A new study in the American Journal of Cardiology shows a dramatic drop in ST-elevation myocardial infarction (STEMI) cases in the ED nationwide between 2006 and 2011 despite increasing incidence of cardiovascular disease.

“Among all age groups and all regions, presentation of STEMIs to the ED is declining by about 30 percent across the board,” said study lead author Michael Ward, MD, MBA, assistant professor of emergency medicine at Vanderbilt University in Nashville, Tennessee.

While the findings are positive news for patients, Dr. Ward said they raise new questions for physicians and policymakers, from how emergency physicians can stay up-to-date on diagnosing and treating this critical population to where funding for disease treatment and prevention should be allocated.

Dr. Ward and his coauthors used the Nationwide Emergency Department Sample, a database of ED visits, to assess STEMI incidence in emergency departments across the country. The researchers found that between 2006 and 2011, STEMI visits to the ED dropped from 300,466 to 227,343 and the incidence rate decreased from 10.1 ED STEMI visits per 10,000 adults to 7.3. Looking at other STEMI studies in the United States, the researchers found STEMI hospitalizations have also been on the decline.

Incidence rates of STEMI presentation in the ED were lowest in the Western United States and highest in the Midwest, the researchers found, though the Midwest also saw the largest geographical decline.

“I think it’s a good thing for patients, but the potential unintended consequence is that providers and facilities themselves are not as experienced with caring for that population.”
—Michael Ward, MD, MBA

There are several possible explanations for these observations, Dr. Ward said, including improved acute and long-term management of cardiovascular disease. It’s not simply a matter of less cardiovascular disease; this year the American Heart Association revised its estimates for the number of people who will be living with cardiovascular disease by 2030 from 41 percent to nearly 44 percent.

“One of the primary reasons is because of prevention,” said Dr. Ward. “We are seeing more and more patients with cardiovascular disease, but they’re living well with it with better medication prevention.”

Also, more patients with STEMI now bypass the ED as a result of 2004 American Heart Association guidelines that recommend patients go straight to the cath lab for myocardial profusion.

Additionally, the largest decline in STEMI incidence in the ED is among patients age 85 and older, the study found

“Perhaps they are pursuing less-aggressive care or they have advanced directives in place, and so that may prevent them from showing up for care,” said Dr. Ward.

With fewer patients presenting to the ED with STEMI, physicians—especially emergency physicians and those in training—need to stay up-to-date on diagnosis and treatment, Dr. Ward advised, particularly since time-to-treatment standards will continue to persist and EDs may be more likely to see atypical, less-clear-cut STEMI patients.

He suggested physicians continue to review characteristic ECGs and other modalities to stay current.

“I think it’s a good thing for patients, but the potential unintended consequence is that providers and facilities themselves are not as experienced with caring for that population,” he said.

In the United States, the estimated costs of acute heart disease care is $67.4 billion for hospital inpatient stays and $5.6 billion for ED visits, the study cited. This is seven times higher than the $10 billion annually it costs for preventive medication, Dr. Ward said.

“At what point do we start to say that we need to shift even more money on prevention?” Dr. Ward asked, noting the current study does not attempt to address this.