Skip to main content

Years of Life Gained from Admission Therapies after a Heart Attack

School of Public Health
January 23, 2015

Emily Bucholz (School of Public Health), an MD/PhD student studying chronic disease epidemiology, won the American Heart Association’s Samuel A. Levine Young Clinical Investigator Award for research she presented at the association’s annual meeting. The award recognizes innovative clinical research by scientists who are at the beginning of their careers.

Emily’s work, “Long-term survival and years of life gained from myocardial infarction admission guidelines,” analyzes the link between specific therapies used when patients are having an acute myocardial infarction (AMI, aka heart attack) and their long-term life expectancy. Prior research has demonstrated improved 30-day survival for patients receiving guideline-based care, but not how these guidelines influence life expectancy over the years. 

Emily analyzed Medicare data from patients who had heart attacks between 1994 and 1995, to see what happened to them in the ensuing years and “found that AMI ‘admission guidelines’ are associated with both early and late survival benefits,” she says.

I chose to study long-term survival after AMI for my PhD because AMIs are associated with significant mortality and morbidity over the long-term, even though they are frequently viewed as acute events. AMIs are caused by blockages of the coronary arteries which perfuse the heart muscle,” she explains. The goal, therefore, is to open the blocked arteries quickly, before the heart muscle sustains permanent damage (ischemia) from being deprived of the oxygen and glucose that its cells need to survive.

The treatments recommended by “admission guidelines” are aspirin, beta-blockers, acute reperfusion therapy, door-to-balloon time in 90 minutes or less, and door-to-needle time in 30 minutes or less.

Beta-blockers are drugs that work by blocking the effects of epinephrine (adrenaline) and slowing the heart rate, thereby decreasing the heart’s demand for oxygen. They are commonly used to treat chronic hypertension and congestive heart failure, but are also effective in preventing cardiac damage during heart attacks.

Acute reperfusion therapy refers to two procedures – percutaneous coronary intervention (angioplasty) and fibrinolytic therapy ­ – either of which may be performed when a heart attack patient first arrives at the hospital. Percutaneous coronary intervention involves the insertion of a deflated balloon or other device through a patient’s blood vessels to the site of a blockage, where it is inflated to open the artery and allow blood to flow freely. Fibrinolytic therapy is the breakdown of arterial blockages using streptokinase, urokinase, or another substance that helps to break down clots and restore blood flow to the heart.

Because these procedures carry an element of risk, there are several criteria a patient must meet to be eligible for these therapies; however, rapid and early administration of these therapies is crucial to restoring cardiac blood flow and preventing further ischemic damage.”

When quantified in terms of life-years saved, early and rapid delivery of AMI admission therapies was associated with meaningful gains in life expectancy and large numbers of years of life saved in elderly patients,” Emily found.  Our findings strengthen the case for why early and rapid delivery of guideline-based therapies is important and demonstrate how much a missed opportunity really costs when eligible patients are not treated.”

Emily’s adviser is Harlan Krumholz, the Harold H. Hines Jr. Professor of Internal Medicine and Epidemiology and Public Health and director of the Robert Wood Johnson Clinical Scholars Program. He also heads the Center for Outcomes Research and Evaluation (CORE).

He has been a truly outstanding mentor and one that I hope to emulate in my own career,” she says. “Despite being incredibly busy, he always makes ample time for mentees to talk about their projects and career goals and is constantly seeking out new opportunities for students and fellows. Through his guidance and mentorship, which have helped to advance my professional and analytic skills, I have had the opportunity to be involved in several projects at CORE in addition to my dissertation work.”

Her dissertation expands on the work for which she won the Young Clinical Investigator Award. In her thesis research, Emily focuses on gender, race, and socioeconomic disparities in life expectancy and years of potential life lost after an AMI. With the help of her dissertation committee, she has been able to develop new methods for estimating life expectancy and has applied these methods to quantify the burden of heart attacks in multiple populations. “We are hoping to look at geographic variation and hospital performance next,” she says.

Born and raised in Dallas, Texas, Emily came to Yale for college and stayed to pursue her graduate studies. “Clearly, I love Yale!” she says.

Her interest in public health “began with a single class I took in college on the relationship between nutrition and chronic disease taught by Susan Mayne.” After a few additional courses at the School of Public Health, she applied for the five-year BS/MPH combined program and spent an additional year obtaining her masters degree.

Initially, my interests were in child nutrition and obesity,” she says. “However, in medical school, I quickly developed an interest in cardiology and ‘outcomes research,’ because I could see the direct implications of this work for patients, providers, and health systems. Fortunately for me, one of the leading research centers in cardiovascular outcomes in the United States resides at Yale under Dr. Krumholz’s directorship, which is how I became involved with CORE.”

Emily plans to pursue an academic career that combines clinical work and research, but she will turn her attention to pediatrics.

Using the analytical and translational skills I have learned during my PhD, I want to tackle questions related to the epidemiology and prognosis of pediatric diseases and develop guidelines and quality measures for treating such diseases. Although I study elderly populations for my PhD, the skills I have learned are easily transferrable. Clinically, I am hoping to practice pediatric cardiology and critical care.”

When not working on her research, Emily loves to travel, hike, climb, and spend time with family and friends. Her fiancé, Yale alumnus Neel Butala (MD, MBA 2014), is an internal medicine resident in Boston, and she enjoys exploring that city with him.