CLINICAL
NEWS JOURNAL WRAP
Low-income Counties Lag Behind in
AMI Outcomes
While rates of hospitalization and
mortality for acute myocardial infarction (AMI) are declining, low-income
counties are still seeing higher hospitalization rates than high-income
counties, with a 4-year lag time,
according to new research published
in JAMA: Cardiology.
Erica S. Spatz, MD, MHS, et al.
identified Medicare beneficiaries enrolled for at least 1 month from Jan.
1, 1999, to Dec. 31, 2013. Counties
were stratified by median income
percentile using 1999 U.S. Census
Bureau data adjusted for inflation:
low- (< 25th), average- (25th–75th), or
high- (> 75th) income groups.
During the study period, hospitalization and mortality rates for AMI
decreased significantly for all three
“Areas with
poor access to
healthy foods,
recreational
activities, and
health care
are limited in
their capacity
to promote [a]
healthy lifestyle.”
—Erica S. Spatz, MD, MHS
16
CardioSource WorldNews
county income groups. Mean hospitalization rates were significantly
higher among low-income counties
than in high-income counties in
1999 (1,353 vs. 1,123 per 100,000
person-years, respectively) and in
2013 (853 vs. 648 per 100,000
person-years, respectively). One-year
mortality rates after hospitalization
for AMI were similar across county
income groups, decreasing from
1999 (31.5%, 31.4%, and 31.1%, for
high-, average-, and low-income counties, respectively) to 2013 (26.2%,
26.1%, and 25.4%, respectively). The
researchers also found that income
was associated with county-level,
risk-standardized AMI hospitalization rates but not mortality rates.
The authors note the fact that
trends in AMI were similar across
communities of different income
levels, pointing out that “differences
in the physical and social environment can affect cardiovascular
outcomes of a population, leading
to health disparities.” They point
out that “areas with poor access to
healthy foods, recreational activities,
and health care are limited in their
capacity to promote healthy lifestyle
behaviors as well as primary and
secondary prevention. Also in these
areas, exposure to stress, unemployment, and inadequate social support
may attenuate the effects of efforts to
improve cardiovascular health.”
Additionally authors found that
an increase in one interquartile range
of media country consumer price
index-adjusted income ($12,000)
was associated with a decline in 46
hospitalizations per 100,000 person
years in 1999 and 37 hospitalizations per 100,000 person years in
2013. While the rate of decline in
AMI hospitalizations was similar
for all income groups, low-income
counties lagged behind high-income
counties by 4.3 years. There were
no significant differences in trends
across geographic regions.
In describing the reason for the
lag-time between income levels, the
authors write, “High-income counties
may have a greater capacity to quickly
adopt new models of care delivery,
join campaigns to reduce AMI, and
implement evidence-based primary
and secondary treatment recommendations. In addition, high-income
communities may have greater
resources to invest in the physical
and social health environment. Conversely, low-income communities may
face unique challenges (e.g., closure
of health centers during economic
depression) or disorganized health
services that could attenuate the success of new primary and secondary
prevention efforts to reduce AMI.”
“Although improvements in mortality and admission rates for AMI
seen over the past decade should give
us great pride, our work is not done,”
write Karen E. Joynt, MD, MPH,
and Thomas M. Maddox, MD,
MSc, in an accompanying editorial.
“Focusing our efforts on areas such
as the quality of ambulatory care in
primary and secondary prevention
of AMI, as well as giving greater attention to the social determinants of
health, may hold immense promise
in addressing significant and persistent disparities in health and health
outcomes for the nation’s most vulnerable populations.”
Spatz ES, Beckman AL, Wang Y, et al.
JAMA Cardiol. 2016;doi:10.1001/jamacardio.2016.0382
Will Lowering BP
Targets Decrease
CV Events and
Death in Older
Patients?
Among adults 75 years of age or
older, treating to a systolic blood
pressure (BP) target of less than 120
mm Hg compared with less than
140 mm Hg may result in considerably lower rates of death and major
cardiovascular events, according to a
study published May 19 in the Journal
of the American Medical Association
and simultaneou sly presented at the
American Geriatrics Society Annual
Scientific Meeting in Long Beach, CA.
Jeffrey D. Williamson, MD,
MHS, et al., conducted a multicenter, randomized clinical trial in
which a subgroup of patients from
the SPRINT Trial aged 75 years or
older who had hypertension but not
diabetes, were randomly assigned to
a systolic BP target of less than 120
mm Hg (intensive treatment group,
n = 1,317) or a systolic BP target
of less than 140 mm Hg (standard
treatment group, n = 1,319).
Results show that patients in the
intensive treatment group had a significantly lower rate of the primary
composite outcome—nonfatal myocardial infarction, acute coronary
syndrome not resulting in a myocardial infarction, nonfatal stroke,
nonfatal acute decompensated heart
failure and death from cardiovascular
causes—than the standard treatment group at a 3.1-year follow-up.
In addition, there were 102 events
in the intensive treatment group vs.
148 events in the standard treatment
group. The intensive treatment group
also had a substantially lower rate of
death from any cause.
“Considering the high prevalence
of hypertension among older persons, patients and their physicians
may be inclined to underestimate
the burden of hypertension or the
benefits of lowering BP, resulting
in undertreatment,” the authors
state. “On average, the benefits that
resulted from intensive therapy required treatment with one additional
antihypertensive drug and additional
early visits for dose titration and
monitoring,” they add.
In an accompanying editorial,
Aram V. Chobanian, MD, remarks
that “achieving the systolic BP goal
of less than 130 mm Hg may be challenging for clinicians, because doing
so could require use of additional
medications, more careful monitoring, and more frequent clinic visits.
Nevertheless, the important results
[…] cannot be discounted, and unless unexpected adverse effects are
observed on further examination of
the trial data, then major changes in
treatment goals for patients 75 years
or older with hypertension will be
warranted.” ■
Williamson JD, Supiano MA, Applegate
WB, et al. JAMA. 2016;doi:10.1001/
jama.2016.7050
July 2016