Profiling B-type natriuretic peptide in a stable heart failure population: a valuable adjunct to care.

AIM: To examine the prognostic importance of absolute values and change in values of BNP in patients with stable heart failure (HF). METHODS: Five-hundred and fifty-nine patients attending a disease management programme were categorized into tertiles of BNP (group 1; ≤ 95 pg/ml, group 2; 96-249 pg/ml and group 3; ≥ 250 pg/ml). A change in BNP between two stable visits was recorded. Patients were followed up for 1 year for death and a composite morbidity measure of HF hospitalization, all-cause hospitalization, unscheduled visits for clinical deterioration(UC) of HF using survival analysis. RESULTS: The risk of the combined morbidity outcome increased with increasing tertiles of BNP (Log rank = 17.8 (2), p < 0.001). Furthermore, a 50 and 25% increase in BNP predicted morbidity in stable HF patients with an initial BNP > 200 pg/ml (p = 0.02) and > 450 pg/ml (p = 0.03), respectively. CONCLUSION: In a stable community HF population, an elevated BNP or an increase in BNP predicts an adverse prognosis thereby potentially identifying a population in need of closer clinical follow-up.

Clinical and psychological impact of prophylactic implantable cardioverter-defibrillators in a community heart failure population.

AIMS: ICD implantation for primary prevention of sudden cardiac death in patients with left ventricular systolic dysfunction (ejection fraction ≤ 35%) has increased since the publication of the SCD-HEFT and MADIT-II data. The aim of this study is to examine the effectiveness and safety of prophylactic ICD use in a community heart failure population and to assess the impact on patient's quality of life. METHODS AND RESULTS: Seventy-one ICDs were inserted between the years 2002 and 2006. The mean follow-up from time of insertion was 24 ± 11 months. Eighteen patients (25%) had potentially life-saving therapy. Seven (10%) patients received inappropriate shocks. Complications were encountered in five patients (7%). CONCLUSION: In a community heart failure population, prophylactic ICD implantation is associated with a high incidence of life-saving therapy, a low complication rate and a high level of tolerability. These data indicate translation of clinical trial benefits to the general heart failure population.

Diagnosis of new onset heart failure in the community: the importance of a shared-care approach and judicious use of BNP.

BACKGROUND: Brain natriuretic peptide (BNP) may help general practitioners (GPs) to "rule-out" heart failure (HF) and reduce referral burden on specialist assessment clinics. AIMS: To determine the diagnostic value of BNP in HF referrals by GPs to a specialist unit. METHODS: From 2003 to 2007, 327 GP referrals were made to a HF new patient diagnostic clinic (NDC) with a provisional diagnosis of HF. The NDC provides rapid assessment of potential HF patients and ensures appropriate therapy and follow-up for those with a confirmed diagnosis. HF diagnosis was confirmed by the Framingham criteria. RESULTS: HF was present in 39% of cases referred (mean age 75 +/- 10 years, 49% male). The inclusion of BNP as a "rule-out" test with a cut-off value of 100 pg/mL would have reduced the number of patients originally referred to the NDC by 175. However, this would have resulted in delayed diagnosis and treatment of 20 (16%) "false-negative" patients. CONCLUSIONS: Availability of BNP to GPs would improve referral patterns but with high risk of delayed diagnosis. The data underline the need for a shared-care approach to the new diagnosis of HF.

Long-term outcome of low-risk patients attending a rapid-assessment chest pain clinic.

OBJECTIVE: To examine the long-term outcome of patients evaluated in a rapid assessment chest pain clinic (RACPC): are "low-risk" patients safely reassured? DESIGN: Retrospective cohort study. SETTING: Staff grade-led RACPC in an urban teaching hospital. PARTICIPANTS: 3378 patients (51% male), attending the RACPC between April 1996 and February 2000. MAIN OUTCOME MEASURES: Death, coronary mortality, morbidity and revascularisation over a median follow-up of 6 years. Coronary standardised mortality ratio (SMR). RESULTS: 2036 (60.3%) patients were categorised as "low risk", 957 (28.3%) as having "stable coronary artery disease" and 214 (6.3%) as being an "acute coronary syndrome". During the study, 3.6% of patients in the low risk category, 11.9% in the stable coronary artery disease category and 24.6% in the acute coronary syndrome category died from coronary artery disease or had a myocardial infarction. 5.5%, 18.2% and 18.4%, respectively, died from any cause. Compared to the local population (coronary SMR = 100), our "low risk/non-coronary chest pain" cohort had a coronary SMR of 51 (95% CI 31 to 83), the "stable coronary artery disease" cohort 240 (187 to 308) and the "acute coronary syndrome" cohort 780 (509 to 1196). CONCLUSION: The RACPC was effective at triaging patients with chest pain. Patients identified as at "low risk" were unlikely to have an adverse coronary outcome and were appropriately reassured.

An epidemiological study of pulmonary arterial hypertension.

All hospitalisations for pulmonary arterial hypertension (PAH) in the Scottish population were examined to determine the epidemiological features of PAH. These data were compared with expert data from the Scottish Pulmonary Vascular Unit (SPVU). Using the linked Scottish Morbidity Record scheme, data from all adults aged 16-65 yrs admitted with PAH (idiopathic PAH, pulmonary hypertension associated with congenital heart abnormalities and pulmonary hypertension associated with connective tissue disorders) during the period 1986-2001 were identified. These data were compared with the most recent data in the SPVU database (2005). Overall, 374 Scottish males and females aged 16-65 yrs were hospitalised with incident PAH during 1986-2001. The annual incidence of PAH was 7.1 cases per million population. On December 31, 2002, there were 165 surviving cases, giving a prevalence of PAH of 52 cases per million population. Data from the SPVU were available for 1997-2006. In 2005, the last year with a complete data set, the incidence of PAH was 7.6 cases per million population and the corresponding prevalence was 26 cases per million population. Hospitalisation data from the Scottish Morbidity Record scheme gave higher prevalences of pulmonary arterial hypertension than data from the expert centres (Scotland and France). The hospitalisation data may overestimate the true frequency of pulmonary arterial hypertension in the population, but it is also possible that the expert centres underestimate the true frequency.

A population study of the long-term consequences of Rose angina: 20-year follow-up of the Renfrew-Paisley study.

OBJECTIVE: To examine the long-term cardiovascular consequences of angina in a large epidemiological study. DESIGN: Prospective cohort study conducted between 1972 and 1976 with 20 years of follow-up (the Renfrew-Paisley Study). SETTING: Renfrew and Paisley, West Scotland, UK. PARTICIPANTS: 7048 men and 8354 women aged 45-64 years who underwent comprehensive cardiovascular screening at baseline, including the Rose Angina Questionnaire and electrocardiography (ECG). MAIN OUTCOME MEASURES: All deaths and hospitalisations for cardiovascular reasons occurring over the subsequent 20 years, according to the baseline Rose angina score and baseline ECG. RESULTS: At baseline, 669 (9.5%) men and 799 (9.6%) women had angina on Rose Angina Questionnaire. All-cause mortality for those with Rose angina was 67.7% in men and 43.3% in women at 20 years compared with 45.4% and 30.4%, respectively, in those without angina (p<0.001). Values are expressed as hazards ratio (HR) (95% confidence interval (CI). In a multivariate analysis, men with Rose angina had an increased risk of cardiovascular death or hospitalisation (1.49 (1.33 to 1.66), myocardial infarction (1.63 (1.41 to 1.85)) or heart failure (1.54 (1.13 to 2.10)) compared with men without angina. The corresponding HR (95% CI) for women were 1.38 (1.23 to 1.55), 1.56 (1.31 to 1.85) and 1.92 (1.44 to 2.56). An abnormality on the electrocardiogram (ECG) increased risk further, and both angina and an abnormality on the ECG increased risk most of all compared with those with neither angina nor ischaemic changes on the ECG. Compared with men, women with Rose angina were less likely to have a cardiovascular event (0.54 (0.46 to 0.64)) or myocardial infarction (0.44 (0.35 to 0.56)), although there was no sex difference in the risk of stroke (1.11 (0.75 to 1.65)), atrial fibrillation (0.84 (0.38 to 1.87)) or heart failure (0.79 (0.51 to 1.21)). CONCLUSIONS: Angina in middle age substantially increases the risk of death, myocardial infarction, heart failure and other cardiovascular events.

Short-term and long-term outcomes in 133,429 emergency patients admitted with angina or myocardial infarction in Scotland, 1990-2000: population-based cohort study.

OBJECTIVE: To analyse short- and long-term outcomes and prognostic factors in a large population-based cohort of unselected patients with a first emergency admission for suspected acute coronary syndrome between 1990 and 2000 in Scotland. METHODS: All first emergency admissions for acute myocardial infarction (AMI) and all first emergency admissions for angina (the proxy for unstable angina) between 1990 and 2000 in Scotland (population 5.1 million) were identified. Survival to five years was examined by Cox multivariate modelling to examine the independent prognostic effects of diagnosis, age, sex, year of admission, socioeconomic deprivation and co-morbidity. RESULTS: In Scotland between 1990 and 2000, 133,429 individual patients had a first emergency admission for suspected acute coronary syndrome: 96 026 with AMI and 37,403 with angina. After exclusion of deaths within 30 days, crude five-year case fatality was similarly poor for patients with angina and those with AMI (23.9% v 21.6% in men and 23.5% v 26.0% in women). The longer-term risk of a subsequent fatal or non-fatal event in the five years after first hospital admission was high: 54% in men after AMI (53% in women) and 56% after angina (49% in women). Event rates increased threefold with increasing age and 20-60% with different co-morbidities, but were 11-34% lower in women. CONCLUSIONS: Longer-term case fatality was similarly high in patients with angina and in survivors of AMI, about 5% a year. Furthermore, half the patients experienced a fatal or non-fatal event within five years. These data may strengthen the case for aggressive secondary prevention in all patients presenting with acute coronary syndrome.

Effect of socioeconomic deprivation on the population risk of incident heart failure hospitalisation: an analysis of the Renfrew/Paisley Study.

BACKGROUND: There are few data describing the effect of socioeconomic deprivation on the risk of developing heart failure (HF). AIMS: To examine the relationship between socioeconomic deprivation and hospitalisation with HF over 20 years. METHODS: Between 1972 and 1976, 15,402 individuals, aged 45-64 years, residing in two towns in Scotland, underwent cardiovascular screening. We report hospitalisations with HF over the subsequent 20 years according to Carstairs deprivation category and Social Class. RESULTS: Following screening, 628 men and women (4.1%) were hospitalised with a primary diagnosis of HF. There was a gradient in the risk of HF hospitalisation with increasing socioeconomic deprivation (P=0.003). Of the most deprived individuals, 6.4% were hospitalised for HF compared to 3.5% of the most affluent group. Cox-proportional Hazard models showed that independent of age, sex and baseline risk factors for cardio-respiratory status, greater socioeconomic deprivation increased the risk of HF admission (P<0.001, overall). The adjusted risk of admission for HF was 39% greater in the most versus least deprived subjects (RR 1.39 95% CI 1.04-2.01; P=0.04). CONCLUSION: These data show a link between social deprivation and the risk of developing HF, irrespective of baseline cardio-respiratory status and cardiovascular risk factors.

Prevalence, incidence, primary care burden and medical treatment of angina in Scotland: age, sex and socioeconomic disparities: a population-based study.

OBJECTIVE: To examine the epidemiology, primary care burden and treatment of angina in Scotland. DESIGN: Cross-sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 2001 and 31 March 2002. SETTING: 55 primary care practices (362 155 patients). PARTICIPANTS: 9508 patients with angina. RESULTS: The prevalence of angina in Scotland was 28/1000 in men and 25/1000 in women (p < 0.05) and increased with age. The prevalence of angina also increased with increasing socioeconomic deprivation from 18/1000 in the least deprived category to 31/1000 in the most deprived group (p < 0.001 for trend). The incidence of angina was higher in men (1.8/1000) than in women (1.4/1000) (p = 0.004) and increased with increasing age and socioeconomic deprivation. Socioeconomically deprived patients (0.48 contacts/patient among the most deprived) were less likely than affluent patients (0.58 contacts/patient among the least deprived) to see their general practitioner on an ongoing basis p = 0.006 for trend). Among men, 52% were prescribed beta blockers, 44% calcium channel blockers, 72% aspirin, 54% statins and 36% angiotensin converting enzyme inhibitors or angiotensin receptor blockers. The corresponding prescription rates for women were 46% (p < 0.001), 41% (p = 0.02), 69% (p < 0.001), 45% (p < 0.001) and 30% (p < 0.001). Among patients < 75 years old 52% were prescribed a beta blocker and 58% a statin. The corresponding figures for patients >or= 75 years were 42% (p < 0.001) and 31% (p < 0.001). CONCLUSIONS: Angina is a common condition, more so in men than in women. Socioeconomically deprived patients are more likely to have angina but are less likely to consult their general practitioner. Guideline-recommended treatments for angina are underused in women and older patients. These suboptimal practice patterns, which are worst in older women, are of particular concern, as in Scotland more women (and particularly older women) than men have angina.

Long-term cardiovascular consequences of obesity: 20-year follow-up of more than 15 000 middle-aged men and women (the Renfrew-Paisley study).

AIMS: To examine the long-term cardiovascular consequences of obesity and project the cardiovascular consequences of the recent increase in prevalence of obesity. METHODS AND RESULTS: Between 1972 and 1976, 15 402 individuals aged 45-64, living in two towns in the west of Scotland underwent comprehensive cardiovascular screening. We analysed all deaths and hospitalizations for cardiovascular reasons occurring over the subsequent 20 years according to baseline body mass index (BMI) category. Compared with normal weight individuals (BMI 18.5-24.9), obesity (BMI > or =30) was associated with an increased adjusted risk of coronary heart disease (hazard ratio for death or hospital admission: 1.60, 95% CI 1.45-1.78), heart failure (2.09, 1.68-2.59), stroke (1.41, 1.21-1.65), venous thrombo-embolism (2.29, 1.60-3.30), and atrial fibrillation (1.75, 1.17-2.65). Obesity was associated with nine additional cardiovascular deaths and 36 additional cardiovascular hospital admissions for every 100 affected middle-aged men over the subsequent 20 years (seven deaths and 28 admissions in women). Assuming no change in cardiovascular risk profile and outcomes related to obesity, the increase in prevalence in 1998, when compared with 1972, is projected to lead to an additional four cardiovascular deaths and 14 admissions per 100 middle-aged men and women over the next 20 years. CONCLUSION: Obesity is associated with an increase in a broad range of fatal and non-fatal cardiovascular events. Consideration of only coronary, only fatal, and only first events greatly underestimates the cardiovascular consequences of obesity.

Reduced between-hospital variation in short term survival after acute myocardial infarction: the result of improved cardiac care?

OBJECTIVES: To re-examine interhospital variation in 30 day survival after acute myocardial infarction (AMI) 10 years on to see whether the appointment of new cardiologists and their involvement in emergency care has improved outcome after AMI. DESIGN: Retrospective cohort study. SETTING: Acute hospitals in Scotland. PARTICIPANTS: 61,484 patients with a first AMI over two time periods: 1988-1991; and 1998-2001. MAIN OUTCOME MEASURES: 30 day survival. RESULTS: Between 1988 and 1991, median 30 day survival was 79.2% (interhospital range 72.1-85.1%). The difference between highest and lowest was 13.0 percentage points (age and sex adjusted, 12.1 percentage points). Between 1998 and 2001, median survival rose to 81.6% (and range decreased to 78.0-85.6%) with a difference of 7.6 (adjusted 8.8) percentage points. Admission hospital was an independent predictor of outcome at 30 days during the two time periods (p < 0.001). Over the period 1988-1991, the odds ratio for death ranged, between hospitals, from 0.71 (95% confidence interval (CI) 0.58 to 0.88) to 1.50 (95% CI 1.19 to 1.89) and for the period 1998-2001 from 0.82 (95% CI 0.60 to 1.13) to 1.46 (95% CI 1.07 to 1.99). The adjusted risk of death was significantly higher than average in nine of 26 hospitals between 1988 and 1991 but in only two hospitals between 1998 and 2001. CONCLUSIONS: The average 30 day case fatality rate after admission with an AMI has fallen substantially over the past 10 years in Scotland. Between-hospital variation is also considerably less notable because of better survival in the previously poorly performing hospitals. This suggests that the greater involvement of cardiologists in the management of AMI has paid dividends.

National survey of the prevalence, incidence, primary care burden, and treatment of heart failure in Scotland.

OBJECTIVE: To examine the epidemiology, primary care burden, and treatment of heart failure in Scotland, UK. DESIGN: Cross sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 1999 and 31 March 2000. SETTING: 53 primary care practices (307,741 patients). SUBJECTS: 2186 adult patients with heart failure. RESULTS: The prevalence of heart failure in Scotland was 7.1 in 1000, increasing with age to 90.1 in 1000 among patients > or = 85 years. The incidence of heart failure was 2.0 in 1000, increasing with age to 22.4 in 1000 among patients > or = 85 years. For older patients, consultation rates for heart failure equalled or exceeded those for angina and hypertension. Respiratory tract infection was the most common co-morbidity leading to consultation. Among men, 23% were prescribed a beta blocker, 11% spironolactone, and 46% an angiotensin converting enzyme inhibitor. The corresponding figures for women were 20% (p = 0.29 versus men), 7% (p = 0.02), and 34% (p < 0.001). Among patients < 75 years 26% were prescribed a beta blocker, 11% spironolactone, and 50% an angiotensin converting enzyme inhibitor. The corresponding figures for patients > or = 75 years were 19% (p = 0.04 versus patients < 75), 7% (p = 0.04), and 33% (p < 0.001). CONCLUSIONS: Heart failure is a common condition, especially with advancing age. In the elderly, the community burden of heart failure is at least as great as that of angina or hypertension. The high rate of concomitant respiratory tract infection emphasises the need for strategies to immunise patients with heart failure against influenza and pneumococcal infection. Drugs proven to improve survival in heart failure are used less frequently for elderly patients and women.

Influence of socioeconomic deprivation on the primary care burden and treatment of patients with a diagnosis of heart failure in general practice in Scotland: population based study.

OBJECTIVE: To examine whether there are socioeconomic gradients in the incidence, prevalence, treatment, and follow up of patients with heart failure in primary care. DESIGN: Population based study. SETTING: 53 general practices (307,741 patients) participating in the Scottish continuous morbidity recording project between 1 April 1999 and 31 March 2000. PARTICIPANTS: 2186 adults with heart failure. MAIN OUTCOME MEASURES: Comorbid diagnoses, frequency of visits to general practitioner, and prescribed drugs. RESULTS: 2186 patients with heart failure were seen (prevalence 7.1 per 1000 population, incidence 2.0 per 1000 population). The age and sex standardised incidence of heart failure increased with greater socioeconomic deprivation, from 1.8 per 1000 population in the most affluent stratum to 2.6 per 1000 population in the most deprived stratum (odds ratio 1.44, P = 0.0003). On average, patients were seen 2.4 times yearly, but follow up rates were less frequent with increasing socioeconomic deprivation (from 2.6 yearly in the most affluent subgroup to 2.0 yearly in the most deprived subgroup, P = 0.00009). Overall, 812 (80.6%) patients were prescribed diuretics, 396 (39.3%) angiotensin converting enzyme inhibitors, 216 (21.4%) beta blockers, 208 (20.7%) digoxin, and 86 (8.5%) spironolactone. The wide discrepancies in prescribing between different general practices disappeared after adjustment for patient age and sex. Prescribing patterns did not vary by deprivation categories on univariate or multivariate analyses. CONCLUSIONS: Compared with affluent patients, socioeconomically deprived patients were 44% more likely to develop heart failure but 23% less likely to see their general practitioner on an ongoing basis. Prescribed treatment did not differ across socioeconomic gradients.

Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK.

OBJECTIVE: To evaluate the cost of atrial fibrillation (AF) to health and social services in the UK in 1995 and, based on epidemiological trends, to project this estimate to 2000. DESIGN, SETTING, AND MAIN OUTCOME MEASURES: Contemporary estimates of health care activity related to AF were applied to the whole population of the UK on an age and sex specific basis for the year 1995. The activities considered (and costs calculated) were hospital admissions, outpatient consultations, general practice consultations, and drug treatment (including the cost of monitoring anticoagulant treatment). By adjusting for the progressive aging of the British population and related increases in hospital admissions, the cost of AF was also projected to the year 2000. RESULTS: There were 534 000 people with AF in the UK during 1995. The "direct" cost of health care for these patients was 244 million pounds sterling (approximately 350 million euros) or 0.62% of total National Health Service (NHS) expenditure. Hospitalisations and drug prescriptions accounted for 50% and 20% of this expenditure, respectively. Long term nursing home care after hospital admission cost an additional 46.4 million pounds sterling (approximately 66 million euros). The direct cost of AF rose to 459 million pounds sterling (approximately 655 million euros) in 2000, equivalent to 0.97% of total NHS expenditure based on 1995 figures. Nursing home costs rose to 111 million pounds sterling (approximately 160 million euros). CONCLUSIONS: AF is an extremely costly public health problem.

The current cost of angina pectoris to the National Health Service in the UK.

OBJECTIVE: To calculate the cost of angina pectoris to the UK National Health Service (NHS) in the year 2000. METHODS: Calculation of the cost of hospital admissions, revascularisation procedures, hospital outpatient consultations, general practice (GP) consultations, and prescribed drug treatment. RESULTS: 634 000 individuals (1.1% of the UK population) consulted GPs 2.35 million times, costing pound 60.5 million. They required 16.0 million prescriptions (cost pound 80.7 million) and 254 000 hospital outpatient referrals (cost pound 30.4 million). There were 149 000 hospital admissions, 117 000 coronary angiograms, 21 400 coronary artery bypass operations, 17 700 percutaneous coronary interventions, and 516 000 outpatient visits, at a cost of pound 208.4 million, pound 69.9 million, pound 106.2 million, pound 60.7 million, and pound 52.2 million, respectively. The direct cost of angina was therefore pound 669 million (1.3% of total NHS expenditure), with hospital bed occupancy and procedures accounting for 32% and 35% of this total, respectively. CONCLUSIONS: Angina is a common and costly public health problem. It consumed over 1% of all NHS expenditure in the year 2000, mainly because of hospital bed occupancy and revascularisation procedures. This is likely to be a conservative estimate of its true cost.