Changing Trends in the Landscape of Patients Hospitalized With Acute Myocardial Infarction (2001 to 2011) (from the Worcester Heart Attack Study)

During the past several decades, new diagnostic tools, interventional approaches, and population-wide changes in the major coronary risk factors have taken place. However, few studies have examined relatively recent trends in the demographic characteristics, clinical profile, and the short-term outcomes of patients hospitalized for acute myocardial infarction (AMI) from the more generalizable perspective of a population-based investigation. We examined decade long trends (2001 to 2011) in patient's demographic and clinical characteristics, treatment practices, and hospital outcomes among residents of the Worcester metropolitan area hospitalized with an initial AMI (n = 3,730) at all 11 greater Worcester medical centers during 2001, 2003, 2005, 2007, 2009, and 2011. The average age of the study population was 68.5 years and 56.9% were men. Patients hospitalized with a first AMI during the most recent study years were significantly younger (mean age = 69.9 years in 2001/2003; 65.2 years in 2009/2011), had lower serum troponin levels, and experienced a shorter hospital stay compared with patients hospitalized during the earliest study years. Hospitalized patients were more likely to received evidence-based medical management practices over the decade long period under study. Multivariable-adjusted regression models showed a considerable decline over time in the hospital death rate and a significant reduction in the proportion of patients who developed atrial fibrillation, heart failure, and ventricular fibrillation during their acute hospitalization. These results highlight the changing nature of patients hospitalized with an incident AMI, and reinforce the need for surveillance of AMI at the community level. During the past several decades, new diagnostic tools, interventional approaches, and population-wide changes in the major coronary risk factors have taken place. However, few studies have examined relatively recent trends in the demographic characteristics, clinical profile, and the short-term outcomes of patients hospitalized for acute myocardial infarction (AMI) from the more generalizable perspective of a population-based investigation. We examined decade long trends (2001 to 2011) in patient's demographic and clinical characteristics, treatment practices, and hospital outcomes among residents of the Worcester metropolitan area hospitalized with an initial AMI (n = 3,730) at all 11 greater Worcester medical centers during 2001, 2003, 2005, 2007, 2009, and 2011. The average age of the study population was 68.5 years and 56.9% were men. Patients hospitalized with a first AMI during the most recent study years were significantly younger (mean age = 69.9 years in 2001/2003; 65.2 years in 2009/2011), had lower serum troponin levels, and experienced a shorter hospital stay compared with patients hospitalized during the earliest study years. Hospitalized patients were more likely to received evidence-based medical management practices over the decade long period under study. Multivariable-adjusted regression models showed a considerable decline over time in the hospital death rate and a significant reduction in the proportion of patients who developed atrial fibrillation, heart failure, and ventricular fibrillation during their acute hospitalization. These results highlight the changing nature of patients hospitalized with an incident AMI, and reinforce the need for surveillance of AMI at the community level. Despite significant advances in patient management and population-wide lifestyle changes in several predisposing factors, acute myocardial infarction (AMI) continues to be a major cause of morbidity and mortality in the United States.1Benjamin EJ Virani SS Callaway CW Chamberlain AM Chang AR Cheng S Chiuve SE Cushman M Delling FN Deo R de Ferranti SD Ferguson JF Fornage M Gillespie C Isasi CR Jimenez MC Jordan LC Judd SE Lackland D Lichtman JH Lisabeth L Liu S Longenecker CT Lutsey PL Mackey JS Matchar DB Matsushita K Mussolino ME Nasir K O'Flaherty M Palaniappan LP Pandey A Pandey DK Reeves MJ Ritchey MD Rodriguez CJ Roth GA Rosamond WD Sampson UKA Satou GM Shah SH Spartano NL Tirschwell DL Tsao CW Voeks JH Willey JZ Wilkins JT Wu JH Alger HM Wong SS Muntner P American Heart Association Council on EPrevention Statistics CStroke Statistics SHeart disease and stroke statistics-2018 update: a report from the American Heart Association.Circulation. 2018; 137: e67-e492Crossref PubMed Scopus (3412) Google Scholar,2Roger VL Go AS Lloyd-Jones DM Benjamin EJ Berry JD Borden WB Bravata DM Dai S Ford ES Fox CS Fullerton HJ Gillespie C Hailpern SM Heit JA Howard VJ Kissela BM Kittner SJ Lackland DT Lichtman JH Lisabeth LD Makuc DM Marcus GM Marelli A Matchar DB Moy CS Mozaffarian D Mussolino ME Nichol G Paynter NP Soliman EZ Sorlie PD Sotoodehnia N Turan TN Virani SS Wong ND Woo D Turner MB American Heart Association Statistics CStroke Statistics SExecutive summary: heart disease and stroke statistics–2012 update: a report from the American Heart Association.Circulation. 2012; 125: 188-197Crossref PubMed Scopus (1098) Google Scholar A limited number of community-based studies have described changes over time in the clinical epidemiology and outcomes of patients hospitalized with AMI in the United States.3Roger VL. Epidemiology of myocardial infarction.Med Clin North Am. 2007; 91 (ix): 537-552Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar These studies include the Worcester Heart Attack Study, the Minnesota Heart Survey, and Rochester Epidemiology Project.4Goldberg RJ Spencer FA Yarzebski J Lessard D Gore JM Alpert JS Dalen JE A 25-year perspective into the changing landscape of patients hospitalized with acute myocardial infarction (the Worcester Heart Attack Study).Am J Cardiol. 2004; 94: 1373-1378Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 5Goldberg RJ Gore JM Alpert JS Dalen JE Incidence and case fatality rates of acute myocardial infarction (1975-1984): the Worcester Heart Attack Study.Am Heart J. 1988; 115: 761-767Crossref PubMed Scopus (163) Google Scholar, 6Goldberg RJ Yarzebski J Lessard D Gore JM A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective.J Am Coll Cardiol. 1999; 33: 1533-1539Crossref PubMed Scopus (252) Google Scholar, 7Goldberg RJ Gorak EJ Yarzebski J Hosmer Jr., DW Dalen P Gore JM Alpert JS Dalen JE A communitywide perspective of sex differences and temporal trends in the incidence and survival rates after acute myocardial infarction and out-of-hospital deaths caused by coronary heart disease.Circulation. 1993; 87: 1947-1953Crossref PubMed Scopus (215) Google Scholar, 8Goldberg RJ Gore JM Alpert JS Dalen JE Recent changes in attack and survival rates of acute myocardial infarction (1975 through 1981). The Worcester Heart Attack Study.JAMA. 1986; 255: 2774-2779Crossref PubMed Scopus (211) Google Scholar, 9Wang H Steffen LM Jacobs DR Zhou X Blackburn H Berger AK Filion KB Luepker RV Trends in cardiovascular risk factor levels in the Minnesota Heart Survey (1980-2002) as compared with the National Health and Nutrition Examination Survey (1976-2002): a partial explanation for Minnesota's low cardiovascular disease mortality?.Am J Epidemiol. 2011; 173: 526-538Crossref PubMed Scopus (18) Google Scholar, 10McGovern PG Jacobs Jr., DR Shahar E Arnett DK Folsom AR Blackburn H Luepker RV Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the Minnesota heart survey.Circulation. 2001; 104: 19-24Crossref PubMed Scopus (310) Google Scholar, 11Hellermann JP Reeder GS Jacobsen SJ Weston SA Killian JM Roger VL Longitudinal trends in the severity of acute myocardial infarction: a population study in Olmsted County, Minnesota.Am J Epidemiol. 2002; 156: 246-253Crossref PubMed Scopus (51) Google Scholar, 12Manemann SM Gerber Y Chamberlain AM Dunlay SM Bell MR Jaffe AS Weston SA Killian JM Kors J Roger VL Acute coronary syndromes in the community.Mayo Clin Proc. 2015; 90: 597-605Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar However, few relatively recent data exist describing the potentially changing landscape of AMI at the community level. The primary objective of this population-based study was to describe decade long trends in the demographic and clinical characteristics, hospital management practices, and in-hospital clinical outcomes among residents of central Massachusetts hospitalized with a first AMI at all 11 metropolitan Worcester medical centers on a biennial basis between 2001 and 2011. Details of the Worcester Heart Attack Study have been previously described.4Goldberg RJ Spencer FA Yarzebski J Lessard D Gore JM Alpert JS Dalen JE A 25-year perspective into the changing landscape of patients hospitalized with acute myocardial infarction (the Worcester Heart Attack Study).Am J Cardiol. 2004; 94: 1373-1378Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 5Goldberg RJ Gore JM Alpert JS Dalen JE Incidence and case fatality rates of acute myocardial infarction (1975-1984): the Worcester Heart Attack Study.Am Heart J. 1988; 115: 761-767Crossref PubMed Scopus (163) Google Scholar, 6Goldberg RJ Yarzebski J Lessard D Gore JM A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective.J Am Coll Cardiol. 1999; 33: 1533-1539Crossref PubMed Scopus (252) Google Scholar, 7Goldberg RJ Gorak EJ Yarzebski J Hosmer Jr., DW Dalen P Gore JM Alpert JS Dalen JE A communitywide perspective of sex differences and temporal trends in the incidence and survival rates after acute myocardial infarction and out-of-hospital deaths caused by coronary heart disease.Circulation. 1993; 87: 1947-1953Crossref PubMed Scopus (215) Google Scholar In brief, residents of the Worcester metropolitan area hospitalized with a possible AMI at all 11 greater Worcester (MA) medical centers during 2001, 2003, 2005, 2007, 2009, and 2011 comprised the study population. The medical records of residents of these patients were individually reviewed and validated according to pre-established criteria.5Goldberg RJ Gore JM Alpert JS Dalen JE Incidence and case fatality rates of acute myocardial infarction (1975-1984): the Worcester Heart Attack Study.Am Heart J. 1988; 115: 761-767Crossref PubMed Scopus (163) Google Scholar, 6Goldberg RJ Yarzebski J Lessard D Gore JM A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective.J Am Coll Cardiol. 1999; 33: 1533-1539Crossref PubMed Scopus (252) Google Scholar, 7Goldberg RJ Gorak EJ Yarzebski J Hosmer Jr., DW Dalen P Gore JM Alpert JS Dalen JE A communitywide perspective of sex differences and temporal trends in the incidence and survival rates after acute myocardial infarction and out-of-hospital deaths caused by coronary heart disease.Circulation. 1993; 87: 1947-1953Crossref PubMed Scopus (215) Google Scholar, 8Goldberg RJ Gore JM Alpert JS Dalen JE Recent changes in attack and survival rates of acute myocardial infarction (1975 through 1981). The Worcester Heart Attack Study.JAMA. 1986; 255: 2774-2779Crossref PubMed Scopus (211) Google Scholar Information was collected by trained study staff about patient's age, sex, co-morbidities, AMI type (ST-segment elevation vs non-ST-segment elevation), and occurrence of clinically significant hospital complications. Information was collected about the prescribing of different cardiac medications during the patient's acute hospitalization and about the receipt of coronary diagnostic and interventional procedures. Patients with a history of AMI were excluded from the present study to provide insights into the descriptive epidemiology of AMI among patients with a first AMI. To facilitate the interpretation of trends in the epidemiology of AMI, the 6 one-year study years were aggregated into 3 two-year periods, namely 2001 and 2003, 2005 and 2007, and 2009 and 2011. Differences in the distribution of demographic factors, medical history, physiologic findings, clinical characteristics, and treatment practices were examined with the use of chi-square tests for trends and analysis of variance for discrete and continuous variables, respectively. To assess changes over time in the occurrence of important clinical complications and in-hospital case-fatality rates, while controlling for potentially confounding factors of prognostic importance, several logistic multivariable adjusted regression analyses were performed. This report is based on the 3,730 residents of the Worcester metropolitan area who satisfied the diagnostic criteria for an initial AMI. The mean age of study patients was 68.5 years, 43.1% were women, and 89.9% were white. Patients hospitalized with a first AMI during the most recent study years were significantly younger compared with patients who had been hospitalized in the earliest study years (Table 1). There were a greater proportion of individuals with previously diagnosed anemia, chronic kidney disease, hyperlipidemia, hypertension, and peripheral vascular disease during the most recent study years. A modest decrease in mean systolic blood pressure and estimated glomerular filtration rate values was observed over time. There was a decline in the mean serum troponin levels at the time of hospital admission as well as in the average length of hospital stay during the years under study (Table 1).Table 1Characteristics of patients Hospitalized with an initial acute myocardial iInfarction according to time period of hospitalizationVariable2001/2003 (n = 1,547)2005/2007 (n = 1,170)2009/2011 (n = 1,013)p ValueAge (mean, years)69.969.365.2Age (years) <5517.8 %19.1%22.0% 55-6417.5%16.8%21.5% 65-7420.9%17.9%19.9% 75-8427.2%27.1%18.3% ≥8516.7%19.1%18.3%<0.001 Men56.9%54.9%59.1%0.09 White87.9%90.6%91.9%<0.001Length of stay (mean, days)5.9%5.7%4.6%<0.001Medical historyAngina16.7%8.9%4.1%<0.001Anemia4.5%11.8%10.0%<0.001CKD11.8%17.5%18.0%<0.001COPD15.0%16.5%12.2%<0.005Diabetes28.0%28.8%31.7%0.33Heart failure15.0%16.5%12.2%<0.005Hyperlipidemia44.2%55.6%65.6%<0.001Hypertension65.0%70.6%69.6%<.01PVD11.6%16.3%16.3%< 0.001Stroke9.3%9.2%7.5%0.42 Systolic BP (mean, mm Hg)1431421400.08 Diastolic BP (mean, mm Hg)7978790.08 eGFR (ml/min/1.73 m2)606254<0.001 Serum Glucose (mean, mg/dl)1691631670.20 ST-segment elevation39%35%35%0.08 Troponin I (mean, ng/ml)34129<0.001CKD = Chronic kidney disease; COPD = chronic obstructive pulmonary disease; PVD = peripheral vascular disease; BP = blood pressure; eGFR = estimated glomerular filtration rate. Open table in a new tab CKD = Chronic kidney disease; COPD = chronic obstructive pulmonary disease; PVD = peripheral vascular disease; BP = blood pressure; eGFR = estimated glomerular filtration rate. The in-hospital use of aspirin and lipid lowering agents increased markedly during the years under study (Figure 1). A statistically significant, but inconsistent increase in the use of β-blockers was observed whereas there was a marked decrease in the use of calcium channel blockers, diuretics, and thrombolytic therapy (Figure 1). The proportion of patients who underwent diagnostic cardiac catheterization and a percutaneous coronary intervention (PCI) increased markedly between 2001 and 2011. In 2009/2011, the percentage of hospitalized patients that received diagnostic catheterization or a PCI was 72.0% and 54.7%, respectively (Figure 2). The proportion of patients who underwent a subsequent PCI following cardiac catheterization increased significantly over time, whereas the proportion of patients who underwent acute coronary artery bypass surgery declined.Figure 2Changing trends in hospital coronary diagnostic and revascularization procedures. CABG = coronary artery bypass grafting; PCI = percutaneous coronary intervention.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In examining changes over time in the occurrence of several major in-hospital complications and all-cause in-hospital death rates, we observed a progressive decline in the proportion of patients who developed ventricular fibrillation, atrial fibrillation, and heart failure as well as a marked decrease in hospital death rates (Table 2). Multivariable adjusted regression analyses were performed to more systematically examine trends in hospital death rates and in major clinical complications (Table 3). Results of the unadjusted analysis (model 1) showed significant declines over time in the odds of dying in the hospital while declines in the odds of developing atrial fibrillation, heart failure, and ventricular fibrillation were noted. These results essentially remained after adjusting for a variety of patient associated demographic and clinical characteristics and duration of the acute hospitalization (regression models 2 and 3) (Table 3).Table 2Frequency of clinical outcomes according to time period of hospitalizationComplications2001/2003 (n = 1,547)2005/2007 (n = 1,170)2009/2011 (n = 1,013)p ValueAtrial fibrillation21.7%21.5%15.1%<0.005Cardiogenic shock4.9%6.1%4.6%0.87Death9.6%9.8%6.5%<0.005Heart failure34.4%33.9%28.2%<0.05Stroke1.7%0.6%1.8%0.88Ventricular fibrillation4.8%3.8%2.6%<0.05 Open table in a new tab Table 3Multivariable-adjusted risk of in-hospital outcomesModel 1 OR (95% CI)Model 2 OR (95% CI)Model 3 OR (95% CI)Outcomes2001/2003*Referent period.2005/20072009/20112005/20072009/20112005/20072009/2011Atrial fibrillation10.99 (0.82, 1.19)0.65 (0.52, 0.80)0.98 (0.799, 1.19)0.71 (0.56, 0.89)1.07 (0.87, 1.32)0.81 (0.64, (0.56, for age, and medical history anemia, heart failure, hyperlipidemia, hypertension, for characteristics in 2 type of AMI and hospital length of COPD = chronic obstructive pulmonary disease; PVD = peripheral artery Open table in a new tab for age, and medical history anemia, heart failure, hyperlipidemia, hypertension, for characteristics in 2 type of AMI and hospital length of COPD = chronic obstructive pulmonary disease; PVD = peripheral artery results highlight the changing landscape of patients hospitalized with AMI at all medical centers in central We significant changes in the demographic characteristics, clinical profile, and hospital management of patients with a first AMI. declines in the proportion of patients who or experienced major clinical complications during their acute hospitalization were Worcester residents hospitalized with a first AMI during the most recent study years were significantly younger and more likely to be men. This to a younger age at is in with observed in the S M M Go AS trends in the incidence and outcomes of acute myocardial J PubMed Scopus Google Scholar and the Rochester Epidemiology VL Weston SA Gerber Y Killian JM Dunlay SM Jaffe AS Bell MR Kors J BP Jacobsen SJ Trends in incidence, and of hospitalized myocardial PubMed Scopus Google Scholar the differences in the between the present study and population-based studies we be in to the of and the use of more diagnostic tests over time as well as to differences in the and clinical characteristics of the study these changes be the of a coronary risk factor in residents of the Worcester metropolitan a younger population at risk for acute coronary We observed marked changes over time in the occurrence of clinically important chronic in patient population. This in patient the admission of younger patients with a greater of be to changes in clinical for the of patients with chronic that during the years under Cushman Jr., DW S Jr., JT EJ National Heart National on of report of the on and treatment of blood the PubMed Scopus Google SM Jr., DB Jr., National Heart of Heart of recent clinical for the National 2004; PubMed Scopus Google Scholar We observed a decline in the average length of hospital stay for residents of the Worcester metropolitan area hospitalized with a first AMI, likely to treatment and Patients with an incident AMI were more likely to have developed a non-ST-segment elevation myocardial infarction during the years under results with trends observed in the Rochester epidemiology during a relatively JP Reeder GS Jacobsen SJ Weston SA Killian JM Roger VL Longitudinal trends in the severity of acute myocardial infarction: a population study in Olmsted County, Minnesota.Am J Epidemiol. 2002; 156: 246-253Crossref PubMed Scopus (51) Google Scholar data showed that serum troponin levels this be an by the of troponin and new the lower serum troponin levels observed over time, and the proportion of as by patient's findings, be of a progressive decline in the severity of patients hospitalized with a first AMI during the period under study. A number of community-based from the Worcester Heart Attack RJ Spencer FA Yarzebski J Lessard D Gore JM Alpert JS Dalen JE A 25-year perspective into the changing landscape of patients hospitalized with acute myocardial infarction (the Worcester Heart Attack Study).Am J Cardiol. 2004; 94: 1373-1378Abstract Full Text Full Text PDF PubMed Scopus (75) Google PG Jacobs Jr., DR Shahar E Arnett DK Folsom AR Blackburn H Luepker RV Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the Minnesota heart survey.Circulation. 2001; 104: 19-24Crossref PubMed Scopus (310) Google S M M Go AS trends in the incidence and outcomes of acute myocardial J PubMed Scopus Google Yarzebski J Spencer FA Lessard D Dalen JE Alpert JS Gore JM RJ A perspective into the changing landscape of patients hospitalized with initial acute myocardial infarction: Worcester Heart Attack PubMed Scopus Google Scholar as well as coronary disease K Go AS DM RJ JH CJ R Jr., Rosamond WD S S Trends in incidence of hospitalized acute myocardial infarction in the J Full Text Full Text PDF PubMed Scopus Google Scholar have of a progressive increase in the prescribing of cardiac in patients hospitalized with AMI during the past 2 a reduction in the of cardiac medications with or a was in the proportion of patients that underwent revascularization and diagnostic were with evidence-based for the hospital management of patients with AMI. new treatment and of to trends in the management of these patients and factors associated with different treatment and patient's in-hospital and long-term A marked over time in the occurrence of clinically important complications was observed in patient population. We a significant reduction in the proportion of patients who developed atrial fibrillation, heart failure, and ventricular These changes with K H H Y E D H M Y H M Acute Study of atrial in patients with acute myocardial infarction with percutaneous coronary J Cardiol. Full Text Full Text PDF PubMed Scopus Google Scholar, J D J infarction data study factors and trends in incidence of heart failure following acute myocardial J Cardiol. 2018; Full Text Full Text PDF PubMed Scopus Google Scholar, J G SH fibrillation in acute myocardial infarction: a of the incidence, clinical and prognostic Heart J. PubMed Scopus Google Scholar We a significant increase in patient's in-hospital a with from this study during RJ Spencer FA Yarzebski J Lessard D Gore JM Alpert JS Dalen JE A 25-year perspective into the changing landscape of patients hospitalized with acute myocardial infarction (the Worcester Heart Attack Study).Am J Cardiol. 2004; 94: 1373-1378Abstract Full Text Full Text PDF PubMed Scopus (75) Google Yarzebski J Spencer FA Lessard D Dalen JE Alpert JS Gore JM RJ A perspective into the changing landscape of patients hospitalized with initial acute myocardial infarction: Worcester Heart Attack PubMed Scopus Google Scholar These with from population-based studies in and PG Jacobs Jr., DR Shahar E Arnett DK Folsom AR Blackburn H Luepker RV Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the Minnesota heart survey.Circulation. 2001; 104: 19-24Crossref PubMed Scopus (310) Google S M M Go AS trends in the incidence and outcomes of acute myocardial J PubMed Scopus Google Scholar and studies in and rates after heart attack in after stroke PubMed Scopus Google J J M S S M Trends from to in incidence and mortality outcomes of heart failure after acute myocardial infarction: a population-based study of patients with first acute myocardial infarction in Am Heart PubMed Scopus Google Scholar The of include a community-based population of patients hospitalized with initial AMI at all central Massachusetts medical study comprised of and to The of possible changes over time in the of out-of-hospital deaths to cardiac disease or changes in the occurrence of on the characteristics and outcomes of patients hospitalized with AMI In the results of this study highlight the changing demographic and clinical nature of patients hospitalized with AMI and the of surveillance at the community level. 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