Myocardial infarction occurrence in Jerusalem: a Mediterranean anomaly

Background: The Jewish population of Israel consumes a diet rich in polyunsaturated fatty acids with a relatively low proportion of saturated fat, has a small alcohol intake and a lipid profile characterized by low HDL-cholesterol and high lipoprotein(a) (Lp(a)). It is therefore of interest to compare occurrence rates of coronary heart disease (CHD) with those elsewhere. Methods: The community-based event rate of CHD [comprising acute myocardial infarction (AMI) and CHD death] and case-fatality was determined in 1995–1997 by active surveillance among Jewish residents of the Jerusalem District aged 25–64 according to standardized WHO-MONICA criteria. We compared our findings with rates among MONICA populations in 21 countries. Twelve hundred and six events occurred in Jerusalem during 670,000 person-years (930 non-fatal AMI and 276 CHD deaths). Results: The age-adjusted incidence of CHD ranked high compared with the 21 countries (men third highest, women eighth highest), far exceeding the Mediterranean countries. In contrast, the pre-hospital mortality rate was low, similar to countries in the Mediterranean basin, and the 28-day case fatality was remarkably low, far lower than for any MONICA population in men, and second lowest in women. Correspondingly, the incidence of non-fatal AMI ranked extraordinarily high (men first, women third). The low case-fatality ranking persisted upon adjustment for treatment differences between populations. Conclusions: We report an unusual combination of a high incidence of CHD among Jewish residents of Jerusalem accompanied by extraordinarily low case fatality, the latter suggesting reduced susceptibility to lethal arrhythmias. Determinants of this anomaly require clarification.