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Worcester Heart Attack Study - Dr. Robert Goldberg

The Worcester Heart Attack Study is an ongoing population-based investigation examining changing trends (1975-2003) in the incidence rates, hospital and post discharge death rates, occurrence of major clinical complications, and use of different management approaches in greater Worcester (MA) residents hospitalized with independently validated acute myocardial infarction (AMI) at all metropolitan Worcester hospitals. Secondary goals of this project are to examine changes over time in duration of prehospital delay following the onset of acute coronary symptoms and community mortality related to coronary heart disease (CHD) in the greater Worcester population. This study has been funded by the NHLBI on an ongoing basis since the mid-1980's.

To accomplish these and additional study objectives, the medical records of residents of the Worcester metropolitan area (2000 census estimate = 478,000) hospitalized with discharge diagnoses suggestive of AMI and CHD are reviewed. The primary ICD-9 codes we select for purposes of identifying cases of AMI include codes 410 (AMI), 411 (angina), 412-414 (ischemic heart disease and/or chronic coronary atherosclerosis), and 786.5 (chest pain). The study periods included to date are 1975, 1978, 1981, 1984, 1986, 1988, 1990, 1991, 1993, 1995, 1997, 1999, 2001, and 2003. The medical records of patients satisfying the study's diagnostic and geographic (resident of metropolitan Worcester) eligibility criteria are reviewed in a standardized manner by trained study physicians and nurses. To date, a total of 12,760 patients with independently confirmed AMI have been included in this population-based investigation.

Patients with possible AMI are identified through the use of passive (cold pursuit) disease surveillance. Computerized hospital printouts, restricted to residents of the Worcester metropolitan area, are reviewed several months after patients have been discharged from all greater Worcester hospitals (present n=11 which was formerly 16) with diagnoses suggestive of AMI. The study sample is selected from this available pool of geographically eligible patients.

Information is collected about patient's age, sex, race, insurance status, medical history (e.g., AMI, CHD, diabetes, heart failure, hypertension, stroke), presenting symptoms, duration of prehospital delay in seeking acute medical care, body mass index, laboratory (e.g., serum electrolytes, blood urea nitrogen, hematocrit, platelets, cholesterol) and physiologic measures (e.g., blood pressure, heart rate), acute clinical complications (e.g., atrial fibrillation, cardiogenic shock, heart failure), medications (e.g., ACE inhibitors, aspirin, beta blockers, calcium antagonists, lipid lowering agents, thrombolytics), diagnostic procedures (e.g., echocardiography, radionuclide scans, treadmill testing), and coronary interventions (e.g., PCI, coronary artery bypass surgery), hospital length of stay, and hospital survival status.

Patients discharged from all greater Worcester hospitals are followed up through a variety of sources (presently available through 2003) to ascertain patient's long-term survival status and possible changes in patient's post discharge survival over time.

With regards to the principal study findings, we observed initial increases, followed by declines, and then relative stabilization in the incidence rates of initial AMI (Figure 1). Patients hospitalized with AMI during more recent study years are increasingly older and present with a greater prevalence of comorbidities (Table 1). The crude and multivariable adjusted risk of dying during hospitalization has declined over the periods under study (Table 2). There have been marked increases over time in the use of various medical treatment approaches (Figure 2) and coronary reperfusion strategies (Figure 3).

Table 1
Changing Face of AMI: Worcester Heart Attack Study

Characteristic
1975/78
1986/88
2001/2003
Age (median, yrs)
66
69
74
Male (%)
62
60
56
Medical history (%)
Angina
24
27
22
Diabetes
22
25
33
Hypertension
41
49
71
Heart Failure
14
14
24
Stroke
5
9
12

Table 2
Trends in Hospital Case-Fatality Rates (CFR): Worcester Heart Attack Study

Time Period of Hospitalization
n
CFR (%)
Multivariable
Adjusted Risk
95% CI
1975/78
1626
20.8
1.0
---
1981/84
1712
17.4
0.69
0.57, 0.82
1986/88
1424
17.3
0.67
0.56, 0.81
1990/91
1514
15.1
0.53
0.43, 0.64
1993/95
1794
13.2
0.44
0.37, 0.53
1999/01
2264
11.6
0.36
0.30, 0.43

Figure 1: Trends in Age Adjusted Incidence Rates of Initial AMI

Trends in AMI incidence, link to data tables

Figure 2: Trends in Use of Selected Medications

Trends in Med Use, link to data tables

Figure 3: Trends in Use of Coronary Reperfusion Strategies

Trends in Coronary Reperfusion, link to data table

A number of publications have resulted from the Worcester Heart Attack Study to date. Examples of these publications are provided in the following areas of hospital incidence rates, hospital and long-term case fatality-rates, trends in management approaches, and changing demographic, clinical, and medical care seeking profile.

Incidence and Case-Fatality Rates

  1. Goldberg RJ, Gore JM, Alpert JS, Dalen JE: Recent changes in the attack rates and survival rates of acute myocardial infarction (1975-1981); The Worcester Heart Attack Study. JAMA 255:2774-2779, 1986.
  2. Goldberg RJ, Yarzebski J, Lessard D, Gore JM. A two-decades (1975-1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: A community-wide perspective. J Am Coll Cardiol 33:1533-1539, 1999.
  3. Furman MI, Dauerman HL, Goldberg RH, Yarzebski J, Lessard D, Gore JM: Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case-fatality rates from initial Q wave and non-Q wave myocardial infarction: A multi-hospital, community-wide perspective. J Am Coll Cardiol 37:1571-80, 2001.
  4. Spencer FA, Lessard D, Gore JM, Yarzebski J, Goldberg RJ. Declining length of hospital stay for acute myocardial infarction and post-discharge outcomes: A community-wide perspective. Arch Intern Med 164:733-40, 2004.
  5. Goldberg RJ, Spencer FA, Yarzebski J, Lessard D, Gore JM, Alpert JS, Dalen JE. A 25-year perspective into the changing landscape of patients hospitalized with acute myocardial infarction (the Worcester Heart Attack Study). Am J Cardiol 94:1373-1378, 2004.

Impact of, and Trends in, Clinical Complications of AMI

  1. Goldberg RJ, Samad NA, Yarzebski J, Gurwitz J, Bigelow C, Gore JM. Temporal trends (1975-1997) in the incidence and hospital death rates of cardiogenic shock complicating acute myocardial infarction (Worcester Heart Attack Study). N Engl J Med 340:1162-1168, 1999.
  2. Spencer FA, Meyer TE, Goldberg RJ, Yarzebski J, Hatton M, Lessard D, Gore JM: Twenty year trends (1975-1995) in the incidence, in-hospital and long-term death rates associated with heart failure complicating acute myocardial infarction. A community-wide perspective. J Am Coll Cardiol 34:1378-1387, 1999.
  3. Goldberg RJ, Yarzebski J, Lessard D, Wu J, Gore JM. Recent trends in the incidence rates of and death rates from atrial fibrillation complicating initial acute myocardial infarction: A community-wide perspective. Am Heart J 143:519-27, 2002.
  4. Spencer FA, Gore JM, Yarzebski J, Lessard D, Jackson EA, Goldberg RJ. Trends (1986-1999) in the incidence and outcomes of in-hospital stroke complicating acute myocardial infarction (The Worcester Heart Attack Study). Am J Cardiol 92:383-388, 2003.

Changing Treatment Practices Over Time

  1. Yarzebski J, Goldberg RJ, Gore JM, Alpert JS: Temporal trends and factors associated with pulmonary artery catheterization in patients with acute myocardial infarction. Chest 105:1003-08, 1994.
  2. Col NF, McLaughlin TJ, Soumerai SB, Hosmer Jr DW, Yarzebski J, Gurwit JH, Gore JM, Goldberg RJ: The impact of clinical trials on the use of medications for acute myocardial infarction: Results of a community-based study. Arch Intern Med 156:54-60, 1996.
  3. Spencer F, Scleparis G, Goldberg RJ, Yarzebski J, Lessard D, Gore JM. Decade long trends (1986 to1997) in the medical management of patients with acute myocardial infarction: a community-wide perspective. Am Heart J 142:594-603, 2001.
  4. Jackson EA, Sivasubramian R, Spencer FA, Yarzebski J, Lessard D, Gore JM, Goldberg RJ. Changes over time in the use of aspirin in patients hospitalized with acute myocardial infarction (1975 to 1997): A population-based perspective. Am Heart J 144:259-68, 2002.
  5. Silvet H, Spencer F, Yarzebski J, Lessard D, Gore JM, Goldberg RJ. Community-wide trends in the use and outcomes associated with beta blockers in patients with acute myocardial infarction (The Worcester Heart Attack Study). Arch Intern Med 163:2175-83, 2003. <

Delays in Seeking Acute Medical Care

  1. Goldberg RJ, Yarzebski JL, Lessard DM, Gore JM. Decade long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction. The Worcester Heart Attack Study. Arch Intern Med 160:3217-23, 2000.

Gender Differences in AMI Risk or Treatment Practices

  1. Pagley PR, Yarzebski J, Goldberg RJ, Chen Z, Chirboga D, Dalen P, Gurwitz J, Alpert JS, Gore JM: Gender differences in the treatment of patients with acute myocardial infarction: A multi-hospital, community-based perspective. Arch Intern Med 153:625-29, 1993.
  2. Vaccarino V, Krumholz H, Yarzebski J, Gore JM, Goldberg RJ. Sex differences in long term mortality after myocardial infarction: effect modification due to age. Ann Intern Med 134:173-81, 2001.
  3. Harrold L, Esteban J, Lessard D, Yarzebski J, Gurwitz J, Gore JM, Goldberg RJ. Narrowing gender differences in procedural utilization in acute myocardial infarction: Insights from the Worcester Heart Attack Study. J Gen Intern Med 18:423-31, 2003.
  4. Crowley A, Menon V, Lessard D, Yarzebski J, Jackson E, Gore JM, Goldberg RJ. Sex differences in survival after acute myocardial infarction in patients with diabetes (Worcester Heart Attack Study). Am Heart J 146:824-31, 2003.
  5. Milner KA, Vaccarino V, Arnold AL, Funk M, Goldberg RJ. Gender and age differences in chief complaints of acute myocardial infarction (Worcester Heart Attack Study). Am J Cardiol 93:606-608, 2004.

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