Do heart failure status and psychosocial variables moderate the relationship between leisure time physical activity and mortality risk among patients with a history of myocardial infarction?

BACKGROUND: Leisure time physical activity (LTPA) is inversely related to mortality risk among patients with a history of myocardial infarction (MI). The aims were to explore if heart failure (HF) status and psychosocial variables moderate the association. METHODS: Participants (n = 1169) were from a multi-center prospective cohort study. Information on LTPA (none, irregular,1-150, 151-300 and >300 weekly minutes), depression, social support and other prognostic indicators were collected 10-13 years after index MI. Cox regressions were conducted, adjusting for potential confounders. In case of significant moderation by HF-status or psychosocial variables, stratified analyses were performed. RESULTS: During follow-up (M = 8.4 years), 25.6 % of the sample had died. LTPA was inversely associated with mortality (p for trend < 0.01 in all models). HF did not, but psychosocial variables did, moderate the association. In the LTPA category 1-150 weekly minutes, patients with a high level of depression had a lower mortality risk in comparison to those with a low level (hazard ratios (95 % confidence intervals) were 0.43 (0.25, 0.75) versus 0.69 (0.36, 1.32)), and patients with a low level of social support had a lower mortality risk in comparison to those with a high level (0.40 (0.21, 0.77) versus 0.71 (0.39, 1.27)). In the category >300 min, patients with a high level of social support had a lower mortality risk than those with a low level (0.38 (0.19, 0.79) versus 0.51 (0.30, 0.87)). CONCLUSIONS: LTPA was inversely related to mortality risk of post-MI patients. HF did not moderate the relationship; depression and social support partially did.

Ethnicity and long-term prognosis after myocardial infarction: a population-based cohort study.

BACKGROUND: Health disparities are systematic differences in health, favoring members of advantaged over disadvantaged groups in the society. This study examines the contribution of multiple socioeconomic status (SES) measures to ethnic differences in after myocardial infarction (MI) prognosis. METHODS: Patients aged 65 years and younger (n=1040) belonging to Ashkenazi and Mizrahi advantaged and disadvantaged ethnic groups discharged from 8 hospitals in central Israel after incident MI in 1992-1993, were followed up through 2005 for all-cause mortality, recurrent MI, heart failure, and ischemic stroke. RESULTS: Advantaged Ashkenazi had higher education, income, employment, and neighborhood SES compared with disadvantaged Mizrahi. Cardiovascular risk factors varied among the different ethnic groups. Results showed that the association between ethnic group and all outcomes differed substantially between models that included a single SES measure and those that included multiple measures. For example, the hazard ratio for mortality in disadvantaged Mizrahi compared with advantaged Ashkenazi was 1.87 [95% confidence interval (CI), 1.40-2.48] in a model adjusting only for demographic variables; 1.58 (95% CI, 1.18-2.12) in a model adjusting also for income; and 1.03 (95% CI, 0.74-2.04) in a model adjusting for all measured SES indicators. Further adjustment for clinical variables did not appreciably change the results. CONCLUSIONS: Findings show that a wide array of modifiable social factors shaped by income, education, and neighborhood socioeconomic conditions can explain ethnic health differences and highlight the importance of using multivariable models of SES.

Depression and anxiety following myocardial infarction and their inverse associations with future health behaviors and quality of life.

BACKGROUND: Post-myocardial infarction (MI) depression and anxiety were found to predict prognosis and quality of life. PURPOSE: The purpose of this study was to test a behavioral pathway from post-MI depression/anxiety to future quality of life. METHODS: This is a longitudinal cohort study. Five hundred forty patients (≤65 years old) filled out questionnaires after a first MI, including socio-demographics, pre-MI health status and behaviors, MI severity, social support, sense of coherence, depression, and anxiety. Reports of health behaviors were obtained 5 years and of quality of life 10 years later. RESULTS: A structural equations model confirmed that depression and anxiety were directly related to poorer quality of life 10 years later. These relationships were partly mediated by a positive association between anxiety and health behaviors at 5 years and a negative one between depression and health behaviors. CONCLUSIONS: The opposite effects of anxiety and depression underscore the need to attend to both emotional reactions to MI while encouraging preventive health behaviors.

Cumulative exposure to particulate matter air pollution and long-term post-myocardial infarction outcomes.

INTRODUCTION: Chronic environmental exposure to particulate matter <2.5µm in diameter (PM2.5) has been associated with cardiovascular disease; however, the effect of air pollution on myocardial infarction (MI) survivors is not clear. We studied the association of chronic exposure to PM2.5 with death and recurrent cardiovascular events in MI survivors. METHODS: Consecutive patients aged ≤65years admitted to all medical centers in central Israel after first-MI in 1992-1993 were followed through 2005 for cardiovascular events and 2011 for survival. Data on sociodemographic and prognostic factors were collected at baseline and during follow-up. Residential exposure to PM2.5 was estimated for each patient based on data recorded at air quality monitoring stations. Cox and Andersen-Gill proportional hazards models were used to study the pollution-outcome association. RESULTS: Among the 1120 patients, 469 (41.9%) died and 541 (48.3%) experienced one or more recurrent cardiovascular event. The adjusted hazard ratios associated with a 10µg/m(3) increase in PM2.5 exposure were 1.3 (95% CI 0.8-2.1) for death and 1.5 (95% CI 1.1-1.9) for multiple recurrences of cardiovascular events (MI, heart failure and stroke). CONCLUSION: When adjustment for socio-demographic factors is performed, cumulative chronic exposure to PM2.5 is positively associated with recurrence of cardiovascular events in patients after a first MI.

Neighborhood socioeconomic context and long-term survival after myocardial infarction.

BACKGROUND: Neighborhood of residence has been suggested to affect cardiovascular risk above and beyond personal socioeconomic status (SES). However, such data are currently lacking for patients with myocardial infarction (MI). We examined all-cause and cardiac mortality according to neighborhood SES in a cohort of MI patients. METHODS AND RESULTS: Consecutive patients < or =65 years of age discharged from 8 hospitals in central Israel after incident MI in 1992 to 1993 were followed up through 2005. Individual data were obtained at study entry, including education, income, and employment. Neighborhood SES was estimated through a composite census-derived index developed by the Israel Central Bureau of Statistics. During follow-up, 326 deaths occurred in 1179 patients. Patients residing in disadvantaged neighborhoods had higher mortality rates, with 13-year survival estimates of 61%, 74%, and 82% in increasing tertiles (P(trend)<0.001). After adjustment for sociodemographic variables, traditional risk factors, MI severity indexes, and individual SES measures, the hazard ratios for death associated with neighborhood SES were 1.47 (95% confidence interval, 1.05 to 2.06) in the lower and 1.19 (95% confidence interval, 0.86 to 1.63) in the middle tertiles compared with the upper tertile (P(trend)=0.02). The respective hazard ratios were even stronger for cardiac death (1.63; 95% confidence interval, 1.09 to 2.25; and 1.41; 95% confidence interval, 0.96 to 2.07). In the final models, neighborhood context and several individual SES measures were concurrently associated with all-cause and cardiac mortality. CONCLUSIONS: Neighborhood SES is strongly associated with long-term survival after MI. The association is partly, but not entirely, attributable to individual SES and clinical characteristics. These data support a multidimensional relationship between SES and MI outcome.

Poor neighborhood socioeconomic status and risk of ischemic stroke after myocardial infarction.

BACKGROUND: Data linking neighborhood socioeconomic status (SES) to stroke risk are scarce. We examined long-term stroke incidence according to neighborhood SES in a population-based cohort of patients hospitalized with first myocardial infarction (MI). METHODS: Consecutive patients aged 65 years or less, discharged from 8 hospitals in central Israel after incident MI in 1992-1993, were followed for stroke through 2005. Individual demographic, socioeconomic, and clinical data were obtained at study entry. We estimated neighborhood SES through a composite census-derived index developed by the Israel Central Bureau of Statistics. RESULTS: During a median follow-up of 13 years, 196 incident ischemic strokes occurred in 1410 patients. Accounting for death as a competing risk, patients residing in disadvantaged neighborhoods had higher rates of ischemic stroke (cumulative survival estimates: 81%, 88%, and 89% in increasing tertiles of neighborhood SES). Upon multivariable adjustment for individual SES measures (including income, education, and employment), cardiovascular risk factors, MI characteristics and severity indices, and acute management, the overall hazard ratio for stroke in the lower versus upper tertile of neighborhood SES was 1.5 (95% confidence interval [CI] = 1.0-2.3); after 13 years, the adjusted absolute risk difference was 7.9 incident stroke cases per 100 participants with MI (95% CI = 1.7-14.1). CONCLUSIONS: Poor neighborhood SES is associated with increased risk of ischemic stroke post-MI. The association is only partly attributable to individual SES and other baseline characteristics. The potential mechanisms for this association require further study.

Role of socioeconomic status measures in long-term mortality risk prediction after myocardial infarction.

BACKGROUND: The relationship of risk factors to outcomes has traditionally been assessed by measures of association such as odds ratio or hazard ratio and their statistical significance from an adjusted model. However, a strong, highly significant association does not guarantee a gain in stratification capacity. Using recently developed model performance indices, we evaluated the incremental discriminatory power of individual and neighborhood socioeconomic status (SES) measures after myocardial infarction (MI). METHODS: Consecutive patients aged ≤65 years (N=1178) discharged from 8 hospitals in central Israel after incident MI in 1992 to 1993 were followed-up through 2005. A basic model (demographic variables, traditional cardiovascular risk factors, and disease severity indicators) was compared with an extended model including SES measures (education, income, employment, living with a steady partner, and neighborhood SES) in terms of Harrell c statistic, integrated discrimination improvement (IDI), and net reclassification improvement (NRI). RESULTS: During the 13-year follow-up, 326 (28%) patients died. Cox proportional hazards models showed that all SES measures were significantly and independently associated with mortality. Furthermore, compared with the basic model, the extended model yielded substantial gains (all P<0.001) in c statistic (0.723 to 0.757), NRI (15.2%), IDI (5.9%), and relative IDI (32%). Improvement was observed both for sensitivity (classification of events) and specificity (classification of nonevents). CONCLUSIONS: This study illustrates the additional insights that can be gained from considering the IDI and NRI measures of model performance and suggests that, among community patients with incident MI, incorporating SES measures into a clinical-based model substantially improves long-term mortality risk prediction.

Long-term predictors of smoking cessation in a cohort of myocardial infarction survivors: a longitudinal study.

BACKGROUND: Smoking has been causally linked to cardiovascular disease, and smoking cessation after myocardial infarction (MI) has been associated with a 50% reduction in mortality. Post-MI smokers are a vulnerable population for which efforts to encourage cessation should be maximized. We examined the determinants of smoking cessation after MI. METHODS: A population-based cohort of 768 Israeli smokers was followed-up longitudinally after first MI. Data were collected at study entry on demographic, socioeconomic, smoking behaviour, and clinical variables. Psychosocial measures were obtained in a subsample (n = 330). Self-reported smoking status was assessed at 3-6 months, 1-2 years, 5 years, and 10-13 years after MI. Generalized estimating equation analyses determined which factors were significant predictors of smoking status. RESULTS: Point abstinence rates throughout follow-up ranged from 55% to 70%, while continuous abstinence rates were 59% after 1-2 years, 44% after 5 years, and 35% after 10-13 years, among survivors. Variables most strongly associated with persistent smoking were young age, long duration and high intensity of pre-MI smoking, low education, poor family income, lack of a steady partner, non-diabetic status, and short hospital stay at the index MI. Significant psychosocial predictors were low sense of coherence and high depression. CONCLUSIONS: Determinants of smoking cessation after MI are multifactorial and include demographic, socioeconomic, smoking behaviour, clinical and psychosocial measures. Post-MI hospitalization is a window of opportunity for smoking cessation interventions. Patients should be assessed for psychosocial characteristics and those with low sense of coherence and high depression should be provided with targeted help to quit.

Long-term trajectory of leisure time physical activity and survival after first myocardial infarction: a population-based cohort study.

The benefits of leisure time physical activity (LTPA) in cardiovascular prevention are well established. While cardiac rehabilitation programmes have been demonstrated as improving myocardial infarction (MI) prognosis, the strength of the association between LTPA and post-MI survival has yet to be quantified. We evaluated long-term survival after MI of inactive, irregularly active, and regularly active patients and examined trajectories of LTPA and their relationship to mortality risk. Consecutive patients aged ≤65 years (n = 1,521), discharged from 8 hospitals in central Israel after first MI in 1992-1993, were followed through 2005. Extensive clinical and sociodemographic data, including self-reported LTPA habits, were obtained at baseline and at 4 subsequent interviews. Pre-MI inactive patients (54%) had lower socioeconomic status, higher prevalence of risk factors and comorbidities and more severe MI. The point prevalence rate of regular LTPA at all follow-up interviews was approximately 40% and 18% were regularly active throughout the entire follow-up. Over a median follow-up of 13.2 years, 427 deaths occurred. After multivariable adjustment, no association was observed between pre-MI LTPA and death. However, with LTPA categories modelled as time-dependent variables, providing an estimation of cumulative assessment and accounting for changes in LTPA post-MI, a strong inverse graded association was revealed (multivariable-adjusted hazard ratios, 0.56 [95% CI: 0.42-0.74] for regular and 0.71 [95% CI: 0.54-0.95] for irregular activity vs. none). Similar estimates were obtained among pre-MI sedentary patients. In summary, after MI, regularly active patients had about half the risk of dying compared with inactive patients, irrespective of pre-MI habits.

Sense of coherence predicts post-myocardial infarction trajectory of leisure time physical activity: a prospective cohort study.

BACKGROUND: Physical activity confers a survival advantage after myocardial infarction (MI), yet the majority of post-MI patients are not regularly active. Since sense of coherence (SOC) has been associated with health outcomes and some health behaviours, we investigated whether it plays a role in post-MI physical activity. We examined the predictive role of SOC in the long-term trajectory of leisure time physical activity (LTPA) after MI using a prospective cohort design. METHODS: A cohort of 643 patients aged ≤ 65 years admitted to hospital in central Israel with incident MI between February 1992 and February 1993 were followed up for 13 years. Socioeconomic, clinical and psychological factors, including SOC, were assessed at baseline, and LTPA was self-reported on 5 separate occasions during follow-up. The predictive role of SOC in long-term trajectory of LTPA was assessed using generalized estimating equations. RESULTS: SOC was consistently associated with engagement in LTPA throughout follow-up. Patients in the lowest SOC tertile had almost twice the odds (odds ratio,1.99; 95% confidence interval,1.52-2.60) of decreasing their engagement in LTPA as those in the highest tertile. A strong association remained after controlling for disease severity, depression, sociodemographic and clinical factors. CONCLUSION: Our evidence suggests that SOC predicts LTPA trajectory post-MI. Assessment of SOC can help identify high-risk MI survivors, who may require additional help in following secondary prevention recommendations which can dramatically improve prognosis.

Cumulative exposure to air pollution and long term outcomes after first acute myocardial infarction: a population-based cohort study. Objectives and methodology.

BACKGROUND: Cardiovascular disease is a leading cause of morbidity and mortality worldwide and epidemiological studies have consistently shown an increased risk for cardiovascular events in relation to exposure to air pollution. The Israel Study of First Acute Myocardial Infarction was designed to longitudinally assess clinical outcomes, psychosocial adjustment and quality of life in patients hospitalized with myocardial infarction. The current study, by introducing retrospective air pollution data, will examine the association between exposure to air pollution and outcome in myocardial infarction survivors. This report will describe the methods implemented and measures employed. The study specifically aims to examine the relationship between residential exposure to air pollution and long-term risk of recurrent coronary event, heart failure, stroke, cardiac and all-cause death in a geographically defined cohort of patients with myocardial infarction. METHODS/DESIGN: All 1521 patients aged < or =65 years, admitted with first myocardial infarction between February 1992 and February 1993 to the 8 hospitals serving the population of central Israel, were followed for a median of 13 years. Data were collected on sociodemographic, clinical and environmental factors. Data from air quality monitoring stations will be incorporated retrospectively. Daily measures of air pollution will be summarised, allowing detailed maps to be developed in order to reflect chronic exposure for each participant. DISCUSSION: This study addresses some of the gaps in understanding of the prognostic importance of air pollution exposure after myocardial infarction, by allowing a sufficient follow-up period, using a well-defined community cohort, adequately controlling for multiple and multilevel confounding factors and providing extensive data on various outcomes.

Prognostic importance and long-term determinants of self-rated health after initial acute myocardial infarction.

BACKGROUND: Self-rated health (SRH) is a valid measure of health and its trajectories over time have been found to predict mortality. A better understanding of the determinants of changes in SRH is required, particularly post-myocardial infarction (MI), where rapid changes in health may occur. OBJECTIVES: To evaluate the prognostic importance of SRH and the determinants of its long-term trajectory in patients with MI. PATIENTS AND METHODS: Between February 1992 and February 1993, 1521 consecutive patients aged

[Clinical outcome and psychosocial adjustment 10-13 years after a first acute myocardial infarction: preliminary findings].

UNLABELLED: Preliminary findings of the previousLy described followup study of myocardial infarction (MI) are summarized herein. All-cause mortality was 28%. One or more cardiac events occurred in 83% of the patients: recurrent MI in 31%; unstable angina pectoris in 52%; heart failure in 23%. Coronary artery bypass surgery was performed in 35% and coronary angioplasty in 38% of the patients. Recurrence of angina/MI was observed in 55% of patients treated with bypass surgery and in 75% of those treated with angioplasty. Stroke occurred in 14% of the cohort. At the fifth interview, anginal symptoms were reported by one third of survivors and left ventricular dysfunction was found in almost half of the patients. Self-reported compliance with diet and exercise was 36% and 44%, respectively. Adequate control of blood cholesterol was 25%, of hypertension - 57%; and of diabetes - 51%. Smoking rate among smokers at the index MI was 42%. Participation in cardiac rehabiLitation at any time since the index infarction was less than 20%. Resumption of work and sexual activity among previously active participants was 83% and 87%, respectively. At the fifth interview, 44% of survivors were employed and 65% were sexually active. Health-related quality of life was inferior in female participants compared with male participants and a normative sample of women. Outcomes of all categories were predicted by sociodemographic, clinical, and psychosocial variables. CONCLUSIONS: In a long-term follow-up of post-MI patients, cardiac events occurred in most participants, risk factors were not adequately controlled and participation in cardiac rehabilitation was poor. Psychosocial and socioeconomic measures had an impact on all outcomes. RECOMMENDATIONS: (A) Further development of cardiac rehabilitation and secondary prevention services in Israel is essential; (B) psychosocial evaluation of cardiac patients should be incorporated into their routine assessment and the findings should be applied to preventive and rehabilitative care; (C) preventive services for low socioeconomic individuals should receive a high priority.

[Prospective cohort study of patients with a first acute myocardial infarction in Israel: study description].

BACKGROUND: Sociodemographic, medical and psychosocial factors affect coronary disease occurrence and clinical course as well as psychosocial adjustment to illness. However, Longitudinal studies of their differential and independent role are scarce. This article describes a Longitudinal prospective investigation of patients hospitalized in Israel in 1992-3 with a first acute myocardial infarction (AMI). OBJECTIVES: (A) To assess long-term clinical course, compliance with medical recommendations, risk-factor control and psychosocial adjustment in a cohort of patients undergoing a first AMI. (B) To evaluate the unique contribution of a wide range of sociodemographic, clinical, and psychosocial variables, assessed at hospital discharge, to various outcomes. METHODOLOGY: A cohort study of all 1,626 patients aged 65 years or younger (81% males) hospitalized with a first AMI in 8 medical centers in central Israel between 15th February, 1992 and 15th February, 1993. Participation rate in long-term follow-up was 98%. Participants were interviewed 5 times: before discharge and again, 3-6 months, 1-2 years, 5 years, and 10-13 years post-AMI. Compilation of data was carried out through a structured interview, standardized psychosocial questionnaires, and review of the entire medical records.

Sense of coherence and 22-year all-cause mortality in adult men.

BACKGROUND: Sense of coherence (SOC) is a central construct in Antonovsky's salutogenic theory, which focuses on people's health-promoting and health-protecting characteristics. We examined prospectively the association of SOC with all-cause mortality during 22 years (1989-2011). METHODS: The data of 585 men from the Israel longitudinal study of Glucose Intolerance, Obesity, and Hypertension (The Israel GOH) comprised the analytic sample. Participants were 48-67 years old at study entry (1989). Information on sociodemographic, medical history and health-related risk factors were obtained at baseline through a face-to-face interview. Participants completed Antonovsky's 29-item SOC scale. Information on all-cause mortality was obtained from the Israeli Mortality Register (1989 through 2011). We evaluated the effect of SOC on time-to-death using multiple Cox proportional hazard regression. RESULTS: Controlling for sociodemographic, smoking status and morbidities, there was strong evidence of an association between SOC and 22-year all-cause mortality [adjusted hazard ratio (aHR)=0.992, 95% CI 0.986-0.998 per unit]. Strong SOC was associated with a 35% reduction in all-cause mortality relative to weak SOC (aHR=0.653, 95% CI 0.454-0.939). There was no convincing evidence of a survival advantage for individuals with intermediate level of SOC relative to persons reporting weak SOC (aHR=0.821, 95% CI 0.595-1.134). CONCLUSIONS: Our study provides strong evidence of an association between SOC and mortality, above and beyond potential confounding factors and established risk factors. Considerable more research is needed on the role of SOC in health and survival and the potential pathways linking SOC and health.

An epidemiological study of depressive symptomatology among Israeli adults: prevalence of depressive symptoms and demographic risk factors.

BACKGROUND: Depression is a common, under-recognized disorder that causes a great burden on the individual, the family and the community. Depressive symptomatology has serious effects on the psychological and medical condition of patients, and also disrupts their well-being and daily activities. The aim of the present study was to investigate the prevalence of depressive symptomatology in the Israeli population, and its relation to demographic variables and perceived health. METHODS: A random sample of 937 Israeli adults filled out the Beck Depression Inventory (BDI) together with a demographic questionnaire. RESULTS: 21.5% scored positively for depressive symptomatology (BDI > 9). 3.8% reached a BDI score in the range of severe depression. Female gender, old age, lower education, immigrant status, manual work and lower income were associated with increased rates of depressive symptomatology. Poor perceived health was also associated with depressive symptomatology. CONCLUSIONS: The rates of depressive symptomatology in this study are similar to those found in other studies, performed mostly in Western countries. Despite several methodological limitations, we conclude that the rate and the demographic risk factors of depression in Israel are similar to that of other developed and Western countries.

[Physical activity for the elderly].

UNLABELLED: Prolongation of life expectancy requires inevitable care for the quality of life of the elderly. Regular physical activity has a very important role in preserving the quality of life and independence, and not only reducing illness and mortality. A better understanding of this issue should enable us to set guidelines for regular physical activity for the elderly. The reaction to regular physical activity of older adults without cardiovascular diseases is similar to the reaction of young people to regular physical activity. In men, the mechanism of cardiovascular adaptation is mainly central, while in old women it is mainly peripheral. Elderly with cardiovascular diseases suffer from oxygen consumption and cardiac output reduction, compared to healthy old people. They also enjoy the cardiovascular benefits of aerobic physical activity and gain the risk factors profile improvement. Therefore, it is recommended to include aerobic physical activity as an integrative part of the daily lifestyle. Resistance strength training in elderly of both sexes leads to similar or even higher values for muscle mass and strength compared to young people, reduces the body fat mass, body weight and helps to preserve the active tissue mass. More beneficial effects of physical activity are: an improvement of posture and physical stability, improved flexibility and mobility capacity, a better cognitive function and a lower level of depression. The beneficial effects of physical activity in the very aged and frail elderly include physiological, metabolic, psychological and functional adaptations, which can substantially contribute to the quality of life and cannot be achieved by other treatments. SUMMARY: Participation in a regular physical activity program is an effective and secure means to avoid and reduce the functional decline associated with aging and to improve the quality of life. The recommended exercise program is multifactorial and includes aerobic and resistance training, and exercises of balance and flexibility.

Clinical relevance of frailty trajectory post myocardial infarction.

BACKGROUND: Frailty describes the heterogeneity of vulnerability in older people and has been shown to predict mortality, disability, and institutionalization. Little is known about the clinical relevance of frailty post myocardial infarction (MI). DESIGN: The Rockwood frailty index, based on accumulation of deficits, was adapted in a cohort of MI survivors followed up for 20 years, in order to assess trajectory and predictive value for clinical outcomes. METHODS: Participants were 1521 patients aged ≤65 years admitted to one of eight Israeli hospitals with first acute MI between 1992 and 1993. A frailty index (on a 0-1 continuous scale) was developed comprising 32 variables, including self-rated health, functional limitations, comorbidity, weight loss, and physical activity. Frailty was assessed at baseline and 10-13 years after MI. RESULTS: Median frailty score increased from 0.08 to 0.19 during follow up. Participants in the frailest group (≥0.25) at baseline had twice the multivariable-adjusted mortality risk of those in the least frail group (<0.10) (hazard ratio, HR, 2.02, 95% CI 1.46-2.79). Frailty index modelled as a time-dependent variable showed a substantially stronger association (HR 3.61, 95% CI 2.82-4.63) and provided incremental value in risk discrimination beyond clinical and socio-demographic variables (p < 0.001 for improvement in c-statistic). The frailest patients were more than twice as likely to be hospitalized during follow up compared to the least frail (adjusted rate ratio 2.14, 95% CI 1.63-2.81). CONCLUSIONS: Frailty, calculated via an index of deficits, was associated with mortality and hospitalizations following MI. Beyond predictive value, accurate identification of frailty may indicate which individuals will benefit most from preventive interventions.

Multilevel socioeconomic status and incidence of frailty post myocardial infarction.

BACKGROUND: Frailty predicts mortality and hospitalizations in post-myocardial infarction (MI) patients. Socioeconomic status (SES) demonstrates a clear relationship with post-MI outcomes and is also associated with community frailty; however this relationship has yet to be evaluated in post-MI patients. We investigated the predictive value of socioeconomic factors in the development of post-MI frailty. METHODS: A cohort of 1151 post-MI patients was followed up from initial hospitalization in 1992-1993 for 10-13 years. Individual and neighborhood SES measures were assessed at baseline and frailty was assessed during follow-up via an index of deficit accumulation. Logistic regression models and discrimination indices enabled determination of the predictive value of socioeconomic factors over basic clinical variables in classifying frailty risk. RESULTS: During follow-up, 399 patients (35%) developed frailty. Individual and neighborhood SES were significantly and independently associated with the risk of developing frailty. Low income patients had more than twice the risk of becoming frail compared with those with high income [odds ratio (OR), 2.29, 95% CI 1.41-3.73]; while being in the lower vs. upper neighborhood SES tertile was associated with a 60% increased odds (OR, 1.60, 95% CI 1.03-2.49). Inclusion of multilevel SES yielded substantial gains in c-statistic (0.70 to 0.76), net reclassification improvement (21.4%) and integrated discrimination improvement (6.4%) over basic clinical factors (all p<0.001), indicating increased predictive value and gains in sensitivity and specificity. CONCLUSIONS: Individual and neighborhood socioeconomic factors influence the development of frailty post-MI, and contribute to risk discrimination in this population.

Recovery of self-rated health as a predictor of recurrent ischemic events after first myocardial infarction: a 13-year follow-up.

OBJECTIVE: Following the trajectory hypothesis for the validity of self-rated health (SRH), we tested whether subjective recovery of health, that is, return to the same or higher level of SRH after a major health event, independently predicts better long-term prognosis. METHODS: Participants were 640 patients (≤ 65 years) admitted to the eight medical centers in central Israel with incident MI in a 1-year period (mean age 54, 17% female). Baseline data were collected within days of the index MI. SRH in the preceding year was assessed at baseline, and current SRH was assessed 3-6 months later. Recurrent ischemic events (recurrent MI, hospitalization with unstable angina pectoris, or cardiac death) were recorded during a mean follow-up of 13 years. RESULTS: A reduced risk of recurrent events was associated with an upward change of one level (e.g., from 3 at T1 to 4 at T2) in SRH (HR = 0.76, 95%CI: 0.69-0.85), controlling for baseline retrospective SRH. Risk was still significantly lower for each unit of improvement after adjusting for sociodemographics, preevent comorbidity, cardiac risk factors, MI severity, and early post-MI events (HR = 0.85, 95% CI 0.75-0.95). CONCLUSIONS: Individuals who perceived themselves 3-6 months after a first MI to be healthier than they had been in the year preceding the MI were more likely to survive event-free throughout the next 13 years, controlling for baseline retrospective SRH and multiple cardiac risk factors. Failure to experience such subjective recovery of one's health is a serious risk factor, which indicates that SRH should be monitored regularly after a MI.