Younger, Heavier, and Uninsured: Trends Point to Rising Risks in Acute MI, Ischemic Stroke Patients

It’s unclear whether more patients are developing atherosclerotic risk factors earlier in life, or whether coding changes are simply recording them better.

Younger, Heavier, and Uninsured: Trends Point to Rising Risks in Acute MI, Ischemic Stroke Patients

Not only are patients diagnosed with acute MI and acute ischemic stroke getting younger, but an increasing proportion of them are also uninsured, according to a nationwide data sample. Additionally, more of these patients over time have been presenting with atherosclerotic risk factors such as hypertension, hyperlipidemia, diabetes, smoking, and obesity despite their younger age.

“Although we have made strides in improving the mortality among patients with acute MI and acute ischemic stroke secondary to improvements in medical therapy alongside management strategies, several disparities with respect to primary and secondary prevention of cardiovascular disease continue to persist and need to be targeted,” write the study authors led by Shikhar Agarwal, MD, MPH (Geisinger Medical Center, Danville, PA).

Changes in the risk factor profile of any patient group are expected over time, but Agarwal and colleagues set out to characterize these specific temporal trends among patients with acute MI and acute ischemic stroke to gain a better understanding of the impacts of “therapeutic advances in clinical medicine, heightened public awareness, governmental health policies, and continuing research efforts,” they say.

The researchers used data from the Nationwide Inpatient Sample on more than 2 million patients diagnosed with either condition between 2003 and 2013. Their results—published online ahead of print in the American Journal of Cardiology—show a significant reduction in the mean age of patients presenting with STEMI, NSTEMI, or acute ischemic stroke throughout the time period (P < 0.001 for all trends). Additionally, the proportion of female patients declined slightly in all three groups, but the percentage of those uninsured went up.

As for atherosclerotic risk factors, the prevalence of hypertension, diabetes, hyperlipidemia, smoking, obesity, and chronic kidney disease all increased over time in each of the three groups. Despite this, in-hospital mortality and hospital length of stay dipped over time among all three clinical syndromes studied, regardless of disease severity (P < 0.001 for all trends).

Lastly, “significant disparities” were observed when comparing patients based on demographic and geographical characteristics, the authors note. Specifically, those without documented insurance and with lower socioeconomic status were more likely to report preventable risk factors such as smoking and obesity compared with insured patients and those with higher socioeconomic status.

Although it’s clear that the patient population has decreased in age, the “increase in the prevalence of hypertension and hyperlipidemia noted in the study might also be secondary to improved detection and increased awareness and reporting of these conditions,” the authors acknowledge.

Yet they remain certain that the current patient population appears “to be more complex compared with a decade ago, by virtue of higher comorbidity burden.”

According to Sorin Brener, MD (New York Methodist Hospital, Brooklyn, NY), however, who was not involved with the study, many of the results observed in this study may be a “manifestation of coding changes [rather] than of disease change.”

Specifically, he told TCTMD, due to the increasing sensitivity of cardiac markers, many patients who are coded to have NSTEMI today would have instead been coded as having unstable angina even just 5 years ago. The same thing goes for smoking, Brener said. “There [has been] a profound decline in smoking, so it's unlikely that people are smoking more, it’s just that we’re coding it more.”

These administrative data are better for researchers wanting “to know something very specific without being too granular about it,” he concluded, advising that data sets such as this cannot be mined too aggressively for clinical insights.

  • Agarwal S, Sud K, Thakkar B, et al. Changing trends of atherosclerotic risk factors among patients with acute myocardial infarction and acute ischemic stroke. Am J Cardiol. 2017;Epub ahead of print.

  • Agarwal and Brener report no relevant conflicts of interest.