Mortality After Myocardial Infarction-Reply

In Reply.—  A serious view of epidemiology as a discipline must reject the comparisons made by Dr Zumoff on an issue of public health importance. Between 1968 and 1976, mortality from coronary heart disease (CHD) declined in the United States by more than 20%, while before this, it had been rising. From two large earlier studies of patients with CHD in the Health Insurance Plan (HIP) of Greater New York, New York, we identified diagnostically comparable male survivors of a first myocardial infarction—436 men followed up in the 1960s and 697 in the 1970s. Controlling for important clinical influences on prognosis, we found no secular improvement in long-term survival during this time period (JAMA 1982;247:1576). Since the evidence on temporal changes in coronary risk factors since the late 1960s suggested that these alone could not have produced the total decline in mortality that had occurred, we concluded that the survival