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CVD decreases with aggressive treatment
Aggressive modification of cardiovascular risk factors seems to be paying dividends, at least for a large population of insured patients in Northern California. In an analysis of nearly 18.7 million patient-years between 1999 and 2008, the rate of myocardial infarction (MI) increased in 1999 and 2000 and then decreased significantly every year thereafter (287 cases/100,000 person-years in 2000, decreasing to 208 cases/100,000 person-years in 2008; 24% relative decrease over the study period). The rate of ST-segment elevation MI decreased over the study period (133 cases/100,000 person-years in 1999 to 50 cases/100,000 person-years in 2008; P < 0.001) and the 30-day mortality rate decreased from 1999 to 2008 as well (adjusted odds ratio, 0.76; 95% confidence interval, 0.65-0.89). This occurred despite more aggressive diagnosis of MI.
The authors conclude, "The lower incidence of myocardial infarction particularly ST-segment elevation myocardial infarction is probably explained, at least in part, by substantial improvements in primary-prevention efforts, ..." including statins and aggressive blood pressure reduction, as well as use of cardioprotective medications such as aspirin (N Engl J Med 2010;362:2155-2165).
An accompanying editorial points out that while these trends are generally the case in the United States, there are significant geographic differences. "The risk among residents of Oklahoma, the lower Mississippi corridor, and Appalachia, for example, is double that among other Americans, ... " suggesting socioeconomic factors play a role. Hypertension and diabetes rates have increased slightly over the last decade, while smoking rates have decreased. Perhaps even more importantly, statin use has increased significantly (among those between age 45 and 64 years, statin use in men increased from 2.5% to 16.8% and from 1.9% to 13.5% in women; among those 65 years of age or older, statin use increased from 1.9% to 38.9% in men and from 3.5% to 32.8% in women). Aspirin, beta-blockers, and ACEIs/ARBs have also contributed to the decline in cardiovascular mortality in the United States (N Engl J Med 2010;362:2150-2153).