CLINICAL PROFILE AND MANAGEMENT OF PATIENTS WITH INCIDENT AND RECURRENT ACUTE MYOCARDIAL INFARCTION IN ALBANIA – A CALL FOR MORE FOCUS ON PREVENTION STRATEGIES Sokol MYFTIU1, Enxhela SULO2, Genc BURAZERI3, Bledar DAKA4, Ilir SHARKA1, Artan SHKOZA5, Gerhard SULO2* 1Department of Cardiology, University Hospital “Mother Teresa”, Tirana, Albania 2University of Bergen, Faculty of Medicine and Dentistry, Department of Global Public Health and Primary Care, Kalfarveien 31, Bergen 5018, Norway 3Maastricht University, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Department of International Health, The Netherlands 4University of Gothenburg, Department of Public Health and Community Medicine, Gothenburg, Sweden 5University of Medicine, Faculty of Medicine, Tirana, Albania Received: Nov 29, 2016 Accepted: Aug 7, 2017 Original scientific article Background. The clinical profile of acute myocardial infarction (AMI) patients reflects the burden of risk factors in the general population. Differences between incident (first) and recurrent (repeated) events and their impact on treatment are poorly described. We studied potential differences in the clinical profile and in-hospital treatment between patients hospitalised with an incident and recurrent AMI. Methods. A total of 324 patients admitted in the Coronary Care Unit of ‘Mother Teresa’ hospital, Tirana, Albania (2013-2014), were included in the study. Information on AMI type, complications and risk factors was obtained from patient’s medical file. Logistic regression analyses were used to explore differences between the incident and recurrent AMIs regarding clinical profile and in-hospital treatment. Results. Of all patients, 50 (15.4%) had a prior AMI. Compared to incident cases, recurrent cases were older (P=0.01), more often women (P=0.01), less educated (P=0.01), and smoked less (P=0.03). Recurrent cases experienced more often heart failure (HF) (OR=2.48; 95% CI: 1.31–4.70), impaired left ventricular ejection fraction (OR=1.97; 95% CI: 1.05–3.71), and multivessel disease (OR=6.32; 95% CI: 1.43–28.03) than incident cases. In-hospital use of beta-blockers was less frequent among recurrent compared to incident cases (OR=0.45; 95% CI: 0.24–0.85), while no statistically significant differences between groups were observed regarding angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, statin, aspirin or invasive procedures. Conclusion. A more severe clinical expression of the disease and underutilisation of treatment among recurrent AMIs are likely to explain their poorer prognosis compared to incident AMIs. Ozadje. Klinični profil pacientov z akutnim miokardnim infarktom (AMI) odraža breme dejavnikov tveganja v splošni populaciji. Razlike med prvim in ponovnimi pojavi in njihovim vplivom na zdravljenje so slabo opisani. Raziskali smo morebitne razlike v kliničnem profilu in bolnišničnim zdravljenjem pri pacientih s prvim pojavom AMI in tistih s ponovnim pojavom. Metode. V raziskavo je bilo skupno vključenih 324 pacientov, ki so bili v letih 2013-2014 sprejeti na Enoto za koronarno nego bolnišnice Matere Terezije v Tirani v Albaniji. Iz kartotek pacientov so pridobili podatke o vrsti AMI, zapletih in dejavnikih tveganja. Za ugotavljanje razlik med prvimi in ponovnimi AMI so bile uporabljene analize logistične regresije z upoštevanjem kliničnega profila in bolnišničnega zdravljenja. Rezultati. Med vsemi pacienti jih je 50 (15,4%) že enkrat doživelo AMI. V primerjavi s pacienti s prvim pojavom so bili tisti s ponovnimi pojavi starejši (P=0,01), pogosteje so bile to ženske (P=0,01), imeli so nižjo izobrazbo (P=0,01) in so manj kadili (P=0,03). Pacienti s ponovnimi pojavi so v primerjavi s pacienti s prvim pojavom pogosteje izkusili odpoved srca (OR=2,48; 95% CI: 1,31–4,70), oslabljeno izmetno frakcijo levega prekata (OR=1,97; 95% CI: 1,05–3,71) in multivaskularno bolezen (OR=6,32; 95% CI: 1,43–28,03). Uporaba beta-blokatorjev v bolnišnični obravnavi je bila manj pogosta pri pacientih s ponovnim pojavom v primerjavi s pacienti s prvim pojavom AMI (OR=0,45; 95% CI: 0,24–0,85), medtem ko ni bilo opaziti statistično pomembnih razlik v zvezi z uporabo zaviralcev angiotenzinske konvertaze/blokatorjev receptorjev angiotenzina, statinov, aspirina ali invazivnih postopkov. Zaključek. Resnejša klinična slika bolezni in manjša poraba zdravil med pacienti s ponovnim pojavom AMI tako lahko razložita njihovo slabšo prognozo v primerjavi s pacienti s prvim pojavom AMI. ABSTRACT Keywords: acute myocardial infarction, epidemiology, in-hospital treatment, prevention, Albania IZVLEČEK Ključne besede: akutni miokardni infarkt, epidemiologija, bolnišnično zdravljenje, preventiva, Albanija *Corresponding author: Tel: + 479 3 897 901; E-mail: gerhard.sulo@uib.no 10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243 KLINIČNI PROFIL IN ZDRAVLJENJE PACIENTOV S PRVIM IN PONOVNIM POJAVOM AKUTNEGA MIOKARDNEGA INFARKTA V ALBANIJI – POZIV ZA VEČJO POZORNOST NA PODROČJU PREVENTIVNIH STRATEGIJ Myftiu S, Sulo E, Burazeri G, Daka B, Sharka I, Shkoza A, Sulo G. Clinical profile and management of patients with incident and recurrent acute myocardial infarction in Albania – a call for more focus on prevention strategies. Zdr Varst 2017; 56(4): 236-243. 236 © Nacionalni inštitut za javno zdravje, Slovenija. 1 BACKGROUND Acute myocardial infarction (AMI) is the most serious clinical expression of coronary heart disease (CHD). The substantial reduction in mortality following an incident (first) AMI (1-4), combined with aging of the population has led to a growing number of AMI survivors who are at risk of experiencing a recurrent (repeated) event. Although recurrent events account for the minority of all AMI-related hospitalisations (5, 6), their prognosis is poor (7-9), contributing thus substantially to the overall cardiovascular mortality. Incident events reflect the burden of coronary risk factors in the population at large (10), whereas recurrences are further influenced by the quality of coronary care during the acute phase of the incident event and secondary prevention (11). In Albania, CHD death rates are among the highest in the Southeast Europe (12). The burden of CHD (both mortality and hospitalisations) has increased in the last decades (13), rendering it the main cause of premature mortality in Albania (14). Simultaneously, the prevalence of classical coronary risk factors in the population is high. A health survey conducted in 2001 in Tirana, reported that among 1120 participants aged 25 years or older, the prevalence of obesity, diabetes mellitus (DM), hypertension and smoking (current) was 29% (15), (9.7%) (16), 31.8% (17) and 28% (18), respectively. Later reports confirmed the high burden of these risk factors; the prevalence of hypertension and obesity (in 2008) and smoking (in 2011) were 36.5%, 21.6% and 26% (19), respectively. Despite these unfavourable developments, the difficult transition from a totalitarian communist regime toward a free, marked-oriented economy in Albania was characterised by the lack of sufficient resources allocated to health care (20). As a consequence, preventive strategies have not been considered a priority. No structured national or regional primary prevention strategies have been applied at the population at large, despite their proven role in reducing CHD burden (21). Further, no structured rehabilitation programmes are available to coronary patients, and secondary prevention is confined to medical advice provided by specialists upon hospital discharge and, occasionally, during check-ups at the family doctor’s office. The consequences of such lack of preventive strategies on the clinical profile of AMI patients and their management are not studied in Albania, and are poorly described elsewhere. Thus, the objective of the current study was to explore the clinical profile and in-hospital treatment of patients hospitalized with an AMI, with a special focus on the differences between patients with and without history of prior AMI. 2. SUBJECTS AND METHODS 2.1 Study Population This study included 324 consecutive patients hospitalized during 2013-2014, with an AMI in the Coronary Care Unit (CCU) of the University Hospital Centre ‘Mother Teresa’,’ the only public hospital providing specialized coronary care in Tirana, the capital of Albania. 2.2 Data Collection Information on patients’ age, gender, educational attainment, height and weight, systolic and diastolic blood pressure, AMI type [ST-elevation myocardial infarction (STEMI) versus non-ST-elevation myocardial infarction (NSTEMI)], location, major complications [including heart failure (HF), ventricular fibrillation (VF) and 2nd or 3rd degree atrioventricular block (AVB)], and in-hospital treatment was obtained from patients’ medical charts. To derive the prevalence of each major risk factor, we combined self-reported information on risk factors and medication use prior to hospitalisation with blood pressure, fasting glucose, and total cholesterol values measured during admission (22). A history of prior AMI was defined as a previous hospitalisation with AMI as the main discharge diagnosis. 2.3 Statistical Analyses Continuous variables were presented as means and standard deviations (SD), and categorical variables were presented as percentages. Independent sample t-test was used to compare mean values of the continuous variables. Categorical variables were compared using the chi-square test or Fisher’s exact test in cases of small sample sizes. Logistic regression models were used to explore differences between incident and recurrent cases regarding AMI complications and in-hospital treatment. They were adjusted for covariates known to influence the outcome, and showed association with the exposure in our data. To account for the role of comorbidities in a potentially influencing use of beta-blockers [chronic obstructive pulmonary disease (COPD), systolic blood pressure (SBP)<85 mm Hg or AVB], angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) (SBP<85 mm Hg) and aspirin (peptic ulcer), we repeated the analyses after excluding patients with any of these conditions. The results of these analyses (referred to in the text as ‘additional analyses’) are presented as supplemental material online. We tested and did not find a statistically significant interaction between gender and history of prior AMI. All models were adjusted for age and gender, and results expressed as odds ratios (OR) and 95% confidence intervals (CI) for prevalent versus incident (the reference 10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243 237 10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243 238 category) AMIs. Two-sided tests with the 0.05 significance level were used. Analyses were performed using STATA software, version 13. 3. RESULTS 3.1 Characteristics of the Study Population Characteristics of the study population are summarized in Table 1. The mean (SD) age of the cohort was 64.4 (11.4) years and the majority (73.8%) were men. Overall, 44.1% of patients had attained only primary education and 55.9% secondary or tertiary education. The prevalence of current smoking, hypertension, diabetes mellitus (DM), and hypercholesterolemia was 59.9%, 83.3%, 50.6% and 55.3%, respectively. At least one major risk factor was observed in 98.8%, and all four major risk factors in 13.9% of the study cohort. Table 1. Characteristics of the study population. COPD: chronic obstructive pulmonary disease; eGFR: estimated glomerular filtration rate. * 4% of patients had missing values Incident cases were younger (P=0.01), more often men (P=0.01), and had attained a higher education (P=0.01) than recurrent cases. No statistically significant differences between groups were observed regarding hypertension, DM, and hypercholesterolemia. Smoking was more frequent among the incident cases (P=0.03). Age (years), mean (SD) Gender (male), n (%) Education, n (%) Primary Secondary or higher Coronary risk factors, n (%) Smoking Hypertension Diabetes Hypercholesterolemia At least one risk factor All four risk factors Comorbidities, n (%) Atrial fibrillation Peripheral artery disease Cerebrovascular disease COPD eGFR<60 mL/min/1.73m2 Peptic ulcer Pulse (beats/min), mean (SD) Hemoglobin* (g/dl), mean (SD) 64.4 (11.4) 239 (73.8) 143 (44.1) 181 (55.9) 194 (59.9) 270 (83.3) 164 (50.6) 179 (55.3) 320 (98.8) 45 (13.9) 39 (12.1) 23 (7.1) 25 (7.4) 17 (5.3) 77 (23.8) 23 (7.1) 78 (16.8) 12.8 (1.9) 63.7 (11.5) 210 (76.6) 113 (41.2) 161 (58.8) 171 (62.4) 229 (83.6) 135 (49.3) 149 (54.4) 270 (98.5) 39 (14.2) 26 (9.4) 20 (7.2) 19 (6.9) 14 (5.1) 59 (21.5) 19 (6.9) 77 (16.5) 12.9 (1.8) 68.4 (10.1) 29 (58.0) 30 (60.0) 20 (40.0) 23 (46.0) 41 (82.0) 29 (58.0) 30 (60.0) 50 (100.0) 6 (12.0) 13 (27.7) 3 (6.4) 6 (12.8) 3 (6.4) 18 (36.0) 4 (8.0) 80 (18.5) 11.9 (1.9) 0.01 0.01 0.01 0.03 0.78 0.26 0.46 0.39 0.63 <0.01 0.84 0.16 0.71 0.03 0.79 0.37 <0.01 Patient characteristics All patients (n=324) Incident cases (n=274) Recurrent cases (n=50) P value 3.2 The Clinical Profile of Patients STEMI accounted for 83.9% of the study population (Table 2). AMI was complicated with HF in 33.6% of the patients. The proportion of impaired LVEF, 2nd or 3rd degree AVB or VF in the study population were 31.2%, 4.0% and 4.9%, respectively. Compared to incident cases, recurrent cases had multivessel CHD (P=0.03), HF (P<0.01), or impaired LVEF (P=0.01) (Table 2). Table 2. Figure 1. Clinical profile and in-hospital treatment of patients with an acute myocardial infarction. Differences in the clinical profile between patients hospitalized with an incident and recurrent acute myocardial infarction. STEMI: ST-segment elevation myocardial infarction; CAD: coronary artery disease; LVEF: left ventricular ejection fraction; AVB: atrioventricular block; VF: ventricular fibrillation; ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker. * Percutaneous coronary intervention or coronary artery bypass grafting among patients undergoing coronary angiography. STEMI, n (%) Multivessel CAD, n (%) Heart failure, n (%) LVEF<0.45, n (%) AVB (2nd/3rd degree), n (%) VF, n (%) Beta-blockers ACEI/ARBs Statins Aspirin All four drug classes Invasive procedures Coronary angiography Revascularization* 271 (83.9) 164 (75.9) 109 (33.6) 101 (31.2) 13 (4.0) 16 (4.9) 192 (59.3) 206 (63.6) 314 (96.9) 308 (95.1) 144 (44.4) 222 (68.5) 139 (64.4) 230 (84.3) 136 (73.1) 81 (29.6) 77 (28.1) 10 (3.7) 11 (4.0) 172 (62.8) 179 (65.3) 268 (97.8) 261 (95.3) 128 (46.7) 192 (70.1) 122 (65.6) 41 (82.0) 28 (93.3) 28 (56.0) 24 (48.0) 3 (6.0) 5 (10.0) 20 (40.0) 27 (54.0) 46 (92.0) 47 (94.0) 16 (32.0) 30 (60.0) 17 (56.7) 0.69 0.03 <0.01 0.01 0.44 0.07 0.01 0.12 0.05 0.71 0.05 0.16 0.34 All patients (n=324) Clinical profile In-hospital treatment Incident cases (n=274) Recurrent cases (n=50) P value 10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243 239 The results of age and gender-adjusted analyses revealed an increase in the odds of HF (OR=2.48; 95% CI: 1.31–4.70), impaired LVEF (OR=1.97; 95% CI: 1.05–3.71), or multivessel CAD (OR=6.32; 95% CI: 1.43–28.03) among recurrent cases compared to incident ones. No statistically significant differences were observed between groups regarding AMI type and other complications (Figure 1). 3.3 In-Hospital Treatment The utilisation rates for beta-blockers, angiotensin- converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), statins, and aspirin were 59.3%, 63.6%, 96.9%, and 95.1%, respectively (Table 2). Less than half (44.4%) of the study population received all four drug classes. Only 68.5% of the patients underwent coronary angiography. Of those, 64.4% received coronary revascularisation. The proportion of patients receiving a beta-blocker or statin was lower among recurrent compared to incident cases (P=0.01 and P=0.03, respectively). No statistically significant differences in the utilisation of other drug classes or invasive diagnostic and treatment procedures were observed between the two groups. Adjusted analyses revealed lower utilisation rates of beta- blockers among recurrent cases as compared to incident cases (OR=0.45; 95% CI: 0.24–0.85) (Figure 2). 10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243 240 Figure 2. Differences in the in-hospital treatment between patients hospitalized with incident and recurrent acute myocardial infarction. No statistically significant differences between groups were observed regarding ACEIs/ARBs, statins or aspirin use [(OR=0.67; 95% CI: 0.36–1.26), (OR=0.34; 95% CI: 0.12– 1.31) and (OR=1.15; 95% CI: 0.30–1.31), respectively]. A similar pattern was observed in the use of invasive diagnostic and treatment procedures. No statistically significant differences between the two groups were found with regard to coronary angiography (OR=0.88; 95% CI: 0.45–1.71) or revascularisation (OR=0.67; 95% CI: 0.30–1.49). The results of additional analyses were similar to those of the main analyses in terms of direction of the association and level of significance (Table 1, supplementary material online). 4. DISCUSSION 4.1 Main Findings The burden of coronary risk factors in our study was very high among both incident and recurrent cases. The prevalence of HF, impaired LVEF, and multivessel CAD (all reliable indications of AMI’s clinical severity) were higher among recurrent compared to incident cases. The use of evidence-based drugs in our study varied widely and, compared to incident cases, recurrent cases seemed to use less often evidence-based treatment, including revascularisation. However, the differences were statistically significant only with regard to the use of beta-blockers. 4.2 A Comparison with Other Studies Data from a case-control study conducted in Tirana between 2003 and 2006, and enrolling 467 acute coronary syndrome (ACS) patients (i.e., a combination of AMI and unstable angina pectoris – UAP), revealed that the prevalence of obesity (BMI≥30), hypertension, DM, and current smoking were 20.6%, 29.6%, 15.8%, and 42.2%, respectively (23). Among 809 incident ACS cases admitted to CCU in Tirana in 2009, the prevalence of current smoking, hypertension, family history of CHD, and overweight/obesity were 63%, 58%, 33%, and 30%, respectively. All patients had at least two coronary risk factors (24). Several factors may have contributed to the higher burden of coronary risk factors in our study, compared to other studies conducted in Albania (23, 24). We included in the analyses, only AMI patients, while others combined AMI and UAP patients. Further, the study by Balla et al. (24) included only incident cases, while our study population was a mixture of incident and prevalent cases. Our study population comprised severely ill patients requiring hospitalisation in CCU, whereas in the study by Burazeri et al. (23), patients were recruited from CCU and hospital wards. Despite these differences in the populations studied, a worrying increase in the burden of risk factors over time cannot be rule out, and needs further investigation. Internationally, the prevalence of smoking, hypertension, DM, and hyperlipidaemia among 122 458 CHD patients enrolled in 14 randomised control trials was 37.9%, 43.2%, 17.5%, and 34.8%, respectively. Eighty-two percent of patients had at least one, whereas 1.0% of the cohort had all four major coronary risk factors (25). Data from the National Cardiovascular Registry (NCDR) showed that 71.4% of AMI patients reported to suffer from hypertension, and 30.5% from DM (26). We could not identify previous publication from Albania comparing incident and recurrent cases regarding their clinical profile or in-hospital treatment. International studies have suggested that recurrent cases presented 10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243 241 more often with pulmonary oedema, cardiogenic shock and asystole (27), and have a higher incidence of HF (28), compared to incident cases. The results of the analyses comparing in-hospital treatment between incident and recurrent cases have been less consistent. In the Netherlands, utilisation rates of aspirin, beta-blockers, and statins among 4718 STEMI patients were higher in incident, compared to recurrent cases (9). In the USA, similar rates were reported in incident and recurrent cases (28). With regard to revascularisation procedures, higher rates were observed in incident, compared to recurrent cases in the USA (28) and Israel (27). The direction of the association in our study suggests a more severe clinical expression of the disease with concurrent lower utilisation rates of medications in recurrent compared to incident cases. However, due to the lack of statistical significance (possibly affected by the relatively small sample size), these findings should be interpreted with caution. A direct comparison of our findings with previously published analyses on the use of invasive procedures is challenging, as the use of these procedures is largely influenced by patients’ age, gender, comorbidities, prior AMI status, and the study period – all factors that differ widely between the published studies. 4.3 Potential Mechanisms and Implications The high burden of coronary risk factors reflects the lack of prevention measures in the population at large in Albania. Interventions aiming at reducing the burden of coronary risk factors have proven to be cost-effective (29), and can reduce CHD mortality up to 75% (30-33). Nevertheless, the majority of resources in the past 2-3 decades were allocated into tertiary care institutions, aiming at modernising the system and improving the quality of care. The observed unfavourable trends in CHD mortality in Albania, combined with our findings, point out to the immediate need for a shift in the focus of attention toward preventive measures. In 2014, health authorities launched a nationwide health campaign, inviting citizens aged 40-65 years (expanded lately to include those aged 35-70 years) to undergo a medical examination aiming at screening for CVD (with a special focus on CHD), cancer, and other relevant conditions. This was the first step in the long process of identifying the burden of coronary risk factors in the population. This campaign can lay the ground for policy and legislative changes to tackle many aspects related to diet and lifestyle, aiming at reducing the burden of risk factors and, subsequently, CHD in Albania. Another worrying finding is the prevalence of risk factors among recurrent cases, which – with an exception of smoking – is similar to (if not higher than) that of incident cases. This reflects the failure of patients with overt CHD to change their risk profile and conduct a healthy lifestyle. Many factors may have contributed to this failure, including i) the lack of personalised recommendations upon discharge from the hospital, ii) lack of rehabilitation programs, iii) poor adherence to treatment, iv) no coordination between different actors involved in the health care system (i.e., the family doctor and specialist) during the follow up. Further studies are needed to tackle each potential component individually and provide a new insight into this phenomenon. Further, national guidelines specifying treatment goals, frequency of follow up visits and role of specialist (versus the family doctor) during the follow up are needed to optimise medical care and reduce the rate of new coronary events in this vulnerable subset of population. Recurrent cases present with a more severe form of the disease, yet, the medication use among them tend to be suboptimal compared to that in incident cases. The reasons for these differences are not clearly explained. One hypothesis is that certain comorbidities and/or AMI complications represent contraindications to individual cardiac drugs. We addressed this issue by conducting additional analyses where we excluded patients with such comorbidities and/or AMI complications. This was associated with a slight increase in the use of beta- blockers (+ 2.4%), ACEI/ARBs (+2.4%), statins (+0.9%), and all four drug classes (+3.8%). However, the differences in the use of cardiac drugs between recurrent and incident cases did not change substantially, indicating that factors other than comorbidities might be involved. Another reason might be related to the fact that medical staff is reluctant to perform revascularisation procedures among severely ill patients due to a poorer outcome compared to that in uncomplicated AMI cases (34). 4.4 Study Limitations Our study has several limitations. The relatively small sample size and low number of patients with a recurrent event, is most probably responsible for the statistically non-significant findings, even though the point estimates indicate that recurrent AMIs present at the hospital with a more severe clinical expression, and underutilise the recommended drug classes compared to incident AMIs. Our sample size did not allow us to explore the role of medications taken prior to hospitalisation on the burden of risk factors, either. Furthermore, we could not determine the proportion of patients with controlled level of risk factors. In addition, we did not know the proportion of patients who might have been scheduled to receive revascularisation upon AMI discharge, as follow- up information was not available. We therefore restricted our focus on treatment during MI hospitalization. The 10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243 242 distinction between ‘never’ and ‘former’ smokers was not available in our study. Consequently, we could not discriminate between patients who smoked and gave up smoking, and those who never smoked. This distinction would have been of particular interest among recurrent cases. We also lacked information on the time from symptom onset to arrival at the hospital; an important factor influencing the decision to perform coronary angiography and revascularisation. 5 CONCLUSIONS Recurrent cases seemed to be admitted with a more severe clinical form of AMI and received optimal treatment less often, compared to incident cases. A more aggressive treatment approach combined with the implementation of preventive strategies would help improving the prognosis of patients suffering a recurrent AMI. CONFLICTS OF INTEREST The authors declare that no conflicts of interest exist. FUNDING None ETHICAL APPROVAL The study was approved by the National Committee for Bio-Medical Ethics in Albania. REFERENCES 1. Sulo E, Vollset SE, Nygard O, Sulo G, Igland J, Egeland GM et al. Trends in 28-day and 1-year mortality rates in patients hospitalized for a first acute myocardial infarction in Norway during 2001-2009: a “Cardiovascular disease in Norway” (CVDNOR) project. J Intern Med 2015; 277: 353-61. 2. Koopman C, Bots ML, van Oeffelen AA, van Dis I, Verschuren WM, Engelfriet PM et al. Population trends and inequalities in incidence and short-term outcome of acute myocardial infarction between 1998 and 2007. Int J Cardiol 2013; 168: 993-8. 3. Schmidt M, Jacobsen JB, Lash TL, Botker HE, Sorensen HT. 25 year trends in first time hospitalisation for acute myocardial infarction, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity: a Danish nationwide cohort study. BMJ 2012; 344: e356. 4. Dudas K, Lappas G, Rosengren A. Long-term prognosis after hospital admission for acute myocardial infarction from 1987 to 2006. Int J Cardiol 2012; 155: 400-5. 5. Messner T, Lundberg V, Bostrom S, Huhtasaari F, Wikstrom B. Trends in event rates of first and recurrent, fatal and non-fatal acute myocardial infarction, and 28-day case fatality in the Northern Sweden MONICA area 1985-98. Scand J Public Health Suppl 2003; 61: 51-9. 6. Sulo G, Vollset SE, Nygard O, Igland J, Egeland GM, Ebbing M et al. Trends in acute myocardial infarction event rates and risk of recurrences after an incident event in Norway 1994 to 2009 (from a Cardiovascular Disease in Norway Project). Am J Cardiol 2014; 113: 1777-81. 7. Shotan A, Gottlieb S, Goldbourt U, Boyko V, Reicher-Reiss H, Arad M et al. Prognosis of patients with a recurrent acute myocardial infarction before and in the reperfusion era--a national study. Am Heart J 2001; 141: 478-84. 8. Orn S, Cleland JG, Romo M, Kjekshus J, Dickstein K. Recurrent infarction causes the most deaths following myocardial infarction with left ventricular dysfunction. Am J Med 2005; 118: 752-8. 9. Rasoul S, Ottervanger JP, de Boer MJ, Dambrink JH, Hoorntje JC, Gosselink AT et al. Poor outcome after recurrent acute myocardial infarction: a plea for optimal secondary prevention. Int J Cardiol 2011; 147: 298-300. 10. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364: 937-52. 11. Kangovi S, Grande D. Hospital readmissions-not just a measure of quality. JAMA 2011; 306: 1796-7. 12. Evaluation IfHMa. Global burden of disease database. Available Nov 29th 2016 from: http://www.healthdata.org. 13. Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe 2014: epidemiological update. Eur Heart J 2014; 35: 2950-9. 14. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1459-544. 15. Shapo L, Pomerleau J, McKee M, Coker R, Ylli A. Body weight patterns in a country in transition: a population-based survey in Tirana City, Albania. Public Health Nutr 2003; 6: 471-7. 16. Shapo L, McKee M, Coker R, Ylli A. Type 2 diabetes in Tirana City, Albania: a rapid increase in a country in transition. Diabet Med 2004; 21: 77-83. 17. Shapo L, Pomerleau J, McKee M. Epidemiology of hypertension and associated cardiovascular risk factors in a country in transition: a population based survey in Tirana City, Albania. J Epidemiol Community Health 2003; 57: 734-9. 18. Shapo L, Gilmore AB, Coker R, McKee M, Shapo E. Prevalence and determinants of smoking in Tirana city, Albania: a population-based survey. Public Health 2003; 117: 228-36. 19. WHO. Global Health Observatory (GHO) data - Albania: country profiles 2017. Available Nov 29th 2016 from: http://www.who.int/ nmh/countries/alb_en.pdf?ua=1. 20. Bank TW. Health expenditure, total (% of GDP) 2015. Available Nov 29th 2016 from: http://data.worldbank.org/indicator/SH.XPD. TOTL.ZS/countries/AL-AT?display=default. 21. Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J (Clin Res Ed) 1981; 282: 1847-51. 22. Myftiu S, Sulo E, Burazeri G, Sharka I, Shkoza A, Sulo G. A higher burden of metabolic risk factors and underutilization of therapy among women compared to men might influence a poorer prognosis: a study among acute myocardial patients in Albania, a transitional country in Southeastern Europe. Croat Med J 2015; 56: 542-9. 10.1515/sjph-2017-0032 Zdr Varst 2017; 56(4): 236-243 243 23. Burazeri G, Goda A, Sulo G, Stefa J, Roshi E, Kark JD. Conventional risk factors and acute coronary syndrome during a period of socioeconomic transition: population-based case-control study in Tirana, Albania. Croat Med J 2007; 48: 225-33. 24. Balla I, Kondili LA, Kondili A. Risk factors among coronary heart disease patients in the context of the Albanian paradox. Anadolu Kardiyol Derg 2012; 12: 82. 25. Khot UN, Khot MB, Bajzer CT, Sapp SK, Ohman EM, Brener SJ et al. Prevalence of conventional risk factors in patients with coronary heart disease. JAMA 2003; 290: 898-904. 26. Paixao AR, Enriquez JR, Wang TY, Li S, Berry JD, Khera A et al. Risk factor burden and control at the time of admission in patients with acute myocardial infarction: results from the NCDR. Am Heart J 2015; 170: 173-9, 9 e1. 27. Shotan A, Blondheim DS, Gottlieb S, Kazatsker M, Frimerman A, Shochat M et al. Comparison of outcome of recurrent versus first ST-segment elevation myocardial infarction (from national Israel surveys 1998 to 2006). Am J Cardiol 2011; 107: 1730-7. 28. Shen L, Shah BR, Nam A, Holmes D, Alexander KP, Bhatt DL et al. Implications of prior myocardial infarction for patients presenting with an acute myocardial infarction. Am Heart J 2014; 167: 840-5. 29. Masters R, Anwar E, Collins B, Cookson R, Capewell S. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health. 2017; 71: 827-34. 30. Koopman C, Vaartjes I, van Dis I, Verschuren WM, Engelfriet P, Heintjes EM et al. Explaining the decline in coronary heart disease mortality in the Netherlands between 1997 and 2007. PLoS One 2016; 11: e0166139. 31. Pereira M, Azevedo A, Lunet N, Carreira H, O’Flaherty M, Capewell S et al. Explaining the decline in coronary heart disease mortality in Portugal between 1995 and 2008. Circ Cardiovasc Qual Outcomes 2013; 6: 634-42. 32. Unal B, Sozmen K, Arik H, Gerceklioglu G, Altun DU, Simsek H et al. Explaining the decline in coronary heart disease mortality in Turkey between 1995 and 2008. BMC public health 2013; 13: 1135. 33. O’Flaherty M, Buchan I, Capewell S. Contributions of treatment and lifestyle to declining CVD mortality: why have CVD mortality rates declined so much since the 1960s? Heart 2013; 99: 159-62. 34. Lu KJ, Yan BP, Ajani AE, Wilson WM, Duffy SJ, Gurvitch R et al. Impact of concomitant heart failure on outcomes in patients undergoing percutaneous coronary interventions: analysis of the Melbourne Interventional Group registry. Eur J Heart Fail 2011; 13: 416-22.