Recent Trends in Acute Coronary Heart Disease — Mortality, Morbidity, Medical Care, and Risk Factors
Paul G. McGovern, Ph.D., James S. Pankow, M.P.H., Eyal Shahar, M.D., Katherine M. Doliszny, Ph.D., Aaron R. Folsom, M.D., Henry Blackburn, M.D., Russell V. Luepker, M.D., for The Minnesota Heart Survey Investigators
Background Mortality from coronary heart disease (CHD) has declinedin the United States since the late 1960s. To understand thereasons for the decline during the period from 1985 to 1990,we examined trends in mortality and morbidity due to CHD, medicalcare, and risk factors for CHD in a large metropolitan population.
Methods We identified all deaths from CHD in residents of theMinneapolis–St. Paul, Minnesota, metropolitan area whowere 30 to 74 years old and classified the deaths accordingto whether they occurred in or out of the hospital. For 1985and 1990, we obtained lists of patients in this age range whowere discharged with a diagnosis of acute CHD from all areahospitals, and we selected the medical records of 50 percentof these patients for abstraction. Definite myocardial infarctionswere identified with a standardized diagnostic algorithm. The1985 and 1990 cohorts of patients hospitalized for myocardialinfarction were followed for at least three years to identifythose who died from any cause. Trends in risk factors for CHDwere investigated through surveys of 25-to-74-year-olds thatwere conducted in 1985 through 1987 and 1990 through 1992.
Results Between 1985 and 1990, mortality from CHD fell by 25percent for both men and women, and the decline in in-hospitalmortality (41 percent) exceeded the decline in out-of-hospitalmortality (17 percent) among men. The rates of hospitalizationfor acute myocardial infarction declined slightly, by 5 to 10percent, between 1985 and 1990. Survival among patients hospitalizedfor acute myocardial infarction increased substantially duringthat period. After adjustment for age and previous myocardialinfarction, the relative risk of dying within three years ofhospitalization for a myocardial infarction (for the 1990 cohortas compared with the 1985 cohort) was 0.76 for men (95 percentconfidence interval, 0.65 to 0.89) and 0.84 for women (95 percentconfidence interval, 0.71 to 1.00). Substantial increases inthe use of thrombolytic therapy, heparin, aspirin, and coronaryangioplasty paralleled the survival trends. In general, therisk-factor profile of the area population with respect to CHDalso improved considerably during that time.
Conclusions The recent decline in mortality due to CHD in theMinneapolis–St. Paul metropolitan area can be explainedby both the declining incidence of myocardial infarction inthe population and the improved survival of patients with myocardialinfarction.
Rates of mortality from coronary heart disease (CHD) in theUnited States, adjusted for age, have declined since the mid-1960s.1During the 1980s, the annual rate of that decline was about3.5 percent for both men and women.2 CHD nonetheless remainsthe leading cause of death in the United States, claiming thelives of 489,171 Americans in 1990.3
Many factors have probably contributed to the decline in mortalitydue to CHD that is evident in official statistics, includingreduced levels of risk factors for CHD in the general population;declining incidence and perhaps severity of disease4; changesin medical care,5,6 which may influence survival; a reductionin the number of people with chronic CHD, which in turn lowersthe rate of recurrent acute myocardial infarction; and finally,artifacts such as changes in coding of causes of death on deathcertificates7,8 or in hospital reimbursement rules.9 The relativecontributions of each of these factors to the decline in mortalitydue to CHD have not been well documented. Several reports haveindicated that changes in both the incidence of myocardial infarction10and the rate or length of survival after myocardial infarction11,12,13probably played a part in the decline in mortality due to CHDin the 1970s and the early 1980s, but little is known aboutmore recent trends.
The Minnesota Heart Survey has examined the trends in mortalityand morbidity due to CHD, medical care, and the risk-factorprofile with respect to cardiovascular disease in the secondhalf of the 1980s. The study population comprised all residents30 to 74 years of age in a large metropolitan area: Minneapolis–St.Paul, Minnesota, and the surrounding suburbs.
Methods
Study Population and Data on Mortality
According to the U.S. Census Bureau, the seven-county metropolitanarea of the Twin Cities of Minneapolis and St. Paul had a populationof 2.29 million in 1990. In that year, the target populationfor this study (those 30 to 74 years old) consisted of 550,719men and 576,690 women. The corresponding population in 1985was estimated by log-linear interpolation from 1980 census data.The population of the Twin Cities metropolitan area is overwhelminglywhite.
Deaths due to CHD (i.e., those for which CHD was the underlyingcause of death) among residents of the Twin Cities area weredefined as those designated by codes 410 through 414 of theInternational Classification of Diseases, 9th revision, ClinicalModification (ICD-9-CM)14 (the codes for ischemic heart disease);such deaths were classified according to whether they occurredin the hospital or out of the hospital. Out-of-hospital deathsincluded those of persons who were listed as dead on arrivalat the hospital or died in the emergency department. A studyof out-of-hospital deaths in the Twin Cities area found thatthe diagnosis of ischemic heart disease on the death certificatehad a high level of sensitivity (90 percent) and a high positivepredictive value (94 percent) for the actual presence of ischemicheart disease.15
Data on Hospitalization for Acute CHD
For 1985 and 1990, we obtained lists of patients 30 to 74 yearsold who were discharged from hospitals in the Twin Cities metropolitanarea with an ICD-9-CM code for acute CHD among the dischargediagnoses. The target ICD-9-CM codes were 410 (acute myocardialinfarction) and 411 (other acute and subacute forms of ischemicheart disease). All 25 hospitals operating in 1990 and all 31hospitals operating in 1985 provided the requested information.From these lists of patients, we randomly selected 50 percentsamples of men and women in 1985 and a 50 percent sample ofmen in 1990. All women with a discharge code indicating acuteCHD were included in the 1990 cohort.
The medical records of the selected patients were abstractedby trained nurses. Information was obtained on the patients'signs and symptoms, medical history, cardiac-enzyme levels,therapy, and (when available) autopsy results. Up to four electrocardiograms(ECGs) were photocopied and coded according to the MinnesotaCode, a standardized method of scoring ECGs.16
To ensure standardized criteria for myocardial infarction overtime, we applied a computer-based diagnostic algorithm to allabstracted records of hospitalizations for acute CHD in whichautopsy findings, information on chest pain, Minnesota ECG codes,and peak cardiac-enzyme levels were included. An abnormal enzymevalue was defined as a peak level of creatine kinase MB thatwas more than twice the upper limit of normal or peak levelsof both lactate dehydrogenase and total creatine kinase thatexceeded twice the upper limit of normal. Cases were classifiedby the diagnostic algorithm, primarily on the basis of peakenzyme values, into three categories: definite myocardial infarction,possible myocardial infarction, or no myocardial infarction;only patients with definite myocardial infarctions were includedin this analysis. In addition, a physician reviewed and classifieddeaths that occurred within 48 hours of hospitalization wheneverthe patient was not classified as having definite myocardialinfarction by the algorithm (n = 78). First and recurrent myocardialinfarctions were distinguished by extensive searches of thepatients' prior hospitalization records.
Follow-Up for Mortality
Each patient's vital status at the time of hospital dischargewas ascertained from his or her medical record. Vital statusafter hospital discharge was determined by computer linkagewith the Minnesota Death Index, a system that has 98 percentagreement with the National Death Index.17 Information on deathswas available through 1993, allowing for the evaluation of three-yearsurvival in all patients. Death due to any cause was consideredthe study end point.
Surveys of Risk Factors in the Population
To estimate trends in the risk-factor profile of the Twin Citiespopulation with respect to CHD during the same period, we conductedpopulation-based surveys in 1985 through 1987 and 1990 through1992. Details of the sampling and survey methods have been publishedelsewhere.18 In brief, a cluster sampling design was used toselect men and women 25 to 74 years old who were residents ofthe seven-county metropolitan area. Data on various demographic,behavioral, and physiologic characteristics were obtained bymeans of an interview conducted in the subjects' homes and asubsequent examination in a survey center. In each survey, 71percent of all subjects of the designated ages who were initiallycontacted took part in the survey-center examination. Bloodpressure was measured with a random-zero sphygmomanometer.
Serum total cholesterol was measured in nonfasting samples withan AutoAnalyzer II (Technicon Instruments, Tarrytown, N.Y.).19We estimated and adjusted for laboratory drift by remeasuring400 samples from each of the two survey periods using the Abell–Kendallmethod. The estimated bias in the results was statisticallysignificant in each survey period (P<0.001), indicating thatthe original measurements were a mean (±SD) of 8.5±0.5mg per deciliter (0.22±0.01 mmol per liter) lower in1985 through 1987 and 4.1±0.3 mg per deciliter (0.11±0.01mmol per liter) higher in 1990 through 1992 than the true values.Serum thiocyanate, a biochemical marker of cigarette smoking,was measured by the method of Butts et al.20 The Minnesota Leisure-TimePhysical Activity questionnaire21 was administered to a systematicsubsample of 50 percent of the study subjects. The body-massindex was computed as the weight in kilograms divided by thesquare of the height in meters.
Statistical Analysis
We computed several rates, all of which were person-based (i.e.,we counted only one event per patient in a given year): therate of acute CHD at hospital discharge (ICD-9-CM codes 410and 411 combined), the rate of acute myocardial infarction atdischarge (ICD-9-CM code 410), and the rate of acute myocardialinfarction as the primary diagnosis at discharge (ICD-9-CM code410 as the first listed diagnosis). Next, we computed the overallattack rate and rate of incidence of definite acute myocardialinfarction among hospitalized patients. Finally, to take intoaccount out-of-hospital deaths due to CHD, we combined suchdeaths with definite myocardial infarctions in hospitalizedpatients to obtain an overall estimate of the rate in the population.
Sex-specific rates were adjusted for age according to the agedistribution of the U.S. population in 1980 by the direct method.The statistical significance of changes between 1985 and 1990was assessed with use of Poisson regression.22 Survival trendswere evaluated by computing the relative risk of dying in 1990as compared with 1985 after adjustment for age and a historyof myocardial infarction.23 The statistical significance ofchanges in acute medical care was determined by means of chi-squaretests. Age-adjusted mean changes in risk-factor levels wereestimated with standard mixed-model multiple regression methods,which took into account the cluster sampling design. All reportedP values are two-tailed.
Results
The total number of hospital discharges with codes for acuteCHD (ICD-9-CM code 410 or 411) among Twin Cities residents whowere 30 to 74 years old was 5568 in 1985 and 6574 in 1990. Ofthese, 59 percent involved ICD-9-CM code 410 in 1985 and 57percent in 1990. About 30 percent of the total discharges wereof female patients. In each year, approximately 75 percent ofpatients discharged with a diagnostic code of ICD-9-CM 410 and12 percent of those with a code of 411 were classified by ouralgorithm as having had a definite acute myocardial infarction.The proportion with first myocardial infarctions remained constantbetween 1985 and 1990, at 64 percent. There were 853 out-of-hospitaldeaths due to CHD in 1985 and 751 in 1990, of which about 25percent in each year occurred in women.
Trends in Mortality Due to CHD
Trends in mortality due to CHD in the Twin Cities area from1970 through 1990 are shown in Figure 1. Between 1985 and 1990,the age-adjusted rate of mortality due to CHD declined by approximately25 percent in both sexes. That downward trend was observed forboth in-hospital and out-of-hospital deaths. In men, however,in-hospital mortality due to CHD declined much more rapidly(at a rate of 9.9 percent per year) than out-of-hospital mortality(3.6 percent per year, P<0.001). Among women, both componentsof mortality due to CHD declined — between 5 percent and6 percent per year in the second half of the 1980s. In-hospitalmortality declined much faster between 1985 and 1990 than between1978 and 1985.
Figure 1. Trends in Mortality Due to Coronary Heart Disease from 1970 to 1990, According to the Location of Death, among Residents of the Twin Cities Area who were 30 to 74 Years of Age.
Mortality rates (shown on a logarithmic scale) have been adjusted by the direct method to the age distribution of the total U.S. population in 1980. Deaths in the emergency room and on arrival at the hospital are included as out-of-hospital deaths.
Trends in Rates of Acute CHD
Trends in age-adjusted rates of acute CHD between 1985 and 1990are shown in Table 1. The rate of discharge of patients withacute CHD listed as a diagnosis increased by 12 percent formen (P<0.001) but remained about the same for women. In contrast,the rate of discharge of patients with a diagnosis of acutemyocardial infarction alone increased by only 3 percent formen (P = 0.40) and decreased by 7 percent for women (P = 0.09).When only patients with acute myocardial infarction as the firstdischarge code were considered, the rate of hospital dischargedeclined significantly, by 10 percent for men (P = 0.002) and11 percent for women (P = 0.03). Although they were not statisticallysignificant, trends among hospitalized patients with confirmedevents (definite myocardial infarction) were also consistentwith a slight decline in the rate of hospitalization for acutemyocardial infarction between 1985 and 1990 (Table 1). The declinewas larger (7 percent for both sexes) when we combined out-of-hospitaldeaths due to CHD with definite cases of acute myocardial infarctionin hospitalized patients.
Table 1. Rates of Acute Coronary Heart Disease (CHD) among Residents of the Twin Cities Area, 30 to 74 Years of Age, in 1985 and 1990.
Trends in Survival after Hospitalization for Acute Myocardial Infarction
Three-year survival curves for patients hospitalized for definitemyocardial infarction showed substantial improvements in long-termsurvival among both men and women with acute myocardial infarctionin the second half of the 1980s (Figure 2). The risk of deathboth within 28 days and within 3 years was 15 to 25 percentlower in 1990 than in 1985, and improvements of similar magnitudewere also evident among patients who survived the first 28 days(Table 2). In the latter group, the risk of death within threeyears decreased by 26 percent among men and 17 percent amongwomen. Among men, but not among women, the survival trend wasless evident for first myocardial infarctions than for recurrentcases, but the difference between the groups was not statisticallysignificant (P = 0.08). Among women, there was similar improvementin survival for first and recurrent myocardial infarctions.None of the relative-risk estimates differed significantly betweenmen and women (P>0.20). Patients hospitalized with acutemyocardial infarction in 1990 who subsequently died within threeyears were less likely to have a diagnosis of cardiovasculardisease as the underlying cause of death than their counterpartsin the 1985 cohort (75 percent vs. 82 percent, P = 0.02).
Figure 2. Trends in Survival in the Three Years after Hospitalization for Definite Acute Myocardial Infarction in 1985 and 1990 among Residents of the Twin Cities Area who were 30 to 74 years of Age.
Survival has been adjusted to the age distribution of the patients in the Twin Cities area who were hospitalized in 1985 and 1990 for definite acute myocardial infarction.
Table 2. Mortality after Hospitalization for Definite Acute Myocardial Infarction among Residents of the Twin Cities Area, 30 to 74 Years of Age, in 1985 and 1990.
Trends in Medical Care for Patients Hospitalized for Myocardial Infarction
Between 1985 and 1990, the median length of stay for patientswith definite acute myocardial infarction in the Twin Citiesarea decreased from 8.5 days to 6.2 days among men and from8.9 days to 6.9 days among women (P<0.001). There were substantialchanges in the proportion of patients who were treated withselected surgical procedures or medications during their hospitalstay (Figure 3). The frequency of administration of thrombolytictherapy more than doubled (from 13 percent to 30 percent) duringthe period, and large increases were documented in the proportionsof patients receiving coronary angioplasty (from 5 percent to21 percent), aspirin (from 27 percent to 81 percent), and heparin(from 53 percent to 75 percent). In contrast, there were moderate,statistically significant declines in the use of warfarin (from20 percent to 14 percent) and beta-blockers (from 56 percentto 50 percent), and little change in the use of bypass surgery(from 8 percent to 10 percent).
Figure 3. Trends in Acute Medical Care for Residents of the Twin Cities Area, 30 to 74 years of Age, who were Hospitalized for Definite Acute Myocardial Infarction in 1985 and 1990.
PTCA denotes percutaneous transluminal coronary angioplasty, and CABG coronary-artery bypass grafting. The differences between 1985 and 1990 were statistically significant (P<0.05) in all cases except that of CABG. Information on aspirin therapy in 1985 was collected from a random 10 percent subsample of hospital records.
Contribution of Thrombolytic Therapy to Trends in Survival
We used two methods to estimate the contribution of thrombolytictherapy to the trends in survival among patients with acutemyocardial infarction. First, we applied the estimated 19 percentreduction in 35-day mortality attributed to thrombolytic therapy24to the increase of 17 percentage points in the use of thrombolytictherapy in the Twin Cities area between 1985 and 1990. Withthat assumption, approximately 20 percent of the observed improvementin 28-day survival among patients hospitalized for acute myocardialinfarction in 1990 might be attributable to the more frequentuse of this therapy. Second, we used logistic-regression techniquesto model the improvement in 28-day mortality among patientshospitalized for definite acute myocardial infarction, withadjustment for age, sex, systolic blood pressure, heart rate,presence or absence of diabetes, and history of myocardial infarction.The addition of a variable representing thrombolytic therapyto this model reduced the absolute magnitude of the effect ofthe year of hospitalization by 30 percent.
Trends in Risk Factors for CHD
The population-based surveys conducted by the Minnesota HeartSurvey in 1985 through 1987 and 1990 through 1992 demonstrateda generally improved risk-factor profile with respect to CHD(Table 3). In particular, the mean serum total cholesterol concentration,prevalence and intensity of smoking, and mean systolic bloodpressure all declined among both men and women. However, thelevel of physical activity changed little in either sex, andthe body-mass index increased, although this change was notstatistically significant. Aspirin use increased, primarilyas a result of its increased use for the prevention of cardiovasculardisease.
Table 3. Trends in the Risk-Factor Profile with Respect to Cardiovascular Disease among Residents of the Twin Cities Area, 25 to 74 Years of Age, in 1985 through 1987 and 1990 through 1992.
Discussion
The decline in rates of mortality from CHD in the Twin Citiesarea during the 1970s and 1980s mirrored national trends. Thedecline, which began around 1968 and averaged 3.5 percent annually,accelerated during the late 1980s and totaled 25 percent between1985 and 1990. This trend is particularly striking in view ofthe absence of any change in the rate of death from all non-cardiovascularcauses during the same period (data not shown).
In general, trends in the rate of out-of-hospital death fromCHD probably reflect the success of primary-prevention measures;trends in in-hospital mortality from CHD, in contrast, are moreclosely tied to advances in acute medical care. Between 1985and 1990, the decline in in-hospital mortality in the Twin Citiesarea accelerated considerably and, at least for men, was greaterthan the decline in out-of-hospital mortality. Both findingssuggest that medical care had a stronger effect than primary-preventionmeasures on trends in mortality due to CHD in the late 1980s.
Most measures of rates of hospitalization for acute myocardialinfarction indicate a moderate decline between 1985 and 1990.Most of the decline occurred in the rate of first-time acutemyocardial infarction; this decline was consistent with a concurrentfavorable trend in the risk-factor profile of the general population,as reported here and elsewhere.25,26,27 We are uncertain whythe rate of discharge of patients with a diagnosis of acuteCHD has increased among men whereas most other measures of trendswith respect to acute myocardial infarction show declines. Twolikely explanations are the introduction in the late 1980s ofthe ICD-9-CM code 410.x2 (with x representing a digit indicatingthe location of the infarct), used to identify a subsequent(nonacute) episode of care for patients with myocardial infarction,and the continued effects of reimbursement according to diagnosis-relatedgroups.9 Both had the potential to increase artifactually theproportion of discharges involving acute CHD as a diagnosis.It is unlikely that rates of hospitalization for acute CHD wereactually increasing at a time of continued decline in mortalitydue to CHD.
There is a paucity of data on trends in rates of acute CHD inthe late 1980s. A study in Worcester, Massachusetts,10 whichexamined trends in the community up to 1988, found little changein the incidence of hospitalization for acute myocardial infarctionbetween 1984 and 1988 among people less than 75 years of age,but there was some evidence of a decline in this rate amongolder persons. Data from the National Hospital Discharge Survey(NHDS)28 on unvalidated, first-listed discharge diagnoses ofacute myocardial infarction suggest that the rate of hospitalizationfor acute myocardial infarction declined somewhat between 1985and 1990.2
Previous reports from the Minnesota Heart Survey12,13 documenteda substantial improvement in both short-term and long-term survivalamong patients hospitalized for definite acute myocardial infarctionfrom 1970 to 1980, but no further improvement from 1980 to 1985.In this study we document substantially improved survival amongpatients hospitalized for acute myocardial infarction, a trendthat had an important role in the continued decline in mortalitydue to CHD. Between 1985 and 1990, the risk of death withinthree years after hospitalization for acute myocardial infarctionwas reduced by 15 to 25 percent. Furthermore, among those whodied, cardiovascular disease was less likely to be the underlyingcause of death.
The trends in therapy for acute myocardial infarction that aredocumented in this study are evidence of the important roleof acute medical care in the tendency toward lower mortalitydue to CHD. Two types of analysis suggest that approximatelyone quarter of the improvement in short-term survival afteracute myocardial infarction may be attributable to more frequentuse of thrombolytic therapy. The results of a study from Gothenburg,Sweden,29 where there was also a large increase in the use ofthrombolytic therapy during the late 1980s, are in agreementwith these findings.
Other therapies with established effects on the survival ofpatients with myocardial infarction — such as aspirin30and anticoagulants31 — were also used more frequentlyin 1990 than in 1985. Indeed, if the benefits of aspirin, inparticular, can be assumed to approximate those reported inthe Second International Study of Infarct Survival,30 then theincrease in aspirin use alone could have accounted for 50 percentof the observed decline between 1985 and 1990 in the short-termcase fatality rate of patients hospitalized with acute myocardialinfarction. Unfortunately, our data do not specify the timingof aspirin administration during the hospital stay, and it maybe that much of the increased use of aspirin in 1990 was notintended as emergency care for evolving myocardial infarction.Although we did not collect data on the use of angiotensin-converting–enzymeinhibitors in 1985, 20 percent of patients with myocardial infarctionin 1990 received such medication on discharge from the hospital.
Our finding of substantially improved survival among patientshospitalized for acute myocardial infarction is similar to theresults reported by two other groups. The NHDS found a declineof about one third in the in-hospital case fatality rate foracute myocardial infarction between 1985 and 1990.28 A similartrend was found in a population-based study in Ontario, Canada32;in that study there was little change in the case fatality rateamong patients with myocardial infarction from 1981 through1985, but survival improved substantially from 1985 to 1991.In contrast, a report from Worcester, Massachusetts, found anincrease in the in-hospital case fatality rate for acute myocardialinfarction between 1984 and 1988.10 Recent trends in medicalcare for acute myocardial infarction, documented by the NHDS,2,28are similar to those reported here and elsewhere.33,34
Lower mortality among patients who survived to 28 days contributedto the overall improved survival of patients with myocardialinfarction as much as did improvement in survival in the first28 days (Table 2). Such improvement could be attributed to themore aggressive use of diagnostic and therapeutic proceduresin the hospital or after discharge, or to greater emphasis onsecondary-prevention measures (such as smoking cessation, lipid-loweringmedications, dietary changes, and aspirin). It is also possiblethat the natural history of acute myocardial infarction haschanged over time.
We conclude that the decline in mortality due to CHD among 30-to-74-year-oldresidents of the Twin Cities area in the second half of the1980s can be explained by both the declining incidence of acutemyocardial infarction in the population and the improved survivalamong patients with myocardial infarction. The decline in incidenceis consistent with continuing improvements in the risk-factorprofile with respect to cardiovascular disease, particularlysmoking and high serum total cholesterol concentrations. Thedramatic improvement in short-term survival among patients hospitalizedfor myocardial infarction probably resulted from the greateruse of beneficial therapies, including thrombolytic agents,anticoagulants, and aspirin.
Supported by a grant (RO1-HL-23727) from the National Heart,Lung, and Blood Institute. Mr. Pankow was partially supportedby an Institutional National Research Service Award (T32 HL07036)from the National Heart, Lung, and Blood Institute.
We are indebted to Dr. Richard Gillum, Dr. David Jacobs, Dr.Ronald Prineas, Dr. Gregory Burke, Dr. J. Michael Sprafka, MaryPorter, the dedicated nurse-abstractors and survey interviewstaff of the Minnesota Heart Survey, and the staff of the MinnesotaDepartment of Health for important contributions to the design,initiation, and conduct of this study; and to the hospitalsin the Twin Cities area for their cooperation.
Source Information
From the Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis.
Address reprint requests to Dr. McGovern at the Division of Epidemiology, School of Public Health, 1300 S. 2nd St., Suite 300, Minneapolis, MN 55454-1015.
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