30-Year Trends in Patient Characteristics, Treatment Practices, and Long-Term Outcomes of Adults Aged 35 to 54 Years Hospitalized With Acute Myocardial Infarction Mayra Tisminetzky, MD, PhDa, David D. McManus, MD, ScMa,b, Joel M. Gore, MDb, Jorge Yarzebski, MD, MPHa, Andrew Coles, PhDc, Darleen Lessard, MSa, and Robert J. Goldberg, PhDa,b,* Much of our knowledge about the characteristics, clinical management, and postdischarge outcomes of acute myocardial infarction (AMI) is derived from clinical studies in middleaged and older subjects with little contemporary information available about the descriptive epidemiology of AMI in relatively young men and women. The objectives of our populationbased study were to describe >3-decade-long trends in the clinical features, treatment practices, and long-term outcomes of young adults aged 35 to 54 years discharged from the hospital after AMI. The study population consisted of 2,142 residents of the Worcester (Massachusetts) metropolitan area who were hospitalized with AMI at all central Massachusetts medical centers during 16 annual periods from 1975 to 2007. Our primarily male study population had an average age of 47 years. Patients hospitalized during the most recent decade (1997 to 2007) under study were more likely to have a history of hypertension and heart failure than those hospitalized during earlier study years. Patients were less likely to have developed heart failure or stroke during their hospitalization in the most recent compared with the initial decade under study (heart failure 13.7% and stroke 0.7% vs 20.9% and 2.0%, respectively). One- and 2-year postdischarge death rates also decreased significantly between 1975 to 1986 (6.2% and 9.0%, respectively) and 1988 to 1995 (2.6% and 4.9%). These trends were concomitant with the increasing use of effective cardiac therapies and coronary interventions during hospitalization. The present results provide insights into the changing characteristics, management, and improving long-term outcomes of relatively young patients hospitalized with AMI. Ó 2014 Elsevier Inc. All rights reserved. (Am J Cardiol 2014;113:1137e1141)

The objectives of our multihospital observational study in residents of central Massachusetts were to describe multidecade-long trends (1975 to 2007) in patient characteristics, treatment practices, and long-term outcomes in adults aged 35 to 54 years discharged from the hospital after acute myocardial infarction (AMI) at all medical centers in central Massachusetts. Data from the Worcester Heart Attack Study were used for purposes of analysis.1e5 Methods The study population consisted of greater Worcester residents aged 35 to 54 years who were hospitalized with a a Department of Quantitative Health Sciences, bDivision of Cardiovascular Medicine, Department of Medicine, and cDepartment of Cell and Developmental Biology, Program in Gene Function and Expression, University of Massachusetts Medical School, Worcester, Massachusetts. Manuscript received October 15, 2013; revised manuscript received and accepted December 16, 2013. This study was supported by grant R01-HL35434 from the National Institutes of Health, Bethesda, Maryland. See page 1140 for disclosure information. *Corresponding author: Tel: (508) 856-3991; fax: (508) 856-8993. E-mail address: [email protected] (R.J. Goldberg).

0002-9149/14/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2013.12.020

discharge diagnosis of AMI at all medical centers in the Worcester (Massachusetts) metropolitan area during 16 annual study periods from 1975 to 2007.1e5 Sixteen hospitals were originally included in this investigation, but fewer hospitals (n ¼ 11) have been included during recent years because of hospital closures or conversion to longterm care or rehabilitation facilities. We restricted the present sample to adults aged 35 to 54 years who were hospitalized with an independently validated AMI because we were interested in describing the clinical epidemiology of AMI in a comparatively young patient population. The details of this study have been extensively described.1e5 In brief, potentially eligible patients were identified through a review of computerized hospital databases of patients with discharge diagnoses consistent with possible AMI. The medical records of residents of the Worcester metropolitan area (2000 census ¼ 478,000) were reviewed in a standardized manner and the diagnosis of AMI was confirmed according to preestablished criteria.1e5 Trained study clinicians abstracted information from hospital medical records with regards to patient’s demographic characteristics, presenting symptoms, medical history, clinical and laboratory findings, receipt of cardiac treatments and revascularization procedures, length of hospital stay, duration of prehospital delay in seeking acute medical care, and www.ajconline.org

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Table 1 Study population characteristics Variable

Total Population, n ¼ 2,142 (%)

Age (yrs, mean  SD) Men Angina pectoris Hypertension Stroke Heart failure Diabetes mellitus Admission serum glucose (mg/dl, mean  SD) Total cholesterol (mg/dl, mean  SD) Length of stay (days, median  SD) STEMI Initial AMI

47.4  5.0 80.4 15.5 42.9 2.4 3.9 17.4 157.3  75.9 213.6  49.8 6.0  7.6 N/A 79.5

Study Period 1975e1986, n ¼ 642 (%)

1988e1995, n ¼ 607 (%)

1997e2007, n ¼ 893 (%)

47.7  5.0 82.1 20.9 39.4 2.0 2.7 15.0 N/A 237.1  46.9 13.0  7.6 N/A 79.3

46.8  5.0 80.2 16.6 39.4 1.3 3.0 15.2 156.3  7.6 220.8  44.6 7.0  6.5 N/A 80.2

47.6  4.8 79.4 10.8 47.8 1.4 5.4 20.7 157.4  76.1 193.0  46.7 3.0  5.2 55.0 79.1

STEMI ¼ ST elevation myocardial infarction.

Table 2 Development of in-hospital clinical complications overall and by study period Complication Atrial fibrillation Heart failure Stroke Cardiogenic shock

Total Population (%)

1975e1986 (%)

1988e1995 (%)

1997e2007 (%)

p Value

5.0 17.2 0.5 2.7

4.7 20.9 2.0 1.9

6.3 18.5 0 0.9

4.4 13.7 0.7 2.9

NS