Long-term prognosis after hospital admission for acute myocardial infarction from 1987 to 2006

An Asian Perspective on Gender Differences in In-Hospital and Long-Term Outcome of Cardiac Mortality and Ischemic Stroke after Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

OBJECTIVES

Gender differences historically exist in cardiovascular disease, with women experiencing higher rates of major adverse cardiovascular events. We investigated these trends in a contemporary Asian cohort, examining the impact of gender differences on cardiac mortality and ischemic stroke after primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

We analysed 3971 consecutive patients who underwent primary PCI for STEMI retrospectively. The primary outcome was cardiac mortality and ischemic stroke in-hospital, at one year and on longer-term follow up (median follow up 3.62 years, interquartile range 1.03-6.03 years).

RESULTS

There were 580 (14.6%) female patients and 3391 (85.4%) male patients. Female patients were older and had higher prevalence of hypertension, diabetes, previous strokes, and chronic kidney disease. Cardiac mortality was higher in female patients during in-hospital (15.5% vs. 6.2%), 1-year (17.4% vs. 7.0%) and longer term follow up (19.9% vs. 8.1%, log-rank test: p < 0.001). Similarly, females had higher incidence of ischemic stroke at in-hospital (2.6% vs. 1.0%), 1-year (3.6% vs. 1.4%) and in the longer-term (6.7% vs. 3.1%) as well (log-rank test: p < 0.001). Female gender remained an independent predictor of in-hospital cardiac mortality (HR 1.395, 95%CI 1.061-1.833, p=0.017) and on longer-term follow-up (HR 1.932 95%CI 1.212-3.080, p=0.006) even after adjusting for confounders.

CONCLUSIONS

Females were at higher risk of in-hospital and long-term cardiac mortality and ischemic stroke after PPCI for STEMI. Future studies are warranted to investigate the role of aggressive management of cardiovascular risk factors and follow-up to improve outcomes in the females with STEMI.

Risk of Cardiovascular Hospital Admission After Exposure to Fine Particulate Pollution

BACKGROUND

Heavy fine particulate matter with an aerodynamic diameter ≤2.5 μm (PM_2.5) pollution events continue to occur frequently in developing countries.

OBJECTIVES

The authors conducted a case-crossover study aimed at exploring the association between heavy PM_2.5 pollution events and hospital admission for cardiovascular diseases.

METHODS

Hospital admissions for cardiovascular diseases were observed by Beijing Municipal Commission of Health and Family Planning Information Center from 2013 to 2017. Air pollution data were collected from the Beijing Municipal Environmental Monitoring Center. Distinct definitions were used to identify heavy and extremely heavy fine particulate pollution events. A conditional logistic regression model was used. The hospital admission burdens for cardiovascular disease were also estimated.

RESULTS

A total of 2,202,244 hospital admissions for cardiovascular diseases and 222 days of extremely heavy PM_2.5 pollution events (PM_2.5 concentration ≥150 μg/m³) were observed. The ORs associated with extremely heavy PM_2.5 pollution events lasting for 3 days or more for total cardiovascular disease, angina, myocardial infarction, ischemic stroke, and heart failure were 1.085 (95% CI: 1.077-1.093), 1.112 (95% CI: 1.095-1.130), 1.068 (95% CI: 1.037-1.100), 1.071 (95% CI: 1.053-1.090), and 1.060 (95% CI: 1.021-1.101), respectively. The numbers and days of cardiovascular disease hospital admission annually related to extremely heavy PM_2.5 pollution events lasting for 1 day or more were 3,311 (95% CI: 2,969-3,655) and 37,020 (95% CI: 33,196-40,866), respectively.

CONCLUSIONS

Heavy and extremely heavy PM_2.5 pollution events resulted in substantial increased hospital admission risk for cardiovascular disease. With higher PM_2.5 concentration and longer duration of heavy PM_2.5 pollution events, a greater risk of cardiovascular hospital admission was observed.

Left Ventricular Ejection Fraction 1 Year After Acute Myocardial Infarction Identifies the Benefits of the Long-Term Use of β-Blockers: Analysis of Data From the KAMIR-NIH Registry

[Figure: see text].

Healthcare disparities for women hospitalized with myocardial infarction and angina

AIMS

Ischaemic heart disease persists as the leading cause of death in both men and women in most countries and sex disparities, defined as differences in health outcomes and their determinants, may be relevant. We examined sex disparities in presenting characteristics, treatment and all-cause mortality in patients hospitalized with myocardial infarction (MI) or angina.

METHODS AND RESULTS

We conducted a cohort study of all patients admitted with MI or angina (01 October 2013 to 30 June 2016) from a secondary care acute coronary syndrome e-Registry in NHS Scotland linked with national registers of community drug dispensation and mortality data. A total of 7878 patients hospitalized for MI or angina were prospectively included; 3161 (40%) were women. Women were older, more deprived, had a greater burden of comorbidity, were more often treated with guideline-recommended therapy preadmission and less frequently received immediate invasive management. Men were more likely to receive coronary angiography [adjusted odds ratio (OR) 1.52, confidence interval (CI) 1.37-1.68] and percutaneous coronary intervention (adjusted OR 1.68, CI 1.52-1.86). Women were less comprehensively treated with evidence-based therapies post-MI. Women had worse crude survival, primarily those with ST-elevation myocardial infarction (14.3% vs. 8.0% at 1 year, P < 0.001), but this finding was explained by differences in baseline factors. Men with non-ST-elevation myocardial infarction had a higher risk of all-cause death at 30 days [adjusted hazard ratio (HR) 1.72, CI 1.16-2.56] and 1 year (adjusted HR 1.38, CI 1.12-1.69).

CONCLUSION

After taking account of baseline risk factors, sex differences in treatment pathway, use of invasive management, and secondary prevention therapies indicate disparities in guideline-directed management of women hospitalized with MI or angina.

Mortality following first-time hospitalization with acute myocardial infarction in Norway, 2001-2014: Time trends, underlying causes and place of death

BACKGROUND

Trends on cause-specific mortality following acute myocardial infarction (AMI) are poorly described and no studies have analyzed where do AMI patients die. We analyzed trends in 28-day and one-year mortality following an incident AMI with focus on changes over time in the underlying cause and place of death.

METHODS

We identified in the 'Cardiovascular Disease in Norway' Project all patients 25+ years, hospitalized with an incident AMI in Norway, 2001-2014. Information on date, underlying cause and place of death was obtained from the Cause of Death Registry.

RESULTS

Of 144,473 patients included in the study, 11.4% died within first 28 days. The adjusted 28-day mortality declined by 5.2% per year (p_trend < 0.001). Of 118,881 patients surviving first 28 days, 10.1% died within one year. The adjusted one-year CVD mortality declined by 6.2% per year (p_trend < 0.001) while non-CVD mortality increased by 1.4% per year (p_trend < 0.001), mainly influenced by increased risk of dying from neoplasms. We observed a shift over time in the underlying cause of death toward more non-CVD deaths, and in the place of death toward more deaths occurring in nursing homes.

CONCLUSIONS

We observed a decline in 28-day mortality following an incident AMI hospitalization. One-year CVD mortality declined while one-year risk of dying from non-CVD conditions increased. The resulting shift toward more non-CVD deaths and deaths occurring outside a hospital need to be considered when formulating priorities in treating and preventing adverse events among AMI survivors.

Short-term and long-term case-fatality rates for myocardial infarction and ischaemic stroke by socioeconomic position and sex: a population-based cohort study in Sweden, 1990-1994 and 2005-2009

OBJECTIVE

Case-fatality rates (CFRs) for myocardial infarction (MI) and ischaemic stroke (IS) have decreased over time due to better prevention, medication and hospital care. It is unclear whether these improvements have been equally distributed according to socioeconomic position (SEP) and sex. The aim of this study is to analyse differences in short-term and long-term CFR for MI and IS by SEP and sex between the periods 1990-1994 to 2005-2009 for the entire Swedish population.

DESIGN

Population-based cohort study based on Swedish national registers.

METHODS

We used logistic regression and flexible parametric models to estimate short-term CFR (death before reaching the hospital or on the disease event day) and long-term CFR (1 year case-fatality conditional on surviving short-term) across five distinct SEP groups, as well as CFR differences (CFRDs) between SEP groups for both MI and IS from 1990-1994 to 2005-2009. : Result S: Overall short-term CFR for both MI and IS decreased between study periods. For MI, differences in short-term and long-term CFR between the least and most favourable SEP group were generally stable, except in long-term CFR among women; intermediate SEP groups mostly managed to catch up with the most favourable SEP group. For IS, short-term CFRD generally decreased compared with the most favourable group; but long-term CFRD were mostly stable, except for an increase for older subjects.

CONCLUSION

Despite a general decline in CFR for MI and IS across all SEP groups and both sexes as well as some reductions in CFRD, we found persistent and even increasing CFRD among the least advantaged SEP groups, older patients and women. We speculate that targeted prevention rather than treatment strategies have the potential to reduce these inequalities.

Clinical Profile and Management of Patients with Incident and Recurrent Acute Myocardial Infarction in Albania - a Call for More Focus on Prevention Strategies

Background

The clinical profile of acute myocardial infarction (AMI) patients reflects the burden of risk factors in the general population. Differences between incident (first) and recurrent (repeated) events and their impact on treatment are poorly described. We studied potential differences in the clinical profile and in-hospital treatment between patients hospitalised with an incident and recurrent AMI.

Methods

A total of 324 patients admitted in the Coronary Care Unit of ‘Mother Teresa’ hospital, Tirana, Albania (2013-2014), were included in the study. Information on AMI type, complications and risk factors was obtained from patient’s medical file.

Logistic regression analyses were used to explore differences between the incident and recurrent AMIs regarding clinical profile and in-hospital treatment.

Results

Of all patients, 50 (15.4%) had a prior AMI. Compared to incident cases, recurrent cases were older (P=0.01), more often women (P=0.01), less educated (P=0.01), and smoked less (P=0.03). Recurrent cases experienced more often heart failure (HF) (OR=2.48; 95% CI: 1.31–4.70), impaired left ventricular ejection fraction (OR=1.97; 95% CI:1.05–3.71), and multivessel disease (OR=6.32; 95% CI: 1.43–28.03) than incident cases. In-hospital use of beta-blockers was less frequent among recurrent compared to incident cases (OR=0.45; 95% CI: 0.24–0.85), while no statistically significant differences between groups were observed regarding angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, statin, aspirin or invasive procedures.

Conclusion

A more severe clinical expression of the disease and underutilisation of treatment among recurrent AMIs are likely to explain their poorer prognosis compared to incident AMIs.

Initiation and persistence with dual antiplatelet therapy after acute myocardial infarction: a Danish nationwide population-based cohort study

OBJECTIVES

The study investigated dual antiplatelet therapy (DAPT) patterns over time and patient characteristics associated with the various treatments in a myocardial infarction (MI) population.

DESIGN

A registry-based observational cohort study was performed using antecedent data.

SETTING

This study linked morbidity, mortality and medication data from Danish national registries.

PARTICIPANTS

All 28 449 patients admitted to a Danish hospital with a first-time MI and alive at discharge from 2009 through 2012 were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was initiation of DAPT and secondary outcomes comprised persistence in DAPT treatment and switches between DAPT treatments.

RESULTS

The overall proportion of patients prescribed DAPT increased from 68% (CL 95% 67-69%) to 73% (CL 95% 72-74%) from 2009 to 2012. For treatment of patients with and without percutaneous coronary intervention (PCI), the corresponding numbers were from 87% (CL 95% 86-88%) to 91% (CL 95% 90-92%) and from 49% (CL 95% 47-50%) to 52% (CL 95% 51-54%), respectively. Non-PCI patients had a higher cardiovascular risk compared with PCI patients. Among PCI patients, age>75 years, atrial fibrillation, diabetes and peripheral arterial disease were associated with a higher risk of treatment breaks for DAPT. Among patients without PCI, ticagrelor treatment was associated with an increased risk of treatment breaks during the first 12 months compared with clopidogrel treatment.

CONCLUSIONS

From 2009 to 2012, there was an increase in the proportion of patients with MI receiving DAPT, and a longer duration of DAPT. Still, a large proportion of patients without PCI are discharged either without DAPT or with a short DAPT duration. These findings may indicate the need for more careful attention to DAPT for patients with MI not undergoing PCI in Denmark.

Fitness predicts long-term survival after a cardiovascular event: a prospective cohort study

OBJECTIVES

To identify the role of fitness, fitness change, body mass index and other factors in predicting long-term (>5 years) survival in patients with coronary heart disease.

DESIGN

Cohort study of patients with coronary heart disease recruited from 1 January 1993 to 31 December 2002, followed up to March 2011 (1 day to 18 years 3 months, mean 10.7 years).

SETTING

A community-based National Health Service (NHS) cardiac rehabilitation programme serving the Basingstoke and Alton area in Hampshire, UK.

PARTICIPANTS

An unselected cohort of NHS patients, 2167 men and 547 women aged 28-88 years, who attended the rehabilitation programme following acute myocardial infarction, an episode of angina or revascularisation, and had a baseline fitness test.

MAIN OUTCOME MEASURES

Cardiovascular mortality and all-cause mortality.

RESULTS

A high level of fitness (VO2≥22 mL/kg/min for men, VO2≥19 mL/kg/min for women) at completion of the programme was associated with decreased all-cause death, as was a prescription for statins or aspirin, and female gender. Increase in all-cause mortality was associated with higher age and ACE inhibitors prescription. Higher risk of cardiovascular mortality was associated with increasing age, prescriptions for ACE inhibitor, and diagnosis of myocardial infarction or angina as compared with the other diagnoses.

CONCLUSIONS

Prior fitness and fitness improvement are strong predictors of long-term survival in patients who have experienced a cardiac event or procedure. Some secondary prevention medications make a significant contribution to reducing all-cause mortality and cardiovascular mortality in these patients. This study supports public health messages promoting fitness for life.

Trends in Gender Differences in Cardiac Care and Outcome After Acute Myocardial Infarction in Western Sweden: A Report From the Swedish Web System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART)

BACKGROUND

Cardiovascular disease is the most common cause of death for both genders. Debates are ongoing as to whether gender-specific differences in clinical course, diagnosis, and management of acute myocardial infarction (MI) exist.

METHODS AND RESULTS

We compared all men and women who were treated for acute MI at cardiac care units in Västra Götaland, Sweden, between January 1995 and October 2014 by obtaining data from the prospective SWEDEHEART (Swedish Web-System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry. We performed unadjusted and adjusted Cox proportional hazards and logistic regression analyses on complete case data and on imputed data sets. Overall, 48 118 patients (35.4% women) were diagnosed with acute MI. Women as a group had better age-adjusted prognosis than men, but this survival benefit was absent for younger women (aged <60 years) and for women with ST-segment elevation MI. Compared with men, younger women and women with ST-segment elevation MI were more likely to develop prehospital cardiogenic shock (adjusted odds ratio 1.67, 95% CI 1.30 to 2.16, P<0.001 and adjusted odds ratio 1.31, 95% CI 1.16 to 1.48, P<0.001) and were less likely to be prescribed evidence-based treatment at discharge (P<0.001 for β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, statins, and P2Y12 antagonists). Differences in treatment between the genders did not decrease over the study period (P>0.1 for all treatments).

CONCLUSIONS

Women on average have better adjusted prognosis than men after acute MI; however, younger women and women with ST-segment elevation MI have disproportionately poor prognosis and are less likely to be prescribed evidence-based treatment.

Twenty-eight day and one-year case fatality after hospitalisation with an acute coronary syndrome: a nationwide data linkage study

OBJECTIVES

To determine 28-day and one-year case fatality in patients hospitalised with acute coronary syndromes (ACS) and identify factors associated with mortality.

METHODS

All New Zealand residents admitted with ACS between 2007 and 2009 were followed for one year using individual patient linkage of national hospitalisation and mortality datasets. Deaths from any cause were used to calculate 28-day and one-year case fatality. Cox-proportional hazards models were constructed to identify factors associated with mortality after an ACS hospitalisation.

RESULTS

The cohort included 42,920 ACS patients. Case fatality increased steeply with age. Māori and Pacific peoples had 1.5 times the risk of 28-day, and twice the risk of one-year, mortality as Europeans/Others. Low (compared to high) socioeconomic status was associated with significantly higher mortality at 28 days but not one year. Patients with unstable angina had half the risk of short-term mortality as NSTEMI patients, whereas STEMI patients had double the NSTEMI risk.

CONCLUSIONS AND IMPLICATIONS

The major determinant of increasing case fatality was increasing age. There were also substantial differences in case fatality by ethnicity, deprivation and diagnostic category. Further research is needed to explore the possible mechanisms by which ethnic and deprivation disparities occur and effective strategies to address them.

Effect of the Lookback Period's Length Used to Identify Incident Acute Myocardial Infarction on the Observed Trends on Incidence Rates and Survival: Cardiovascular Disease in Norway Project

BACKGROUND

In studies using patient administrative data, the identification of the first (incident) acute myocardial infarction (AMI) in an individual is based on retrospectively excluding previous hospitalizations for the same condition during a fixed time period (lookback period [LP]). Our aim was to investigate whether the length of the LP used to identify the first AMI had an effect on trends in AMI incidence and subsequent survival in a nationwide study.

METHODS AND RESULTS

All AMI events during 1994 to 2009 were retrieved from the Cardiovascular Disease in Norway project. Incident AMIs during 2004 to 2009 were identified using LPs of 10, 8, 7, 5, and 3 years. For each LP, we calculated time trends in incident AMI and subsequent 28-day and 1-year mortality rates. Results obtained from analyses using the LP of 10 years were compared with those obtained using shorter LPs. In men, AMI incidence rates declined by 4.2% during 2004 to 2009 (incidence rate ratio, 0.958; 95% confidence interval, 0.935-0.982). The use of other LPs produced similar results, not significantly different from the LP of 10 years. In women, AMI incidence rates declined by 7.3% (incidence rate ratio, 0.927; 95% confidence interval, 0.901-0.955) when an LP of 10 years was used. The decline was statistically significantly smaller for the LP of 5 years (6.2% versus 7.3%; P=0.02) and 3 years (5.9% versus 7.3%; P=0.03). The choice of LP did not influence trends in 28-day and 1-year mortality rates.

CONCLUSIONS

The length of LP may influence the observed time trends in incident AMIs. This effect is more evident in older women.

Trends in 28-day and 1-year mortality rates in patients hospitalized for a first acute myocardial infarction in Norway during 2001-2009: a "Cardiovascular disease in Norway" (CVDNOR) project

OBJECTIVE

The aim of this study was to investigate the trends in 28-day and 1-year mortality rates in patients hospitalized for a first acute myocardial infarction (AMI) in Norway during the period 2001-2009. Potential age group and gender differences in these trends were also examined.

DESIGN, SUBJECTS AND SETTING

In this retrospective nationwide cohort study, patients hospitalized for a first AMI between 2001 and 2009 were identified in the Cardiovascular Disease in Norway 1994-2009 (CVDNOR) project and followed for 1 year.

MAIN OUTCOME MEASURES

Trends in 28-day and 1-year mortality [both all-cause and cardiovascular disease (CVD) mortality] were investigated.

RESULTS

A total of 115,608 patients (60.6% men) were hospitalized for a first AMI during the study period. Mortality at 28 days was reduced annually by 3.8% overall and by 6.7%, 4.1% and 2.6% in patients aged 25-64, 65-84 and ≥85 years, respectively (all Ptrend < 0.001). In addition, 1-year all-cause mortality was reduced annually by 2.0% overall (Ptrend < 0.001) and by 3.7% (Ptrend = 0.02), 2.5% (Ptrend < 0.001) and 1.1% (Ptrend < 0.001) in patients aged 25-64, 65-84 and ≥85 years, respectively. Furthermore, 1-year CVD mortality was reduced overall by 6.2% annually; a reduction was observed in all age groups. Finally, 1-year non-CVD mortality increased annually overall by 3.9% due to an increase in patients aged ≥65 years.

CONCLUSION

Mortaity at 28 days after the first AMI declinedin Norway between 2001 and 2009 in both men and women and in all age groups. All-cause mortality at 1 year also declined both in men and women due to decreases in CVD mortality rates, whilst non-CVD mortality rates increased amongst patients ≥65 years of age.

Association of various risk factors with prognosis and hospitalization cost in Chinese patients with acute myocardial infarction: A clinical analysis of 627 cases

Acute myocardial infarction (AMI) is the leading cause of morbidity and mortality in the developed world and is becoming increasingly more common in developing countries. The risk factors affecting the prognosis of Chinese patients may differ from those in other populations. This study was conducted to investigate the potential risk factors that may correlate with prognosis and hospitalization costs of Chinese AMI patients. A total of 627 hospitalized AMI patients were recruited and their general information and relevant laboratory parameters were collected. Accordingly, the patients were grouped into different subgroups and potential risk factors and their correlations with prognosis and hospitalization costs were analyzed. Age, high blood pressure, infarct location and percutaneous coronary intervention (PCI) were the variables significantly associated with the differences in the prognosis of AMI patients (P<0.05), whereas times and duration of hospitalization, high blood pressure, infarct location and PCI treatment were found to be significantly associated with the cost of hospitalization (P<0.05). However, the AMI patients enrolled in this study may not be representative of all AMI patients in China. In addition, the prognosis of these patients was limited to their hospital stay. Therefore, long-term follow-up requires careful assessment.

Trends in mortality after first hospitalization with atrial fibrillation diagnosis in Sweden 1987 to 2006

BACKGROUND

To examine trends in 3-year mortality after a first hospitalization with diagnosed atrial fibrillation in a large cohort with and without important comorbidities.

METHODS

The Swedish Hospital Discharge and Cause of Death Registries were linked to investigate trends in mortality for all patients 35 to 84 years hospitalized for the first time with a discharge diagnosis (principal or contributory) of atrial fibrillation in Sweden during 1987 to 2006.We performed an analysis of temporal trends in mortality stratified for presence or absence of co-morbidities affecting survival.

RESULTS

Exactly 376,000 patients (56% male, mean age 72 years) with a first diagnosis of atrial fibrillation during 1987–2006 were identified and followed for 3 years. Patients with one or more of the prespecified comorbidities had the highest mortality and the largest absolute decline in mortality, but patients without these comorbidities had a slightly larger relative decline (absolute risk reduction in 3-year mortality (AAR) from 42.5 to 34.7%, Hazard Ratio (HR) 0.76; 95% confidence interval (95% CI) 0.74 to 0.77 versus ARR 16.2% to 11.7%, HR 0.71; 0.68 to 0.74. In patients aged below 65 years,with no comorbidities, there was minimal change inmortality, and they still had a 2 times increased mortality compared to the general population (SMR 1.95; 1.84-2.06).

CONCLUSIONS

Survival after a first hospitalization with a diagnosis of atrial fibrillation improved regardless comorbidities. Patients aged < 65 years old without diagnosed comorbidities still had a poor prognosis compared to the general population.

Sex-specific trends in 4-year survival in 37 276 men and women with acute myocardial infarction before the age of 55 years in Sweden, 1987-2006: a register-based cohort study

OBJECTIVE

To examine sex-specific trends in 4-year mortality among young patients with first acute myocardial infarction (AMI), 1987-2006.

DESIGN

Prospective cohort study.

SETTING

Sweden.

PARTICIPANTS

We identified 37 276 cases (19.4% women; age, 25-54 years) from the Swedish Inpatient Register, 1987-2006, who had survived 28 days after an AMI.

OUTCOME MEASURES

4-year mortality from all causes and standard mortality ratio (SMR).

RESULTS

From the first to last 5-year period, the absolute excess risk decreased from 1.38 to 0.50 and 1.53 to 0.59 per 100 person-years among men aged 25-44 and 45-54 years, respectively. Corresponding figures for women were a decrease from 2.26 to 1.17 and from 1.93 to 1.45 per 100 person-years, respectively. Trends for women were non-linear, decreasing to the same extent as those for men until the third period, then increasing. For the last 5-year period, the standardised mortality ratio for young survivors of AMI compared with the general population was 4.34 (95% CI 3.04 to 5.87) and 2.43 (95% CI 2.12 to 2.76) for men aged 25-44 and 45-54 years, respectively, and 13.53 (95% CI 8.36 to 19.93) and 6.42 (95% CI 5.24 to 7.73) for women, respectively. Deaths not associated with cardiovascular causes increased from 21.5% to 44.6% in men and 41.5% to 65.9% in women.

CONCLUSIONS

Young male survivors of AMI have low absolute long-term mortality rates, but these rates remain twofold to fourfold that of the general population. After favourable development until 2001, women now have higher absolute mortality than men and a 6-fold to 14-fold risk of death compared with women in the general population.

Experiences and actions during the decision making process among men with a first acute myocardial infarction

BACKGROUND

Previous studies have shown that people hesitate to seek medical attention when experiencing the initial symptoms of acute myocardial infarction (AMI), but the reasons why and the events underpinning the decision-making process are unclear. The aim of this study was to describe the actions and experiences involved in the process of seeking medical attention in men with a first AMI.

METHODS

We studied 21 men, aged 39-73 years, hospitalized with a first AMI between May 2011 and March 2013. All were interviewed in the coronary unit before discharge, with one exception. Data collection and analysis were carried out simultaneously in accordance with grounded theory methodology.

RESULTS

Men diagnosed with a first AMI experienced a spectrum of insidious and vague symptoms, which they did not associate with an AMI. This caused uncertainty in how to interpret symptom severity and contributed to a reluctance to seek medical care. Participants also had difficulty interpreting online information when seeking to explain their symptoms. Weighing up and comparing the various experiences during the early stages of AMI proved to be the trigger that changed the men's perspectives and made them aware of the abnormality, the severity of their illness, and the need for action.

CONCLUSION

Healthcare professionals should be aware that men experience a range of insidious and vague symptoms during their first AMI and must give greater emphasis to their narratives, particularly when objective clinical signs are limited or absent. Consideration should be given to the ways laypeople interpret online information when designing healthcare resources for the Internet.

ECG signs of acute myocardial ischemia in the prehospital setting of a suspected acute coronary syndrome and its association with outcomes

AIMS

The aims of this study were (a) to determine the prehospital prevalence of electrocardiographic (ECG) signs of acute myocardial ischemia in patients with suspected acute coronary syndrome and (b) to describe the relationships between the various ECG patterns and the diagnosis of acute myocardial infarction (AMI) and outcomes.

METHODS

Prospective cohort study using data from an interventional trial in acute chest pain patients transported by the emergency medical services. These patients were classified into 3 groups: patients with ECG showing signs of acute myocardial ischemia, patients with ECG showing other abnormal changes (bundle-branch block, pacemaker rhythm, Q-wave or T-wave inversion) and patients without significant pathologic findings. All P values are age-adjusted.

RESULTS

Among 1546 patients, 312 (20%) had ECG signs of acute myocardial ischemia. Of them, 57% had a final diagnosis of AMI versus 26% of those with other abnormal ECGs and 12% of those with ECG without significant pathologic findings (P<.0001). In all, 53% of all AMI cases involved patients without ECG signs of acute myocardial ischemia. Although ECG signs of acute myocardial ischemia predicted heart failure and ventricular tachyarrhythmias both prior to and after hospital admission, there was no significant difference in 30-day mortality between the 3 patient groups (4.3%, 3.7%, and 1.2%, respectively, P=.11).

CONCLUSION

Among patients with a clinical suspicion of AMI in the prehospital setting, the prevalence of ECG signs suggesting AMI was low, as was the ability to identify AMI patients using ECG findings only. We therefore need better instruments in the prehospital triage of patients with acute chest pain.

Continuing decrease in coronary heart disease mortality in Sweden

Background

Deaths from coronary heart disease (CHD) have been decreasing in most Western countries over the last few decades. In contrast, a flattening of the decrease in mortality has been recently reported among younger age groups in some countries. We aimed to determine whether the decrease in CHD mortality is flattening among Swedish young adults.

Methods

We examined trends in CHD mortality in Sweden between 1987 and 2009 among persons aged 35 to 84 years using CHD mortality data from the Swedish National Register on Cause of Death. Annual percent changes in rates were examined using Joinpoint software.

Results

Overall, CHD mortality rates decreased by 67.4% in men and 65.1% in women. Among men aged 35–54 years, there was a modest early attenuation from a marked initial decrease. In the oldest women aged 75–84 years, an attenuation in the mortality decrease was observed from 1989 to 1992, followed by a decrease, as in all other age groups.

Conclusions

In Sweden, coronary heart disease deaths are still falling. We were unable to confirm a flattening of the decline in young people. Death rates continue to decline in men and women across all age groups, albeit at a slower pace in younger men since 1991. Continued careful monitoring of CHD mortality trends in Sweden is required, particularly among young adults.

Differences between acute myocardial infarction and unstable angina: a longitudinal cohort study reporting findings from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA)

OBJECTIVES

The aim of this study was to compare risk factors and comorbidities in patients with a first episode of acute coronary syndrome (ACS), being either acute myocardial infarction (AMI) or unstable angina pectoris (UAP).

DESIGN

Cross-sectional and prospective.

SETTING

The Swedish population.

PARTICIPANTS

A total of 145 346 consecutive patients aged 25-105 years included in the Swedish Register of Cardiac Intensive Care Admission (Register of Information and Knowledge about Swedish Heart Intensive Care) and admitted to hospital between 1 January 1996 and 30 June 2009 with a first episode of either AMI or UAP.

PRIMARY AND SECONDARY OUTCOME MEASURES

Type of ACS and 1-year outcome.

RESULTS

Compared with patients with UAP, AMI patients were more likely to be older; men; and former or current smokers; they were also more likely to have had diabetes and peripheral artery disease, but had lower rates of prior heart failure (HF) and fewer cardioprotective medications on admission. Among patients aged <65 years, 1.4% of men and 1.6% of women with UAP died within 1 year in 2003-2006 compared with 4.2% of men and 3.1% of women AMI patients (multiple-adjusted OR 3.54 (99% CI 2.29 to 5.48) in women and 2.65 (99% CI 2.11 to 3.34) in men). Corresponding proportions in patients aged ≥65 years was 7.5% in men and 7.6% in women with UAP and 21.5% in men and 17.8% in women with AMI.

CONCLUSIONS

In patients with a first-time ACS episode, male sex, slightly older age, smoking, diabetes and peripheral arterial disease (PAD), but fewer cardioprotective medications, were major determinants for presenting with AMI. Despite increasingly active treatment in AMI and more inclusive diagnostic criteria in recent years, persistently worse prognosis was observed in AMI patients.

The aging population in Sweden: can declining incidence rates in MI, stroke and cancer counterbalance the future demographic challenges?

It is often taken for granted that an ageing population will lead to an increased burden for the health care sector. However, for several diseases of big public health impact the rates have actually come down for a substantial period of time. In this study we investigate how much the incidence rates for myocardial infarction (MI), stroke, and cancer will have to decline in order to counterbalance future demographic changes (changes in population size and age structure) and compare these figures with observed historical trends. Information on incidence rates were obtained from the National Board of Health and Welfare and referred to the total Swedish population. Population projections were obtained from Statistics Sweden. We projected the number of MI events to increase 50-60% between 2010 and 2050. The decline in incidence rates that is required to keep the number of events constant over time is, on average, 1.2%/year for men and 0.9%/year for women, somewhat higher than the trend for the past 10 years. For stroke the corresponding figures were 1.3% (men) and 1% (women), well in line with historical trends. For cancer the results indicate an increasing number of events in the future. Population ageing is more important than population growth when projecting future number of MI, stroke and cancer events. The required changes in incidence rates in order to counterbalance the demographic changes are well in line with historical figures for stroke, almost in line regarding MI, but not in line regarding cancer. For diseases with age dependence similar to these diseases, a reduction of incidence rates in the order of 1-2% is sufficient to offset the challenges of the ageing population. These are changes that have been observed for several diseases indicating that the challenges posed by the ageing population may not be as severe as they may seem when considering the demographic component alone.