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Many clinical improvements in treating patients with acute ST-elevation myocardial infarction (STEMI) have been realized in the past 20 years, including angiotensin-converting enzyme inhibitors, antiplatelet agents, and reduced time to cardiac cauterization procedures for acute myocardial infaction.1 Presumably, primary and secondary prevention measures have also resulted in changes in coronary artery disease (CAD) risk factors over the past 20 years. We sought to quantify mortality outcomes for patients treated in our catherization laboratory and to investigate trends in cardiovascular risk factors in patients during the same period.2
STEMI OUTCOMES
Data from our catherization laboratory database of 3,913 patients treated for STEMI at our tertiary care center from 1995 through 2014 were analyzed. To evaluate outcomes over time, patients were grouped based on years treated in 5-year increments resulting in 4 groups spanning 20 years.2
CARDIOVASCULAR RISK FACTORS
A reduction in mortality rates in patients treated for STEMI is to be expected over time, given the improvements in clinical practices and procedures and novel medications developed since 1996. But it is also possible that patients presenting with STEMI are healthier than in the past as a result of primary prevention efforts to minimize CAD risk factors and changes in CAD risk factors over time.
To determine whether CAD risk factors have changed over time, we analyzed the risk factors in the 3,913 patients treated for STEMI in our database. Risk factors included in the analysis were:
- Age
- Sex
- Diabetes mellitus
- Hypertension
- Smoking
- Hyperlipidemia
- Chronic renal impairment (serum creatinine greater than 1.5 mg/dL)
- Obesity (body mass index greater than 30 kg/m2).2
The prevalence of risk factors was determined in the entire cohort as well as in the 34% (n = 1,325) of patients previously diagnosed with CAD. The trend in risk factors in patients previously diagnosed with CAD could indicate the effectiveness of secondary prevention efforts compared with primary prevention in the broader patient population.
These data suggest that despite a better understanding of cardiovascular risk factors, the cardiovascular risk profiles of patients with acute STEMI have deteriorated over the past 20 years: patients are younger at presentation and more likely to be obese, to smoke, and to have hypertension and diabetes. These trends hold true in patients with and without a history of CAD, suggesting primary and secondary prevention efforts are ineffective.
TRENDS IN THE UNITED STATES
To evaluate whether geographic or patient population characteristics could have biased our results, we analyzed mortality and risk factor data from the National (Nationwide) Inpatient Sample (NIS) for patients presenting with STEMI (N = 445,319), non-STEMI (N = 915,341), and stroke (N = 937,425) from 2003 to 2013.4,5
Mortality rates
Consistent with the trend in our data, the 10-year NIS data showed a lower mortality rate in 2003 compared with 2013 in patients admitted with extreme-severity STEMI (22% vs 18%), non-STEMI (13% vs 8%), and stroke (15% vs 10%), as well as in patients with moderate-severity disease.4
Risk factors
Unfortunately, the prevalence of these relatively preventable CAD risk factors is moving in the wrong direction. The prevalence of smoking in patients presenting with non-STEMI, STEMI, or acute stroke is higher than in the past, contrary to the nationwide trend of decreasing rates of smoking.6 The increased rate of obesity evident in our data and the NSI data is consistent with rising obesity rates in the United States, which went from 30% to 37% in adults and from 14% to 17% in youth from 2000 to 2014.7 The percentage of adults with diabetes has increased tremendously in the United States, from 4.4% of adults in 1994 to 9.1% of adults in 2015.8 The rise in diabetes has led to increased rates of CAD, heart disease, and stroke in patients with diabetes.9
OPPORTUNITIES AHEAD
Despite improved STEMI outcomes, trends in cardiovascular risk profiles are deteriorating, emphasizing the critical need to educate people about primary and secondary prevention. Folsom et al10 conducted an analysis of a community-based sample to determine the prevalence of ideal cardiovascular health based on 4 ideal health behaviors (nonsmoking, low body mass index, adequate physical activity, healthy diet) and 3 ideal risk health factors (total cholesterol, blood pressure, and moderate glucose control).10 Each of the 7 behavior and risk factors was defined by ideal, intermediate, and poor characteristics. Very few study participants (0.1%) had ideal levels for all 7 healthy cardiovascular behaviors and risk factors, and over 82% had poor levels for all 7 behaviors and characteristics. The need to educate and improve cardiovascular health exists for both adults and youth. Measures of cardiovascular health in the United States indicate that 18% of adults age 50 or older and 46% of youth (ages 12 to 19) have 5 or more of the 7 health cardiovascular behaviors and risk factors at ideal levels.11
Improvement in primary and secondary prevention measures may also present opportunities to contain or reduce the cost of care. Thus far, according to NIS registry data from 2003 to 2013, the mean adjusted cost of hospitalization for patients with STEMI increased about 14%, remained about the same for patients with non-STEMI, and increased about 3% for patients with stroke.4
CONCLUSION
Advances in clinical care have improved outcomes for patients with CAD during the past 2 decades. These gains have come despite a higher prevalence of CAD risk factors in patients. More emphasis on primary and secondary prevention to reduce CAD risk factors may further improve outcomes and possibly lower the cost of care. Aggressive encouragement of risk factor modification is necessary and should go beyond cardiologists to include primary care physicians, preventive clinics, secondary cardiovascular prevention, and population-based efforts.
- Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 2004; 129:e28–e292.
- Mentias A, Hill E, Barakat AF, et al. An alarming trend: change in the risk profile of patients with ST elevation myocardial infarction over the last two decades. Int J Cardiol 2017; doi:10.1016/j.ijcard.2017.05.011. [Epub ahead of print]
- Mentias A, Raza MQ, Barakat AF, et al. Effect of shorter door-to-balloon times over 20 years on outcomes of patients with anterior ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol 2017; Jul 24. doi:10.1016/j.amjcard.2017.07.006. [Epub ahead of print].
- Agarwal S, Sud K, Thakkar B, Menon V, Jaber WA, Kapadia SR. Changing trends of atherosclerotic risk factors among patients with acute myocardial infarction and acute ischemic stroke. Am J Cardiol 2017; 119:1532–1541.
- HCUP NIS Database Documentation. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp. March 2017. Accessed September 11 2017.
- Centers for Disease Control and Prevention. Trends in current cigarette smoking among high school students and adults, United States, 1965–2014. https://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking. Updated March 30, 2016. Accessed September 11, 2017.
- Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. 2015. Available at https://www.cdc.gov/nchs/data/databriefs/db219.htm. Accessed September 11, 2017.
- Centers for Disease Control and Prevention. Diabetes data and statistics. https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html. Updated July 17, 2017. Accessed September 11, 2017.
- Centers for Disease Control and Prevention. Diabetes, heart disease, and you. https://www.cdc.gov/features/diabetes-heart-disease/index.html. Updated November 19, 2016. Accessed September 11, 2017.
- Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD; for the ARIC Study Investigators. Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol 2011; 57:1690–1696.
- Mozaffarian D, Benjamin EJ, Go AS, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016; 133:e38–e360.
Many clinical improvements in treating patients with acute ST-elevation myocardial infarction (STEMI) have been realized in the past 20 years, including angiotensin-converting enzyme inhibitors, antiplatelet agents, and reduced time to cardiac cauterization procedures for acute myocardial infaction.1 Presumably, primary and secondary prevention measures have also resulted in changes in coronary artery disease (CAD) risk factors over the past 20 years. We sought to quantify mortality outcomes for patients treated in our catherization laboratory and to investigate trends in cardiovascular risk factors in patients during the same period.2
STEMI OUTCOMES
Data from our catherization laboratory database of 3,913 patients treated for STEMI at our tertiary care center from 1995 through 2014 were analyzed. To evaluate outcomes over time, patients were grouped based on years treated in 5-year increments resulting in 4 groups spanning 20 years.2
CARDIOVASCULAR RISK FACTORS
A reduction in mortality rates in patients treated for STEMI is to be expected over time, given the improvements in clinical practices and procedures and novel medications developed since 1996. But it is also possible that patients presenting with STEMI are healthier than in the past as a result of primary prevention efforts to minimize CAD risk factors and changes in CAD risk factors over time.
To determine whether CAD risk factors have changed over time, we analyzed the risk factors in the 3,913 patients treated for STEMI in our database. Risk factors included in the analysis were:
- Age
- Sex
- Diabetes mellitus
- Hypertension
- Smoking
- Hyperlipidemia
- Chronic renal impairment (serum creatinine greater than 1.5 mg/dL)
- Obesity (body mass index greater than 30 kg/m2).2
The prevalence of risk factors was determined in the entire cohort as well as in the 34% (n = 1,325) of patients previously diagnosed with CAD. The trend in risk factors in patients previously diagnosed with CAD could indicate the effectiveness of secondary prevention efforts compared with primary prevention in the broader patient population.
These data suggest that despite a better understanding of cardiovascular risk factors, the cardiovascular risk profiles of patients with acute STEMI have deteriorated over the past 20 years: patients are younger at presentation and more likely to be obese, to smoke, and to have hypertension and diabetes. These trends hold true in patients with and without a history of CAD, suggesting primary and secondary prevention efforts are ineffective.
TRENDS IN THE UNITED STATES
To evaluate whether geographic or patient population characteristics could have biased our results, we analyzed mortality and risk factor data from the National (Nationwide) Inpatient Sample (NIS) for patients presenting with STEMI (N = 445,319), non-STEMI (N = 915,341), and stroke (N = 937,425) from 2003 to 2013.4,5
Mortality rates
Consistent with the trend in our data, the 10-year NIS data showed a lower mortality rate in 2003 compared with 2013 in patients admitted with extreme-severity STEMI (22% vs 18%), non-STEMI (13% vs 8%), and stroke (15% vs 10%), as well as in patients with moderate-severity disease.4
Risk factors
Unfortunately, the prevalence of these relatively preventable CAD risk factors is moving in the wrong direction. The prevalence of smoking in patients presenting with non-STEMI, STEMI, or acute stroke is higher than in the past, contrary to the nationwide trend of decreasing rates of smoking.6 The increased rate of obesity evident in our data and the NSI data is consistent with rising obesity rates in the United States, which went from 30% to 37% in adults and from 14% to 17% in youth from 2000 to 2014.7 The percentage of adults with diabetes has increased tremendously in the United States, from 4.4% of adults in 1994 to 9.1% of adults in 2015.8 The rise in diabetes has led to increased rates of CAD, heart disease, and stroke in patients with diabetes.9
OPPORTUNITIES AHEAD
Despite improved STEMI outcomes, trends in cardiovascular risk profiles are deteriorating, emphasizing the critical need to educate people about primary and secondary prevention. Folsom et al10 conducted an analysis of a community-based sample to determine the prevalence of ideal cardiovascular health based on 4 ideal health behaviors (nonsmoking, low body mass index, adequate physical activity, healthy diet) and 3 ideal risk health factors (total cholesterol, blood pressure, and moderate glucose control).10 Each of the 7 behavior and risk factors was defined by ideal, intermediate, and poor characteristics. Very few study participants (0.1%) had ideal levels for all 7 healthy cardiovascular behaviors and risk factors, and over 82% had poor levels for all 7 behaviors and characteristics. The need to educate and improve cardiovascular health exists for both adults and youth. Measures of cardiovascular health in the United States indicate that 18% of adults age 50 or older and 46% of youth (ages 12 to 19) have 5 or more of the 7 health cardiovascular behaviors and risk factors at ideal levels.11
Improvement in primary and secondary prevention measures may also present opportunities to contain or reduce the cost of care. Thus far, according to NIS registry data from 2003 to 2013, the mean adjusted cost of hospitalization for patients with STEMI increased about 14%, remained about the same for patients with non-STEMI, and increased about 3% for patients with stroke.4
CONCLUSION
Advances in clinical care have improved outcomes for patients with CAD during the past 2 decades. These gains have come despite a higher prevalence of CAD risk factors in patients. More emphasis on primary and secondary prevention to reduce CAD risk factors may further improve outcomes and possibly lower the cost of care. Aggressive encouragement of risk factor modification is necessary and should go beyond cardiologists to include primary care physicians, preventive clinics, secondary cardiovascular prevention, and population-based efforts.
Many clinical improvements in treating patients with acute ST-elevation myocardial infarction (STEMI) have been realized in the past 20 years, including angiotensin-converting enzyme inhibitors, antiplatelet agents, and reduced time to cardiac cauterization procedures for acute myocardial infaction.1 Presumably, primary and secondary prevention measures have also resulted in changes in coronary artery disease (CAD) risk factors over the past 20 years. We sought to quantify mortality outcomes for patients treated in our catherization laboratory and to investigate trends in cardiovascular risk factors in patients during the same period.2
STEMI OUTCOMES
Data from our catherization laboratory database of 3,913 patients treated for STEMI at our tertiary care center from 1995 through 2014 were analyzed. To evaluate outcomes over time, patients were grouped based on years treated in 5-year increments resulting in 4 groups spanning 20 years.2
CARDIOVASCULAR RISK FACTORS
A reduction in mortality rates in patients treated for STEMI is to be expected over time, given the improvements in clinical practices and procedures and novel medications developed since 1996. But it is also possible that patients presenting with STEMI are healthier than in the past as a result of primary prevention efforts to minimize CAD risk factors and changes in CAD risk factors over time.
To determine whether CAD risk factors have changed over time, we analyzed the risk factors in the 3,913 patients treated for STEMI in our database. Risk factors included in the analysis were:
- Age
- Sex
- Diabetes mellitus
- Hypertension
- Smoking
- Hyperlipidemia
- Chronic renal impairment (serum creatinine greater than 1.5 mg/dL)
- Obesity (body mass index greater than 30 kg/m2).2
The prevalence of risk factors was determined in the entire cohort as well as in the 34% (n = 1,325) of patients previously diagnosed with CAD. The trend in risk factors in patients previously diagnosed with CAD could indicate the effectiveness of secondary prevention efforts compared with primary prevention in the broader patient population.
These data suggest that despite a better understanding of cardiovascular risk factors, the cardiovascular risk profiles of patients with acute STEMI have deteriorated over the past 20 years: patients are younger at presentation and more likely to be obese, to smoke, and to have hypertension and diabetes. These trends hold true in patients with and without a history of CAD, suggesting primary and secondary prevention efforts are ineffective.
TRENDS IN THE UNITED STATES
To evaluate whether geographic or patient population characteristics could have biased our results, we analyzed mortality and risk factor data from the National (Nationwide) Inpatient Sample (NIS) for patients presenting with STEMI (N = 445,319), non-STEMI (N = 915,341), and stroke (N = 937,425) from 2003 to 2013.4,5
Mortality rates
Consistent with the trend in our data, the 10-year NIS data showed a lower mortality rate in 2003 compared with 2013 in patients admitted with extreme-severity STEMI (22% vs 18%), non-STEMI (13% vs 8%), and stroke (15% vs 10%), as well as in patients with moderate-severity disease.4
Risk factors
Unfortunately, the prevalence of these relatively preventable CAD risk factors is moving in the wrong direction. The prevalence of smoking in patients presenting with non-STEMI, STEMI, or acute stroke is higher than in the past, contrary to the nationwide trend of decreasing rates of smoking.6 The increased rate of obesity evident in our data and the NSI data is consistent with rising obesity rates in the United States, which went from 30% to 37% in adults and from 14% to 17% in youth from 2000 to 2014.7 The percentage of adults with diabetes has increased tremendously in the United States, from 4.4% of adults in 1994 to 9.1% of adults in 2015.8 The rise in diabetes has led to increased rates of CAD, heart disease, and stroke in patients with diabetes.9
OPPORTUNITIES AHEAD
Despite improved STEMI outcomes, trends in cardiovascular risk profiles are deteriorating, emphasizing the critical need to educate people about primary and secondary prevention. Folsom et al10 conducted an analysis of a community-based sample to determine the prevalence of ideal cardiovascular health based on 4 ideal health behaviors (nonsmoking, low body mass index, adequate physical activity, healthy diet) and 3 ideal risk health factors (total cholesterol, blood pressure, and moderate glucose control).10 Each of the 7 behavior and risk factors was defined by ideal, intermediate, and poor characteristics. Very few study participants (0.1%) had ideal levels for all 7 healthy cardiovascular behaviors and risk factors, and over 82% had poor levels for all 7 behaviors and characteristics. The need to educate and improve cardiovascular health exists for both adults and youth. Measures of cardiovascular health in the United States indicate that 18% of adults age 50 or older and 46% of youth (ages 12 to 19) have 5 or more of the 7 health cardiovascular behaviors and risk factors at ideal levels.11
Improvement in primary and secondary prevention measures may also present opportunities to contain or reduce the cost of care. Thus far, according to NIS registry data from 2003 to 2013, the mean adjusted cost of hospitalization for patients with STEMI increased about 14%, remained about the same for patients with non-STEMI, and increased about 3% for patients with stroke.4
CONCLUSION
Advances in clinical care have improved outcomes for patients with CAD during the past 2 decades. These gains have come despite a higher prevalence of CAD risk factors in patients. More emphasis on primary and secondary prevention to reduce CAD risk factors may further improve outcomes and possibly lower the cost of care. Aggressive encouragement of risk factor modification is necessary and should go beyond cardiologists to include primary care physicians, preventive clinics, secondary cardiovascular prevention, and population-based efforts.
- Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 2004; 129:e28–e292.
- Mentias A, Hill E, Barakat AF, et al. An alarming trend: change in the risk profile of patients with ST elevation myocardial infarction over the last two decades. Int J Cardiol 2017; doi:10.1016/j.ijcard.2017.05.011. [Epub ahead of print]
- Mentias A, Raza MQ, Barakat AF, et al. Effect of shorter door-to-balloon times over 20 years on outcomes of patients with anterior ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol 2017; Jul 24. doi:10.1016/j.amjcard.2017.07.006. [Epub ahead of print].
- Agarwal S, Sud K, Thakkar B, Menon V, Jaber WA, Kapadia SR. Changing trends of atherosclerotic risk factors among patients with acute myocardial infarction and acute ischemic stroke. Am J Cardiol 2017; 119:1532–1541.
- HCUP NIS Database Documentation. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp. March 2017. Accessed September 11 2017.
- Centers for Disease Control and Prevention. Trends in current cigarette smoking among high school students and adults, United States, 1965–2014. https://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking. Updated March 30, 2016. Accessed September 11, 2017.
- Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. 2015. Available at https://www.cdc.gov/nchs/data/databriefs/db219.htm. Accessed September 11, 2017.
- Centers for Disease Control and Prevention. Diabetes data and statistics. https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html. Updated July 17, 2017. Accessed September 11, 2017.
- Centers for Disease Control and Prevention. Diabetes, heart disease, and you. https://www.cdc.gov/features/diabetes-heart-disease/index.html. Updated November 19, 2016. Accessed September 11, 2017.
- Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD; for the ARIC Study Investigators. Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol 2011; 57:1690–1696.
- Mozaffarian D, Benjamin EJ, Go AS, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016; 133:e38–e360.
- Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 2004; 129:e28–e292.
- Mentias A, Hill E, Barakat AF, et al. An alarming trend: change in the risk profile of patients with ST elevation myocardial infarction over the last two decades. Int J Cardiol 2017; doi:10.1016/j.ijcard.2017.05.011. [Epub ahead of print]
- Mentias A, Raza MQ, Barakat AF, et al. Effect of shorter door-to-balloon times over 20 years on outcomes of patients with anterior ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol 2017; Jul 24. doi:10.1016/j.amjcard.2017.07.006. [Epub ahead of print].
- Agarwal S, Sud K, Thakkar B, Menon V, Jaber WA, Kapadia SR. Changing trends of atherosclerotic risk factors among patients with acute myocardial infarction and acute ischemic stroke. Am J Cardiol 2017; 119:1532–1541.
- HCUP NIS Database Documentation. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp. March 2017. Accessed September 11 2017.
- Centers for Disease Control and Prevention. Trends in current cigarette smoking among high school students and adults, United States, 1965–2014. https://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking. Updated March 30, 2016. Accessed September 11, 2017.
- Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. 2015. Available at https://www.cdc.gov/nchs/data/databriefs/db219.htm. Accessed September 11, 2017.
- Centers for Disease Control and Prevention. Diabetes data and statistics. https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html. Updated July 17, 2017. Accessed September 11, 2017.
- Centers for Disease Control and Prevention. Diabetes, heart disease, and you. https://www.cdc.gov/features/diabetes-heart-disease/index.html. Updated November 19, 2016. Accessed September 11, 2017.
- Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD; for the ARIC Study Investigators. Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol 2011; 57:1690–1696.
- Mozaffarian D, Benjamin EJ, Go AS, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016; 133:e38–e360.
KEY POINTS
- Advances in treatment of CAD have improved patient outcomes over the past 20 years.
- Prevalence of risk factors for CAD has increased over the past 20 years in patients presenting with STEMI with patients now more likely to be younger and with higher prevalence of smoking, obesity, hypertension, and diabetes.
- Emphasis on primary and secondary prevention to reduce CAD risk factors is needed to improve outcomes and reduce the cost of care.
