Clinical burden, risk factor impact and outcomes following myocardial infarction and stroke:A 25-year individual patient level linkage study

Shah, A.S.V. and Lee, K.K. and Pérez, J.A.R. and Campbell, D. and Astengo, F. and Logue, J. and Gallacher, P.J. and Katikireddi, S.V. and Bing, R. and Alam, S.R. and Anand, A. and Sudlow, C. and Fischbacher, C.M. and Lewsey, J. and Perel, P. and Newby, D.E. and Mills, N.L. and McAllister, D.A. (2021) Clinical burden, risk factor impact and outcomes following myocardial infarction and stroke:A 25-year individual patient level linkage study. The Lancet Regional Health - Europe, 7.

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Background: Understanding trends in the incidence and outcomes of myocardial infarction and stroke, and how these are influenced by changes in cardiovascular risk factors can inform health policy and healthcare provision. Methods: We identified all patients 30 years or older with myocardial infarction or stroke in Scotland. Risk factor levels were determined from national health surveys. Incidence, potential impact fractions and burden attributable to risk factor changes were calculated. Risk of subsequent fatal and non-fatal events (myocardial infarction, stroke, bleeding and heart failure hospitalization) were calculated with multi-state models. Findings: From 1990 to 2014, there were 372,873 (71±13 years) myocardial infarctions and 290,927 (74±13 years) ischemic or hemorrhagic strokes. Age-standardized incidence per 100,000 fell from 1,069 (95% confidence interval, 1,024-1,116) to 276 (263-290) for myocardial infarction and from 608 (581-636) to 188 (178-197) for ischemic stroke. Systolic blood pressure, smoking and cholesterol decreased, but body-mass index increased, and diabetes prevalence doubled. Changes in risk factors accounted for a 74% (57-91%) reduction in myocardial infarction and 68% (55-83%) reduction in ischemic stroke. Following myocardial infarction, the risk of death decreased (30% to 20%), but non-fatal events increased (20% to 24%) whereas the risk of both death (47% to 34%) and non-fatal events (22% to 17%) decreased following stroke. Interpretation: Over the last 25 years, substantial reductions in myocardial infarction and ischemic stroke incidence are attributable to major shifts in risk factor levels. Deaths following the index event decreased for both myocardial infarction and stroke, but rates remained substantially higher for stroke. Funding: British heart foundation.

Item Type:
Journal Article
Journal or Publication Title:
The Lancet Regional Health - Europe
Additional Information:
CH/09/002, RE/18/5/34216, RG/16/10/32375, SPHSU17, WT103782AIA Funding details: National Rosacea Society, NRS, SCAF/15/02 Funding details: Wellcome Trust, WT, 201492/Z/16/Z Funding details: Medical Research Council, MRC, MC_UU_00022/2 Funding details: British Heart Foundation, BHF, FS/19/17/34172 Funding details: Academy of Medical Sciences Funding text 1: Declaration of interest: JL has is on the Advisory Board and has received Research Consultancy fees from Novo Nordisk . This study was funded by the British Heart Foundation through an Intermediate Clinical Research Fellowship (FS/19/17/34172) and a Clinical Lecturer Starter Grant from the Academy of Medical Sciences. DAM is supported by a Wellcome Trust Intermediate Clinical Fellowship (201492/Z/16/Z). SVK is funded by a NRS Senior Clinical Fellowship (SCAF/15/02), the Medical Research Council (MC_UU_00022/2 and the Scottish Government Chief Scientist Office (SPHSU17). DC is funded by an unrestricted gift from Baillie Gifford. DEN is supported by the British Heart Foundation (CH/09/002, RG/16/10/32375, RE/18/5/34216) and Wellcome Trust (WT103782AIA). All other authors have no conflicts to declare. References: Rothwell, P.M., Coull, A.J., Silver, L.E., Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study) (2005) Lancet, 366, pp. 1773-1783; Falkeborn, M., Persson, I., Terent, A., Bergstrom, R., Lithell, H., Naessen, T., Long-term trends in incidence of and mortality from acute myocardial infarction and stroke in women: Analyses of total first events and of deaths in the Uppsala Health Care Region, Sweden (1996) Epidemiology, 7, pp. 67-74; Hata, J., Ninomiya, T., Hirakawa, Y., Secular trends in cardiovascular disease and its risk factors in Japanese: half-century data from the HisayamaStudy (1961-2009) (2013) Circulation, 128, pp. 1198-1205; Hunink, M.G., Goldman, L., Tosteson, A.N., The recent decline in mortality from coronary heart disease, 1980-1990.The effect of secular trends in risk factors and treatment (1997) JAMA, 277, pp. 535-542; Goldman, L., Cook, E.F., The decline in ischemic heart disease mortality rates.An analysis of the comparative effects of medical interventions and changes in lifestyle (1984) Ann Intern Med, 101, pp. 825-836; Capewell, S., Morrison, C.E., McMurray, J.J., Contribution of modern cardiovascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994 (1999) Heart, 81, p. 380—6.; Capewell, S., Beaglehole, R., Seddon, M., McMurray, J., Explanation for the decline in coronary heart disease mortality rates in Auckland, New Zealand, between 1982 and 1993 (2000) Circulation, 102, p. 1511—6; Ford, E.S., Ajani, U.A., Croft, J.B., Explaining the decrease in U.S. deaths from coronary disease, 1980-2000 (2007) N Engl J Med, 356, pp. 2388-2398; Hotchkiss, J.W., Davies, C.A., Dundas, R., Explaining trends in Scottish coronary heart disease mortality between 2000 and 2010 using IMPACTSEC model: retrospective analysis using routine data (2014) BMJ, 348, p. g1088; Sarti, C., Stegmayr, B., Tolonen, H., Are changes in mortality from stroke caused by changes in stroke event rates or case fatality? Results from the WHO MONICA Project (2003) Stroke, 34, pp. 1833-1840; Li, L., Scott, C.A., Rothwell, P.M., Oxford Vascular S. Trends in Stroke Incidence in High-Income Countries in the 21st Century: Population-Based Study and Systematic Review (2020) Stroke, 51, pp. 1372-1380; Feigin, V.L., Forouzanfar, M.H., Krishnamurthi, R., Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010 (2014) Lancet, 383, pp. 245-254; Feigin, V.L., Lawes, C.M., Bennett, D.A., Barker-Collo, S.L., Parag, V., Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review (2009) Lancet Neurol, 8, pp. 355-369; Yusuf, S., Hawken, S., Ounpuu, S., Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study (2004) Lancet, 364, p. 937—52; O'Donnell, M.J., Chin, S.L., Rangarajan, S., Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study (2016) Lancet, 388, pp. 761-775; O'Donnell, M.J., Xavier, D., Liu, L., Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study (2010) Lancet, 376, p. 112—23; Moran, A.E., Oliver, J.T., Mirzaie, M., Assessing the Global Burden of Ischemic Heart Disease: Part 1: Methods for a Systematic Review of the Global Epidemiology of Ischemic Heart Disease in 1990 and 2010 (2012) Glob Heart, 7, pp. 315-329; Yeh, R.W., Sidney, S., Chandra, M., Sorel, M., Selby, J.V., Go, A.S., Population trends in the incidence and outcomes of acute myocardial infarction (2010) N Engl J Med, 362, pp. 2155-2165; Chen, J., Normand, S.L., Wang, Y., Drye, E.E., Schreiner, G.C., Krumholz, H.M., Recent declines in hospitalizations for acute myocardial infarction for Medicare fee-for-service beneficiaries: progress and continuing challenges (2010) Circulation, 121, pp. 1322-1328; Feigin, V.L., Lawes, C.M., Bennett, D.A., Anderson, C.S., Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century (2003) Lancet Neurol, 2, pp. 43-53; Chung, S.C., Gedeborg, R., Nicholas, O., Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK (2014) Lancet, 383, p. 1305—12; Global Burden of Disease Stroke Expert G. Methodology of the global and regional burden of stroke study (2012) Neuroepidemiology, 38, pp. 30-40; Roth, G.A., CO, J., Nguyen, G., Methods for Estimating the Global Burden of Cerebrovascular Diseases (2015) Neuroepidemiology, 45, pp. 146-151; Myerson, M., Coady, S., Taylor, H., Rosamond, W.D., Goff, D.C., Jr., Declining severity of myocardial infarction from 1987 to 2002: the Atherosclerosis Risk in Communities (ARIC) Study (2009) Circulation, 119, pp. 503-514; Brieger, D., Fox, K.A., Fitzgerald, G., Predicting freedom from clinical events in non-ST-elevation acute coronary syndromes: the Global Registry of Acute Coronary Events (2009) Heart, 95, pp. 888-894; Johansson, S., Rosengren, A., Young, K., Jennings, E., Mortality and morbidity trends after the first year in survivors of acute myocardial infarction: a systematic review (2017) BMC CardiovascDisord, 17, p. 53; Vora, A.N., Rao, S.V., Temporal Trends in Bleeding among Acute Coronary Syndrome Patients: Is It Going Up or Down? Does It Matter? (2015) Cardiology, 132, pp. 159-162; Wellings, J., Kostis, J.B., Sargsyan, D., Cabrera, J., Kostis, W.J., Myocardial Infarction Data Acquisition System Study G. Risk Factors and Trends in Incidence of Heart Failure Following Acute Myocardial Infarction (2018) Am J Cardiol, 122, pp. 1-5; Goldberg, R.J., Spencer, F.A., Yarzebski, J., A 25-year perspective into the changing landscape of patients hospitalized with acute myocardial infarction (the Worcester Heart Attack Study) (2004) Am J Cardiol, 94, pp. 1373-1378; Ogren, J., Irewall, A.L., Soderstrom, L., Mooe, T., Serious hemorrhages after ischemic stroke or TIA - Incidence, mortality, and predictors (2018) PLoS One, 13; Petty, G.W., Brown, R.D., Jr., Whisnant, J.P., Sicks, J.D., O'Fallon, W.M., Wiebers, D.O., Frequency of major complications of aspirin, warfarin, and intravenous heparin for secondary stroke prevention.A population-based study (1999) Ann Intern Med, 130, pp. 14-22; Shah, A.S.V., McAllister, D.A., Gallacher, P., Incidence, Microbiology, and Outcomes in Patients Hospitalized With Infective Endocarditis (2020) Circulation, 141, pp. 2067-2077; (2020),, Scottish Health Survey. 2020. Accessed 14/12/2020 at; Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013 (2015) Lancet, 386, p. 2287—323; (2020),, European Standard Population. 2020. Accessed 23/12/2020 at; Barendregt, J.J., Veerman, J.L., Categorical versus continuous risk factors and the calculation of potential impact fractions (2010) J Epidemiol Community Health, 64, pp. 209-212; Rothwell, P.M., Coull, A.J., Giles, M.F., Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study) (2004) Lancet, 363, pp. 1925-1933; McCartney, D., Scarborough, P., Webster, P., Rayner, M., Trends in social inequalities for premature coronary heart disease mortality in Great Britain, 1994-2008: a time trend ecological study (2012) BMJ Open, 2; Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19.1 million participants (2017) Lancet, 389, pp. 37-55; Repositioning of the global epicentre of non-optimal cholesterol (2020) Nature, 582, pp. 73-77; Williams, B., Mancia, G., Spiering, W., 2018 ESC/ESH Guidelines for the management of arterial hypertension (2018) Eur Heart J, 39, pp. 3021-3104; Mach, F., Baigent, C., Catapano, A.L., 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk (2020) Eur Heart J, 41, pp. 111-188; Pell, J.P., Haw, S., Cobbe, S., Smoke-free legislation and hospitalizations for acute coronary syndrome (2008) N Engl J Med, 359, pp. 482-491; O'Keeffe, A.G., Nazareth, I., Petersen, I., Time trends in the prescription of statins for the primary prevention of cardiovascular disease in the United Kingdom: a cohort study using The Health Improvement Network primary care data (2016) ClinEpidemiol, 8, pp. 123-132; Kumanyika, S., Dietz, W.H., Solving Population-wide Obesity - Progress and Future Prospects (2020) N Engl J Med, 383, pp. 2197-2200; Ingelfinger, J.R., Jarcho, J.A., Increase in the Incidence of Diabetes and Its Implications (2017) N Engl J Med, 376, pp. 1473-1474; Piepoli, M.F., Hoes, A.W., Agewall, S., 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR) (2016) Eur Heart J, 37, pp. 2315-2381; Ntaios, G., Papavasileiou, V., Diener, H.C., Makaritsis, K., Michel, P., Nonvitamin-K-antagonist oral anticoagulants in patients with atrial fibrillation and previous stroke or transient ischemic attack: a systematic review and meta-analysis of randomized controlled trials (2012) Stroke, 43, pp. 3298-3304; Langhorne, P., Ramachandra, S., Stroke Unit Trialists C. Organised inpatient (stroke unit) care for stroke: network meta-analysis (2020) Cochrane Database Syst Rev, 4. , CD000197; Keeley, E.C., Boura, J.A., Grines, C.L., Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials (2003) Lancet, 361, pp. 13-20; Shah, A.S., McAllister, D.A., Mills, R., Sensitive troponin assay and the classification of myocardial infarction (2015) Am J Med, 128. , 493-501.e3; Mills, N.L., Churchhouse, A.M., Lee, K.K., Implementation of a sensitive troponin I assay and risk of recurrent myocardial infarction and death in patients with suspected acute coronary syndrome (2011) Jama, 305, pp. 1210-1216; Simonsson, M., Wallentin, L., Alfredsson, J., Temporal trends in bleeding events in acute myocardial infarction: insights from the SWEDEHEART registry (2020) Eur Heart J, 41, pp. 833-843; Coronary CT Angiography and 5-Year Risk of Myocardial Infarction (2018) N Engl J Med, 379, p. 924—33; Shah, A.S.V., Anand, A., Strachan, F.E., High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial (2018) Lancet, 392, p. 919—28; Shah, A.S.V., Sandoval, Y., Noaman, A., Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study (2017) Bmj, 359, p. j4788; Mackay, D.F., Russell, E.R., Stewart, K., MacLean, J.A., Pell, J.P., Stewart, W., Neurodegenerative Disease Mortality among Former Professional Soccer Players (2019) N Engl J Med, 381, pp. 1801-1808; Computerised record linkage: compared with traditional patient follow-up methods in clinical trials and illustrated in a prospective epidemiological study (1995) J ClinEpidemiol, 48, pp. 1441-1452; Turner, M., Barber, M., Dodds, H., Agreement between routine electronic hospital discharge and Scottish Stroke Care Audit (SSCA) data in identifying stroke in the Scottish population (2015) BMC Health Serv Res, 15, p. 583; Soo, M., Robertson, L.M., Ali, T., Approaches to ascertaining comorbidity information: validation of routine hospital episode data with clinician-based case note review (2014) BMC Res Notes, 7, p. 253; Rowe, A.K., Powell, K.E., Flanders, W.D., Why population attributable fractions can sum to more than one (2004) Am J Prev Med, 26, pp. 243-249; Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants (2016) Lancet, 387, pp. 1513-1530; Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128.9 million children, adolescents, and adults (2017) Lancet, 390, pp. 2627-2642
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