The Changing Epidemiology of Acute Coronary Syndromes: Implications for practice: Dr. Sonia Anand, McMaster University

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1 The Changing Epidemiology of Acute Coronary Syndromes: Implications for practice: Dr. Sonia Anand, McMaster University Expert Opinions CCS Vancouver, BC October 23, 2011

2 Overview of ACS Epidemiology: Global Burden Trends overtime in North America What accounts for these differences? Reduction of Risk Factors Treatment of Risk Factors Improved Diagnosis In-hospital Treatments What does the future hold?

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5 Millions of Deaths from Cardiovascular Disease Worldwide Deaths from Cardiovascular Causes Reddy K. N Engl J Med 2004;350:

6 Community vs In-Hospital Trends In-Hospital ACS Case Fatality Rate Community Chronic Stable CAD Risk Factors High Normals Prevention s Greatest Impact Number of cases

7 CAD Declines in USA CDC reports that the Behavior Risk Factor Surveillance System shows age-adjusted Coronary Disease prevalence dropped from 6.7% in 2006 to 6% in 2010 Prevention of CHD was 19.8% > 65 yrs, 7.1 % in people 45 to 64 yrs, and 1.2% in young adults CHD more common in men than women (7.8% vs 4.6%) CHD more common in those a high school education (9.2%) than high school graduates (6/7%) or those with a college degree 4.6% Morbidity and Mortality Weekly Report Oct, 2011

8 Trends in Canada 1994 to 2005 Between 1994 and 2005, the ageadjusted CHD mortality rate in Ontario decreased by 35% from 191 to 125 deaths per inhabitants. The IMPACT model estimated that there were 7,585 deaths prevented or delayed in Wijeysundera JAMA 2010

9 Deaths Figure. Deaths Prevented or Delayed or in Delayed 2005, Stratified by in Age and 2005, Sex Stratified by Age and Sex Deaths Prevented or Delayed Female Male Age Range, y Wijeysundera, H. C. et al. JAMA 2010;303:

10 Population Trends in the US 46,086 hospitalizations for MI during follow-up from 1999 to 2008 Patients > 30 years diverse, community-based population hospitalized for incident MI between 1999 and 2008 Patient characteristics, outpatient medications, and cardiac biomarker levels during hospitalization were identified from health plan databases 30-day mortality was determined from administrative databases, state death data, and Social Security Administration files Yeh RW et al. N Engl J Med 2010;362:

11 Age- and Sex-Adjusted Incidence Rates of Acute Myocardial Infarction, 1999 to % relative decline Yeh RW et al. N Engl J Med 2010;362:

12 Proportion of STEMI vs NSTEMI ,086 patients from STEMI NSTEMI * Proportion of STEMI decreased by 50% since 1999

13 In-patient characteristics over time Age at first presentation increased: 67 to 69 yrs Increased # women by 2% (64 M:36F) Increased proportion patients with: Hypertension: 45 to 76% Diabetes: 27 to 32% Dyslipidemia: 46 to 80%

14 Use of Medications increased Outpatient Basis (prior to MI) A) Before MI Medication Use (%) ACE inhibitors and ARBs Statins Nonstatin lipidlowering agents Beta - blockers Thienopyridine Yeh RW et al. N Engl J Med 2010;362:

15 Diagnostics and Procedures Trends Over time CK- MB testing declined: 75% to 56% Troponin I use increased: 53% to 84% Revascularization increased: 40.7% to 47.2% STEMI: 49% to 69% NSTEMI: 33% to 41%

16 Adjusted Odds Ratio for 30-Day Mortality, According to Year 1.4 This Decrease was driven by the CFR for NSTEMI which decreased from 10.0% to 7.6%; No significant change for STEMI ( Adjusted Odds Ration (vs. 1999) Yeh RW et al. N Engl J Med 2010;362:

17 Summary USA data Reduced Incidence of MI hospitlizations (mostly STEMI) over 8 yrs Increased use of Statins, ACE/ARB/ B-Blockers in community Increases in risk factors in hospitalized patients 24% lower case fatality rate (mostly NSTEMI) Increased Revascularization

18 Canadian Analysis Prospective analytic study of the Ontario, population aged 25 to 84 years between 1994 and 2005 Validated IMPACT model, integrates data on population size, CHD mortality, risk factors, and treatment uptake changes Outcomes linked with administrative databases (ICES) Wijeysundera HC et al JAMA 2010

19 Canadian Trends: Ontario Between 1994 and 2005, the age-adjusted CHD mortality rate decreased by 35% from 191 to 125 deaths/100,000 resulting in 7585 fewer CHD deaths in 2005 Risk factor changes associated with 48% (range, 28%-64%) of the total mortality decrease New medical and surgical treatments were associated with 43% (range, 11%-124%) of the decrease The decrease in observed CHD deaths was concentrated in older patients aged 75 to 84 years JAMA 2010

20 Explaining Mortality Decrease 7585 fewer CHD deaths in 2005 explained by: 43% Medical and Surgical Treatments 48% Risk Factor Decrease Treatments Statins *Risk Factor Improvement Revasc Ace/Arb Antiplatelet Tchol Sys BP Smoking Activity JAMA 2010

21 CAD, AMI and ACS Chronic Stable CAD 17% deaths prevented 1305 out of AMI 8.3% Deaths prevented 630 of 16,640 ACS 2% Deaths Prevented 150 of 10,180 1% Revasc CFR 1yr =15.4% 3% ACE 5% Aspirin 0.1% CPR 0.2% Tlysis 0.4% ACE 0.7% PCI 1.4% BB CFR 1yr =5.4% 9% Statin 1.4% A+C 4% Statin 0.1% PCI 0.1% Clop 0.1% Asp+Hep 0.8% Statin JAMA 2010

22 What accounted for these changes? CV deaths prevented or delayed associated with improvements in medical and surgical treatments between 1994 and 2005 Change in statin use from 8% to 78% of patients with chronic stable coronary artery Percutaneous and surgical revascularizations were associated with only 1% (range, 0%-2%) of the overall deaths prevented or delayed. JAMA 2010

23 Community vs In-Hospital Trends In-Hospital 95% of Resources spent here ACS Case Fatality Rate Community 5% of Resources spent here Chronic Stable CAD Risk Factors High Normals Prevention s Greatest Impact Number of cases

24 ACS Epidemiology Summary 1) The incidence of myocardial infarction has decreased significantly since 2000, and the incidence of STEMI decreased markedly after 1999 in North America. 2) Short-term case fatality rates for ACS have improved due to improved diagnostics, medical management and a modest contribution of revascularization including PCI 3) The reduced incidence in ACS is primarily attributable to improved control of CV risk factors (Tchol, sys BP, but offset by BMI and DM) in the population. 4) CHD mortality reduction associated with medical and revasc treatments were mostly observed in community-dwelling patients with chronic stable coronary artery disease

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