• Myocardial Infarction
• Cardiology Clinical Trials

The overall rate of cardiovascular (CV) mortality among patients with ST-segment elevation myocardial infarction (STEMI) in France has decreased 68% over the past 15 years, but the profile of patients hospitalized for STEMI has changed, with a higher prevalence of younger patients with no comorbidities or history of CV disease. The change has occurred especially among women, with the proportion of women <60 years with STEMI doubling from 1995 to 2010. Increases in smoking and obesity in that population seem to be the cause, said Nicolas Danchin, MD, Hospital European Georges Pompidou, Paris, France, who reported the findings.

Prof. Danchin and his colleagues reviewed data from 4 nationwide French registries (USIK 1995, USIC [Unite′ de Soins Intensifs Coronaires] 2000, FAST-MI [French Registry of Acute Coronary Syndrome With or Without ST Elevation; NCT00673036] 2005, and FAST-MI 2010 [NCT01237418]), with 1-month surveys conducted every 5 years from 1995 to 2010. Lower mortality rates associated with STEMI have been attributed to improved interventions, but the investigators hypothesized that temporal changes in patient characteristics may have also played a role in the mortality decline.

The study, which was published to coincide with its presentation at the European Society of Cardiology Congress [Puymirat E et al. JAMA 2012], included data from 6707 patients with STEMI who were admitted to an intensive care or cardiac care unit. The primary endpoint of the study was 30-day all-cause mortality. The crude 30-day mortality decreased from 13.7% to 4.4%, and the standardized mortality decreased from 11.3% to 4.4% (Figure 1). In a multivariate analysis, mortality decreased consistently from 1995 to 2010 after controlling for clinical characteristics such as age, sex, body-mass index, risk factors, CV history, and use and type of reperfusion therapy. The odds ratio for mortality was 0.39 (95% CI, 0.29 to 0.53; p<0.001) in 2010 compared with 1995.

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Figure 1.

Evolution of 30-Day Mortality.

Reproduced with permission from N. Danchin, MD.

The average age of patients with STEMI in France significantly decreased (from 66.2 years in 1995 to 63.3 years in 2010; p<0.001). The greatest change occurred among women, with the proportion of women <60 years with STEMI increasing from 11.8% in 1995 to 25.5% in 2010 (p<0.001).

Many other patient characteristics changed significantly over the 15 years; most notably the percentage of current smokers (32.0% to 40.9%; p<0.001) and the rate of obesity (14.3% to 20.1%; p<0.001). These increases were greater among women than among men, especially for women <60 years, among whom smoking increased from 37.3% to 73.1% and obesity increased from 17.6% to 27.1%. Prof. Danchin noted that these findings indicate the crucial need to target future preventive measures toward younger women. Overall, significantly fewer patients had a CV history (p<0.001), but significantly more had typical risk factors, such as hypertension (p=0.006) and hypercholesterolemia (p=0.001) compared with 15 years ago.

The study also demonstrated significant increases in the use of reperfusion therapy compared with 15 years ago, with the rate of percutaneous coronary intervention increasing from 11.9% to 60.8% (p<0.001). The use of evidence-based interventions within the first 48 hours, such as treatment with β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and statins, also increased significantly (p<0.001). In addition, the time from onset of symptoms to first medical contact significantly decreased over time (p<0.001). All of these factors likely contribute to the decreasing mortality rate observed over time.

Filippo Crea, MD, PhD, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy, noted that the study had several strengths, but its weaknesses included potential bias related to a prevalent inclusion of large-volume hospitals and a lack of information on infarct size, microvascular obstruction, and ejection fraction at discharge; and lack of follow-up data on recurrence of acute coronary events.

• © 2012 MD Conference Express®