C t t d iC t t d iContemporary trends in myocardial infarction: incidence
Contemporary trends in myocardial infarction: incidence yoca d a a ct o c de ce
and outcomesyoca d a a ct o c de ce
and outcomesVé i L R MD MPHVé i L R MD MPHVéronique L Roger, MD, MPH
Professor of Medicine and Epidemiology, Mayo Clinic College of Medicine
Véronique L Roger, MD, MPHProfessor of Medicine and Epidemiology, Mayo Clinic
College of MedicineCollege of MedicineGreat Innovations in Cardiology. 6th Joint Meeting with
Mayo Clinic Torino 2010
College of MedicineGreat Innovations in Cardiology. 6th Joint Meeting with
Mayo Clinic Torino 2010Mayo Clinic Torino 2010Mayo Clinic Torino 2010
Disclos resDisclos resDisclosuresDisclosures
RO1 HL 59205 RO1 HL 72435 RO1 HL 59205 RO1 HL 72435 K24 HL 68765R01 AR 30582K24 HL 68765R01 AR 30582R01 AR 30582
American Heart AssociationEstablished Investigator award
R01 AR 30582 American Heart Association
Established Investigator awardEstablished Investigator awardEstablished Investigator award
ObjectivesObjectivesObjectivesObjectives
•Why and how to measure MI trends?
•Why and how to measure MI trends?trends?
•MI trends: then and nowtrends?
•MI trends: then and now•MI trends: then and nowWh t d thi ?
•MI trends: then and nowWh t d thi ?•What does this mean?•What does this mean?
Why measure MI trends?Why measure MI trends?yy
Science: measurement of trends and determinants generates mechanistic Science: measurement of trends and determinants generates mechanistic hypotheseshypotheses
Clinical practice: Effectiveness and quality of care, detecting disparitiesClinical practice: Effectiveness and quality of care, detecting disparitiesq y , g p
Public health: design interventions,
q y , g p
Public health: design interventions, g ,plan for resources, delineate policies
g ,plan for resources, delineate policies
Trends in MI and ACSTrends in MI and ACSConceptsConcepts
IncidenceIncidence FatalitiesFatalities
Primary preventionPrimary prevention Medical careMedical carePrimary prevention Primary prevention Medical careMedical careReperfusion RxReperfusion Rx
Better preventionBetter preventionBetter preventionBetter preventionBetter careBetter care
How to measure MI trendsHow to measure MI trendsHow to measure MI trendsHow to measure MI trends
•National statistics and surveys•National statistics and surveys
•Administrative databases•Administrative databasesAdministrative databases
C it ill
Administrative databases
C it ill•Community surveillance•Community surveillance
National Statistics and SurveysNational Statistics and SurveysNational Statistics and SurveysNational Statistics and Surveys
•Mortality and morbidity reports•Hospital discharge data•Mortality and morbidity reports•Hospital discharge dataHospital discharge data•Procedural registries (surgery)
E A i
Hospital discharge data•Procedural registries (surgery)
E A i•EuroAspire•National Health and Nutrition •EuroAspire•National Health and Nutrition
Examination Survey Examination Survey
Not validated, captures episodes not personsUseful to ask questionsUseful to ask questions
Disease surveillanceDisease surveillance
Systematic approach to measure validated MI mortality, MI incidence, and post-MI survival to
provide insight into the determinants of the trends
Systematic approach to measure validated MI mortality, MI incidence, and post-MI survival to
provide insight into the determinants of the trendsprovide insight into the determinants of the trendsprovide insight into the determinants of the trends
• Defined population
• Rigorous• Defined population
• Rigorous• Rigorous event definition
• Constant criteria across time, place, person
• Rigorous event definition
• Constant criteria across time, place, person
CVD surveillanceCVD surveillance“A strategic goal of the AHA is to reduce heart “A strategic goal of the AHA is to reduce heart disease, stroke, and the risk for both bydisease, stroke, and the risk for both bydisease, stroke, and the risk for both by disease, stroke, and the risk for both by 25%,… However, the current health tracking 25%,… However, the current health tracking systems (surveillance) in the United States systems (surveillance) in the United States cannot track progress toward these goals in acannot track progress toward these goals in acannot track progress toward these goals in a cannot track progress toward these goals in a comprehensive and systematiccomprehensive and systematic manner”manner”
Circulation, 2007 115:127Circulation, 2007 115:127--5555
Community surveillanceCommunity surveillanceyyIn defined populationsIn defined populationsIn defined populationsIn defined populations
• Rigorous event definition
• Constant• Rigorous event definition
• Constant• Constant criteria across time, place, person• Constant criteria across time, place, person
ARIC, Minnesota Heart Survey, ARIC, Minnesota Heart Survey, Olmsted County StudyOlmsted County StudyWorcester Heart Attack Study some insurance plansWorcester Heart Attack Study some insurance plansWorcester Heart Attack Study, some insurance plansWorcester Heart Attack Study, some insurance plans
MONICAMONICA
Olmsted CountyOlmsted CountyOlmsted County2,000 pop=124,470Olmsted County2,000 pop=124,470
Home of Mayo Clinic Rochester and Olmsted Medical CenterHome of Mayo Clinic Rochester and Olmsted Medical Center
CP1176446-5
yyGeographically isolated from other providers of medical careGeographically isolated from other providers of medical careLinkage of all medical, surgical and tissue diagnosesLinkage of all medical, surgical and tissue diagnoses
ObjectivesObjectivesObjectivesObjectives
•Why and how to measure MI trends?
•Why and how to measure MI trends?trends?
•MI trends: then and nowtrends?
•MI trends: then and now•MI trends: then and nowWh t d thi ?
•MI trends: then and nowWh t d thi ?•What does this mean?•What does this mean?
MI IncidenceOlmsted CountyMI Incidence
Olmsted County450
WWWW
Olmsted CountyOlmsted County
31% decline350
WomenWomenWomenWomenMenMenMenMen
31% decline
Incidencerate x
100 000
Incidencerate x
100 000250
100,000100,000
150
5051% increase
5079 81 83 85 87 89 91 93 95 97
CP1145262-1Annals of Int Med, 2002Annals of Int Med, 2002
MI incidenceMI incidenceMI incidence Olmsted County-1998 vs 79
MI incidence Olmsted County-1998 vs 79
M W31% decline Men Women31% decline
40 years old 0.69 (0.48-0.97)* 0.92 (0.68-1.54)
60 years old 0.83 (0.67-1.02) 1.24 (0.96-1.60)
80 years old 1.00 (0.78-1.28) 1.49 (1.16-1.92)*
Annals of Int Med, 2002Annals of Int Med, 2002 51% increase
The New York The New York TimesTimes
May 2003May 2003
CP1099138-11
or rather “theor rather “the…or rather “the stereotypical heart
…or rather “the stereotypical heartstereotypical heart attack patient is nostereotypical heart attack patient is noattack patient is no longer a whiteattack patient is no longer a whitelonger a whiteman ”longer a whiteman ”man…man…
Incidence of Myocardial InfarctionIncidence of Myocardial Infarction
10 312
s
yy
6 2
10.3
6 1
9.2
5.1 7.28
10
on Y
ears
3.5
6.2
3.0
6.1
2.4 4.34
6
00 P
erso
1.20.90.3
1.00.7
1.8
0
2
Per 1
,00
035-44 45-54 55-64 65-74
White Men Black Men White Women Black Women
ARIC Surveillance: 1987ARIC Surveillance: 1987 20042004
White Men Black Men White Women Black Women
ARIC Surveillance: 1987ARIC Surveillance: 1987--20042004
Q wave and non-Q wave MIQ wave and non-Q wave MIMI IncidenceMI Incidence
WorcesterWorcester
170
2001975/19781975/1978
1981/1984
1986/19881986/1988
1990/1991
1993/19951993/1995
1997
146
109
130
120
1601981/19841981/1984 1990/19911990/1991 19971997
62
78
109
74
103
84
98105
100
80
120
%%
40
0
Q-wave MI Non-Q-wave MI
Furman et al: JACC, 2001Furman et al: JACC 2001,Furman et al: JACC, 2001
In the 1980’s and 90’s shift ofIn the 1980’s and 90’s shift ofIn the 1980 s and 90 s shift of the burden of MI towards…
In the 1980 s and 90 s shift of the burden of MI towards…
•Elderly•ElderlyElderly•WomenElderly
•Women•Women•Non Caucasians•Women•Non Caucasians•Non Caucasians•“N Q ” MI•Non Caucasians•“N Q ” MI•“Non Q wave” MIs•“Non Q wave” MIs
What abo t no ?What abo t no ?What about now?What about now?
Elliott Antman, Jean-Pierre Bassand, Werner Klein, Magnus Ohman,Jose Luis Lopez Sendon, Lars Rydén, Maarten Simoons and Michal Tendera
ESC/ACC consensus documentESC/ACC consensus documentESC/ACC consensus documentESC/ACC consensus document
All elevated (trop)values are associated with a worsenedPROGNOSIS. It should be emphasized that there is a continuous relation between minimal myocardial damage, characterized by elevation of troponin without elevation of other bio-markersp(e.g., CK-MB) and large infarcts.”
“Thus, any amount of myocardial necrosis caused by ischemia should be labeled as MI ”caused by ischemia should be labeled as MI.
Definitions of acute MIDefinitions of acute MIDefinitions of acute MIDefinitions of acute MI
WHO• At least 2 of the followingWHO• At least 2 of the following
ACC/ESC 2000• 1. Typical rise and fall of bio-marker
ith t l t
ACC/ESC 2000• 1. Typical rise and fall of bio-marker
ith t l tAt least 2 of the following• Rise and fall of serum
markers
At least 2 of the following• Rise and fall of serum
markers
with at least one : • ischemic symptoms • development of pathologic Q
waves on the ECG
with at least one : • ischemic symptoms • development of pathologic Q
waves on the ECG• ischemic symptoms• Serial changes on
ECG
• ischemic symptoms• Serial changes on
ECG
waves on the ECG • ECG changes indicative of
ischemia (ST segment elevation or depression)
waves on the ECG • ECG changes indicative of
ischemia (ST segment elevation or depression)ECGECG elevation or depression)
• coronary artery intervention (e.g., angioplasty)
• 2 Pathologic findings of acute MI
elevation or depression) • coronary artery intervention
(e.g., angioplasty)• 2 Pathologic findings of acute MI2. Pathologic findings of acute MI
Preferred biomarkertroponin more sensitive and
2. Pathologic findings of acute MI
Preferred biomarkertroponin more sensitive andtroponin, more sensitive and
less specifictroponin, more sensitive and
less specific
H Tunstall-Pedoe 2001H Tunstall-Pedoe, 2001
“Small degrees of biomarker elevations undoubtedly reflect myocardial necrosis but whether it has any impact on survivalafter otherwise uncomplicated procedures”….. remains to be demonstrated.Circulation 2001Circulation 2001
Challenges of the new definitionChallenges of the new definitionChallenges of the new definitionChallenges of the new definition
•Interventional cardiology outcomes•Interventional cardiology outcomes•Interventional cardiology outcomes •Rehabilitation•Interventional cardiology outcomes •RehabilitationRehabilitation•EmploymentRehabilitation
•Employmentp y•Insurance
p y•Insurance•Health care costs•Health care costs•Labeling and public misunderstanding•Labeling and public misunderstanding
Elevations of Troponin - False Positives, the Real TruthJaffe, AS, Cardiovascular Toxicology 2001
Elevations of Troponin - False Positives, the Real TruthJaffe, AS, Cardiovascular Toxicology 2001Jaffe, AS, Cardiovascular Toxicology 2001Jaffe, AS, Cardiovascular Toxicology 2001
• Trauma (contusion, ablation, pacing, ICD firings, DCCV, endomyocardial bx, cardiac surgery)
• Trauma (contusion, ablation, pacing, ICD firings, DCCV, endomyocardial bx, cardiac surgery)g y)
Heart failure Hypertension or Hypotension, often with arrhythmias Postoperative noncardiac surgery patients who seem to do well
g y) Heart failure Hypertension or Hypotension, often with arrhythmias Postoperative noncardiac surgery patients who seem to do well Postoperative noncardiac surgery patients who seem to do well Renal failure Sepsis, critically ill patients, esp. with diabetes
Postoperative noncardiac surgery patients who seem to do well Renal failure Sepsis, critically ill patients, esp. with diabetes Drug toxicity, eg adriamycin, 5 FU, herceptin Hypothyroidism and inflammatory diseases eg. myocarditis. Infiltrative diseases including
amyloidosis, hemachromatosis, sarcoidosis and scleroderma
Drug toxicity, eg adriamycin, 5 FU, herceptin Hypothyroidism and inflammatory diseases eg. myocarditis. Infiltrative diseases including
amyloidosis, hemachromatosis, sarcoidosis and scleroderma Post PCI patients who appear to be uncomplicated Pulmonary embolism Burns, esp. if TBSA > 30%
Post PCI patients who appear to be uncomplicated Pulmonary embolism Burns, esp. if TBSA > 30% Acute neurological disease, including CVA Rhabdomyolysis with cardiac injury Transplant vasculopathy
Acute neurological disease, including CVA Rhabdomyolysis with cardiac injury Transplant vasculopathy Transplant vasculopathy Vital Exhaustion Transplant vasculopathy Vital Exhaustion
New definition of MINew definition of MINew definition of MIESC/ACC consensus document
New definition of MIESC/ACC consensus document
Th h i MI i i “ illTh h i MI i i “ ill•The change in MI criteria “will confuse efforts to follow trends
•The change in MI criteria “will confuse efforts to follow trendsconfuse efforts to follow trends in disease rates and outcomes.”confuse efforts to follow trends in disease rates and outcomes.”
Journal of the American College of Cardiologyg gySeptember 2000; Pages 959-969
MI Incidence- The role of biomarkersF i h
MI Incidence- The role of biomarkersF i hFraminghamFramingham
MI-MarkerMI-MarkerMM5
MI-ECGMI-ECGMM MenMen
rate
rate
5
4
3
MenMen
50-59 yr 60-69 yr 70-79 yr
Log
rLo
g r
2
1 50-59 yr 60-69 yr 70-79 yrP<0.009 P=0.60 P<0.02
0P<0.001 P=0.32 P<0.05
WomenWomenWomenWomen5
4
g ra
teg
rate
4
3
2
50-59 yrP=0.40
60-69 yrP=0.63
70-79 yrP=0.003
50-59 yrP=0.63
60-69 yrP=0.28
70-79 yrP<0.01
LoLo
2
1
0
CP1348386-14Parikh et al: Circ, 2009Parikh et al: Circ, 20091960s 1970s 1980s 1990s1960s 1970s 1980s 1990s
February 2010February 2010February 2010February 2010
What if troponin had never existed?What if troponin had never existed?
Prospecti e comm nit based epidemiolog st dProspective community-based epidemiology study
Incidence of MIIncidence of MI
400Olmsted CountyOlmsted County
3000,00
00,
000
MenMen
200djus
ted
djus
ted
ate/
100
ate/
100
200
Age
Age
--adad
ence
raen
ce ra
100AAin
cid
inci
d
WomenWomen-------only CKMB, 20% decline
01987 1992 1997 2002
Circulation 2010
Incidence of MIIncidence of MI
300 Including troponin T MIsIncluding troponin T MIs
Olmsted CountyOlmsted Countyus
ted
uste
d0,
000
0,00
0Including troponin T MIsIncluding troponin T MIsExcluding troponin T MIsExcluding troponin T MIs
49% increase
200
exex--a
dju
adju
ate/
100
ate/
100
NonNon--STEMISTEMI
100and
sean
d se
ence
raen
ce ra
Age
Age
--in
cid
inci
d
STEMISTEMI01987 1992 1997 2002
STEMISTEMI
41% decline
Circulation 2010
Death at 30 days post MIDeath at 30 days post MI
25P=0 001P=0 00119871987--19911991
Olmsted CountyOlmsted County
20
P=0.001P=0.00119921992--1996199619971997--2001200120022002--20062006
P=0.003P=0.003
15%%
20022002--20062006
P=0.001P=0.001
10
%%
P=0 084P=0 084
P=0.110P=0.110
5P=0.084P=0.084
0OverallOverall MenMen WomenWomen Age <75Age <75 Age Age ≥≥7575
Circulation 2010
June 2010
Incidence of MIKaiser PermanenteIncidence of MIKaiser Permanente
300--yr)yr)
Kaiser PermanenteKaiser Permanente20% decline
ee pers
onpe
rson
--
MIMI200
ce ra
tece
rate
0,00
0 p
0,00
0 p
100ncid
ennc
iden
ses/
100
ses/
100
NonNon--STEMISTEMI
InIn. o
f cas
. of c
as STEMISTEMI
62% decline
01999 2000 2001 2002 2003 2004 2005 2006 2007 2008
(no
(no
Yeh, NEJM 2010
Death at 30 days post MIDeath at 30 days post MIy pKaiser Permanente
y pKaiser Permanente
•1999: 10.5%•1999: 10.5%•2008: 7.8%•2008: 7.8%•Adjusted for age and sex, driven by improvement in
•Adjusted for age and sex, driven by improvement indriven by improvement in survival among NSTEMI, no driven by improvement in survival among NSTEMI, no g ,change in STEMI
g ,change in STEMI
ObjectivesObjectivesObjectivesObjectives
•Why and how to measure MI trends?
•Why and how to measure MI trends?trends?
•MI trends: then and nowtrends?
•MI trends: then and now•MI trends: then and nowWh t d thi ?
•MI trends: then and nowWh t d thi ?•What does this mean?•What does this mean?
SummarySummarySummary Summary Enormous changes in epidemiology of MI• Incidence declining partially masked byEnormous changes in epidemiology of MI• Incidence declining partially masked byIncidence declining, partially masked by
introduction of troponinS f
Incidence declining, partially masked by introduction of troponin
S f•Decline in STEMI, amplified but not only related to troponin
•Decline in STEMI, amplified but not only related to troponin
•Shift in case mix towards NSTEMISh t t t h b tt
•Shift in case mix towards NSTEMISh t t t h b tt•Short term outcomes are much better
Causes: improved primary prevention•Short term outcomes are much betterCauses: improved primary preventionCauses: improved primary prevention,
population penetration of various drugs…Causes: improved primary prevention,
population penetration of various drugs…
ImplicationsImplicationsImplicationsImplicationsEnormous changes = enormous
implicationsEnormous changes = enormous
implicationsimplications•We are still processing the data
implications•We are still processing the datap g•STEMIs are declining: quality of care
ff t h ld t t NSTEMI
p g•STEMIs are declining: quality of care
ff t h ld t t NSTEMIefforts should target NSTEMI•Care of MI beyond the acute phaseefforts should target NSTEMI
•Care of MI beyond the acute phase•Care of MI beyond the acute phase•Care of MI beyond the acute phase
G i ill !G i ill !Grazie mille!Grazie mille!