Is acute myocardial infarction disappearing?

Epidemiology and pathophysiologic insights of coronary atherosclerosis relevant for contemporary non-invasive imaging

In the past few years significant changes have taken place in the diagnostic and therapeutic approach to patients with coronary artery disease (CAD) and/or ischemic heart disease (IHD). New discoveries about the development and progression of coronary atherosclerosis have changed the clinical landscape. At the same time a marked decrease in cardiovascular (CV) mortality and CAD incidence have been observed in many Countries but particularly in the most industrialized ones. This fall has been also observed in the incidence of stroke, sudden death, myocardial ischemia, myocardial infarction (MI), and prevalence of CAD. As a consequence, an increasing number of patients with chest pain exhibits non-significant stenosis at both invasive and non-invasive coronary angiography and the rate of coronary vessels revascularizations has greatly reduced. Coronary atherosclerosis and its characteristics have shown to be both diagnostic and therapeutic targets beyond obstructive CAD. The decreased prevalence of CAD in the general population has modified the pre-test probability (PTP) of disease. In this landscape the conventional stress imaging tests appear to have limited accuracy making the diagnosis of obstructive CAD very challenging. These diagnostic tests have been introduced and tested in a population with a much higher probability of disease and therefore the contemporary accuracy of these old tests appear much lower than in the past. In addition, in the past few years the relevance of the traditional ischemia guided coronary intervention strategy has been questioned. Given the low CV events granted by an optimal medical therapy in CAD the major attention has been directed on detecting coronary atherosclerosis. The earlier the better. At the same time, a growing number of data from clinical studies have shown a significant prognostic role for non-obstructive CAD and coronary atherosclerosis. All these facts have shifted the clinicians' attention from the functional evaluation of the coronary circulation to the anatomic burden of disease.

Impact of the Regional Network for AMI in the Management of STEMI on Care Processes, Outcomes and Health Inequities in the Veneto Region, Italy

Cardiovascular diseases are a leading cause of death in Europe. Outcomes in terms of mortality and health equity in the management of patients with ST-Elevation Myocardial Infarction (STEMI) are influenced by health care service organization. The main aim of the present study was to examine the impact of the new organizational model of the Veneto Region’s network for Acute Myocardial Infarction (AMI) to facilitate primary percutaneous coronary intervention (PCI) on STEMI, and its efficacy in reducing health inequities. A retrospective cohort study was conducted on HDRs in the Veneto Region for the period 2007–2016, analyzing 65,261 hospitalizations for AMI. The proportion of patients with STEMI treated with PCI within 24 h increased significantly for men and women, and was statistically much higher for patients over 75 years of age (APC, 75–84: 9.8; >85: 12.5) than for younger patients (APC, <45: 3.3; 45–64: 4.9), with no difference relating to citizenship. The reduction in in-hospital, STEMI-related mortality was only statistically significant for patients aged 75–84 (APC: −3.0 [−4.5;−1.6]), and for Italians (APC: −1.9 [−3.2;−0.6]). Multivariate analyses confirmed a reduction in the disparities between socio-demographic categories. Although the new network improved the care process and reduced health care disparities in all subgroups, these efforts did not result in the expected survival benefit in all patient subgroups.

Access to percutaneous transluminal coronary angioplasty and 30-day mortality in patients with incident STEMI: Differentials by educational level and gender over 11 years

Background

Socioeconomic status and gender are associated with access to cardiac procedures and mortality after AMI, also in countries with universal health care systems. Our objective was to evaluate the association and trends of educational level or gender and the following outcomes: 1) access to PTCA; 2) 30-day mortality.

Methods

We conducted an observational study based on 14,013 subjects aged 35–74 years, residing in Rome in 2001, and hospitalised for incident STEMI within 2012 in the Lazio region. We estimated adjusted ORs of educational level or gender and: 1) PTCA within 2 days after hospitalisation, 2) 30-day mortality. We evaluated time trends of outcomes, and time trends of educational or gender differentials estimating ORs stratified by time period (two time periods between 2001 and 2012). We performed a hierarchical analysis to account for clustering of hospitals.

Results

Access to PTCA among patients with incident STEMI increased during the study period, while 30-day mortality was stable. We observed educational differentials in PTCA procedure only in the first time period, and gender differentials in both periods. Patterns for 30-day mortality were less marked, with educational differentials emerging only in the second period, and gender differentials only in the first one, with patients with low educational level and females being disadvantaged.

Conclusions

Educational differentials in the access to PTCA disappeared in Lazio region over time, coherently with scientific literature, while gender differentials seem to persist. It may be important to assess the role of female gender in patients with STEMI, both from a social and a clinical point of view.

Beneficial role of tamoxifen in isoproterenol-induced myocardial infarction

ER-α and ER-β agonist 17β-estradiol is reported to attenuate cardiac hypertrophy. Tamoxifen is a selective estrogen receptor modulator. Hence, the objective of this study was to investigate the effects of tamoxifen in myocardial infarction. For this, tamoxifen was administered to Sprague–Dawley rats for 1–14 days, and isoproterenol (ISO) (100 mg·(kg body mass)−1·day−1) was administered subcutaneously on the 13th and 14th days of the study in order to induce myocardial infarction, after which, various biochemical, cardiac, and morphometric parameters were evaluated. ISO produced significant dyslipidemia, hypertension, bradycardia, oxidative stress, and an increase in serum cardiac markers. Treatment with tamoxifen significantly controlled dyslipidemia, hypertension, bradycardia, oxidative stress, and reduced serum cardiac markers. The ISO control rats exhibited significant increases in the infarct size of the left ventricle (LV), LV cavity area, cardiac and LV hypertrophic indices, LV-wall thickness, cardiomyocyte diameter, and area. Treatment with tamoxifen significantly reduced infarction as well as hypertrophic and morphometric parameters. ISO also produced significant increases in the LV collagen level, decreases in Na+K+ATPase activity, and a reduction in the rate of pressure development and decay, which were prevented by tamoxifen treatment. The protective effect of tamoxifen on myocardial infarct was further confirmed by histopathological examination. Our data thus suggest that tamoxifen exerts beneficial effects in ISO-induced myocardial infarction.

Future of polypill use for the prevention of cardiovascular disease and strokes

Cardiovascular disease (CVD) remains still the leading cause of death in the United States, and it is estimated to be the leading cause of death in the developing countries by 2020. In addition, the modifiable cardiovascular risk factors (CVRFs), hypertension, hypercholesterolemia, diabetes, and obesity, have increased significantly and by 2020 will account for 80% of all CVD deaths worldwide. Because the CVD and stroke risk increases significantly for subjects aged >50 years, it has been proposed to treat these subjects with a polypill containing 4 to 5 drugs, which is known to reduce the CVRFs for all subjects aged ≥55 years with an estimated reduction of CVD and stroke by 80%. However, this proposal is neither practical nor cost-effective, because it will involve a large number of subjects. Some investigators suggest to incorporate the coronary artery calcium score (CACS) with the Framingham Risk Score (FRS) to reduce the number of subjects who will benefit from the polypill. They have shown that patients with a CACS = 0 at age 50 years will derive no benefit from the polypill regardless of existing CVRFs, whereas those with a CACS of >100 will derive the best benefit. This strategy will reduce the number of qualified subjects for treatment with the polypill by 60%. Greater benefits will be derived with the combination of CACS and FRS. Additionally, other issues will have to be considered before approval of a polypill, and these issues will be discussed in this concise review. In conclusion, a polypill treatment strategy may be effective in the prevention of CVD and stroke, but, to be cost-effective, it may be reasonable to target patients with a high CACS and FRS.

[Prevalence of myocardial infarction and coronary heart disease in adults aged 40-79 years in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1)]

In the German Health Interview and Examination Survey for Adults (DEGS1), data on the prevalence of myocardial infarction and coronary heart disease were collected from 2008-2011 in a representative population-based sample of 5,901 adults aged 40-79 years. The results of DEGS1 were compared with the prevalence estimates from the German National Health Interview and Examination Survey 1998 (GNHIES98). The lifetime prevalence of myocardial infarction amongst 40-79 year olds in DEGS1 is 4.7 % (women 2.5 %; men 7 %). In comparison with GNHIES98 a small increase was observed in men, but not in women. The lifetime prevalence of coronary heart disease in adults aged 40-79 years in DEGS1 is 9.3 % (women 6.4 %; men 12.3 %). In comparison to GNHIES98 there is a slight reduction only in women. There is a significant inverse relationship between disease prevalence and socioeconomic status. The trend in prevalence of coronary heart disease is comparable with that in other high-income countries. Given a falling incidence of myocardial infarction and a decrease in the mortality rates due to coronary heart disease, the basically stable prevalence rates indicate a positive development in the field of cardiovascular prevention and therapy. An English full-text version of this article is available at SpringerLink as supplemental.

Comprehensive smoking bans and acute myocardial infarction among Medicare enrollees in 387 US counties: 1999-2008

Restrictions on smoking in public places have become increasingly widespread in the United States, particularly since the year 2005. National-scale studies in Europe and local-scale studies in the United States have found decreases in hospital admissions for acute myocardial infarction (AMI) following smoking bans. The authors analyzed AMI admission rates for the years 1999-2008 in 387 US counties that enacted comprehensive smoking bans across 9 US states, using a study population of approximately 6 million Medicare enrollees aged 65 years or older. Effects of smoking bans on AMI admissions were estimated by using Poisson regression with linear and nonlinear adjustment for secular trend and random effects at the county level. Under the assumption of linearity in the secular trend of declining AMI, smoking bans were associated with a statistically significant ban-associated decrease in admissions for AMI in the 12 months following the ban. However, the estimated effect was attenuated to nearly zero when the assumption of linearity in the underlying trend was relaxed. This analysis demonstrates that estimation of potential health benefits associated with comprehensive smoking bans is challenged by the need to adjust for nonlinearity in secular trend.

Acute myocardial infarction in New York State: 1996-2008

We examined the Acute Myocardial Infarction (AMI) incidence and mortality rates in New York State for a recent 13-year period. Hospital discharge data and death certificate information are combined to create patient episodes for AMI. Trends in the risk-adjusted AMI incidence and mortality are examined for the years 1996 through 2008. Between 1996 and 2008, the AMI incidence rate declined by 35.8% and AMI mortality fell from 161.0 to 71.6 per 100,000 population. This 55.5% decline in mortality is accompanied by a 23.9% decline in the number of AMI admissions to acute care hospitals and by a 37.8% improvement in mortality among those hospitalized. New York State follows the national trend in decline in AMI. That decline is accompanied by reductions in AMI mortality, reduced demand on hospitals, and significant improvement in hospital care quality among AMI patients.

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.

Cardiovascular disease: rise, fall, and future prospects

Cardiovascular disease (CVD) became the leading cause of chronic disease morbidity and mortality in industrialized countries in the twentieth century. In many nations, it peaked and began to decline, while in developing countries it is rising. The contributions of risk factors, sociocultural changes, and medical care are debated, but all play a role in understanding these disease patterns. Public health approaches such as dietary change along with widespread use of medications such as aspirin, statins, diuretics, and beta-blockers may impact future trends in this chronic disease epidemic.