Eric Whitsel, Lynne Wagenknecht, Hanyu Ni and Aaron R. Folsom Wayne D. Rosamond, Lloyd E ...

35 Pages·2012·1.31 MB·English

Twenty-Two- Year Trends in Incidence of Myocardial Infarction, Coronary Heart Disease
Mortality, and Case Fatality in 4 US Communities, 1987- 2008
Wayne D. Rosamond, Lloyd E. Chambless, Gerardo Heiss, Thomas H. Mosley, Josef Coresh,
Eric Whitsel, Lynne Wagenknecht, Hanyu Ni and Aaron R. Folsom
Circulation. 2012;125:1848-1857; originally published online March 15, 2012;
doi: 10.1161/CIRCULATIONAHA.111.047480
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Epidemiology and Prevention
Twenty-Two–Year Trends in Incidence of Myocardial
Infarction, Coronary Heart Disease Mortality, and Case
Fatality in 4 US Communities, 1987–2008
Wayne D. Rosamond, PhD, MS; Lloyd E. Chambless, PhD; Gerardo Heiss, MD, PhD;
Thomas H. Mosley, PhD; Josef Coresh, MD, PhD; Eric Whitsel, MD; Lynne Wagenknecht, DrPH;
Hanyu Ni, PhD; Aaron R. Folsom, MD, MPH
Background—Knowledge of trends in the incidence of and survival after myocardial infarction (MI) in a community
setting is important to understanding trends in coronary heart disease (CHD) mortality rates.
MethodsandResults—Weestimatedrace-andgender-specifictrendsintheincidenceofhospitalizedMI,casefatality,and
CHDmortalityfromcommunity-widesurveillanceandvalidationofhospitaldischargesandofin-andout-of-hospital
deathsamong35-to74-year-oldresidentsof4communitiesintheAtherosclerosisRiskinCommunities(ARIC)Study.
Biomarker adjustment accounted for change from reliance on cardiac enzymes to widespread use of troponin
measurementsovertime.During1987–2008,atotalof30985fatalornonfatalhospitalizedacuteMIeventsoccurred.
Rates of CHD death among persons without a history of MI fell an average 4.7%/y among men and 4.3%/y among
women. Rates of both in- and out-of-hospital CHD death declined significantly throughout the period. Age- and
biomarker-adjusted average annual rate of incident MI decreased 4.3% among white men, 3.8% among white women,
3.4%amongblackwomen, and1.5%among blackmen. DeclinesinCHDmortalityandMIincidenceweregreaterin
the second decade (1997–2008). Failure to account for biomarker shift would have masked declines in incidence,
particularlyamongblacks.Age-adjusted28-daycasefatalityafterhospitalizedMIdeclined3.5%/yamongwhitemen,
3.6%/y among black men, 3.0%/y among white women, and 2.6%/y among black women.
Conclusions—Althoughthesefindingsfrom4communitiesmaynotbedirectlygeneralizabletoblacksandwhitesinthe
entireUnitedStates,weobservedsignificantdeclinesinMIincidence,primarilyasaresultofdownwardtrendsinrates
between 1997 and 2008. (Circulation. 2012;125:1848-1857.)
Key Words: epidemiology (cid:1) mortality rates (cid:1) myocardial infarction (cid:1) surveillance (cid:1) survival
Recentstudiessuggestthattrendsintheincidencerateof ized.14,15 Although available studies offer valuable insights
myocardial infarction (MI) in the United States may into recent trends in the occurrence of MI and mortality due
have changed substantially in the last 2 decades from rela- tocoronaryheartdisease(CHD),additionaldataontrendsin
tively stable rates in the 1980s and 1990s1–4 to significant annual incidence of MI and CHD mortality from other large
declines in the new millennium.5–9 Some recent studies geographically and ethnically diverse environments with the
furthered our understanding of contemporary patterns of MI use of a common methodology are needed and can provide
ratesbyexaminingtrendsbytypeofMI(presenceorabsence valuable insights into disease trends in the population. The
of ST-segment elevation) and by estimating the impact on importanceofthesetypesofdatawasemphasizedinarecent
ratesbroughtaboutbytheintroductionoftroponinmeasure- Institute of Medicine report on cardiovascular disease sur-
ments and new definitions of clinical events.8,10–13 Whether veillance needs in the United States.16 We studied trends in
or not these recently reported trends apply similarly across mortality due to CHD and in the incidence of MI with and
race and gender groups and the extent to which changes in without a unique adjustment for changes in biomarkers over
biomarkers account for these trends are less well character- time during 1987–2008, as well as trends in short-term
ReceivedJune2,2011;acceptedMarch2,2012.
FromtheDepartmentsofEpidemiology(W.D.R.,G.H.,E.W.),Biostatistics,GillingsSchoolofGlobalPublicHealth(L.E.C.),andMedicine(E.W.),
School of Medicine, University of North Carolina, Chapel Hill; Department of Medicine, School of Medicine, University of Mississippi, Jackson
(T.H.M.);DepartmentofEpidemiology,BloombergSchoolofPublicHealth,JohnsHopkinsUniversity,Baltimore,MD(J.C.);DivisionofPublicHealth
Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (L.W.); National Institutes of Health, National Heart, Lung, and Blood
Institute,Bethesda,MD(H.N.);andDivisionofEpidemiologyandCommunityHealth,SchoolofPublicHealth,UniversityofMinnesota,Minneapolis
(A.R.F.).
Theonline-onlyDataSupplementisavailablewiththisarticleathttp://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.
111.047480/-/DC1.
CorrespondencetoWayneRosamond,PhD,CardiovascularEpidemiologyProgram,DepartmentofEpidemiology,BankofAmericaBuilding,137E
FranklinSt,Suite306,ChapelHill,[email protected]
©2012AmericanHeartAssociation,Inc.
Circulationisavailableathttp://circ.ahajournals.org DOI:10.1161/CIRCULATIONAHA.111.047480
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Rosamond et al Community Trends in MI Incidence Rates 1849
Table1. HospitalizedMIs,CHDDeaths,andPopulationEstimatesforSubjectsAged35–74Yearsinthe4ARICCommunities:ARIC
Study1987–2008*
HospitalizationsforMI DeathsDuetoCHD Population†
Men Women Total Men Women Total Men Women
Race
Black 3937(72) 3140(76) 7077(74) 1206(59) 891(64) 2097(61) 41138 52807
White 16423(65) 7485(73) 23908(67) 4280(47) 1780(54) 6061(49) 147072 155497
Total 20360(66) 10625(74) 30985(69) 5486(49) 2671(57) 8158(52) 188210 208304
Community
ForsythCounty,NC 8014(70) 4147(75) 12161(71) 2163(50) 1000(56) 3163(52) 72894 81573
Jackson,MS 4384(68) 2697(77) 7081(71) 1595(55) 878(68) 2473(60) 31102 38494
Minneapolissuburbs,MN 4275(64) 2045(73) 6320(67) 974(44) 382(48) 1357(45) 52454 56212
WashingtonCounty,MD 3686(59) 1736(67) 5422(62) 754(41) 410(48) 1165(43) 31760 32025
Valuesarenumber(percentagewithfirstevents).MIindicatesmyocardialinfarction;CHD,coronaryheartdisease;andARIC,AtherosclerosisRiskinCommunities.
*Numbersshowninthetablewereestimatedfromsampledeventsthatwerevalidated:12947hospitalizedforMIinmenand7128inwomen;4657deathsdue
toCHDinmenand2406inwomen.ThepercentagesshowhowmanyofthosewithaneventhadnohistoryofMI.
†Populationnumbersshownareofblacksandwhitesaged35–74yearsin2008.
(28-day) case fatality after MI from community surveillance Criteria for each of these 3 diagnostic elements in the algorithm
in the Atherosclerosis Risk in Communities (ARIC) Study. remainedconstantoverthestudyperiodandaredescribedindetail
intheARICStudysurveillancemanual.19Caseswithdisagreements
Clinical Perspective on p 1857 betweenthecomputerdiagnosisanddischargediagnosiscodeswere
reviewed by physicians on the ARIC Mortality and Morbidity
ClassificationCommitteeforfinalclassification.Alleligiblehospi-
Methods
talizedeventswereclassifiedaseitherdefinite,probable,suspect,or
Study Population no MI.17 Definite or probable MI was combined to define MI for
analysis unless otherwise specified. MI events with equivocal or
Since1987,theARICStudy17hasconductedcontinuousretrospec- abnormal biomarkers were further classified as non–ST-segment
tive surveillance of hospital discharges for MI and deaths due to
elevation MI (NSTEMI) or ST-segment elevation MI (STEMI) on
CHD occurring in or out of the hospital among residents aged 35
thebasisofthecodedECGs.
through74yearsinForsythCounty,NC;thecityofJackson,MS;8
Afirst(incident)MIwasdefinedasoneinapatientforwhomthe
northern suburbs of Minneapolis, MN; and Washington County, medicalrecordeitherstatedthattherewasnohistoryofMIordidnot
MD,withacombinedstudypopulationof(cid:1)396000personsin2008 containanyreferencetoahistoryofMI.RecurrentMIwasdefined
(Table 1). Twenty-four percent of the study population was black. asanydefiniteorprobableMIforwhichthemedicalrecordstateda
The trends reported here in ARIC blacks and whites in these 4 historyofMI.
communities are of interest, even though the ARIC design cannot Eligiblehospitalizationsforwhichthechartcouldnotbelocated
totally separate race effects from regional effects, given that suffi- were deemed unclassifiable. Because missing hospital records are
cientnumbersofblackstoyieldstableestimateswerepresentinonly likely not random and may have included events that would have
2communities(Jackson,MS,andForsythCounty,NC). been validated as MI had the medical record been available, we
adjustedthetrendsinhospitalizedMIratesinsensitivityanalysesto
Identification of Hospitalized MI Events accountforthispossiblesourceofbias.
Hospitalized MIs were identified from electronic discharge lists
obtained from all hospitals serving the 4 communities (n(cid:2)31). Identification of CHD Deaths
TrainedARICstaffmembersabstractedmedicalrecordsforpossible For the period 1987–1998, deaths with underlying cause of death
events,selectedonthebasisofage,residenceinthecommunity,and ICD-9-CMcodes250,401,402,410to414,427to429,440,518.4,
discharge code (International Classification of Diseases, Ninth 798,and799weresampled.Beginningin1999,ICD-10-CMcodes
Revision, Clinical Modification [ICD-9-CM] codes 402, 410–414, E10toE14,I10toI11,I21toI25,I46toI51,I70,I97,J81,J96,R96,
427, 428, and 518.4) through random sampling within discharge and R98 to R99 were sampled. Sampling fractions varied by sex,
codestrata.Seetheonline-onlyDataSupplementforadescriptionof field center, and code group and were adjusted over time. Deaths
ICD-9-CM codes used to identify events for investigation and amongcommunityresidentsoccurringoutsidethestateofresidence
validation. Sampling probabilities varied by race, sex, field center, were omitted. The number of such deaths was few (10 eligible
anddischargecodegroupandwereadjustedperiodically.18,19Hos- out-of-statedeathsin2008)andstableovertime.Deathsinnursing
pitalizationsofcommunityresidentsthatoccurredoutsidethestudy homes and emergency departments and hospital admissions of
area were not included unless the subjects were transferred to and persons dead on arrival were classified as out-of-hospital deaths.
dischargedfromasurveillancehospital.Diagnosticinformationfrom Trained ARIC staff reviewed death certificates that met sampling
the transferring hospital was included in the validation of events. eligibilitycriteria.Forin-hospitaldeaths,medicalrecordswerealso
Informationobtainedfrommedicalrecordsincludedthefollowing: reviewed. For out-of-hospital deaths, additional information was
presenceofchestpain,historyofMIorothercardiovascular-related sought from the next of kin and other informants, certifying and
conditions, and measures of cardiac biomarkers (total creatinine family physicians, and coroners or medical examiners. Using stan-
phosphokinase[CK],CK-MB,lactatedehydrogenase,andtroponin). dardizedcriteria,17theMortalityandMorbidityClassificationCom-
Copiesofupto3ECGswereobtainedandsenttotheUniversityof mitteereviewedthesedatafordeathsandassignedafinaldiagnosis,
Minnesota Electrocardiographic Reading Center for classification withdisagreementsadjudicated.TrendsinCHDmortalityincluded
according to the Minnesota code.20 A standardized computerized deaths classified as due to either definite fatal MI or definite fatal
algorithmwasappliedtodataonchestpain,cardiacbiomarkers,and CHD.Becauseofstateregulationsthatprohibitedfullinvestigation
ECGevidencetodetermineeachpatient’scomputerMIdiagnosis.17 of out-of-hospital deaths in Washington County until 1995, this
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1850 Circulation April 17, 2012
Table2. AverageAnnualPercentChange(95%ConfidenceInterval)inRatesofDeathDuetoCHDorRatesofHospitalizedMI,for
Men,AdjustedforAge,intheARICStudy1987–2008*
Whites
EventType 1987–1996 1997–2008 AllYears
DeathduetoCHD (cid:3)4.0((cid:3)5.1to(cid:3)3.0) (cid:3)9.8((cid:3)11.1to(cid:3)8.5) (cid:3)6.5((cid:3)7.0to(cid:3)6.1)
DeathduetoCHDwithouthistoryofMI (cid:3)4.5((cid:3)6.2to(cid:3)2.8) (cid:3)7.3((cid:3)9.3to(cid:3)5.2) (cid:3)5.7((cid:3)6.4to(cid:3)4.9)
In-hospitaldeathduetoCHD (cid:3)4.9((cid:3)6.7to(cid:3)3.2) (cid:3)12.4((cid:3)15.0to(cid:3)9.7) (cid:3)7.9((cid:3)8.7to(cid:3)7.1)
Out-of-hospitaldeathduetoCHD (cid:3)3.4((cid:3)4.8to(cid:3)2.0) (cid:3)8.4((cid:3)9.9to(cid:3)6.8) (cid:3)5.6((cid:3)6.2to(cid:3)5.0)
FirstMIordeathduetoCHD‡ (cid:3)3.7((cid:3)4.5to(cid:3)3.0) (cid:3)6.4((cid:3)7.3to(cid:3)5.4) (cid:3)4.9((cid:3)5.3to(cid:3)4.5)
FirstMIordeathduetoCHD (cid:3)1.7((cid:3)2.6to(cid:3)0.9) (cid:3)4.0((cid:3)5.2to(cid:3)2.8) (cid:3)2.9((cid:3)3.4to(cid:3)2.4)
FirstMI‡ (cid:3)3.6((cid:3)4.5to(cid:3)2.7) (cid:3)5.1((cid:3)6.4to(cid:3)3.8) (cid:3)4.3((cid:3)4.7to(cid:3)3.8)
FirstMI (cid:3)1.4((cid:3)2.4to(cid:3)0.5) (cid:3)3.7((cid:3)5.0to(cid:3)2.4) (cid:3)2.6((cid:3)3.1to(cid:3)2.1)
FirstSTEMI‡ (cid:3)3.0((cid:3)4.5to(cid:3)1.5) (cid:3)8.4((cid:3)11.1to(cid:3)5.6) (cid:3)5.4((cid:3)6.2to(cid:3)4.5)
FirstSTEMI (cid:3)1.2((cid:3)2.7to0.3) (cid:3)8.8((cid:3)11.2to(cid:3)6.4) (cid:3)4.8((cid:3)5.5to(cid:3)4.0)
FirstNSTEMI‡ (cid:3)6.3((cid:3)7.6to(cid:3)5.1) (cid:3)3.5((cid:3)5.2to(cid:3)1.8) (cid:3)4.8((cid:3)5.5to(cid:3)4.1)
FirstNSTEMI (cid:3)2.1((cid:3)3.4to(cid:3)0.9) (cid:3)0.8((cid:3)2.4to0.8) (cid:3)1.4((cid:3)2.1to(cid:3)0.7)
RecurrentMI‡ (cid:3)4.1((cid:3)5.6to(cid:3)2.7) (cid:3)9.3((cid:3)11.4to(cid:3)7.2) (cid:3)6.3((cid:3)7.0to(cid:3)5.6)
CHDindicatescoronaryheartdisease;MI,myocardialinfarction;ARIC,AtherosclerosisRiskinCommunities;STEMI,ST-segmentelevationmyocardialinfarction;
andNSTEMI,non–ST-segmentelevationmyocardialinfarction.
*Averageannualpercentchangefromquadraticregressionmodels.Negativenumbersindicateadecrease,andpositivenumbersindicateanincrease.
†Adjustedalsoforrace.
‡Trendsadjustedalsoforchangesincardiacbiomarkersovertime.
community was not included in computation of trends involving Adjustment for Biomarker Change
CHDdeathbeforethatyear. Dramatic shifts in the use of cardiac biomarkers to diagnose MI
ForfatalCHDevents,presenceorabsenceofahistoryofMIwas occurredbetween1987and2008.10,11IntheARICcommunities,the
based on information obtained from the next of kin and other proportionofeligiblehospitalizationswithatroponinmeasurement
informants including the certifying physician, coroner, or medical increasedfrom8%in1996to98%by2001.Patternsofbiomarker
examiner or from medical records for any eligible hospitalization adoption varied by community and by hospital within community.
within28daysbeforedeath.VitalstatusofhospitalizedMIevents To permit a more meaningful interpretation of trends in MI, we
afterdischargewasdeterminedthroughlinkagewithNationalDeath developedanimputationmethodthatstandardizestheeventratesto
Indexfilesandusedforcomputingcase-fatalitypercentages. aconsistentusageofcardiacbiomarkers.Detailsofthismethodas
Table3. AverageAnnualPercentChange(95%ConfidenceInterval)inRatesofDeathDuetoCHDorRatesofHospitalizedMI,for
Women,AdjustedforAge,intheARICStudy1987–2008*
Whites
EventType 1987–1996 1997–2008 AllYears
DeathduetoCHD (cid:3)1.6((cid:3)3.3to0.1) (cid:3)10.9((cid:3)12.8to(cid:3)9.0) (cid:3)5.8((cid:3)6.5to(cid:3)5.1)
DeathduetoCHDwithouthistoryofMI 0.4((cid:3)2.0to2.9) (cid:3)10.2((cid:3)12.8to(cid:3)7.6) (cid:3)4.7((cid:3)5.6to(cid:3)3.7)
In-hospitaldeathduetoCHD (cid:3)2.7((cid:3)5.0to(cid:3)0.4) (cid:3)13.5((cid:3)16.3to(cid:3)10.7) (cid:3)7.2((cid:3)8.2to(cid:3)6.3)
Out-of-hospitaldeathduetoCHD (cid:3)0.3((cid:3)3.0to2.4) (cid:3)8.8((cid:3)11.4to(cid:3)6.2) (cid:3)4.4((cid:3)5.5to(cid:3)3.4)
FirstMIordeathduetoCHD‡ (cid:3)2.4((cid:3)3.7to(cid:3)1.2) (cid:3)5.5((cid:3)6.9to(cid:3)4.2) (cid:3)3.9((cid:3)4.5to(cid:3)3.4)
FirstMIordeathduetoCHD (cid:3)0.1((cid:3)1.7to1.4) (cid:3)3.3((cid:3)4.8to(cid:3)1.7) (cid:3)1.8((cid:3)2.5to(cid:3)1.1)
FirstMI‡ (cid:3)3.0((cid:3)4.5to(cid:3)1.5) (cid:3)4.8((cid:3)6.5to(cid:3)3.1) (cid:3)3.8((cid:3)4.5to(cid:3)3.1)
FirstMI (cid:3)0.9((cid:3)2.4to0.6) (cid:3)2.5((cid:3)4.2to(cid:3)0.9) (cid:3)1.7((cid:3)2.4to(cid:3)1.0)
FirstSTEMI‡ (cid:3)2.2((cid:3)4.5to0.2) (cid:3)6.9((cid:3)10.5to(cid:3)3.3) (cid:3)4.4((cid:3)5.6to(cid:3)3.1)
FirstSTEMI (cid:3)0.5((cid:3)3.0to1.9) (cid:3)7.3((cid:3)10.8to(cid:3)3.8) (cid:3)3.8((cid:3)4.9to(cid:3)2.7)
FirstNSTEMI‡ (cid:3)5.5((cid:3)7.4to(cid:3)3.5) (cid:3)3.7((cid:3)6.0to(cid:3)1.5) (cid:3)4.5((cid:3)5.4to(cid:3)3.6)
FirstNSTEMI (cid:3)1.4((cid:3)3.3to0.5) (cid:3)0.5((cid:3)2.4to1.5) (cid:3)0.9((cid:3)1.8to0.0)
RecurrentMI‡ (cid:3)5.8((cid:3)8.0to(cid:3)3.7) (cid:3)6.4((cid:3)9.4to(cid:3)3.4) (cid:3)5.9((cid:3)7.1to(cid:3)4.8)
CHDindicatescoronaryheartdisease;MI,myocardialinfarction;ARIC,AtherosclerosisRiskinCommunities;STEMI,ST-segmentelevationmyocardialinfarction;
andNSTEMI,non–ST-segmentelevationmyocardialinfarction.
*Averageannualpercentchangefromquadraticregressionmodels.Negativenumbersindicateadecrease,andpositivenumbersindicateanincrease.
†Adjustedalsoforrace.
‡Trendsadjustedalsoforchangesincardiacbiomarkersovertime.
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Rosamond et al Community Trends in MI Incidence Rates 1851
Table2. Continued
Blacks Total†
1987–1996 1997–2008 AllYears 1987–1996 1997–2008 AllYears
(cid:3)0.9((cid:3)3.3to1.5) (cid:3)5.3((cid:3)7.5to(cid:3)3.2) (cid:3)3.2((cid:3)4.1to(cid:3)2.2) (cid:3)3.4((cid:3)4.3to(cid:3)2.4) (cid:3)8.6((cid:3)9.7to(cid:3)7.5) (cid:3)5.7((cid:3)6.1to(cid:3)5.3)
(cid:3)1.1((cid:3)4.3to2.2) (cid:3)3.2((cid:3)6.0to(cid:3)0.4) (cid:3)2.2((cid:3)3.5to(cid:3)0.9) (cid:3)3.6((cid:3)5.1to(cid:3)2.1) (cid:3)6.0((cid:3)7.6to(cid:3)4.3) (cid:3)4.7((cid:3)5.3to(cid:3)4.1)
(cid:3)0.2((cid:3)5.2to4.9) (cid:3)8.7((cid:3)13.7to(cid:3)3.7) (cid:3)4.3((cid:3)6.3to(cid:3)2.4) (cid:3)4.1((cid:3)5.7to(cid:3)2.4) (cid:3)11.6((cid:3)13.9to(cid:3)9.3) (cid:3)7.2((cid:3)8.0to(cid:3)6.5)
(cid:3)1.2((cid:3)3.9to1.6) (cid:3)4.1((cid:3)6.5to(cid:3)1.7) (cid:3)2.7((cid:3)3.8to(cid:3)1.6) (cid:3)2.8((cid:3)4.0to(cid:3)1.6) (cid:3)7.1((cid:3)8.4to(cid:3)5.9) (cid:3)4.9((cid:3)5.4to(cid:3)4.3)
(cid:3)0.9((cid:3)2.8to1.1) (cid:3)2.6((cid:3)4.1to(cid:3)1.0) (cid:3)1.8((cid:3)2.6to(cid:3)1.0) (cid:3)3.2((cid:3)3.9to(cid:3)2.5) (cid:3)5.5((cid:3)6.3to(cid:3)4.6) (cid:3)4.3((cid:3)4.6to(cid:3)3.9)
2.3((cid:3)0.1to4.6) (cid:3)0.8((cid:3)2.6to0.9) 0.4((cid:3)0.5to1.4) (cid:3)0.9((cid:3)1.8to(cid:3)0.1) (cid:3)3.1((cid:3)4.1to(cid:3)2.1) (cid:3)2.1((cid:3)2.5to(cid:3)1.7)
(cid:3)0.4((cid:3)3.3to2.6) (cid:3)2.5((cid:3)4.7to(cid:3)0.4) (cid:3)1.5((cid:3)2.7to(cid:3)0.4) (cid:3)3.2((cid:3)4.1to(cid:3)2.3) (cid:3)4.5((cid:3)5.6to(cid:3)3.4) (cid:3)3.8((cid:3)4.2to(cid:3)3.3)
3.2(0.4to6.1) (cid:3)0.5((cid:3)2.5to1.5) 1.0((cid:3)0.1to2.1) (cid:3)0.8((cid:3)1.7to0.1) (cid:3)2.9((cid:3).3.9to(cid:3)1.8) (cid:3)1.9((cid:3)2.3to(cid:3)1.4)
4.2(0.0to8.3) (cid:3)7.4((cid:3)12.1to(cid:3)2.8) (cid:3)2.2((cid:3)3.8to(cid:3)0.5) (cid:3)2.0((cid:3)3.4to(cid:3)0.5) (cid:3)8.0((cid:3)10.4to(cid:3)5.7) (cid:3)4.8((cid:3)5.6to(cid:3)4.0)
6.3(2.2to10.5) (cid:3)5.9((cid:3)10.2to(cid:3)1.6) (cid:3)0.7((cid:3)2.3to0.9) (cid:3)0.2((cid:3)1.6to1.2) (cid:3)7.9((cid:3)10.0to(cid:3)5.9) (cid:3)4.0((cid:3)4.7to(cid:3)3.3)
(cid:3)4.0((cid:3)7.8to(cid:3)0.2) (cid:3)0.4((cid:3)3.1to2.3) (cid:3)2.0((cid:3)3.6to(cid:3)0.4) (cid:3)6.0((cid:3)7.2to(cid:3)4.8) (cid:3)2.7((cid:3)4.2to(cid:3)1.3) (cid:3)4.3((cid:3)4.9to(cid:3)3.7)
1.1((cid:3)2.6to4.8) 2.2((cid:3)0.2to4.6) 1.8(0.3to3.2) (cid:3)1.7((cid:3)2.9to(cid:3)0.5) (cid:3)0.1((cid:3)1.4to1.3) (cid:3)0.8((cid:3)1.4to(cid:3)0.2)
(cid:3)2.2((cid:3)5.6to1.2) (cid:3)2.8((cid:3)6.3to0.8) (cid:3)2.5((cid:3)4.1to(cid:3)0.9) (cid:3)4.0((cid:3)5.3to(cid:3)2.7) (cid:3)8.0((cid:3)9.8to(cid:3)6.2) (cid:3)5.7((cid:3)6.4to(cid:3)5.1)
applied to ARIC surveillance data are described in the online-only pretroponinyear)andthenimputedtheprobabilityofMIsineachof
Data Supplement and are described here only briefly. We adjusted the pretroponin combinations. We then standardized the imputed
theeventratesthatincludehospitalizedMIforchangesinbiomark- probability of MIs, and therefore the number of events, to the
ersbyimputingthenumberofeventsthatwouldhaveoccurredina distribution of the pretroponin combinations in a reference period
pretroponin year (ie, had troponin not been introduced and other mimicking direct adjustment. This was an extension of direct
biomarkers not dropped) and had the distribution of the biomarker adjustmentinwhichthedistributionofthepretroponincombinations
usage combinations been the same across years. The adjustment forpost-1995eventswasimputed,fromwhichtheprobabilityofMIs
included both an imputation and a standardization procedure. First ineachofthepretroponincombinationscouldbeestimatedbydata
weimputedthedistributionofthepretroponincombinations(ie,the regarding overlaps in troponin use and other biomarkers. The last
biomarker usage combinations that would have occurred in a stepwasweightingthepretroponincombination–specificprobability
Table3. Continued
Blacks Total†
1987–1996 1997–2008 AllYears 1987–1996 1997–2008 AllYears
(cid:3)3.2((cid:3)6.0to(cid:3)0.4) (cid:3)5.1((cid:3)7.5to(cid:3)2.6) (cid:3)4.0((cid:3)5.2to(cid:3)2.9) (cid:3)2.3((cid:3)3.7to(cid:3)0.9) (cid:3)8.6((cid:3)10.0to(cid:3)7.1) (cid:3)5.2((cid:3)5.8to(cid:3)4.6)
(cid:3)3.1((cid:3)6.3to0.1) (cid:3)4.2((cid:3)7.2to(cid:3)1.2) (cid:3)3.6((cid:3)5.0to(cid:3)2.2) (cid:3)1.1((cid:3)3.0to0.8) (cid:3)7.7((cid:3)9.6to(cid:3)5.7) (cid:3)4.3((cid:3)5.1to(cid:3)3.5)
(cid:3)7.1((cid:3)11.9to(cid:3)2.4) (cid:3)5.1((cid:3)9.2to(cid:3)1.1) (cid:3)6.0((cid:3)7.9to(cid:3)4.1) (cid:3)4.3((cid:3)6.5to(cid:3)2.1) (cid:3)10.6((cid:3)12.9to(cid:3)8.3) (cid:3)6.9((cid:3)7.8to(cid:3)6.0)
0.2((cid:3)3.2to3.5) (cid:3)5.2((cid:3)8.3to(cid:3)2.1) (cid:3)2.6((cid:3)4.0to(cid:3)1.2) (cid:3)0.3((cid:3)2.3to1.8) (cid:3)7.2((cid:3)9.2to(cid:3)5.3) (cid:3)3.7((cid:3)4.6to(cid:3)2.9)
(cid:3)2.0((cid:3)4.3to0.3) (cid:3)5.0((cid:3)6.9to(cid:3)3.0) (cid:3)3.5((cid:3)4.4to(cid:3)2.6) (cid:3)2.4((cid:3)3.5to(cid:3)1.3) (cid:3)5.3((cid:3)6.4to(cid:3)4.2) (cid:3)3.8((cid:3)4.3to(cid:3)3.3)
0.3((cid:3)2.0to2.7) 0.2((cid:3)1.7to2.2) 0.3((cid:3)0.8to1.3) (cid:3)0.1((cid:3)1.4to1.2) (cid:3)1.9((cid:3)3.1to(cid:3)0.7) (cid:3)1.1((cid:3)1.7to(cid:3)0.5)
(cid:3)2.4((cid:3)5.6to0.7) (cid:3)3.3((cid:3)5.8to(cid:3)0.8) (cid:3)2.9((cid:3)4.2to(cid:3)1.5) (cid:3)2.8((cid:3)4.2to(cid:3)1.5) (cid:3)4.2((cid:3)5.7to(cid:3)2.8) (cid:3)3.5((cid:3)4.1to(cid:3)2.9)
0.8((cid:3)2.0to3.6) 0.9((cid:3)1.4to3.1) 0.8((cid:3)0.4to2.1) (cid:3)0.5((cid:3)1.8to0.8) (cid:3)1.2((cid:3)2.5to0.1) (cid:3)0.9((cid:3)1.5to(cid:3)0.3)
(cid:3)0.8((cid:3)5.2to3.6) (cid:3)5.5((cid:3)11.2to0.1) (cid:3)3.3((cid:3)5.2to(cid:3)1.3) (cid:3)1.9((cid:3)3.9to0.2) (cid:3)6.5((cid:3)9.5to(cid:3)3.5) (cid:3)4.1((cid:3)5.1to(cid:3)3.0)
0.4((cid:3)4.1to5.0) (cid:3)2.6((cid:3)8.3to3.2) (cid:3)1.2((cid:3)3.3to0.9) (cid:3)0.4((cid:3)2.6to1.7) (cid:3)5.8((cid:3)8.8to(cid:3)2.8) (cid:3)3.1((cid:3)4.1to(cid:3)2.1)
(cid:3)4.4((cid:3)8.3to(cid:3)0.6) (cid:3)3.5((cid:3)6.6to(cid:3)0.3) (cid:3)3.9((cid:3)5.5to(cid:3)2.2) (cid:3)5.1((cid:3)6.9to(cid:3)3.3) (cid:3)3.5((cid:3)5.4to(cid:3)1.7) (cid:3)4.2((cid:3)5.1to(cid:3)3.4)
(cid:3)0.0((cid:3)3.5to3.5) 1.5((cid:3)1.1to4.1) 0.9((cid:3)0.7to2.4) (cid:3)1.0((cid:3)2.7to0.7) 0.3((cid:3)1.2to1.9) (cid:3)0.2((cid:3)1.0to0.5)
(cid:3)1.9((cid:3)7.0to3.2) (cid:3)10.8((cid:3)15.8to(cid:3)5.8) (cid:3)6.0((cid:3)7.8to(cid:3)4.1) (cid:3)4.7((cid:3)6.8to(cid:3)2.7) (cid:3)7.5((cid:3)10.0to(cid:3)4.9) (cid:3)5.8((cid:3)6.8to(cid:3)4.9)
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1852 Circulation April 17, 2012
Figure1.Age-andbiomarker-adjustedrate(per1000persons)infirsthospitalizedmyocardialinfarctionordeathduetocoronaryheart
diseasewithoutpriormyocardialinfarctionandage-adjustedtrendsbylinearandquadraticPoissonregression,formenandwomen
aged35to74years,intheAtherosclerosisRiskinCommunitiesStudy1987–2008.
of MI by the distribution of the pretroponin combinations in the sampling procedure are reported elsewhere.18 Our analyses were
referenceperiod. weightedandstandarderrorswerecomputedbystratifiedrandom
Tovalidateourbiomarkeradjustmentmethodprocedure,weused sample methodology to reflect the sampling scheme.
ARIC data during 1997–2008 for those events that had “troponic Annualeventratesper1000personsspecificforsex,race,and
AND other enzymes” whenever they had “troponin OR other communitywerecomputedonthebasisofpopulationdenomina-
enzymes,”simulatinganexperimentinwhichhospitalskeptcollect- tors estimated by interpolation and extrapolation of 1980, 1990,
ing enzyme data as usual while adding troponins. We then com- and 2000 US census population estimates. Race-specific rates
pletelydroppedtroponinsfor1997–2002,anartificial“pretroponin reported by sex were adjusted for age by the direct method with
era.” In our artificial data we used 2002 as the standard enzyme theuseofthe2000UStotalage-specificpopulationcensuscounts
group distribution. We estimated age- and enzyme distribution– as the standard. Sex-specific rates reported were similarly ad-
standardized“true”trendsinMIattackratefromthebiomarkerdata justed for age and race. In Tables 2 and 3, we report overall
22-year age-adjusted trends by gender and race or by gender
withouttroponins.Nextweproduced200datasetsthatsimulatedthe
adjusted additionally for race from linear or quadratic Poisson
dropping of other enzymes when troponin was introduced. The
regressionmodels.Resultsbytimeperiodarefromthequadratic
choiceofeventsfromwhichtodropsomeenzymedatawasrandom
models showing trends separately for the first (1987–1996) and
and was done independently in each of the 200 simulations. We
second (1997–2008) decades as the average annual percent
simulated an increasing proportion over time of events that had
changeineachtimeperiod.Figure1showsage-andbiomarker-
enzymesdropped.Witheachofthese200datasets,weappliedthe
adjusted event rates with both linear and quadratic regression
biomarker adjustment algorithm to obtain biomarker-adjusted rates
model fits displayed.
andtrendsforthe4race/sexgroupsfortheperiod1997–2008and
Annual 28-day and 1-year case-fatality percentages specific for
then took the averages over the 200 data sets and compared them
sexandracewerecomputedonthebasisofdenominatorsofthose
with “true trends.” We considered only linear trend. The true age-
who were hospitalized with a MI or a combined hospitalized plus
and enzyme distribution–adjusted trends were (cid:3)4.4 and (cid:3)3.7 for
fatal CHD event. Race-specific percentages reported by sex were
men and women, respectively, whereas the biomarker-adjusted
adjusted for age by the direct method with the use of the ARIC
values averaged over the 200 simulated ARIC-like data sets were
combined hospitalized MI plus fatal CHD events as the standard.
(cid:3)4.0and(cid:3)3.3,whichwereveryclosetothetruevalues.
Figure2showsage-adjusted28-daycasefatalityforhospitalizedMI
with both linear and quadratic logistic regression model fits dis-
Statistical Analysis
played. The statistical package SUDAAN Logistic was used for
Sampling probabilities were reviewed periodically and modified case-fatality trends analysis, and SUDAAN Loglink was used for
overthe22-yearsurveillanceperiodforefficiency.Detailsofthe eventratetrendsanalysis.
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Rosamond et al Community Trends in MI Incidence Rates 1853
Figure2.Age-adjusted28-daycase-fatality(CF)percentageforhospitalizedmyocardialinfarctioneventsandage-adjustedtrendsby
linearandquadraticPoissonregression,formenandwomenaged35to74years,intheAtherosclerosisRiskinCommunitiesStudy
1987–2007.
Results ofARICblackmenregardlessoftimeperiod.Ofnoteisthe
During 1987–2008, a total of 30985 fatal or nonfatal hospi- statistically significant age-adjusted decline in total CHD
talized acute MI events (on the basis of a stratified random mortalityratesof5.3%/y(95%CI,(cid:3)7.5%to(cid:3)3.2%)among
sample of 20075 hospitalizations investigated) occurred ARIC black men during 1997–2008 compared with a non–
among residents aged 35 through 74 years in the 4 study statistically significant decline of just 0.9%/y (95% CI,
communities in ARIC (Table 1). Of these, 69% were in (cid:3)3.3%to1.5%)inthepreceding10yearsduring1987–1996.
persons with no recorded history of MI. There were an Among women, the age- and race-adjusted trends in total
estimated 8158 deaths due to CHD (on the basis of 7063 CHD mortality rates were generally similar to those in men
deaths sampled), including both in-hospital and out-of- (ie, to downward trends in rates greater in the more recent
hospital deaths. period;P(cid:4)0.01).Theage-adjustedtrendsinCHDdeathsnot
The average annual percentage of age- and race-adjusted preceded by a MI history mirrored those of total CHD
decline(95%confidenceinterval[CI])inratesofdeathdueto mortality.
CHDwas5.7%(95%CI,(cid:3)6.1%to(cid:3)5.3%)inmenand5.2% Rates of out-of-hospital and in-hospital mortality due to
(95% CI, (cid:3)5.8% to (cid:3)4.6%) in women (Tables 2 and 3). CHD declined significantly among both men and women
Among men, the decline was nonlinear, with the decline (Tables2and3).Age-andrace-adjusteddeclinesinratesof
steeperinthelatterhalfofthestudyperiod(1997–2008)than out-of-hospital mortality due to CHD were smaller in per-
in the first 10 years (1987–1996), at (cid:3)8.6%/y (95% CI, centage compared with in-hospital CHD deaths. Adjusted
(cid:3)9.7% to (cid:3)7.5%) and (cid:3)3.4%/y (95% CI, (cid:3)4.3% to percentdeclinesinbothin-hospitalandout-of-hospitalCHD
(cid:3)2.4%), respectively (P(cid:4)0.01). The overall downward age- deathratesweresubstantiallygreaterinthemorerecenttime
adjusted trend in total CHD mortality among men was period(1997–2008)thaninthepreviousdecade(1987–1996).
statistically significant in both ARIC black men ((cid:3)3.2%/y; Amongmenandwomen,theage-andbiomarker-adjusted
95%CI,(cid:3)4.1%to(cid:3)2.2%)andARICwhitemen((cid:3)6.5%/y; rate of combined first hospitalization for acute MI or fatal
95%CI,(cid:3)7.0%to(cid:3)6.1%),withthepercentdeclineperyear CHDamongpatientswithnohistoryofMIhadasignificant
among ARIC white men generally approximately twice that age-adjusteddeclineduring1987–2008(Figure1andTables
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1854 Circulation April 17, 2012
2 and 3). The overall age-adjusted trend predicted by the blacksinthemostrecenttimeperiodfoundinthebiomarker-
fitted quadratic models in annual incidence rates showed a adjusted rates were masked when shifts in biomarkers were
decline of 4.9%/y (95% CI, (cid:3)5.3 to (cid:3)4.5) among ARIC notconsidered.Forexample,theage-adjustedaverageannual
white men, 3.9%/y (95% CI, (cid:3)4.5 to (cid:3)3.4) among ARIC percent change in first hospitalized MI over the 22-year
whitewomen,3.5%/y(95%CI,(cid:3)4.4to(cid:3)2.6)amongARIC surveillance period among black men in ARIC showed an
black women, and 1.8%/y (95% CI, (cid:3)2.6 to (cid:3)1.0) among increase of 1.0%/y (95% CI, (cid:3)0.1 to 2.1) before we ac-
ARIC black men. The average trend for the 2 decades sepa- counted for the use of more sensitive biomarkers. After
ratelyfromquadraticregressionmodelsshowsthatthedeclinein adjustment for biomarker change over time, a significant
incidenceofMIandfatalCHDwasgenerallytwiceaslargein downward trend of 1.5%/y (95% CI, (cid:3)2.7 to (cid:3)0.4) was
thelatterdecadecomparedwiththefirstdecade.Thedifference revealed.
in the average annual percent change between the 2 decades The annual incidence rate of STEMI had age- and
was statistically significant for ARIC white men and women biomarker-adjusteddeclinesamongmenandwomen(Tables
(P(cid:4)0.01).However,thetrendscomparingthefirstandsecond 2 and 3). For men, the decline was greater in the period
decades among ARIC black men and women did not reach 1997–2008 ((cid:3)8.0%/y; 95% CI, (cid:3)10.4 to (cid:3)5.7) than in the
statisticalsignificance(P(cid:5)0.10).Nevertheless,age-adjustedde- prior decade ((cid:3)2.0%/y; 95% CI, (cid:3)3.4 to (cid:3)0.5) (P(cid:4)0.01).
clinesinbiomarker-adjustedMIandfatalCHDincidencewere Theage-andbiomarker-adjustedincidenceofNSTEMIalso
statistically significant in all 4 race/gender groups in the most declined over the 22-year period. Without biomarker adjust-
recenttimeperiod(1996–2008). ment,therateofdeclineinNSTEMIwasapproximatelyhalf
Theage-andbiomarker-adjustedincidenceofhospitaliza- of that observed for STEMI.
tions for MI had significant adjusted declines over the The trends in 28-day case-fatality percentages among
22-year period. The overall downward trend showed a hospitalizedMIcasesareshowninFigure2andTable4.The
pattern similar to the trend in combined incident hospital- overall decline in 28-day case fatality among men for
ized MI and fatal CHD, although a test for differences in hospitalized cases was similar in both decades, although a
the average change in trends between the decades did not greater improvement in 28-day case fatality in the more
reach statistical significance. Among black men and recent decade occurred among black men in ARIC. For
women in ARIC, the lack of a statistically significant men, the age- and race-adjusted annual percent change in
downwardtrendinfirsthospitalizedMIintheearliertime 28-day case fatality for hospitalized MI was (cid:3)4.4%/y
period transitioned to significant declines in MI incidence (95% CI, (cid:3)7.6 to (cid:3)1.2) during 1987–1996 and (cid:3)2.3%/y
during the more recent period (1997–2008), of (cid:3)2.5%/y (95% CI, (cid:3)5.4 to 0.8) during 1997–2007 (Table 4).
(95% CI, (cid:3)4.7 to (cid:3)0.4) and (cid:3)3.3%/y (95% CI, (cid:3)5.8 to Among women, the significant decline in 28-day case
(cid:3)0.8),respectively.Anexaminationoftrendsinrecurrent fatality seen during 1987–1996 was no longer significant
MI revealed significant declines overall, with the declines in the more recent decade.
in men in the period 1997–2008 greater than in the earlier Trends in a modified definition of MI not including
decade (P(cid:4)0.01). biomarkers(presenceofevolvingdiagnosticQ-wavepatterns
The impact of biomarker change adjustment was particu- onserialECGsoranyevidenceofanydiagnosticQwaveor
larly notable in investigating trends within and across race/ ST-segment elevation on any ECGs and a history of chest
gender groups (Tables 2 and 3). The statistically significant pain of cardiac origin) yielded patterns similar to those seen
declinesinincidenceofhospitalizedMIeventsamongARIC in Tables 2 and 3. Accounting for lack of data on out-of-
Table4. AverageAnnualPercentChange(95%ConfidenceInterval)inProportionofEventsNotSurviving28Days(28-DayCase
Fatality),AdjustedforAge,intheARICStudy1987–2007
Whites
1987–1996 1997–2008 AllYears
Men
HospitalizedMIpatientsonly
28-dcasefatality (cid:3)5.8((cid:3)12.0to0.5) (cid:3)0.9((cid:3)6.9to5.2) (cid:3)3.5((cid:3)5.3to1.7)
HospitalizedMIpatientsplusout-of-hospital
fatalCHDevents
28-dcasefatality (cid:3)2.2((cid:3)5.2to0.8) (cid:3)3.7((cid:3)6.2to(cid:3)1.2) (cid:3)2.8((cid:3)3.5to(cid:3)2.2)
Women
HospitalizedMIpatientsonly
28-dcasefatality (cid:3)3.2((cid:3)10.2to3.8) (cid:3)2.8((cid:3)8.8to3.3) (cid:3)3.0((cid:3)4.7to(cid:3)1.2)
HospitalizedMIpatientsplusout-of-hospital
fatalCHDevents
28-dcasefatality (cid:3)1.1((cid:3)3.4to1.3) (cid:3)5.9((cid:3)8.1to(cid:3)3.6) (cid:3)3.2((cid:3)4.2to(cid:3)2.2)
ARICindicatesAtherosclerosisRiskinCommunities;MI,myocardialinfarction;andCHD,coronaryheartdisease.
*Adjustedalsoforrace.
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Rosamond et al Community Trends in MI Incidence Rates 1855
hospitaldeathsamongcommunityresidentsforwhomneither found in the Kaiser Permanente study is in agreement with
an informant interview nor a physician questionnaire was the trends in STEMI and NSTEMI we observed in the 4
available had little effect on the overall patterns of CHD ARIC communities. However, the Kaiser data were not
mortality trends. Similarly, adjustment of hospitalized MI reportedbyethnicity,werenotadjustedforchangeinuseof
events for missing records did not change the original trend cardiac biomarkers, and represented trends in nonvalidated
estimates appreciably. events based solely on discharge diagnosis codes or through
billing claims.
Discussion RecentreportsfromOlmstedCounty,MN,8andWorcester,
Wefoundthattheage-adjustedCHDmortalityratesdeclined MA,9 indicate that trends in incidence of MI varied by the
among subjects aged 35 to 74 years in 4 geographically and presence or absence of ST elevation. In Olmsted County,
ethnically diverse communities in the ARIC Study during incidence rates of STEMI declined by 41% during 1987–
2006,whereastheincidenceratesofNSTEMIincreasedbya
1987–2008.AlthoughtheeventtrendsobservedintheARIC
similar percentage. In Olmsted County, when all MIs were
communities may not be representative of the entire United
includedirrespectiveofthebiomarkerusedfordiagnosis,the
States, the decline in CHD mortality rate was statistically
incidence rates of MI did not change during 1987–2006. In
significantforbothblacksandwhitesinARIC.Thisdecline
analysis restricted to those cases meeting only CK and
in CHD mortality in the ARIC communities was similar to
CK-MB criteria, a significant temporal decline in the inci-
that reported from national vital statistics.21–23 However, the
denceofMIof(cid:1)1%/ywasfound.However,thismethodof
3-fold acceleration of the decline in CHD mortality rates in
adjustment may not adequately account for the addition of
the most recent decade (1997–2008) in the ARIC communi-
new biomarkers and the elimination of older biomarkers in
tieswasgreaterthanthe2-foldaccelerationofthedeclinein
some hospitals.
the early 2000s reported with the use of US statistics.23 The
Our findings agree with a recent study of hospitalization
Framingham Study cohort and a community surveillance
ratesamongtheMedicarefee-for-servicebeneficiaries.5Dur-
study in Worcester, MA, also reported that the decline in
ing 2002–2007, white men experienced a 24% decrease in
CHD mortality and sudden cardiac death has accelerated in
hospitalized MI rates, whereas black men experienced a
recent decades.24,25
decline of 18%. Direct comparisons between Medicare data
A major determinant of the accelerated decline in CHD
andARICarelimitedbecauseMedicareeventswerenonvali-
mortality observed is the concomitant decline in MI inci-
dated,lackedadifferentiationbetweenincidentandrecurrent
dence.Afterweaccountedforshiftsinbiomarkersovertime, events, and were restricted to individuals aged (cid:5)65 years.
the incidence of hospitalized MI declined an average of However, the Medicare findings agree well with those from
3.8%/y in men and 3.5%/y in women. The percent declines theNationalHospitalDischargeSurveyshowingadeclinein
duringthemostrecenttimeperiod(1997–2008)wereapprox- hospitalization rates for acute MI during 1996–2005 after a
imately twice those of the previous decade and were most period of stability in rates during 1987–1995.6
dramatic among blacks. Our findings corroborate those re- Our results on case-fatality trends agree with previous
ported in the Kaiser Permanente Northern California health- studies reporting steady improvements in age-and sex-
care system,7 in which the incidence of MI increased from adjustedmortalityafterMIinrecentdecades,7,8althoughwe
1999to2000andthendecreasedeachyearthereafterthrough found the decline among women to be less consistent than
2008. A greater decline in STEMI compared with NSTEMI that observed in men.
Table4. Continued
Blacks Total*
1987–1996 1997–2008 AllYears 1987–1996 1997–2008 AllYears
0.8((cid:3).29to4.4) (cid:3)7.2((cid:3)10.7to(cid:3)3.7) (cid:3)3.4((cid:3)6.1to(cid:3)0.6) (cid:3)4.4((cid:3)7.6to(cid:3)1.2) (cid:3)2.3((cid:3)5.4to0.8) (cid:3)3.4((cid:3)9.9to(cid:3)1.6)
(cid:3)1.4((cid:3)3.5to0.7) (cid:3)4.0((cid:3)6.3to(cid:3)1.6) (cid:3)2.7((cid:3)3.7to(cid:3)1.6) (cid:3)2.0((cid:3)3.7to(cid:3)0.3) (cid:3)3.8((cid:3)5.5to(cid:3)2.0) (cid:3)2.8((cid:3)3.4to(cid:3)2.2)
(cid:3)3.2((cid:3)5.9to(cid:3)0.5) (cid:3)2.1((cid:3)6.8to2.6) (cid:3)2.6((cid:3)5.6to0.4) (cid:3)3.3((cid:3)5.8to(cid:3)0.8) (cid:3)2.6((cid:3)6.4to1.2) (cid:3)2.9((cid:3)4.5to(cid:3)1.4)
(cid:3)1.9((cid:3)3.1to(cid:3)0.8) (cid:3)2.2((cid:3)4.1to(cid:3)0.3) (cid:3)2.1((cid:3)3.3to(cid:3)0.8) (cid:3)1.5((cid:3)2.5to(cid:3)0.5) (cid:3)4.2((cid:3)5.6to(cid:3)2.7) (cid:3)2.8((cid:3)3.6to(cid:3)2.0)
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1856 Circulation April 17, 2012
Strengthsofourstudyincludeitspopulation-baseddesign, 3. RogerVL,JacobsenSJ,WestonSA,GorayaT,KillianBB,ReederGS,
inclusion of multiple ethnically diverse communities, stan- KottkeTE,YawnBP,FryeRL.Trendsintheincidenceandsurvivalof
patientswithhospitalizedmyocardialinfarction,OlmstedCounty,Min-
dardized event validation procedures, and innovative appli-
nesota,1979to1994.AnnInternMed.2002;136:341–348.
cationofstandardstatisticaladjustmentmethodsforaccount- 4. McGovern PG, Pankow JS, Shahar E, Doliszny KM, Folsom A,
ing for shifts in biomarker use over time. However, BlackburnH,LuepkerR.Recenttrendsinacutecoronaryheartdisease:
conducting ongoing community surveillance and validation mortality, morbidity, medical care, and risk factors. N Engl J Med.
1996;334:884–890.
ofhospitalizationsamongallresidentsinmultiplecommuni-
5. ChenJ,NormandST,WangY,DryeEE,SchreinerBS,KrumholzHM.
tiesover22yearspresentschallengestomaintainingcompa- Recent declines in hospitalizations for acute myocardial infarction for
rabilityacrosstime.Hospitalizationsofcommunityresidents Medicare fee-for-service beneficiaries: progress and continuing chal-
occurringinhospitalsoccurringoutofstateareonlyincluded lenges.Circulation.2010;121:1322–1328.
6. FangJ,AldermanMH,KeenanNL,AyalaC.Acutemyocardialinfarction
if the patient was transferred to a surveillance hospital.
hospitalizationintheUnitedStates,1979to2005.AmJMed.2010;123:
Althoughthismaybeasourceofbiasinourstudy,datafrom 259–266.
death certificate surveillance suggest that the relatively few 7. YehRW,SidneyS,ChandraM,SorelM,SelbyJV,GoAS.Population
trends in the incidence and outcomes of acute myocardial infarction.
out-of-state events have little impact on our trend estimates.
NEnglJMed.2010;362:2155–2165.
Inaddition,becauseofsmallnumbersofblacksin2ofthe4
8. RogerVL,WestonSA,GerberY,KillianBB,DunlaySM,JaffeAS,Bell
communities, event rates for blacks only represent those MR,KorsJ,YawnBP,JacobsenSJ.Trendsinincidence,severity,and
occurringin2communities.Thismaylimitthegeneralizabil- outcome of hospitalized myocardial infarction. Circulation. 2010;121:
863–869.
ity of our findings.
9. McManusDD,GoreJM,YarzebskiJ,SpencerF,LessardD,Goldberg
The ultimate measure of successful public health and
RJ.Recenttrendsintheincidence,treatment,andoutcomesofpatients
clinical efforts to reduce the major cause of mortality in the withSTEMIandNSTEMI.AmJMed.2011;124:40–47.
United States comes from community-based studies of dis- 10. Alpert JS, Thygesen K, Antman E, Bassand J. Myocardial infarction
redefined:aconsensusdocumentoftheJointEuropeanSocietyofCar-
ease incidence rates.26,27 ARIC findings on declining inci-
diology/AmericanCollegeofCardiologyCommitteefortheredefinition
dence trends of hospitalized MI and out-of-hospital CHD ofmyocardialinfarction.JAmCollCardiol.2000;36:959–969.
death and steady improvements in 28-day case fatality, 11. ThygesenK,AlpertJS,WhiteHD.Universaldefinitionofmyocardial
viewed together with other reports from community-based infarction.Circulation.2007;116:2634–2653.
12. Parikh NI, Gona P, Larson MG, Fox CS, Benjamin EJ, Murabito JM,
studies, large national databases, and large health mainte-
O’Donnell CJ, Vasan RS, Levy D. Long-term trends in myocardial
nanceorganizations,stronglysupporttheconclusionthatthe infarction incidence and case fatality in the National Heart, Lung, and
past decade has seen a new era of impact from primary Blood Institute’s Framingham Heart Study. Circulation. 2009;119:
preventioneffortsintheUnitedStates.5,7,8,28Thisconclusion 1203–1210.
13. Salomaa V, Koukkunen H, Ketonen M, Immonen-Raiha P, Karja-
could not be made 10 years ago when, although CHD
KoskenkariP,MustonenJ,LehtoS,TorppaJ,LehtonenA,Tuomilehto
mortality rates were falling, incidence of hospitalized MI J,KesaniemiYA,PyoralaK.Anewdefinitionformyocardialinfarction:
remained static.1,29 Our novel approach to accounting for whatdifferencedoesitmake?EurHeartJ.2005;26:1719–1725.
changingdiagnosticbiomarkersovertimeaddsnewevidence 14. Yeh RW, Go AS. Rethinking the epidemiology of acute myocardial
infarction.ArchInternMed.2010;170:759–764.
in support of this conclusion. Maintaining the decline in
15. Luepker RV, Berger AK. Is acute myocardial infarction disappearing?
incidence of MI that has gained momentum in the new Circulation.2010;121:1280–1282.
millennium and continuing the decline in death due to CHD 16. IOM(InstituteofMedicine).ANationwideFrameworkforSurveillance
ofCardiovascularandChronicLungDisease.Washington,DC:National
will require continued efforts to promote cardiovascular
AcademyofSciencePress;2011.
health at the community level.
17. WhiteAD,FolsomAR,ChamblessLE,SharretAR,YanyK,Conwill
DE,HigginsM,WilliamsOD,TyrolerHA.Communitysurveillanceof
Acknowledgments coronary heart disease in the Atherosclerosis Risk in Communities
(ARIC) Study: methods and initial two years’ experience. J Clin Epi-
TheauthorsthankthestaffandparticipantsoftheARICStudyfor
demiol.1996;49:223–233.
theirimportantcontributions.
18. Rosamond W, Chambless L, Sorlie P, Bell E, Weitzman S, Smith J,
Folsom A. Trends in the sensitivity, positive predictive value, false-
Sources of Funding
positive rate, and comparability ratio of hospital discharge diagnosis
TheARICStudyisperformedasacollaborativestudysupportedby codesforacutemyocardialinfarctioninfourUnitedStatescommunities,
NationalHeart,Lung,andBloodInstitutecontractsN01-HC-55015, 1987to2000.AmJEpidimiol.2004;160:1137–1146.
N01-HC-55016, N01-HC-55018, N01-HC-55019, N01-HC-55020, 19. ARIC Investigators. Manual 3: surveillance component procedures
N01-HC-55021,andN01-HC-55022. manualofoperations.http://www.cscc.unc.edu/aric/displaydata.php?pg_
id(cid:2)19.Published2009.AccessedMarch26,2012.
Disclosures 20. EdlavitchSA,CrowR,BurkeGL,HuberJ,PrineasR,BlackburnH.The
effectofthenumberofelectrocardiogramsanalyzedoncardiovascular
None.
disease surveillance: the Minnesota Heart Study (MHS). J Clin Epi-
demiol.1990;43:93–99.
References
21. NationalHeart,Lung,andBloodInstitute.MorbidityandMorality:2009
1. RosamondWD,ChamblessLE,FolsomAR,CooperLS,ConwillDE, ChartBookonCardiovascular,Lung,andBloodDisorders.Bethesda,
Glegg L, Wang CH, Heiss G. Trends in the incidence of myocardial MD:NationalInstitutesofHealth;2009.
infarctionandinmortalityduetocoronaryheartdisease,1987to1994. 22. Lloyd-Jones D AR, Brown TM, Carnethon M, Dai S, De Simone G,
NEnglJMed.1998;339:861–867. FergusonTB,FordE,FurieK,GillespieC,GoA,GreenlundK,HaaseN,
2. Goldberg RJ, Yarzebski J, Lessard D, Gore J. A two-decade (1975 to Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D,
1995)longexperienceintheincidence,in-hospitalandlong-termcase- LisabethL,MarelliA,McDermottMM,MeigsJ,MozaffarianD,Mus-
fatality rates of acute myocardial infarction: a community-wide per- solinoM,NicholG,RogerV,RosamondW,SaccoR,SorlieP,Stafford
spective.JAmCollCardiol.1999;33:1533–1539. R, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J. Heart
Downloaded from http://circ.ahajournals.org/ at UNIV OF NORTH CAROLINA on June 20, 2012