To detect a long-term increase in the incidence of acute myocardial infarction (AMI) after Hurricane Katrina and to investigate the pertinent contributing factors, we conducted a single-center retrospective cohort observational study. The patients admitted with AMI to Tulane University Hospital in the 2 years before Katrina and the 3 years after the hospital reopened were identified from the hospital medical records. The pre- and post-Katrina groups were compared for prespecified demographic and clinical data. In the 3-year post-Katrina group, 418 admissions (2.0%) for AMI occurred of a total census of 21,092 patients compared to 150 (0.7%) of a census of 21,079 in the 2-year pre-Katrina group (p <0.0001). The post-Katrina group had a greater prevalence of unemployment (p <0.0001), lack of medical insurance (p <0.001), smokers (p <0.01), medical noncompliance (p <0.0001), first-time hospitalizations (p <0.001), history of coronary artery disease (p <0.01), multiple vessel disease (p <0.05), and percutaneous coronary interventions (p <0.0001). The mean age of onset of AMI decreased from 62 years before Katrina to 59 years after Katrina (p <0.05), and a significantly greater percentage of patients were men (p <0.05). No significant differences were found between the two groups in terms of race, substance abuse, and a history of hypertension or diabetes mellitus. Our data suggest that chronic stress after natural disasters may significantly affect cardiovascular risk factors such as tobacco abuse and increase medical noncompliance. In conclusion, our data is consistent with a significant change in the overall health of the population and support the need for additional study into the health effects of chronic stress after natural disasters.
Hurricane Katrina was one of the most devastating storms to affect the United States. Responsible for ≥1,800 deaths along the Gulf Coast, Katrina was the third most deadly hurricane ever endured by the United States and also the most expensive, with a cost of nearly $80 billion dollars. In 2009, Gautam et al from Tulane University Health Sciences Center (TUHSC) in New Orleans investigated the change in the incidence of acute myocardial infarction (AMI) in New Orleans during the 2 years after Hurricane Katrina. The investigators found a threefold increase in the incidence of AMI. Our present study continued to investigate the long-term cardiovascular effects of a natural disaster on a large population by examining the local incidence of AMI in the 3 years after Hurricane Katrina.
Methods
This was a single-center retrospective study performed at TUHSC. The researchers identified patients admitted to TUHSC with a diagnosis of AMI using the International Classification of Disease, version 9, codes 410.1 to 410.9. Only patients with the following criteria were selected as patients with AMI: ischemic symptoms at rest, lasting >10 minutes, within 24 hours of hospital presentation, and an elevated troponin I greater than the upper limit of normal (as defined by the TUHSC Biochemistry Laboratory). The exclusion criteria for the study were age <18 years and a nonspecific increase in serum troponin in the presence of severe noncardiac illness, including sepsis, renal failure, and hypovolemic shock.
The 2 cohorts were separated by date criteria: the pre-Katrina cohort (group 1) consisted of patients with AMI from August 29, 2003 to August 28, 2005, and the post-Katrina cohort (group 2) consisted of patients with AMI from February 14, 2006 to February 13, 2009. In addition, data on the total number of adult patients during these two periods were also compiled.
The patient medical records were accessed to record the demographic, clinical, and laboratory data. The demographic data included age, gender, date of admission, date of cardiac catheterization, body mass index, medical history, medications, medication compliance, insurance status, marital status, employment status, Katrina evacuee status, and psychiatric co-morbidities. Medication noncompliance was determined by information from the initial histories taken by the nurses and physicians. The clinical data included blood pressure at triage, heart rate, ST-segment elevation or depression, culprit vascular territory, type of coronary intervention (angioplasty with/without coronary stenting), and door to balloon time. The laboratory data consisted of random blood glucose, glycosylated hemoglobin, total cholesterol, low-density lipoprotein, high-density lipoprotein, serum triglycerides, serum creatinine, and glomerular filtration rate.
All the charts were reviewed by one of us (Z.J.), a medical professional experienced in chart review. All the cases excluded from the study were agreed on one of us (Z.J.), and the abstractor (A.I.) was not unaware of the study. The study data were entered by a standardized Microsoft Excel worksheet. The statistician (S.S.) was unaware of the hypothesis and received a revised data sheet with alphabetical coding of all the study parameters. The study data were statistically analyzed to detect any difference in the incidence of AMI in the pre-Katrina and post-Katrina groups and any relation to these parameters.
The goal of the present study was to investigate any long-term difference in the incidence of AMI after Hurricane Katrina and to determine the contributing factors to any such difference. The institutional review board at the Tulane Office of Human Research Protection approved the study, with a waiver of the requirement for informed consent.
Results
In the post-Katrina group, 418 (2.00%) confirmed admissions for AMI occurred of a total census of 21,092 patients compared to 150 (0.7%) of a census of 21,079 in the 2-year pre-Katrina group (p <0.0001; Figure 1 ) .
The comparison of the demographic data between the two groups ( Table 1 ) indicated that the post-Katrina group had a significantly greater prevalence of unemployment (p <0.0001), lack of medical insurance (p <0.001), smoking (p <0.01), temporary housing (p <0.0001), and divorce (p <0.05). In addition, the mean age of onset of AMI decreased from 62 years before Katrina to 59 years after Katrina (p <0.05). The post-Katrina group also had a significantly increased number of men (p <0.05). No significant difference was found in the prevalence of psychiatric co-morbidities and substance abuse between the two groups.
| Indicator | p Value | Hospital Admissions | |
|---|---|---|---|
| Before Katrina (2 years, n = 150) | After Katrina (3 years, n = 418) | ||
| Age (years) | <0.05 | 62 ± 13 | 59 ± 12 |
| Male gender | <0.05 | 61.3% | 71.2% |
| Race | 0.2 | ||
| White | 49.4% | 46.4% | |
| Black | 45.3% | 47.2% | |
| Asian | 0.7% | 1.7% | |
| Unknown | 0% | 1.92% | |
| Substance abuse | 0.08 | 6.67% | 13.2% |
| Smoking | <0.01 | 39.3% | 56.9% |
| Medication noncompliance | <0.0001 | 7.3% | 27.5% |
| Unemployed | <0.0001 | 2.0% | 15.3% |
| Uninsured | <0.001 | 6.0% | 15.6% |
| Divorced | <0.05 | 2.0% | 4.3% |
| Temporary housing | <0.0001 | 1.3% | 5.8% |
| Local residents | <0.0001 | 70% | 83.7% |
Among the clinical parameters ( Table 2 ), the post-Katrina patients were more likely to be noncompliant with medication (p <0.0001) and to present to the hospital for the first time during the AMI event (p <0.001). The post-Katrina group was also more likely to present with multiple vessel disease (p <0.05) and undergo percutaneous coronary intervention as treatment (p <0.0001). Between the two groups, no significant difference was found in body mass index, history of hypertension, diabetes mellitus, or chronic renal diseases ( Figure 2 ) .
| Indicator | p Value | Hospital Admissions | |
|---|---|---|---|
| Before Katrina | After Katrina | ||
| Acute myocardial infarction | <0.0001 | 0.7% (n = 150) | 2.00% (n = 418) |
| Diabetes mellitus | 0.4 | 28.7% | 30.2% |
| Hypertension | 0.4 | 74.0% | 72.0% |
| Hyperlipidemia | 0.05 | 44.9% | 46.2% |
| Coronary artery disease | <0.01 | 30.7% | 31.6% |
| Psychiatric co-morbidities | 0.8 | 6.7% | 6.5% |
| High-density lipoprotein | <0.07 | 38.6 ± 15.5 | 41.3 ± 13.9 |
| Low-density lipoprotein | <0.05 | 105.4 ± 47.2 | 115.8 ± 48 |
| Triglycerides | 0.4 | 140.0 ± 75.6 | 148.2 ± 102.1 |
| Glomerular filtration rate (mL/min) | 0.09 | 60.7 ± 27.7 | 60.5 ± 25.4 |
| Body mass index (kg/m 2 ) | 0.9 | 28.6 ± 7.1 | 28.7 ± 6.4 |
| Hemoglobin A1c (%) | 0.9 | 7.4 ± 1.7 | 7.4 ± 2.2 |
| Aspirin | 0.8 | 31.3% | 28.7% |
| Coronary bypass artery grafting | 0.1 | 9.3% | 13.6% |
| Multiple vessel disease | <0.05 | 21.3% | 23.9% |
| Systolic blood pressure | 0.08 | 146 ± 39 | 139 ± 37 |
| Diastolic blood pressure | 0.3 | 84 ± 22 | 87 ± 22 |
| Coronary stenting | <0.0001 | 50% | 65.2% |
| ST-segment elevation | 0.6 | 42% | 45.9% |
| First-time hospitalization | (p <0.001) | 7.3% | 24.1% |
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