Normalization of AMI mortality rates: a better reflection of differences in German federal states?

Age‑standardized mortality rates (ASMR) of acute myocardial infarction (AMI) differ strongly between the federal states in Germany regarding its extent and temporal trends. Since 2000, the ASMR for AMI has decreased continuously, showing short‑term, pronounced fluctuations in some states, and even increased in Berlin. In 2024, the ASMR for AMI in Berlin (men: 80, women: 59 per 100,000) and Mecklenburg‑West Pomerania (MV; men: 90, women: 54 per 100,000) was markedly higher than in Hamburg (men: 34, women: 25 per 100,000) and North Rhine‑Westphalia (NRW; men: 40, women: 25 per 100,000). Morbidity, risk factor burden or health care cannot fully explain these patterns. Varying preferences in selecting the underlying cause of death may play a role. It is examined whether normalization of ASMR yields a more plausible representation of AMI mortality. For 2000–2024, all deaths, AMI deaths and AMI ASMR by sex and federal state were used from GBE‑bund.de. The ASMR for AMI was normalized by dividing it by the proportion of deaths from AMI among all deaths. In 2024, the normalized mortality rate (NMR) for AMI in women was highest in NRW, Saxony‑Anhalt, and Lower Saxony (12.3 per 100,000 per 1%-share of deaths from AMI), and lowest in Saxony and Baden‑Württemberg (10.9). In men, MV (13.5) and Saxony‑Anhalt (14.0) showed the highest normalized AMI mortality, whereas Baden‑Württemberg (10.8) and Bavaria (11.3) had the lowest. In contrast to the ASMR, normalization led to a largely parallel declining trend across all federal states from 2000–2024, including Berlin. Normalizing the ASMR for AMI for a 1%-share of AMI as cause-of-death among all deaths yields plausible rankings regarding the burden of AMI mortality for German federal states in cross‑sectional comparisons and over time, better reflecting morbidity and risk factor burden. The NMR should be reported alongside the ASMR in regional and temporal comparative reporting on myocardial infarction mortality. Key messages • Age-standardized mortality rates for acute myocardial infarction differ strongly in German federal states which cannot be explained by differences in morbidity, risk factor burden or health care. • Normalization of age-standardized mortality rates to a 1%-share of AMI as cause-of-death among all deaths yields a more plausible representation of the states’ burden of AMI mortality.