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Population Trends in the Incidence and Outcomes of Acute Myocardial Infarction. Robert W. Yeh, MD MSc Massachusetts General Hospital Alan S. Go, MD Kaiser Division of Research University of California, San Francisco. BACKGROUND. The “Ecosystem” of Acute Myocardial Infarction.

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population trends in the incidence and outcomes of acute myocardial infarction

Population Trends in the Incidence and Outcomes of Acute Myocardial Infarction

Robert W. Yeh, MD MSc

Massachusetts General Hospital

Alan S. Go, MD

Kaiser Division of Research

University of California, San Francisco

the ecosystem of acute myocardial infarction

BACKGROUND

The “Ecosystem” of Acute Myocardial Infarction

Population at Risk for

Myocardial Infarction

Widespread use of statins

Obese population rising

Better antiplatelet therapy

DM & HTN increasing

More use of beta blockers

and ACE-I

Aging of the population

Increased use of smoking

cessation programs

NET EFFECT?

existing recent literature on myocardial infarction incidence
Existing Recent Literature on Myocardial Infarction Incidence
  • Mostly limited to trends prior to 2002
  • Focused on groups with limited diversity with respect to race and ethnic group, age and sex
  • Have not distinguished ST and non-ST-elevation MI
  • Have not examined trends in improvements in outpatient cardiovascular medication use
goals of proposed research

OBJECTIVE

Goals of Proposed Research

To provide a comprehensive, contemporary assessment of the epidemiology of STEMI and NSTEMI in a large population-based sample between 1999 and 2008

  • An evaluation of progress in the care of MI patients
  • A test of the true impact of medical and public health interventions
  • Suggestions for more optimal health resource allocation
kaiser permanente of northern california
Kaiser Permanente of Northern California
  • Integrated health care delivery system providing comprehensive care of ~3.3 million persons
  • 20 medical centers + large set of ambulatory practices
  • Diverse population representative of northern California and statewide
  • Low churn rate
incidence of myocardial infarction

METHODS

Incidence of Myocardial Infarction

Incidence rates of STEMI and NSTEMI calculated for each year

  • All Kaiser members age ≥ 30
  • Numerator: Hospitalized admission for MI based on ICD-9-CM primary discharge diagnosis.
    • STEMI: 4101 – 410.6, 410.8
    • NSTEMI 410.7, 410.9
    • Codes validated by detailed chart review in a random sample of 800 MI admissions.
  • Denominator: Person-months, annualized, based on monthly updated membership status.
  • Direct Age-Sex adjustment
slide7

Comprehensive Clinical and Administrative Electronic Databases

Health plan databases capture the large majority of aspects of clinical care and linked through single medical record number

  • Detailed demographic information
  • Multiple data sources to ascertain comorbid conditions
  • Longitudinal outpatient prescription medication use before and after incident MI
  • Outcomes – detailed discharge and billing codes with access to medical records; linked to state death files and Social Security Administration vital status data
outcomes
Outcomes

Cardiac Biomarkers

  • Peak CK-MB and MB fraction ascertained for all identified MI admissions

Mortality

  • 30-day all-cause mortality ascertained from linked health plan administrative databases, proxy information, Social Security Administration vital status files, and California state death certificate information
  • Logistic regression using generalized estimating equations to account for facility-based clustering used to examine trends in yearly adjusted mortality.
incidence of myocardial infarction1

RESULTS

Incidence of Myocardial Infarction

46,086 hospitalized patients with myocardial infarction over 18,691,131 person-years

Any MI

NSTEMI

STEMI

medication use

Statin

β-Blocker

ACE-I/ARB

Thienopyridine

Non-Statin Lipid Lowering

Statin

β-Blocker

ACE-I/ARB

Non-Statin Lipid Lowering

Thienopyridine

Statin

β-Blocker

ACE-I/ARB

Thienopyridine

Non-Statin Lipid Lowering

Medication Use
biomarkers
Biomarkers
  • Troponin I testing increased from 53% in 1999 to 84% in 2004
    • Stable testing rates after 2004
  • Peak CK-MB and CK-MB fraction decreased significantly over time for all MI and for NSTEMI.
  • No change in biomarker peak levels over time after STEMI
conclusions
Conclusions
  • There has been a 24% decline in the incidence of MI since 2000, with steep decline in STEMI incidence throughout time period.
  • Significant improvements in the outpatient use of cardiovascular medications including statins and beta blockers have occurred, which may, in part, explain declines in MI incidence.
  • Lower severity NSTEMI have been detected over time, coinciding with increased use of troponin.
  • Improvements in adjusted mortality have been modest, and are likely driven by in part by increased ascertainment of low-acuity NSTEMI
limitations
Limitations
  • Reliance on diagnosis codes
    • Sensitivity analyses that broadened the definition of MI to include other codes showed similar trends.
    • Trends in STEMI and NSTEMI were similar at 95% confidence limits of positive predictive value of codes based on validation.
  • Large, diverse population but may not be completely generalizable to all health care settings and populations

Whether declines in MI incidence have occurred similarly in other geographic regions is not known.

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