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Original Investigation |

Better Diet Quality and Decreased Mortality Among Myocardial Infarction Survivors

Shanshan Li, MD, MSc, ScD1; Stephanie E. Chiuve, ScD2,3; Alan Flint, MD, DrPH1,2; Jennifer K. Pai, ScD1,4,5; John P. Forman, MD, MSc4; Frank B. Hu, MD, PhD1,2,4; Walter C. Willett, MD, DrPH1,2,4; Kenneth J. Mukamal, MD, MPH6; Eric B. Rimm, ScD1,2,4
[+] Author Affiliations
1Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
2Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
3Channing Division of Network Medicine, Division of Preventive Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
4Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
5currently with Informatics, Merck & Co, Boston, Massachusetts
6Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Brookline, Massachusetts
JAMA Intern Med. 2013;173(19):1808-1819. doi:10.1001/jamainternmed.2013.9768.
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Importance  Information about diet after myocardial infarction (MI) and mortality is limited, despite the growing number of MI survivors in the United States.

Objective  To examine the association of post-MI dietary quality and changes from pre- to post-MI with all-cause and cardiovascular mortality among MI survivors.

Design, Setting, and Participants  We included 2258 women from the Nurses’ Health Study and 1840 men from the Health Professionals Follow-up Study. Participants had survived an initial MI during the study follow-up period and completed the pre- and post-MI food frequency questionnaire. Diet quality was measured using Alternative Healthy Eating Index 2010 (AHEI2010), which consists of food and nutrients associated with the risk of chronic disease reported in the literature. We adjusted for medication use, medical history, and lifestyle risk factors using Cox proportional hazards regression models.

Main Outcomes and Measures  All-cause and cardiovascular mortality.

Results  During follow-up, we confirmed 682 all-cause deaths for women and 451 for men. The median survival time after the initial MI onset was 8.7 years for women and 9.0 years for men. When the results were pooled, the adjusted hazard ratio (HR) was 0.76 (95% CI, 0.60-0.96) for all-cause mortality and 0.73 (95% CI, 0.51-1.04) for cardiovascular mortality, comparing the extreme quintiles of post-MI AHEI2010. A greater increase in the AHEI2010 score from pre- to post-MI was significantly associated with lower all-cause mortality (pooled HR, 0.71; 95% CI, 0.56-0.91) and cardiovascular mortality (pooled HR, 0.60; 95% CI, 0.41- 0.86), comparing the extreme quintiles. The adjusted HRs associated with post-MI AHEI2010 were 0.73 (95% CI, 0.58-0.93) for all-cause mortality and 0.81 (95% CI, 0.64-1.04) for cardiovascular mortality when the alcohol component was excluded.

Conclusions and Relevance  Myocardial infarction survivors who consume a higher-quality diet, which has been associated with a lower risk of coronary heart disease in primary prevention, have lower subsequent all-cause mortality.

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Figure 1.
Components of the Alternative Healthy Eating Index 2010 Score (AHEI2010) Post-Myocardial Infarction (MI) and Changes From Pre- to Post-MI Period Among MI Survivors

Scores were age-standardized. Higher score represents higher diet quality (ie, less consumption of red meat, sugar-sweetened beverages, trans fat, and sodium components). For changes in AHEI2010 from pre- to post-MI, a positive number represents improvement in diet quality; a negative number, a decrease in diet quality.15 DHA indicates dihydroxyacetone docosahexaenoic acid; EPA, eicosapentaenoic acid.

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Figure 2.
Adjusted Survival Curve Comparing Myocardial Infarction (MI) Survivors in the Highest Quintile of Alternative Healthy Eating Index 2010 (AHEI2010) Score vs Those in the Lowest Quintile

Survival curve was adjusted for time since MI onset, age at diagnosis (continuous), calendar year (questionnaire cycle, continuous, 2-y period), total caloric intake (quintiles of kilocalories), physical activity (simple updated, quintiles of metabolic equivalents/wk), aspirin use (yes or no), diabetes mellitus (yes or no), hypertension (yes or no), lipid-lowering medication use (yes or no), currently married (yes or no), body mass index (<21.0, 21.0-22.9, 23.0-24.9, 25.0-27.4, 27.5-29.9, ≥30.0, calculated as weight in kilograms divided by height in meters squared), coronary artery bypass surgery (yes or no) and pre-MI AHEI2010 score (quintiles). For women, additionally adjusted for postmenopausal hormone use status (premenopause, postmenopausal hormone never user, postmenopausal hormone current user, postmenopausal hormone past user), and smoking (never smoker or missing, past smoker, current smoker 1-14 cigarettes/d, current smoker 15-24 cigarettes/d, and current smoker ≥25 cigarettes/d). For men, additionally adjusted for heart failure (yes or no), left-ventricular ejection fraction (≥40%, <40%, or missing), acute therapy during hospitalization (received either angioplasty or thrombolytics, or none), and smoking (never smoker or missing, past smoker, current smoker <15 cigarettes/d, current smoker ≥15 cigarettes/d).

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