Carla Koopman

Persisting gender differences and attenuating age differences in cardiovascular drug use for prevention and treatment of coronary heart disease, 1998-2010.

BACKGROUND Evidence on recent time trends in age-gender differences in cardiovascular drug use is scarce. We studied time trends in age-gender-specific cardiovascular drug use for primary prevention, secondary prevention, and in-hospital treatment of coronary heart disease. METHODS AND RESULTS The PHARMO database was used for record linkage of drug dispensing, hospitalization, and population data to identify drug use between 1998 and 2010 in 1 203 290 persons ≥25 years eligible for primary prevention, 84 621 persons hospitalized for an acute coronary syndrome (ACS), and 15 651 persons eligible for secondary prevention. The use of cardiovascular drugs increased over time in all three settings. In primary prevention, the proportion of women that used lipid-lowering drugs was lower than men between 2003 and 2010 (5.7 vs. 7.3% in 2010). The higher proportion of women that used blood pressure-lowering drugs for primary prevention, compared with men, attenuated over time (15.1 vs. 13.8% in 2010). During hospital admission for an ACS, the proportion of women that used cardiovascular drugs was lower than men. In secondary prevention (36 months after hospital discharge), drug use was lowest in young women. The proportion receiving lipid-lowering drugs declined after the age of 75 in all three settings. This age difference attenuated over time. CONCLUSION Age differences in drug use tended to attenuate over time, whereas gender differences persisted. Areas potentially for improvement are in the hospital treatment of ACS in young women, in secondary prevention among young women and the elderly, and in the continuity of drug use in secondary prevention.

Population trends and inequalities in incidence and short-term outcome of acute myocardial infarction between 1998 and 2007☆

OBJECTIVE We studied time trends in acute myocardial infarction (AMI) incidence, including out-of-hospital mortality proportions and hospitalized case-fatality rates. In addition, we compared AMI trends by age, gender and socioeconomic status. METHODS We linked the national Dutch hospital discharge register with the cause of death register to identify first AMI in patients ≥ 35 years between 1998 and 2007. Events were categorized in three groups: 178,322 hospitalized non-fatal, 43,210 hospitalized fatal within 28 days, and 75,520 out-of-hospital fatal AMI events. Time trends were analyzed using Joinpoint and Poisson regression. RESULTS Since 1998, age-standardized AMI incidence rates decreased from 620 to 380 per 100,000 in 2007 in men and from 323 to 210 per 100,000 in 2007 in women. Out-of-hospital mortality decreased from 24.3% of AMI in 1998 to 20.6% in 2007 in men and from 33.0% to 28.9% in women. Hospitalized case-fatality declined from 2003 onwards. The annual percentage change in incidence was larger in men than women (-4.9% vs. -4.2%, P<0.001). Furthermore, the decline in AMI incidence was smaller in young (35-54 years: -3.8%) and very old (≥ 85 years: -2.6%) men and women compared to middle-aged individuals (55-84 years: -5.3%, P<0.001). Smaller declines in AMI rates were observed in deprived socioeconomic quintiles Q5 and Q4 relative to the most affluent quintile Q1 (P=0.002 and P=0.015). CONCLUSIONS Substantial improvements were observed in incidence, out-of-hospital mortality and short-term case-fatality after AMI in the Netherlands. Young and female groups tend to fall behind, and socioeconomic inequalities in AMI incidence persisted and have not narrowed.

Neighbourhood socioeconomic inequalities in incidence of acute myocardial infarction: a cohort study quantifying age- and gender-specific differences in relative and absolute terms

BackgroundSocioeconomic status has a profound effect on the risk of having a first acute myocardial infarction (AMI). Information on socioeconomic inequalities in AMI incidence across age- gender-groups is lacking. Our objective was to examine socioeconomic inequalities in the incidence of AMI considering both relative and absolute measures of risk differences, with a particular focus on age and gender.MethodsWe identified all patients with a first AMI from 1997 to 2007 through linked hospital discharge and death records covering the Dutch population. Relative risks (RR) of AMI incidence were estimated by mean equivalent household income at neighbourhood-level for strata of age and gender using Poisson regression models. Socioeconomic inequalities were also shown within the stratified age-gender groups by calculating the total number of events attributable to socioeconomic disadvantage.ResultsBetween 1997 and 2007, 317,564 people had a first AMI. When comparing the most deprived socioeconomic quintile with the most affluent quintile, the overall RR for AMI was 1.34 (95 % confidence interval (CI): 1.32 – 1.36) in men and 1.44 (95 % CI: 1.42 – 1.47) in women. The socioeconomic gradient decreased with age. Relative socioeconomic inequalities were most apparent in men under 35 years and in women under 65 years. The largest number of events attributable to socioeconomic inequalities was found in men aged 45–74 years and in women aged 65–84 years. The total proportion of AMIs that was attributable to socioeconomic inequalities in the Dutch population of 1997 to 2007 was 14 % in men and 18 % in women.ConclusionsNeighbourhood socioeconomic inequalities were observed in AMI incidence in the Netherlands, but the magnitude across age-gender groups depended on whether inequality was expressed in relative or absolute terms. Relative socioeconomic inequalities were high in young persons and women, where the absolute burden of AMI was low. Absolute socioeconomic inequalities in AMI were highest in the age-gender groups of middle-aged men and elderly women, where the number of cases was largest.

Downward trends in acute myocardial infarction incidence: how do migrants fare with the majority population? Results from a nationwide study

Aims In previous decades, a steep decline in acute myocardial infarction (AMI) incidence occurred in Western countries. We assessed whether this decline was also present in migrant groups living in the Netherlands. Methods and results Nationwide registers were linked between 1998 and 2007. Poisson regression analyses were used to calculate the biannual percentage change in AMI incidence within major non-Western migrant groups, and the differences in these changes with the Dutch majority population. Within the Dutch majority population, AMI incidence significantly declined in men (−12%) and women (−9.5%). Incidence also declined among most migrant groups under study, ranging from −12 to −4.0% in men, and from −16 to −9.5% in women. Only in Turkish women and Moroccan men the AMI incidence remained stable over time (−0.3 and 2.8%, respectively). There were no statistically significant trend differences between the Dutch majority population and the migrant groups under study. The higher AMI incidence in Turkish men and Surinamese men and women, and the lower AMI incidence in Moroccan men persisted over time. Conclusions There was a declining AMI incidence rate within the Dutch majority population as well as within most of the major migrant groups living in the Netherlands, except in Turkish women and Moroccan men. Trend patterns among migrant groups did not significantly differ from the Dutch majority population. To reduce ethnic inequalities, primary preventive strategies should be targeted at those migrant groups with a persisting higher incidence.

Shifts in the age distribution and from acute to chronic coronary heart disease hospitalizations

Background Shifts in the burden of coronary heart disease (CHD) from an acute to chronic illness have important public health consequences. Objective To assess age-sex-specific time trends in rates and characteristics of acute and chronic forms of CHD hospital admissions in the Netherlands. Methods Using nationwide Dutch registers, we assessed time trends between 1998 and 2007 in hospitalization rates of 188,266 acute myocardial infarction (AMI, ICD-9 410), 294,374 unstable angina (ICD-9 411, 413) and 205,649 chronic forms of CHD (ICD-9 412, 414) admissions. Results Between 1998 and 2007, the age-standardized CHD hospitalization rate declined from 688 to 545 per 100,000 in men and from 281 to 229 per 100,000 in women. Overall, hospitalization rates decreased at younger age (<75 years) but increased in very old age (≥85 years). The annual percentage change in hospitalization rates was larger for AMI (men:-5.1%, women:-4.4%) than for unstable angina patients (men:-2.0%, women:-2.0%). For chronic CHD, the average annual percentage change was +0.7% in men and +2.1% in women. The proportion of chronic CHD in the total of CHD admissions increased between 1998 and 2007 from 29% to 36% in men and from 23% to 30% in women. The proportion of AMI decreased from 30% to 24% in men and from 27% to 22% in women. Conclusions An increasing proportion of Dutch CHD hospital admissions was for chronic forms of CHD. The age at hospitalization was pushed towards older age: premature CHD admission declined over time and admission rates at very old age increased.

Explaining the Decline in Coronary Heart Disease Mortality in the Netherlands between 1997 and 2007

Objective We set out to determine what proportion of the mortality decline from 1997 to 2007 in coronary heart disease (CHD) in the Netherlands could be attributed to advances in medical treatment and to improvements in population-wide cardiovascular risk factors. Methods We used the IMPACT-SEC model. Nationwide information was obtained on changes between 1997 and 2007 in the use of 42 treatments and in cardiovascular risk factor levels in adults, aged 25 or over. The primary outcome was the number of CHD deaths prevented or postponed. Results The age-standardized CHD mortality fell by 48% from 269 to 141 per 100.000, with remarkably similar relative declines across socioeconomic groups. This resulted in 11,200 fewer CHD deaths in 2007 than expected. The model was able to explain 72% of the mortality decline. Approximately 37% (95% CI: 10%-80%) of the decline was attributable to changes in acute phase and secondary prevention treatments: the largest contributions came from treating patients in the community with heart failure (11%) or chronic angina (9%). Approximately 36% (24%-67%) was attributable to decreases in risk factors: blood pressure (30%), total cholesterol levels (10%), smoking (5%) and physical inactivity (1%). Ten% more deaths could have been prevented if body mass index and diabetes would not have increased. Overall, these findings did not vary across socioeconomic groups, although within socioeconomic groups the contribution of risk factors differed. Conclusion CHD mortality has recently halved in The Netherlands. Equally large contributions have come from the increased use of acute and secondary prevention treatments and from improvements in population risk factors (including primary prevention treatments). Increases in obesity and diabetes represent a major challenge for future prevention policies.

PP05 Shifts in the type of Coronary Heart Disease Hospitalisations: Increasing Proportions of Chronic forms, Especially among the Elderly

Background Shifts in the burden of coronary heart disease (CHD) from an acute to chronic illness may have important public health consequences. The objective of this study was to assess age-gender-specific time trends in rates and characteristics of acute and chronic forms of CHD hospital admissions in the Netherlands. Methods Using nationwide Dutch registers, we assessed time trends between 1998 and 2007 in hospitalisation rates of 188,266 acute myocardial infarction (AMI, ICD-9 410), 294,374 unstable angina (ICD-9 411, 413) and 203,881 chronic forms of CHD (ICD-9 412, 414) admissions. Results Between 1998 and 2007, the age-standardised CHD hospitalisation rate declined from 688 to 545 per 100,000 in men and from 281 to 229 per 100,000 in women. Overall trends masked age differences, with increasing hospitalisation rates in very old age (≥85 years). The annual percentage change in hospitalisation rates was larger for AMI (men: -5.1%, women: -4.4%) than for unstable angina patients (men: -2.0%, women: -2.0%). For chronic CHD, the average annual percentage change was +0.5% in men and +2.1% in women. The proportion of chronic CHD in the total of CHD admissions increased between 1998 and 2007 from 29% to 36% in men and from 23% to 30% in women. The proportion of AMI decreased from 30% to 24% in men and from 27% to 22% in women. Conclusion An increasing proportion of CHD hospital admissions in the Netherlands were for chronic forms of CHD. This may in part be accounted for by the increased use of revascularization procedures, especially among the elderly.