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Trends in cardiovascular risk profiles

December 1, 2017|Cleveland Clinic Journal of Medicine
Samir Kapadia, MD
Author and Disclosure Information

Samir Kapadia, MD
Director, Sones Catherization Laboratories and Head, Section of Invasive and Interventional Cardiology, Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Correspondence: Samir Kapadia, MD, Department of Cardiovascular Medicine, Heart & Vascular Institute, J2-3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; kapadis@ccf.org

This article is based on Dr. Kapadia’s presentation at the Sones/Favaloro Scientific Program, “Transforming the Delivery of Cardiovascular Care: Research and Innovation in the Heart & Vascular Institute,” held in Cleveland, OH, November 18, 2016. The article was drafted by Cleveland Clinic Journal of Medicine and was then reviewed, revised, and approved by Dr. Kapadia.

Dr. Kapadia reported no financial interests or relationships that pose a potential conflict of interest with this article.

ABSTRACT

Outcomes for patients with coronary artery disease (CAD) have improved in the past 20 years likely due to advances in clinical care such as angiotensin-converting enzyme inhibitors, antiplatelet agents, and reduced time to cardiac cauterization procedures. But how have the risk factors for CAD changed in the past 2 decades? Analysis of nearly 4,000 patients with ST-elevation myocardial infarction (STEMI) at a tertiary care center found that patients presenting with acute STEMI are younger and more obese than in the past. The prevalence of smoking, hypertension, and diabetes mellitus is also increasing. Primary and secondary prevention and aggressive efforts to modify risk factors for CAD is essential for further improvement in cardiovascular outcomes.

KEY POINTS

  • Advances in treatment of CAD have improved patient outcomes over the past 20 years.
  • Prevalence of risk factors for CAD has increased over the past 20 years in patients presenting with STEMI with patients now more likely to be younger and with higher prevalence of smoking, obesity, hypertension, and diabetes.
  • Emphasis on primary and secondary prevention to reduce CAD risk factors is needed to improve outcomes and reduce the cost of care.

Many clinical improvements in treating patients with acute ST-elevation myocardial infarction (STEMI) have been realized in the past 20 years, including angiotensin-converting enzyme inhibitors, antiplatelet agents, and reduced time to cardiac cauterization procedures for acute myocardial infaction.1 Presumably, primary and secondary prevention measures have also resulted in changes in coronary artery disease (CAD) risk factors over the past 20 years. We sought to quantify mortality outcomes for patients treated in our catherization laboratory and to investigate trends in cardiovascular risk factors in patients during the same period.2

STEMI OUTCOMES

Data from our catherization laboratory database of 3,913 patients treated for STEMI at our tertiary care center from 1995 through 2014 were analyzed. To evaluate outcomes over time, patients were grouped based on years treated in 5-year increments resulting in 4 groups spanning 20 years.2

Rates of 30-day, 1-year, and 3-year mortality for patients treated for ST-elevation myocardial infarction.
Figure 1. Rates of 30-day, 1-year, and 3-year mortality for patients treated for ST-elevation myocardial infarction.
Analysis showed reduced mortality rates for patients with STEMI over the past 20 years: the 30-day mortality rate in patients treated from 2010 to 2014 was 7.8%, nearly half the rate of 14% in patients treated from 1995 to 1999. The trend in reduced mortality rates for patients with STEMI was also noted at 1 year and 3 years (Figure 1).3

CARDIOVASCULAR RISK FACTORS

A reduction in mortality rates in patients treated for STEMI is to be expected over time, given the improvements in clinical practices and procedures and novel medications developed since 1996. But it is also possible that patients presenting with STEMI are healthier than in the past as a result of primary prevention efforts to minimize CAD risk factors and changes in CAD risk factors over time.

To determine whether CAD risk factors have changed over time, we analyzed the risk factors in the 3,913 patients treated for STEMI in our database. Risk factors included in the analysis were:

  • Age
  • Sex
  • Diabetes mellitus
  • Hypertension
  • Smoking
  • Hyperlipidemia
  • Chronic renal impairment (serum creatinine greater than 1.5 mg/dL)
  • Obesity (body mass index greater than 30 kg/m2).2

The prevalence of risk factors was determined in the entire cohort as well as in the 34% (n = 1,325) of patients previously diagnosed with CAD. The trend in risk factors in patients previously diagnosed with CAD could indicate the effectiveness of secondary prevention efforts compared with primary prevention in the broader patient population.

Patient age at presentation with ST-elevation myocardial infarction.
Based on data from reference 2.
Figure 2. Patient age at presentation with ST-elevation myocardial infarction.
Results show that the average age of patients presenting with STEMI has decreased from 64 to 60 over the past 20 years, and the trend is consistent regardless of a history of CAD (Figure 2).2

Prevalence of risk factors in patients presenting with ST-elevation myocardial infarction over time.
Based on data from reference 2.
Figure 3. Prevalence of risk factors in patients presenting with ST-elevation myocardial infarction over time.
The prevalence of the cardiovascular risk factors of tobacco use, obesity, hypertension, and diabetes in patients with STEMI increased from 1995 to 2014, as well as patients with a history of CAD (Figure 3).2

These data suggest that despite a better understanding of cardiovascular risk factors, the cardiovascular risk profiles of patients with acute STEMI have deteriorated over the past 20 years: patients are younger at presentation and more likely to be obese, to smoke, and to have hypertension and diabetes. These trends hold true in patients with and without a history of CAD, suggesting primary and secondary prevention efforts are ineffective.

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