Trends in incidence, severity, and outcome of hospitalized myocardial infarction

Epidemiology of heart failure

Heart failure (HF) has been singled out as an epidemic and is a staggering clinical and public health problem, associated with significant mortality, morbidity, and healthcare expenditures, particularly among those aged ≥ 65 years. The case mix of HF is changing over time with a growing proportion of cases presenting with preserved ejection fraction for which there is no specific treatment. Despite progress in reducing HF-related mortality, hospitalizations for HF remain frequent and rates of readmissions continue to rise. To prevent hospitalizations, a comprehensive characterization of predictors of readmission in patients with HF is imperative and must integrate the impact of multimorbidity related to coexisting conditions. New models of patient-centered care that draw on community-based resources to support HF patients with complex coexisting conditions are needed to decrease hospitalizations.

Contemporary trends in heart failure with reduced and preserved ejection fraction after myocardial infarction: a community study

Major changes have recently occurred in the epidemiology of myocardial infarction (MI) that could possibly affect outcomes such as heart failure (HF). Data describing trends in HF after MI are scarce and conflicting and do not distinguish between preserved and reduced ejection fraction (EF). We evaluated temporal trends in HF after MI. All residents of Olmsted County, Minnesota (n = 2,596) who had a first-ever MI diagnosed in 1990-2010 and no prior HF were followed-up through 2012. Framingham Heart Study criteria were used to define HF, which was further classified according to EF. Both early-onset (0-7 days after MI) and late-onset (8 days to 5 years after MI) HF were examined. Changes in patient presentation were noted, including fewer ST-segment-elevation MIs, lower Killip class, and more comorbid conditions. Over the 5-year follow-up period, 715 patients developed HF, 475 of whom developed it during the first week. The age- and sex-adjusted risk declined from 1990-1996 to 2004-2010, with hazard ratios of 0.67 (95% confidence interval (CI): 0.54, 0.85) for early-onset HF and 0.63 (95% CI: 0.45, 0.86) for late-onset HF. Further adjustment for patient and MI characteristics yielded hazard ratios of 0.86 (95% CI: 0.66, 1.11) and 0.63 (95% CI: 0.45, 0.88) for early- and late-onset HF, respectively. Declines in early-onset and late-onset HF were observed for HF with reduced EF (<50%) but not for HF with preserved EF, indicating a change in the case mix of HF after MI that requires new prevention strategies.

Patients with cardiac disease: Changes observed through last decade in out-patient clinics

AIM: To describe current profile of patients with cardiovascular disease (CVD) and assessing changes through last decade.

METHODS: Comparison of patients with established CVD from two similar cross-sectional registries performed in 1999 (n = 6194) and 2009 (n = 4639). The types of CVD were coronary heart disease (CHD), heart failure (HF) and atrial fibrillation (AF). Patients were collected from outpatient clinics. Investigators were 80% cardiologist and 20% primary care practitioners. Clinical antecedents, major diagnosis, blood test results and medical treatments were collected from all patients.

RESULTS: An increase in all risk factors, except for smoking, was observed; a 54.4% relative increase in BP control was noted. CHD was the most prevalent CVD but HF and AF increased significantly, 41.5% and 33.7%, respectively. A significant reduction in serum lipid levels was observed. The use of statins increased by 141.1% as did all cardiovascular treatments. Moreover, the use of angiotensin-renin system inhibitors in patients with HF, beta-blockers in CHD patients or oral anticoagulants in AF patients increased by 83.0%, 80.3% and 156.0%, respectively (P < 0.01).

CONCLUSION: The prevalence of all cardiovascular risk factors has increased in patients with CVD through last decade. HF and AF have experienced the largest increases.

Nationwide trends in the incidence of acute myocardial infarction in Australia, 1993-2010

Although most of the additional increases in coronary heart disease morbidity and mortality are estimated to occur outside developed regions such as North America and Europe, few nationwide studies have been published of acute myocardial infarction (MI) epidemiology from other regions. We thus sought to expand the global data regarding MI trends. Nationwide trends of incident MI, ST-segment elevation MI (STEMI), and non-ST-segment MI (non-STEMI) were analyzed during a 17-year period in Australia. We identified 714,262 hospitalizations for MI from 1993 to 2010, representing 331,871,389 person-years. During the study period, the age- and gender-adjusted incidence of all MIs increased from 215 to 251 cases per 100,000 person-years, a relative increase of 76% (p <0.0001 for trend). The adjusted incidence of STEMI decreased from 147 to 70 cases per 100,000 person-years, a relative decrease of 30% (p <0.0001 for trend). In contrast, the adjusted incidence of non-STEMI increased from 67 to 182 cases per 100,000 person-years, a relative increase of 315% (p <0.0001 for trend). Age-specific analyses suggested that statistically significant increases in MI incidence were present in those aged <50 and ≥80 years. In conclusion, although it has previously been suggested that declining trends in MI incidence in North American and European reports might be generalizable given the seemingly consistent observations thus far, the present results highlight the possibility that other global populations might have less favorable trends. The incidence of MI in Australia might not be decreasing as rapidly as that seen in other regions and requires additional exploration.

Causes of death in patients ≥75 years of age with non-ST-segment elevation acute coronary syndrome

The causes of death within 1 year of hospital admission in patients with non-ST-segment elevation acute coronary syndromes are ill defined, particularly in patients aged ≥75 years. From January 2008 through May 2010, we enrolled 645 patients aged ≥75 years with non-ST-segment elevation acute coronary syndromes: 313 in a randomized trial comparing an early aggressive versus an initially conservative approach, and 332, excluded from the trial for specific reasons, in a parallel registry. Each death occurring during 1 year of follow-up was adjudicated by an independent committee. The mean age was 82 years in both study cohorts, and 53% were men. By the end of the follow-up period (median 369 days, interquartile range 345 to 391), 120 patients (18.6%) had died. The mortality was significantly greater in the registry (23.8% vs 13.1%, p = 0.001). The deaths were classified as cardiac in 94% of the cases during the index admission and 68% of the cases during the follow-up period. Eighty-six percent of the cardiac deaths were of ischemic origin. In a multivariate logistic regression model that included the variables present on admission in the whole study population, the ejection fraction (hazard ratio 0.95, 95% confidence interval 0.94 to 0.97; p <0.001), hemoglobin level (hazard ratio 0.85, 95% confidence interval 0.76 to 0.94; p = 0.001), older age (hazard ratio 1.05, 95% confidence interval 1.01 to 1.10, p = 0.010), and creatinine clearance (hazard ratio 0.99, 95% confidence interval 0.97 to 0.99; p = 0.030) were the independent predictors of all-cause death at 1 year. In conclusion, within 1 year after admission for non-ST-segment elevation acute coronary syndromes, most deaths in patients aged ≥75 years have a cardiac origin, mostly owing to myocardial ischemia.

Cardiac troponins I and T: molecular markers for early diagnosis, prognosis, and accurate triaging of patients with acute myocardial infarction

Acute myocardial infarction (AMI) is the leading cause of death worldwide, with early diagnosis still being difficult. Promising new cardiac biomarkers such as troponins and creatine kinase (CK) isoforms are being studied and integrated into clinical practice for early diagnosis of AMI. The cardiac-specific troponins I and T (cTnI and cTnT) have good sensitivity and specificity as indicators of myocardial necrosis and are superior to CK and its MB isoenzyme (CK-MB) in this regard. Besides being potential biologic markers, cardiac troponins also provide significant prognostic information. The introduction of novel high-sensitivity troponin assays has enabled more sensitive and timely diagnosis or exclusion of acute coronary syndromes. This review summarizes the available information on the potential of troponins and other cardiac markers in early diagnosis and prognosis of AMI, and provides perspectives on future diagnostic approaches to AMI.

Epidemiology of acute coronary syndromes in Spain: estimation of the number of cases and trends from 2005 to 2049

Acute coronary syndromes are a leading cause of mortality, morbidity, and health care cost in Spain. The aims of this report are to estimate the number of acute coronary syndromes cases in the Spanish population in 2013 and 2021, and the trend from 2005 to 2049. We estimated the number of acute coronary syndromes cases by sex and Spanish autonomous community using data from the most updated population and hospital registries. We present the estimated number of cases with an exact 95% confidence interval, assuming that the number of cases followed a Poisson distribution. There will be 115,752 acute coronary syndromes cases in Spain in 2013 (95% confidence interval, 114,822-116,687). Within 28 days, 39,086 of these patients will die and 85,326 will be hospitalized. Non-ST segment elevation acute coronary syndromes (56%) and acute myocardial infarction (81%) will be the most common admission and discharge diagnoses, respectively. We estimate approximately 109,772 acute coronary syndromes cases in 2021 (95% confidence interval, 108,868-110,635). The trend of acute coronary syndromes cases from 2005 to 2049 will stabilize in the population aged 25 to 74 years, but increase in those older than 74 years. Due to population aging, the number of acute coronary syndrome cases will increase overall until 2049, it may stabilize in the population aged <75 years. The acute coronary syndromes case-fatality has decreased in hospitalized patients but the proportion of sudden deaths remains unchanged.

Myocardial infarction and sudden cardiac death in Olmsted County, Minnesota, before and after smoke-free workplace laws

BACKGROUND

Reductions in admissions for myocardial infarction (MI) have been reported in locales where smoke-free workplace laws have been implemented, but no study has assessed sudden cardiac death in that setting. In 2002, a smoke-free restaurant ordinance was implemented in Olmsted County, Minnesota, and in 2007, all workplaces, including bars, became smoke free.

METHODS

To evaluate the population impact of smoke-free laws, we measured, through the Rochester Epidemiology Project, the incidence of MI and sudden cardiac death in Olmsted County during the 18-month period before and after implementation of each smoke-free ordinance. All MIs were continuously abstracted and validated, using rigorous standardized criteria relying on biomarkers, cardiac pain, and Minnesota coding of the electrocardiogram. Sudden cardiac death was defined as out-of-hospital deaths associated with coronary disease.

RESULTS

Comparing the 18 months before implementation of the smoke-free restaurant ordinance with the 18 months after implementation of the smoke-free workplace law, the incidence of MI declined by 33% (P < .001), from 150.8 to 100.7 per 100,000 population, and the incidence of sudden cardiac death declined by 17% (P = .13), from 109.1 to 92.0 per 100,000 population. During the same period, the prevalence of smoking declined and that of hypertension, diabetes mellitus, hypercholesterolemia, and obesity either remained constant or increased.

CONCLUSIONS

A substantial decline in the incidence of MI was observed after smoke-free laws were implemented, the magnitude of which is not explained by community cointerventions or changes in cardiovascular risk factors with the exception of smoking prevalence. As trends in other risk factors do not appear explanatory, smoke-free workplace laws seem to be ecologically related to these favorable trends. Secondhand smoke exposure should be considered a modifiable risk factor for MI. All people should avoid secondhand smoke to the extent possible, and people with coronary heart disease should have no exposure to secondhand smoke.

Are adverse events following an invasive strategy in patients with non-ST-segment elevation acute coronary syndromes more frequent at US sites versus non-US sites? Analysis from the ACUITY trial

OBJECTIVE

To compare outcomes between US and non-US (OUS) sites in patients with non ST-elevation acute coronary syndromes (NSTEACS) and to evaluate potential reasons for differences in outcomes.

BACKGROUND

There are little data comparing outcomes at US versus OUS sites in patients with NSTEACS managed with an invasive strategy.

METHODS

The ACUITY trial randomized 13,819 patients with NSTEACS in 17 countries to an invasive approach with one of three strategies: (1) heparin plus glycoprotein platelet inhibitors (GPI), (2) bivalirudin plus GPI, or (3) bivalirudin alone.

RESULTS

US patients were more often female, were younger, heavier, and had more diabetes, prior myocardial infarction (MI), and prior bypass surgery. US patients were less often treated with percutaneous coronary intervention but had more frequent drug-eluting stent use. US patients had lower mortality and higher MI rates at 30 days and 1 year and higher composite ischemic outcome at 30 days. After adjusting for differences in baseline variables, US patients had higher rates of MI and composite ischemic outcome at 30 days and higher rates of MI at 1 year {HR [95% confidence interval (CI)] = 1.36 [1.18-1.56], P < 0.0001} with no differences in mortality. There were no differences in treatment effects comparing bivalirudin with the other strategies between US and OUS sites.

CONCLUSIONS

US versus OUS patients with NSTEACS had higher adjusted rates of MI and ischemia. The reasons for these differences are not clear but may be due to unmeasured confounders, different thresholds for event reporting, or valid differences in systems of care which may impact outcomes.

Cord lining-mesenchymal stem cells graft supplemented with an omental flap induces myocardial revascularization and ameliorates cardiac dysfunction in a rat model of chronic ischemic heart failure

Myocardial restoration using tissue-engineered grafts to regenerate the ischemic myocardium offers improved donor cell retention, yet a limited cell survival resulting from poor vascularization needs to be addressed. A cell type derived from the subamnion, namely, cord-lining mesenchymal stem cells (CL-MSC), has recently been identified. Here we present a restorative strategy that combines a fibrin graft containing human CL-MSC and omental flap providing, thereby, cell-, structural-, and angiogenic support to the injured myocardium. The graft consisted of a mixture of 2×10(6) CL-MSC-GFP-Fluc and fibrin. Myocardial infarction (MI) was induced in nude rats and following confirmation of ensued heart failure with echocardiography 2 weeks after injury, therapeutic intervention was performed as follows: untreated (MI, n=7), CL-MSC graft (CL-MSCG, n=8), CL-MSCG and omental flap (CL-MSCG+OM, n=11), and omental flap (OM, n=8). In vivo bioluminescence imaging at 1, 3, 7, and 14 days post-treatment indicated comparable early donor cell viability between the CL-MSCG and CL-MSCG+OM. Treatment with CL-MSCG+OM improved the myocardial function as assessed by the measurement of end-diastolic left ventricular (LV) pressure (3.53±0.34 vs. 5.21±0.54 mmHg, p<0.05), contractility (+dP/dt, 3383.8±250.78 mmHg vs. 2464.9±191.8 mmHg, p<0.05), and the relaxation rate (-dP/dt, -2707.2±250.7 mmHg vs. 1948.7±207.8 mmHg, p<0.05), compared to MI control 6 weeks after ischemic injury. Furthermore, evidence of a 20.32% increase in the ejection fraction was observed in CL-MSCG+OM rats from week 2 to 6 after injury. Both CL-MSCG and CL-MSCG+OM led to an enhanced cardiac output (p<0.05), and attenuated the infarct size (35.7%±4.2% and 34.7%±4.8%), as compared to MI (60.7%±3.1%; p<0.01 and p<0.001, respectively). All treated groups had a higher arteriole density than controls. Yet, a higher amount of functional blood vessels, and a 20-fold increase in arteriole numbers were found in CL-MSCG+OM. Altogether, CL-MSCGs supplemented with vascular supply have the potential to repair the failing, chronically ischemic heart by improving myocardial revascularization, attenuating remodeling, and ameliorating cardiac dysfunction.

Cardiovascular and noncardiovascular disease associations with hip fractures

BACKGROUND

There is growing awareness of an association between cardiovascular disease and fractures, and a temporal increase in fracture risk after myocardial infarction has been identified. To further explore the nature of this relationship, we systematically examined the association of hip fracture with all disease categories and assessed related secular trends.

METHODS

By using resources of the Rochester Epidemiology Project, a population-based incident case-control study was conducted. Disease history was compared among all Olmsted County, Minnesota, residents aged 50 years or more with a first radiographically confirmed hip fracture in 1985-2006 and community control subjects individually matched (1:1) to cases on age, sex, and index year (n = 3808; mean age, 82 years; standard deviation, 9 years; 76% were women).

RESULTS

All cardiovascular and numerous non-cardiovascular disease categories (eg, infectious diseases, nutritional and metabolic diseases, mental disorders, diseases of the nervous system and sense organs, and diseases of the respiratory system) were associated with fracture risk. However, increasing temporal trends were detected almost exclusively in cardiovascular disease categories. The largest increases in association were observed for ischemic heart disease, other forms of heart disease (including heart failure), hypertension, and diabetes, and were more pronounced among elderly women than other demographic subgroups.

CONCLUSIONS

Although the association with hip fracture was not specific to cardiovascular disease, temporal increases were mainly detected in cardiometabolic diseases, all of which have been linked previously to frailty. This mechanism and others warrant further investigation.

Overview of large animal myocardial infarction models (review)

There are several experimental models for the in vivo investigation of myocardial infarction (MI) in small (mouse, rat) and large animals (dog, pig, sheep and baboons). The application of large animal models raises ethical concerns, the design of experiments needs longer follow-up times, requiring proper breeding and housing conditions, therefore resulting in higher cost, than in vitro or small animal studies. On the other hand, the relevance of large animal models is very important, since they mostly resemble to human physiological and pathophysiological processes. The first main difference among MI models is the method of induction (open or closed chest, e.g. surgical or catheter based); the second main difference is the presence or absence of reperfusion. The former (i.e. reperfused MI) allows the investigation of reperfusion injury and new catheter based techniques during percutaneous coronary interventions, while the latter (i.e. nonreperfused MI) serves as a traditional coronary occlusion model, to test the effects of new pharmacological agents and biological therapies, as cell therapy. The reperfused and nonreperfused myocardial infarction has different outcomes, regarding left ventricular function, remodelling, subsequent heart failure, aneurysm formation and mortality. Our aim was to review the literature and report our findings regarding experimental MI models, regarding the differences among species, methods, reproducibility and interpretation.

Intra-arterial thrombolysis vs. standard treatment or intravenous thrombolysis in adults with acute ischemic stroke: a systematic review and meta-analysis

BACKGROUND

Recent evidence has suggested that intra-arterial thrombolysis may provide benefit beyond intravenous thrombolysis in ischemic stroke patients. Previous meta-analyses have only compared intra-arterial thrombolysis with standard treatment without thrombolysis. The objective was to review the benefits and harms of intra-arterial thrombolysis in ischemic stroke patients.

METHODS

We undertook a meta-analysis of randomized controlled trials comparing the efficacy and safety of intra-arterial thrombolysis with either standard treatment or intravenous thrombolysis following acute ischemic stroke. Primary outcomes included poor functional outcomes (modified Rankin Scale 3-6), mortality, and symptomatic intracranial hemorrhage. Study quality was assessed, and outcomes were stratified by comparison treatment received.

RESULTS

Four trials (n = 351) comparing intra-arterial thrombolysis with standard treatment were identified. Intra-arterial thrombolysis reduced the risk of poor functional outcomes (modified Rankin Scale 3-6) [relative risk (RR) = 0·80; 95% confidence interval = 0·67-0·95; P = 0·01]. Mortality was not increased (RR = 0·82; 95% confidence interval = 0·56-1·21; P = 0·32); however, risk of symptomatic intracranial hemorrhage was nearly four times more likely (RR = 3·90; 95% confidence interval = 1·41-10·76; P = 0·006). Two trials (n = 81) comparing intra-arterial thrombolysis with intravenous thrombolysis were identified. Intra-arterial thrombolysis was not found to reduce poor functional outcomes (modified Rankin Scale 3-6) (RR = 0·68; 95% confidence interval = 0·46-1·00; P = 0·05). Mortality was not increased (RR = 1·12; 95% confidence interval = 0·47-2·68; P = 0·79); neither was symptomatic intracranial hemorrhage (RR = 1·13; 95% confidence interval = 0·32-3·99; P = 0·85). Differences in time from symptom onset-to-treatment and type of thrombolytic administered were found across the trials.

CONCLUSIONS

This analysis finds a modest benefit of intra-arterial thrombolysis over standard treatment, although it does not find a clear benefit of intra-arterial thrombolysis over intravenous thrombolysis in acute ischemic stroke patients. However, few trials, small sample sizes, and indirectness limit the strength of evidence.

Trends in the incidence of hospitalized acute myocardial infarction and stroke in Korea, 2006-2010

This study attempted to calculate and investigate the incidence of hospitalized acute myocardial infarction (AMI) and stroke in Korea. Using the National Health Insurance claim data, we investigated patients whose main diagnostic codes included AMI or stroke during 2006 to 2010. As a result, we found out that the number of AMI hospitalized patients had decreased since 2006 and amounted to 15,893 in 2010; and that the number of those with stroke had decreased since 2006 and amounted to 73,501 in 2010. The age-standardized incidence rate of hospitalized AMI, after adjustment for readmission, was 41.6 cases per 100,000-population in 2006, and had decreased to 29.4 cases in 2010 (for trend P < 0.001). In the case of stroke was estimated at 172.8 cases per 100,000-population in 2006, and had decreased to 135.1 cases in 2010 (for trend P < 0.001). In conclusion, the age-standardized incidence rates of both hospitalized AMI and stroke in Korea had decreased continuously during 2006 to 2010. We consider this decreasing trend due to the active use of pharmaceuticals, early vascular intervention, and the national cardio-cerebrovascular disease care project as the primary and secondary prevention efforts.

Assessing the Global Burden of Ischemic Heart Disease: Part 1: Methods for a Systematic Review of the Global Epidemiology of Ischemic Heart Disease in 1990 and 2010

BACKGROUND

Ischemic heart disease (IHD) is the leading cause of death worldwide. The GBD (Global Burden of Disease, Injuries, and Risk Factors) study (GBD 2010 Study) conducted a systematic review of IHD epidemiology literature from 1980 to 2008 to inform estimates of the burden on IHD in 21 world regions in 1990 and 2010.

METHODS

The disease model of IHD for the GBD 2010 Study included IHD death and 3 sequelae: myocardial infarction, heart failure, and angina pectoris. Medline, EMBASE, and LILACS were searched for IHD epidemiology studies in GBD high-income and low- and middle-income regions published between 1980 and 2008 using a systematic protocol validated by regional IHD experts. Data from included studies were supplemented with unpublished data from selected high-quality surveillance and survey studies. The epidemiologic parameters of interest were incidence, prevalence, case fatality, and mortality.

RESULTS

Literature searches yielded 40,205 unique papers, of which 1,801 met initial screening criteria. Upon detailed review of full text papers, 137 published studies were included. Unpublished data were obtained from 24 additional studies. Data were sufficient for high-income regions, but missing or sparse in many low- and middle-income regions, particularly Sub-Saharan Africa.

CONCLUSIONS

A systematic review for the GBD 2010 Study provided IHD epidemiology estimates for most world regions, but highlighted the lack of information about IHD in Sub-Saharan Africa and other low-income regions. More complete knowledge of the global burden of IHD will require improved IHD surveillance programs in all world regions.

Atrial Fibrillation Complicating Acute Coronary Syndromes

Atrial fibrillation frequently complicates myocardial infarction. Patients with atrial fibrillation complicating acute coronary syndrome have increased morbidity and mortality relative to patients that remain in normal sinus rhythm. No studies have identified a mortality benefit to rhythm control compared with rate control in the setting of acute coronary syndrome. Stroke prevention should be pursued with oral anticoagulation therapy, although the majority of patients with atrial fibrillation associated with acute coronary syndrome receive only antiplatelet therapy. There are several novel oral anticoagulant therapies now available, but these agents have not been well studied in combination with dual antiplatelet therapy. Therefore, warfarin as part of triple therapy is the most conservative approach until additional data becomes available.

Trends in clinical, demographic, and biochemical characteristics of patients with acute myocardial infarction from 2003 to 2008: a report from the american heart association get with the guidelines coronary artery disease program

Background

An analysis of the changes in the clinical and demographic characteristics of patients with acute myocardial infarction could identify successes and failures of risk factor identification and treatment of patients at increased risk for cardiovascular events.

Methods and Results

We reviewed data collected from 138 122 patients with acute myocardial infarction admitted from 2003 to 2008 to hospitals participating in the American Heart Association Get With The Guidelines Coronary Artery Disease program. Clinical, demographic, and laboratory characteristics were analyzed for each year stratified on the electrocardiogram at presentation. Patients with non–ST-segment–elevation myocardial infarction were older, more likely to be women, and more likely to have hypertension, diabetes mellitus, and a history of past cardiovascular disease than were patients with ST-elevation myocardial infarction. In the overall patient sample, significant trends were observed of an increase over time in the proportions of non–ST-segment–elevation myocardial infarction, patient age of 45 to 65 years, obesity, and female sex. The prevalence of diabetes mellitus decreased over time, whereas the prevalences of hypertension and smoking were substantial and unchanging. The prevalence of “low” high-density lipoprotein increased over time, whereas that of “high” low-density lipoprotein decreased. Stratum-specific univariate analysis revealed quantitative and qualitative differences between strata in time trends for numerous demographic, clinical, and biochemical measures. On multivariable analysis, there was concordance between strata with regard to the increase in prevalence of patients 45 to 65 years of age, obesity, and “low” high-density lipoprotein and the decrease in prevalence of “high” low-density lipoprotein. However, changes in trends in age distribution, sex ratio, and prevalence of smokers and the magnitude of change in diabetes mellitus prevalence differed between strata.

Conclusions

There were notable differences in risk factors and patient characteristics among patients with ST-elevation myocardial infarction and those with non–ST-segment–elevation myocardial infarction. The increasing prevalence of dysmetabolic markers in a growing proportion of patients with acute myocardial infarction suggests further opportunities for risk factor modification. (J Am Heart Assoc. 2012;1:e001206 doi: 10.1161/JAHA.112.001206.)

Thirty-day rehospitalizations after acute myocardial infarction: a cohort study

BACKGROUND

Rehospitalization is a quality-of-care indicator, yet little is known about its occurrence and predictors after myocardial infarction (MI) in the community.

OBJECTIVE

To examine 30-day rehospitalizations after incident MI.

DESIGN

Retrospective cohort study.

SETTING

Population-based registry in Olmsted County, Minnesota.

PATIENTS

3010 patients who were hospitalized in Olmsted County with first-ever MI from 1987 to 2010 and survived to hospital discharge.

MEASUREMENTS

Diagnoses, therapies, and complications during incident and subsequent hospitalizations were identified. Manual chart review was performed to determine the cause of all rehospitalizations. The hazard ratios and cumulative incidence of 30-day rehospitalizations were determined by using Cox proportional hazards regression models.

RESULTS

Among 3010 patients (mean age, 67 years; 40.5% female) with incident MI (31.2% ST-segment elevation), 643 rehospitalizations occurred within 30 days in 561 (18.6%) patients. Overall, 30.2% of rehospitalizations were unrelated to the incident MI and 42.6% were related; the relationship was unclear in 27.2% of rehospitalizations. Angiography was performed in 153 (23.8%) rehospitalizations. Revascularization was performed in 103 (16.0%) rehospitalizations, of which 46 (44.7%) had no revascularization during the index hospitalization. After adjustment for potential confounders, diabetes, chronic obstructive pulmonary disease, anemia, higher Killip class, longer length of stay during the index hospitalization, and a complication of angiography or reperfusion or revascularization were associated with increased rehospitalization risk. The 30-day incidence of rehospitalization was 35.3% in patients who experienced a complication of angiography during the index MI hospitalization and 31.6% in those who experienced a complication of reperfusion or revascularization during the index MI hospitalization, compared with 16.8% in patients who had reperfusion or revascularization without complications.

LIMITATION

This study represents the experiences of a single community.

CONCLUSION

Comorbid conditions, longer length of stay, and complications of angiography and revascularization or reperfusion are associated with increased 30-day rehospitalization risk after MI. Many rehospitalizations seem to be unrelated to the incident MI.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Long-Term Survival and Recurrence After Acute Myocardial Infarction in England, 2004 to 2010

Background—

There are limited population-based national data on prognosis in survivors of acute myocardial infarction (AMI), particularly on long-term survival and the risk of recurrence.

Methods and Results—

Record linkage of hospital and mortality data identified 387 452 individuals in England who were admitted to hospital with a main diagnosis of AMI between 2004 and 2010 and who survived for at least 30 days. Seven years after an AMI, the risk of death from any cause in survivors of first or recurrent AMI was, respectively, 2 and 3 times higher than that in the English general population of equivalent age. For all survivors of a first AMI, the risk of a second AMI was highest during the first year and the cumulative risk increased more gradually thereafter. For men, 1- and 7-year cumulative risks were 5.6% (95% confidence interval [CI], 5.5–5.7) and 13.9% (95% CI, 13.7–14.1); for women, they were 7.2% (95% CI, 7.1–7.4) and 16.2% (95% CI, 16.0–16.5). Older age, higher deprivation, no revascularization procedures, and presence of comorbidities were associated with higher recurrence risk.

Conclusions—

Survivors of both first and recurrent AMI remained at a significantly higher risk of death compared with the general population for at least 7 years after the event. For survivors of first AMI, the influence of predisposing factors for second AMI lessened with time after the initial event. The results reinforce the importance of acute clinical care and secondary prevention in improving long-term prognosis of hospitalized AMI patients.

Case definitions for acute myocardial infarction in administrative databases and their impact on in-hospital mortality rates

OBJECTIVE

To identify validated ICD-9-CM/ICD-10 coded case definitions for acute myocardial infarction (AMI).

DATA SOURCES

Ovid Medline (1950-2010) was searched to identify studies that validated acute myocardial infarction (AMI) case definitions. Hospital discharge abstract data and chart data were linked to validate identified AMI definitions.

STUDY DESIGN

Systematic literature review, chart review, and administrative data analysis.

DATA COLLECTION/EXTRACTION METHODS

Data on sensitivity/specificity/positive and negative predictive values (PPV and NPV) were extracted from previous studies to identify validated case definitions for AMI. These case definitions were validated in administrative data through chart review and applied to hospital discharge data to assess in-hospital mortality.

PRINCIPAL FINDINGS

Of the eight ICD-9-CM definitions validated in the literature, use of ICD-9-CM code 410 to define AMI had the highest sensitivity (94 percent) and specificity (99 percent). In our data, ICD-9-CM/ICD-10 codes 410/I21-I22 in all available coding fields had high sensitivity (83.3 percent/82.8 percent) and PPV (82.8 percent/82.2 percent). The in-hospital mortality among AMI patients identified using this case definition was 7.6 percent in ICD-9-CM data and 6.6 percent in ICD-10 data.

CONCLUSIONS

We recommend that ICD-9-CM 410 or ICD-10 I21-I22 in the primary diagnosis coding field should be used to define AMI. The use of a consistent validated case definition would improve comparability across studies.

Recent trends in hospitalization for acute myocardial infarction

Rates of acute myocardial infarction (AMI) hospitalizations for elderly Medicare patients decreased during the previous decade. However, trends in population rates of AMI hospitalizations for all adults by subgroups have not been described. Using data from a large all-payer administrative database of hospitalizations, we calculated annual AMI hospitalization rates from 2001 through 2007. Trend analysis was performed across age, gender, and ethnicity categories using survey regression. Overall rate decreased from 314 to 222 AMI hospitalizations per 100,000 patients from 2001 through 2007, representing a 29.2% decrease. Significant decreases were observed in AMI hospitalization rate for each group by age categories (p <0.001) and by gender (p <0.001). When stratified by ethnicity and gender, age-adjusted AMI hospitalization rates in white men and women decreased by 30.8% and 31.4%, whereas black men and women had significantly slower rates of decrease of 13.6% and 12.6%, respectively. In conclusion, although the overall rate of AMI hospitalizations decreased from 2001 through 2007, the observed decrease was smaller for black patients compared to white patients across all age groups studied.

Twenty-two-year trends in incidence of myocardial infarction, coronary heart disease mortality, and case fatality in 4 US communities, 1987-2008

BACKGROUND

Knowledge of trends in the incidence of and survival after myocardial infarction (MI) in a community setting is important to understanding trends in coronary heart disease (CHD) mortality rates.

METHODS AND RESULTS

We estimated race- and gender-specific trends in the incidence of hospitalized MI, case fatality, and CHD mortality from community-wide surveillance and validation of hospital discharges and of in- and out-of-hospital deaths among 35- to 74-year-old residents of 4 communities in the Atherosclerosis Risk in Communities (ARIC) Study. Biomarker adjustment accounted for change from reliance on cardiac enzymes to widespread use of troponin measurements over time. During 1987-2008, a total of 30 985 fatal or nonfatal hospitalized acute MI events occurred. Rates of CHD death among persons without a history of MI fell an average 4.7%/y among men and 4.3%/y among women. Rates of both in- and out-of-hospital CHD death declined significantly throughout the period. Age- and biomarker-adjusted average annual rate of incident MI decreased 4.3% among white men, 3.8% among white women, 3.4% among black women, and 1.5% among black men. Declines in CHD mortality and MI incidence were greater in the second decade (1997-2008). Failure to account for biomarker shift would have masked declines in incidence, particularly among blacks. Age-adjusted 28-day case fatality after hospitalized MI declined 3.5%/y among white men, 3.6%/y among black men, 3.0%/y among white women, and 2.6%/y among black women.

CONCLUSIONS

Although these findings from 4 communities may not be directly generalizable to blacks and whites in the entire United States, we observed significant declines in MI incidence, primarily as a result of downward trends in rates between 1997 and 2008.

Prognostic value of cardiac troponin T after myocardial infarction: a contemporary community experience

OBJECTIVE

To evaluate the role of cardiac troponin T (cTnT) in predicting death, recurrent ischemic events, and heart failure among community-dwelling persons with first myocardial infarction (MI).

PATIENTS AND METHODS

Consecutive Olmsted County, Minnesota, residents with an incident MI between November 6, 2002, and December 31, 2007, were studied (N=1177; mean age, 68 years). Maximal cTnT value was measured at a median of 1 day after MI (median, 0.52 ng/mL; interquartile range, 0.16-1.75 ng/mL) and evaluated as a prognostic factor using measures of absolute risk.

RESULTS

During a mean follow-up of 16 months, 276 deaths (23%) occurred, 341 patients (29%) experienced a recurrent ischemic event, and 326 patients (28%) experienced heart failure. A dose-response relationship was demonstrated early after MI between cTnT and the adjusted cumulative incidence of all outcomes. The multivariate-adjusted absolute risk differences (events per 100 patients) between the upper and lower cTnT tertiles at 30 days were 5.8 (95% confidence interval [CI], 1.4-10.2) for death, 5.2 (95% CI, 0.2-10.3) for recurrent ischemic event, and 6.9 (95% CI, 1.4-12.4) for heart failure. These differences were either maintained or increased at 2 years.

CONCLUSION

In the community, cTnT level predicts death and nonfatal cardiac events independently of other prognostic factors. The increased risk associated with elevated cTnT level appears shortly after MI and persists for at least 2 years.

Geographic disparities in the incidence and outcomes of hospitalized myocardial infarction: does a rising tide lift all boats?

BACKGROUND

Improvements in prevention have led to declines in incidence and mortality of myocardial infarction (MI) in selected populations. However, no studies have examined regional differences in recent trends in MI incidence, and few have examined whether known regional disparities in MI care have narrowed over time.

METHODS AND RESULTS

We compared trends in incidence rates of MI, associated procedures and mortality for all US Census Divisions (regions) in Medicare fee-for-service patients between 2000-2008 (292 773 151 patient-years). Two-stage hierarchical models were used to account for patient characteristics and state-level random effects. To assess trends in geographic disparities, we calculated changes in between-state variance for outcomes over time. Although the incidence of MI declined in all regions (P<0.001 for trend for each) between 2000-2008, adjusted rates of decline varied by region (annual declines ranging from 2.9-6.1%). Widening geographic disparities, as measured by percent change of between-state variance from 2000-2008, were observed for MI incidence (37.6% increase, P=0.03) and percutaneous coronary intervention rates (31.4% increase, P=0.06). Significant declines in risk-adjusted 30-day mortality were observed in all regions, with the fastest declines observed in states with higher baseline mortality rates.

CONCLUSIONS

In a large contemporary analysis of geographic trends in MI epidemiology, the incidence of MI and associated mortality declined significantly in all US Census Divisions between 2000-2008. Although geographic disparities in MI incidence may have increased, regional differences in MI-associated mortality have narrowed.

Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study

OBJECTIVE

To report trends in event and case fatality rates for acute myocardial infarction and examine the relative contributions of changes in these rates to changes in total mortality from acute myocardial infarction by sex, age, and geographical region between 2002 and 2010.

DESIGN

Population based study using person linked routine hospital and mortality data.

SETTING

England.

PARTICIPANTS

840,175 people of all ages who were admitted to hospital for acute myocardial infarction or died suddenly from acute myocardial infarction.

MAIN OUTCOME MEASURES

Acute myocardial infarction event, 30 day case fatality, and total mortality rates.

RESULTS

From 2002 to 2010 in England, the age standardised total mortality rate fell by about half, whereas the age standardised event and case fatality rates both declined by about one third. In men, the acute myocardial infarction event, case fatality, and total mortality rates declined at an average annual rate of, respectively, 4.8% (95% confidence interval 3.0% to 6.5%), 3.6% (3.4% to 3.7%), and 8.6% (5.4% to 11.6%). In women, the corresponding figures were 4.5% (1.7% to 7.1%), 4.2% (4.0% to 4.3%), and 9.1% (4.5% to 13.6%). Overall, the relative contributions of the reductions in event and case fatality rates to the decline in acute myocardial infarction mortality rate were, respectively, 57% and 43% in men and 52% and 48% in women; however, the relative contributions differed by age, sex, and geographical region.

CONCLUSIONS

Just over half of the decline in deaths from acute myocardial infarction during the 2000s in England can be attributed to a decline in event rate and just less than half to improved survival at 30 days. Both prevention of acute myocardial infarction and acute medical treatment have contributed to the decline in deaths from acute myocardial infarction over the past decade.

25 year trends in first time hospitalisation for acute myocardial infarction, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity: a Danish nationwide cohort study

OBJECTIVES

To examine 25 year trends in first time hospitalisation for acute myocardial infarction in Denmark, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity.

DESIGN

Nationwide population based cohort study using medical registries.

SETTING

All hospitals in Denmark.

SUBJECTS

234,331 patients with a first time hospitalisation for myocardial infarction from 1984 through 2008.

MAIN OUTCOME MEASURES

Standardised incidence rate of myocardial infarction and 30 day and 31-365 day mortality by sex. Comorbidity categories were defined as normal, moderate, severe, and very severe according to the Charlson comorbidity index, and were compared by means of mortality rate ratios based on Cox regression.

RESULTS

The standardised incidence rate per 100,000 people decreased in the 25 year period by 37% for women (from 209 to 131) and by 48% for men (from 410 to 213). The 30 day, 31-365 day, and one year mortality declined from 31.4%, 15.6%, and 42.1% in 1984-8 to 14.8%, 11.1%, and 24.2% in 2004-8, respectively. After adjustment for age at time of myocardial infarction, men and women had the same one year risk of dying. The mortality reduction was independent of comorbidity category. Comparing patients with very severe versus normal comorbidity during 2004-8, the mortality rate ratio, adjusted for age and sex, was 1.96 (95% CI 1.83 to 2.11) within 30 days and 3.89 (3.58 to 4.24) within 31-365 days.

CONCLUSIONS

The rate of first time hospitalisation for myocardial infarction and subsequent short term mortality both declined by nearly half between 1984 and 2008. The reduction in mortality occurred for all patients, independent of sex and comorbidity. However, comorbidity burden was a strong prognostic factor for short and long term mortality, while sex was not.

Patients with micro or other myocardial infarctions have equal long-term survival

OBJECTIVES

To investigate differences in prognosis after myocardial infarction (MI) in patients classified according to the old and new definitions of MI. Patients not fulfilling the old definitions were classified as having a micro MI.

DESIGN

Data on 1216 consecutive patients with a diagnosis of first MI (38.3% women) and who were discharged from or died in one hospital in the 5-year period from 2001 were included in the study. Surviving patients were followed for a mean of 8.2 years. Risk factors and death after MI were analysed according to MI classification.

RESULTS

Of the patients, 20.1% were classified as having a micro MI. During follow-up, 47.2% of all the patients died. Patients with micro MI were older and fewer were current smokers than patients with other MI. In multivariate Cox regression analysis for the total risk of mortality, age, diabetes mellitus, a positive smoking history, history of stroke and living alone were significantly related to long-term prognosis, and there was no difference in long-term survival between the two types of MI (p 0.50).

CONCLUSIONS

After adjustment for confounders, patients with micro MI had no significant difference in long-term survival compared with those with other MI.

Baseline characteristics, management practices, and long-term outcomes of Middle Eastern patients in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-2)

BACKGROUND AND OBJECTIVES

Limited data are available on patients with acute coronary syndromes (ACS) and their long-term outcomes in the Arabian Gulf countries. We evaluated the clinical features, management, in-hospital, and long-term outcomes of in such a population.

DESIGN AND SETTING

A 9-month prospective, multicenter study conducted in 65 hospitals from 6 countries that also included 30 day and 1-year mortality follow-up.

PATIENTS AND METHODS

ACS patients included those with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTEACS), including non-STEMI and unstable angina. The registry collected the data prospectively.

RESULTS

Between October 2008 and June 2009, 7930 patients were enrolled. The mean age (standard deviation), 56 (17) years; 78.8% men; 71.2% Gulf citizens; 50.1% with central obesity; and 45.6% with STEMI. A history of diabetes mellitus was present in 39.5%, hypertension in 47.2%, and hyperlipidemia in 32.7%, and 35.7% were current smokers. The median time from symptom onset to hospital arrival for STEMI patients was 178 minutes (interquartile range, 210 minutes); 22.3% had primary percutaneous coronary intervention (PCI) and 65.7% thrombolytic therapy, with 34% receiving therapy within 30 minutes of arrival. Evidence-based medication rates upon hospital discharge were 68% to 95%. The in-hospital PCI was done in 21% and the coronary artery bypass graft surgery in 2.9%. The in-hospital mortality was 4.6%, at 30 days the mortality was 7.2% , and at 1 year after hospital discharge the mortality was 9.4% ; 1-year mortality was higher in STEMI (11.5%) than in NSTEACS patients (7.7%; P<.001).

CONCLUSIONS

Compared to developed countries, ACS patients in Arabian Gulf countries present at a relatively young age and have higher rates of metabolic syndrome features. STEMI patients present late, and their acute management is poor. In-hospital evidence-based medication rates are high, but coronary revascularization procedures are low. Long-term mortality rates increased severalfold compared with in-hospital mortality.

Burden of systemic hypertension in patients admitted to cardiology hospitalization units

Hypertension is 1 of the most prevalent cardiovascular risk factors; nevertheless, some studies have reported that the antecedent of hypertension does not impair prognosis in patients with established cardiovascular disease. The objective of this study was to describe the impact of hypertension on readmission and 1-year mortality in patients admitted to a single cardiology hospitalization unit. All consecutive hospitalizations in a single cardiology department through 10 months were included, and 1-year follow-up was performed. Clinical antecedents, risk factors, and main discharge diagnoses were collected. A total of 1,007 patients were included (mean age 71.1 ± 13.5 years). The antecedent of hypertension was present in 69.0%, and these patients had older mean age and higher prevalence of risk factors and previous cardiovascular disease. No differences in hospital discharge main diagnoses were observed according to the antecedent of hypertension. During a mean follow-up period of 404.82 ± 122.2 days, patients with hypertension had higher rates of rehospitalization for cardiac causes (31.1% vs 17.9%, p = 0.01) and of total (17.4% vs 9.3%, p <0.01) and cardiovascular (13.9% vs 5.9%, p <0.01) mortality. Multivariate analysis identified the antecedent of hypertension as an independent risk factor for cardiovascular readmission (hazard ratio 1.46, 95% confidence interval 1.10 to 1.98) and the combined end point of readmission or mortality (hazard ratio 1.45, 95% confidence interval 1.12 to 1.88); no independent association was observed for total mortality. In conclusion, hypertension was present in most patients admitted to a cardiology unit, and they had higher rates of rehospitalization and mortality at 1-year follow-up.

Associations of preexisting depression and anxiety with hospitalization in patients with cardiovascular disease

OBJECTIVE

To determine the risk of hospitalization and death in relation to preexisting depression and anxiety among patients with cardiovascular disease (CVD).

PATIENTS AND METHODS

The cohort consisted of 799 Olmsted County, MN, residents diagnosed with CVD (myocardial infarction or heart failure) from January 1, 1979, to December 31, 2009, who completed a Minnesota Multiphasic Personality Inventory (MMPI) prior to their event. The MMPI was used to identify depression and anxiety, and participants were followed up for hospitalizations and death during an average of 6.2 years.

RESULTS

Depression and anxiety were identified in 282 (35%) and 210 (26%) participants, respectively. After adjustment, depression and anxiety were independently associated with a 28% (95% confidence interval [CI], 8%-51%) and 26% (95% CI, 3%-53%) increased risk of being hospitalized, respectively. Depression also conferred an increased risk of all-cause mortality of similar magnitude, whereas the hazard ratio for anxiety was not statistically significant. The combined occurrence of depression and anxiety led to a 35% (95% CI, 8%-71%) increase in the risk of hospitalizations.

CONCLUSION

Among patients with CVD, both preexisting depression and anxiety, occurring on average 17 years before the CVD event, independently predict hospitalizations. In addition, the 2 conditions may act synergistically on increasing health care utilization in patients with CVD.

National gender-specific trends in myocardial infarction hospitalization rates among patients aged 35 to 64 years

In recent years, the prevalence of myocardial infarction (MI) has increased among women and decreased among men aged 35 to 54 years. To determine the extent to which changes in incidence account for recent variations in prevalence, we assessed the temporal trends in gender-specific hospitalization rates for MI. Using the Nationwide Inpatient Sample, we identified patients aged 35 to 64 years admitted to United States hospitals with a primary discharge diagnosis of MI from 1997 to 2006 (n = 2,824,615). The age-standardized MI hospitalization rates per 100,000 subjects were assessed for men and women aged 35 to 44, 45 to 54, and 55 to 64 years. The MI hospitalization rates per 100,000 subjects decreased by 26% from 168 to 126 for men and by 18% from 56 to 46 for women (both p <0.001). The reductions in the MI hospitalization rates were greatest among men aged 45 to 54, men aged 55 to 64, and women aged 55 to 64 years (standardized rates of change -3%, -4%, and -3% annually, p <0.001). The MI hospitalization rates decreased slightly for women aged 45 to 54 years and men aged 35 to 44 years (standardized rate of change -2% annually, p <0.001) and increased for women aged 35 to 44 years (standardized rate of change 2% annually, p = 0.008). In conclusion, from 1997 to 2006, men and women aged 35 to 64 years experienced an overall decrease in MI hospitalization rates; the reductions were more pronounced in men than in women. The slight increase in MI hospitalizations among women aged 35 to 44 years might have played a small role in the previously noted increases in MI prevalence among middle-age women.

Atrial fibrillation and mortality in heart failure: a community study

BACKGROUND

Heart failure (HF) and atrial fibrillation (AF) share common risk factors and often coexist. The combination of HF and AF may carry a worse prognosis than either condition alone; however, the magnitude of this risk remains controversial and it is not known whether the timing of AF influences the risk of death.

METHODS AND RESULTS

We determined the risk of all-cause mortality in relation to the presence of AF prior to or after HF diagnosis in a community-based cohort of persons diagnosed as having HF between 1983 and 2006. Of 1664 individuals with HF, 553 had a history of AF and 384 developed AF after HF. During a median follow-up of 4.0 years, 450 deaths occurred among persons with prior AF, 314 among those with AF after HF, and 572 among patients without AF. In fully adjusted models, compared with patients without AF, those with AF prior to HF had a 29% increased risk of death, whereas those who developed AF after HF exhibited >2-fold increased risk of death.

CONCLUSIONS

In the community, AF is frequent in the setting of HF and is associated with a large excess risk of death. The magnitude of this excess risk differs markedly according to the timing of AF, with AF developing after HF conferring the largest increased risk of death compared with HF patients without AF.

Trends in Q-wave acute myocardial infarction case fatality from 1978 to 2007 and analysis of the effectiveness of different treatments

BACKGROUND

We sought to analyze the trends in first Q-wave acute myocardial infarction (AMI) case fatality from 1978 to 2007 in a population-based hospital register, to determine the variables related to these changes, and to assess the effectiveness of current AMI management.

METHODS

Population-based hospital registry included patients with first Q-wave AMI aged 25 to 74 years admitted between 1978 and 2007. Sociodemographic and clinical characteristics, treatments, and procedures used during hospital stay, and 28-day case fatality were recorded. Logistic regression was used for multivariate analysis of six 5-year periods.

RESULTS

The 30-year study included 3,982 patients. Mean 28-day case fatality was 8.96%, with a decreasing trend from 16.6% in the first 5-year period to 4.7% in the sixth (P for trend < .001). Study period was independently associated with case fatality. Case-fatality reduction attributable to pharmacologic treatments was 51% overall; in 24-hour survivors, pharmacologic treatments and broad use of invasive procedures explained 39% and 38%, respectively, of the difference between the observed case fatality in 2003-2007 and 1978-1982.

CONCLUSION

A dramatic decrease in 28-day case fatality occurred during this 30-year period and was mainly related to the use of antiplatelet drugs, β-blockers, thrombolysis, and invasive procedures. These data support the current guidelines for the management of acute coronary syndrome.

Age- and sex-specific trends in the incidence of hospitalized acute coronary syndromes in Western Australia

BACKGROUND- The incidence of myocardial infarction has declined during the past 4 decades in many populations. However, there are limited population data measuring trends in acute coronary syndromes (ACS). We therefore examined temporal trends in the incidence of hospitalized ACS by age and sex in a population-based cohort. METHODS AND RESULTS- The Western Australian Data Linkage System, a repository of linked administrative health data, was used to identify 29 421 incident ACS hospitalizations between 1996 and 2007. Poisson log-linear regression models were used to calculate incidence rate changes. Age-standardized incidence rates of ACS declined annually in men by 1.7% (95% confidence interval [CI], -2.1 to -1.3) and in women by 1.6% (95% CI, -2.1 to -1.0). These declining rates were underpinned by annual reductions in the incidence of unstable angina (men, -3.0%; 95% CI, -3.7 to -2.4; women, -2.5; 95% CI, -3.3 to -1.7), whereas annual changes in myocardial infarction incidence were less (men, -1.0%; 95% CI, -1.5 to -0.5; women, -0.8%; 95% CI, -1.6 to 0). However, the overall trends masked age group differences, with ACS incidence increasing annually in 35- to 54-year-old women (2.3%; 95% CI, 1.0 to 3.8), predominantly driven by increasing incidence of myocardial infarction. CONCLUSIONS- The age-standardized incidence of ACS decreased significantly in Western Australia from 1996 to 2007. However, an increase in ACS incidence in women ages 35 to 54 years is troubling and warrants further investigation.

Age and gender differences in incidence and case fatality trends for myocardial infarction: a 30-year follow-up. The Tromso Study

BACKGROUND

Although the mortality of coronary heart disease (CHD) has declined in Western countries during the last decades, studies have suggested that the prevention and treatment of CHD may not have been as effective in women as in men. We examined gender- and age-specific trends in incidence, case fatality and the severity of first myocardial infarction (MI) in a large Norwegian population-based study.

DESIGN

Prospective population-based cohort study.

METHODS

A total of 31,323 participants enrolled between 1974 and 2001 were followed throughout 2004 for a total of 400,572 person-years. Suspected coronary events were adjudicated by a review of hospital records and death certificates. A total of 1669 events fulfilled standardized criteria of first-ever fatal or non-fatal MI.

RESULTS

In the age group 35-79 years, the age-adjusted incidence of MI declined significantly in men, whereas an increase was observed in women. For men and women ≥ 80 years the incidence rates remained unchanged. The severity of MI and the 28-day and 1-year case fatality rates declined significantly and similarly in men and women.

CONCLUSION

Trends in MI incidence differed by sex and age; in the age group 35-79 years a marked decrease was observed among men but an increase was observed among women, while no change was observed among older patients. MI severity and case fatality were clearly reduced for both sexes. These data suggest that the burden of CHD is shifting from middle-aged men toward middle-aged women and elderly patients.

[Reduction in 28 days and 6 months of acute myocardial infarction mortality from 1995 to 2005. Data from PRIAMHO I, II and MASCARA registries]

INTRODUCTION AND OBJECTIVES

To determine whether mortality from acute myocardial infarction has reduced in Spain and the possibly related therapeutic factors.

METHODS

Nine thousand, nine hundred and forty-nine patients with ST-segment elevation myocardial infarction admitted to the Coronary Care Unit were identified from PRIAMHO I, II and MASCARA registries performed in 1995, 2000 and 2005, with a 6 month follow-up.

RESULTS

From 1995 to 2005 patients were increasingly more likely to have hypertension, hyperlipidemia and anterior infarction, but age of onset and the proportion of females did not increase. Twenty-eight-day mortality rates were 12.6%, 12.3% and 6% in 1995, 2000 and 2005 respectively, and 15.3%, 14.6% and 9.4% at 6 months (both P-trend <.001). Multivariate analysis was performed and the adjusted odds ratio for 28-day mortality for an infarction occuring in 2005 (compared with 1995) was 0.62 (95% confidence interval: 0.44-0.88) whereas the adjusted hazard ratio for mortality at 6 months was 0.40 (95% confidence interval: 0.24-0.67). Other variables independently associated with lower mortality at 28 days were: reperfusion therapy, and the use of anti-thrombotic treatment, beta-blockers and angiotensin-converting enzyme inhibitors. The 28-day-6-month period had an independent protective effect on the following therapies: coronary reperfusion, and prescription of antiplatelet agents, beta-blockers and lipid lowering drugs upon discharge.

CONCLUSIONS

Twenty-eight-day and six-month mortality rates fell among patients with ST-elevation myocardial infarction in Spain from 1995 to 2005. The possibly related therapeutic factors were the following: more frequent reperfusion therapy and increased use of anti-thrombotic drugs, beta-blockers, angiotensin-converting enzyme inhibitors and lipid lowering drugs.

Association between myocardial infarction and fractures: an emerging phenomenon

BACKGROUND

Data on the association between myocardial infarction (MI) and fractures are scarce. Recent changes in the epidemiology of MI justify exploring this relationship. We evaluated whether MI constitutes a risk factor for osteoporotic fracture and examined secular trends in this association.

METHODS AND RESULTS

Consecutive Olmsted County, Minnesota, residents with incident MI diagnosed in 1979 to 2006 and community control subjects individually matched (1:1) to cases on age, sex, and year of onset (n=6642) were followed up through 2009. Outcome measures were time to osteoporotic fracture, overall and by anatomic site, and death. Fracture incidence rates were stable in controls but increased markedly over time among MI cases. Accordingly, although an overall excess of fracture risk after MI was observed (adjusted hazard ratio, 1.32; 95% confidence interval, 1.12 to 1.56), substantial temporal variations were noted (1979 to 1989: hazard ratio, 0.81; 95% confidence interval, 0.58 to 1.12; 1990 to 1999: hazard ratio, 1.47; 95% confidence interval, 1.10 to 1.96; 2000 to 2006: hazard ratio, 1.73; 95% confidence interval, 1.32 to 2.27; P for trend <0.001). Trends were similar regardless of age, sex or fracture site. Conversely, the overall hazard ratio for death in MI cases versus controls did not change materially despite a continuous decline in 30-day case fatality rate (12.5% in 1979 to 1989; 6.7% in 2000 to 2006). Observed changes in the baseline prevalence of cardiovascular risk factors, MI characteristics, and comorbidities did not fully account for the trends in fracture risk.

CONCLUSIONS

Over the past decades, the association between MI and osteoporotic fractures increased steadily. The trend is consistent with the displacement of post-MI outcomes toward noncardiovascular events, highlighting the need for comprehensive prevention strategies to accommodate the changing epidemiology of MI.

Can we monitor heart attack in the troponin era? Evidence from a population-based cohort study

Background

Troponins (highly sensitive biomarkers of myocardial damage) increase counts of myocardial infarction (MI) in clinical practice, but their impact on trends in admission rates for MI in National statistics is uncertain.

Methods

Cases coded as MI or other cardiac diagnoses in the Hospital Morbidity Data Collection (MI-HMDC) in Western Australia in 1998 and 2003 were classified using revised criteria for MI developed by an International panel convened by the American Heart Association (AHA criteria) using information on symptoms, ECGs and cardiac biomarkers abstracted from samples of medical notes. Age-sex standardized rates of MI-HMDC were compared with rates of MI based on AHA criteria including troponins (MI-AHA) or traditional biomarkers only (MI-AHAck).

Results

Between 1998 and 2003, rates of MI-HMDC decreased by 3.5% whereas rates of MI-AHA increased by 17%, a difference largely due to increased false-negative cases in the HMDC associated with marked increased use of troponin tests in cardiac admissions generally, and progressively lower test thresholds. In contrast, rates of MI-AHA_ck declined by 18%.

Conclusions

Increasing misclassification of MI-AHA by the HMDC may be due to reluctance by clinicians to diagnose MI based on relatively small increases in troponin levels. These influences are likely to continue. Monitoring MI using AHA criteria will require calibration of commercially available troponin tests and agreement on lower diagnostic thresholds for epidemiological studies. Declining rates of MI-AHA_ck are consistent with long-standing trends in MI in Western Australia, suggesting that neither MI-HMDC nor MI-AHA reflect the true underlying population trends in MI.