence of and risk factors for sudden coronary death and coronary heart disease are well known.^{1 2 3} However, the sociodemographic characteristics and risk factors that distinguish sudden from nonsudden coronary death are less well understood. Knowledge about these characteristics may improve both understanding of sudden death and planning for prevention programs. Sudden coronary death more often results from ventricular fibrillation than from acute transmural myocardial infarction.^{4 5} Coronary heart disease risk factors that increase ventricular irritability, such as cigarette smoking,⁶ may therefore increase risk for sudden coronary death. Moreover, if the frequency of a specific location at death differs between those with and those without sudden coronary death, then these differences may suggest intervention strategies tailored to preventing sudden coronary death.

We therefore examined data from the 1986 National Mortality Followback Survey to determine whether the presence of selected coronary heart disease risk factors and the person's location at death distinguished those with and those without sudden coronary death.

	Methods

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Source of Data
The National Mortality Followback Survey is a stratified, random sample of 1% of deaths of US residents (except those residing in Oregon) who were 25 years of age and older in 1986 (n=18 733).⁷ The person identified as the informant on the death certificate provided information through a questionnaire or an interview about demographic, economic, behavioral, and health-related characteristics of the decedent. Eighty-nine percent of the informants responded, and 83% of the respondents were first-degree relatives.

Data Collection and Definitions
We considered a death to have resulted from coronary heart disease if the death certificate listed rubrics 410 through 414 from the International Classification of Diseases, 9th revision (n=4729). Each informant was asked the following question about the death: "Within the hour before death, did [decedent] start having a new or sharply increased problem such as chest pain, difficulty breathing, or fainting?"

With this information, we defined three mutually exclusive categories of death caused by coronary heart disease: (1) sudden coronary deaths were deaths that occurred within 1 hour of the onset of these cardiovascular symptoms (n=1608); (2) nonsudden coronary deaths were deaths that occurred in the absence of these symptoms, or if symptoms were reported, death occurred more than 1 hour after symptom onset (n=1585); and (3) other coronary deaths were deaths in which information about the onset of these cardiovascular symptoms before death was unknown (n=1053). Information was unavailable for 483 decedents because of nonresponse by informants.

Never smokers were persons who had not smoked more than 100 cigarettes in their lifetime; former smokers, persons who had smoked 100 cigarettes or more but had quit before their deaths; and current smokers, persons who smoked until their death. Information about the following potential confounders was also available: the decedent's body weight, history of diabetes and hypertension, reported vigorous physical activity (yes, no, or irregular), family history of myocardial infarction (yes, no), location at death, and educational attainment.

Mortality Burden
It was possible to estimate the total number of sudden coronary deaths reported from among all coronary deaths in the United States in this survey because the study sample was representative of all coronary disease deaths in 1986. We assumed that the percentage of sudden coronary deaths among deaths with available symptom data resembled that among deaths without such data. The sum of the number of reported sudden deaths and the number of estimated sudden deaths among other coronary deaths provides an estimate of the total number of sudden coronary deaths in the United States in 1986. The standard error (used to calculate the 95% CI) for this total is the square root of the sum of the variances of each of these component numbers.

To calculate the rates of sudden, nonsudden, and other coronary deaths, we divided the number of deaths (weighted to national totals) by the 1986 resident⁸ or noninstitutional⁹ population, as published by the US Bureau of the Census, and these rates were directly standardized to the age distribution of the 1980 US population.¹⁰

Comparison Studies
To assess risk factors for sudden coronary death in persons who died of coronary disease, we compared risk factors among sudden coronary deaths (cases) and nonsudden coronary deaths (controls). However, because 25% of all coronary disease deaths lacked information about cardiovascular symptoms in the hour before death, these other coronary deaths could have been either sudden or nonsudden. To determine whether these other deaths more closely resembled the sudden or nonsudden coronary deaths, we therefore used the deaths that lacked information as a second control group to compare with the sudden coronary deaths. (It is probably unrealistic to expect complete information about circumstances at death in most community settings.) We calculated the percent distribution of each coronary death (sudden, nonsudden, and other) by risk factor. Logistic regression methods for survey data¹¹ were used to calculate the adjusted odds ratio (OR), which represents the ratio of the odds of a risk factor among sudden deaths to the odds of the same risk factor among nonsudden deaths (in one model) or among other coronary deaths (in a second model).

	Results

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An estimated 186 000 sudden coronary deaths, 205 000 nonsudden coronary deaths, and 135 000 coronary deaths without information on suddenness of symptoms occurred in the United States in 1986. If the proportion (48%) of sudden deaths reported among all coronary deaths with information on suddenness of symptoms also applies to deaths without such information, an additional 65 000 sudden deaths occurred among the latter group, for a total of 251 000 sudden coronary deaths (95% CI=238 000 to 263 000).

Mortality rates for sudden, nonsudden, or other coronary disease death increased rapidly with age (Table 1). Rates for men consistently exceeded rates for women. Sudden coronary death rates were highest for Hispanics; nonsudden coronary death rates were highest for whites and blacks. Mortality rates, except for other coronary death rates, increased with decreasing educational attainment.

View this table: [in this window] [in a new window]   Table 1. Coronary Heart Disease Death Rates by Suddenness of Onset, Age, Sex, Race or Ethnicity, and Educational Attainment, United States, 1986

After adjustment for other risk factors, sudden death still occurred more often than nonsudden death among younger persons, current cigarette smokers, and those who died on the way to the hospital or at an emergency room (Table 2). Individuals were also less likely to die of sudden coronary death than of other kinds of coronary death if they were at home or in a nursing home. These associations, with slight differences in the ORs, also occurred in the comparison between sudden deaths and other coronary deaths.

View this table: [in this window] [in a new window]   Table 2. Risk Factors for Sudden Coronary Deaths Compared With Nonsudden and Other Coronary Deaths, United States, 1986

	Discussion

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The present study compares the coronary heart disease risk factor profile in sudden and nonsudden coronary deaths. Cigarette smoking increases risk for sudden coronary death, and it may do so by provoking ventricular arrhythmias. The nicotine in cigarette smoke stimulates sympathetic nerves, increases the propensity toward arrhythmias,⁶ and increases vulnerability to cardiac arrest.¹² Nicotine may provoke the acute ventricular arrhythmias that more likely precede sudden coronary death than the premature ventricular complexes usually associated with chronic cardiac disease.^{13 14} Improving access to smoking cessation programs may reduce mortality from sudden coronary death among smokers with coronary heart disease.

Individuals with another coronary disease risk factor, hypertension, had only a slightly higher risk for sudden coronary death than those without hypertension (OR=1.2, 95% CI=1.0 to 1.4). This slightly higher risk may have resulted from inadequate treatment for hypertension, which may have led to ventricular hypertrophy.¹⁵ However, in the Framingham study, antihypertensive treatment itself increased the risk for sudden coronary death.¹⁶ Because information about antihypertensive treatment was unknown in a large percentage of subjects in the present study, we could not assess the effect of antihypertensive therapy on the risk of sudden coronary death.

Compared with nonsudden and other coronary deaths, sudden coronary deaths were less likely to occur in the home and more likely to occur on the way to the hospital or in the hospital emergency room. This pattern may reflect attempts to transport victims to a hospital setting, where they eventually die; but the pattern does not support the view that a coronary death outside the hospital reliably indicates a sudden coronary death.³

Sudden coronary death occurred 20% less frequently among blacks than whites and was highest among Hispanics. Differences by race in coding the cause of death on death certificates or in detection rates for coronary disease may account for the lower rates of sudden coronary deaths in blacks than whites.¹⁷

The estimated number of sudden coronary deaths (251 000, with an upper 95% CI of 263 000) in 1986 in the United States agrees with the range of 200 000 to 400 000 sudden deaths estimated in previous studies.¹⁸ The use of national survey sample data in the present study permitted direct estimation of this total; previous estimates have been indirect extrapolations.

Inaccurate coding for cause of death on death certificates and the use of proxy data are two possible limitations of the present study because they can lead to misclassification. Information on the death certificate is reasonably accurate for coronary heart disease.⁶ However, other causes of sudden death that may occur at younger ages (such as pulmonary embolus, stroke, hypertensive disease, toxic or metabolic disturbances,¹⁸ or drug overdoses) may have been misclassified as sudden coronary death. Proxy data are reasonably accurate for smoking, dietary habits, and health-related events,^{19 20} especially when the informant is a first-degree relative,^{21 22} as was true in 83% of respondents in the present study.

Nonsudden coronary deaths occur more often at home than sudden coronary deaths. Hence, there may be greater opportunities to prevent nonsudden coronary deaths. Interventions that are highly effective in the early treatment of myocardial infarction, such as PTCA²³ and thrombolytic therapy,²⁴ are generally unavailable for the treatment of most sudden coronary deaths.¹⁸ Although dedicated emergency prehospital care programs may help reduce sudden and nonsudden coronary deaths outside the hospital,²⁵ few communities in the United States enjoy the benefits of such programs.²⁶ Greater availability of training programs in cardiopulmonary resuscitation, early defibrillation, and access to advanced cardiac life support²⁷ may enable communities to improve access to emergency medical care and reduce the number of coronary deaths.

	Acknowledgments

 
We thank Barbara Gray and Fredrick L. Hull for their helpful comments in the preparation of the manuscript.

Received October 11, 1995; revision received November 13, 1995; accepted November 21, 1995.

	References

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Escobedo, L. G. Articles by Zack, M. M. Search for Related Content PubMed PubMed Citation Articles by Escobedo, L. G. Articles by Zack, M. M.