ct t dicontemporary trends in myocayoca d a a ct o c de

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?

@roger.veronique@mayo.edu

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!