The importance of validating the diagnosis of coronary heart disease when measuring secondary prevention:a cross-sectional study in general practice

To compare levels of recorded risk factors and drug treatment between patients with validated and non-validated diagnoses of coronary heart disease (CHD) in Northern Ireland.

[Manifestation and course of coronary heart disease in men and women--consequences for diagnosis and treatment]

Gender related issues in manifestation, diagnosis and treatment of coronary artery disease are important but still not well recognized. Women are more likely to present late after first symptoms of myocardial infarction. Myocardial infarction is more often unrecognized. In regard to complications after myocardial infarctions ventricular tachycardia and cardiac arrest are more frequent and women are also more likely to develop heart failure or cardiogenic shock. The reason for this is most probably the fact that women presenting with myocardial infarction are of older age and have a higher incidence of co-morbidities. Thrombolysis and coronary angioplasty are less often performed in women in the setting of myocardial infarction. However there is a clear trend toward improvement of this situation during the last years. The reopening rate of occluded coronary arteries with thrombolysis and with coronary angioplasty is similar in women compared to men. Perioperative risk with aorto-coronary bypass surgery is higher in women, which can not be fully explained by higher age and co-morbidities. However 10 years survival rate after aorto-coronary bypass-surgery is similar for men and women, although occlusion of venous grafts is seen more often in women. The benefit of structured cardiac rehabilitation after an acute event is similar for younger and older women and as good as in men. Positive effects of cardiac rehabilitation include increased physical performance, reduction of body fat, improvement of lipid-profiles and an improvement of the psychosocial situation and quality of life.

Is there any gender difference for smoking persistence or relapse following diagnosis or hospitalization for coronary heart disease? Evidence from a systematic review and meta-analysis

INTRODUCTION: Persistent smoking in patients diagnosed with coronary heart disease (CHD) has a significant effect on morbidity and mortality. Although there has been considerable debate around gender differences in smoking cessation, conclusive evidence on how gender impacts rates of smoking cessation and/or relapse following CHD diagnosis is lacking. AIMS AND METHODS: Our aim was to test the hypothesis that female smokers with CHD were more likely to persist in smoking or relapse post-diagnosis or hospitalization than male smokers. We searched PubMed and Web of Science databases for studies published in the last 10 years. Meta-analyses were conducted using a random effects model. RESULTS: Sixteen studies met the inclusion criteria. The aggregated sample size was 36 591, 20 617 (56%) were smokers of which 2564 (12%) were female. Meta-analyses of eight studies where smoking prevalence could be measured, showed that females were less likely to be smokers at baseline than males (OR = 0.30, 95% CI = 0.13 to 0.70). Overall, one in two (47%) smokers persisted in smoking/relapsed following a diagnosis or hospitalization for CHD; but there was no gender difference in the rate of persistent smoking/relapse (OR = 1.07, 95% CI = 0.95 to 1.21). CONCLUSIONS: Female smokers with CHD were relatively uncommon in the included study populations. However, the rate of persistent smoking/relapse was high in both female and male smokers following a diagnosis or hospitalization for CHD. Therefore similar, sustained smoking cessation efforts are warranted for both genders. IMPLICATIONS: There was no gender difference for persistent smoking/relapse following a diagnosis or hospitalization for CHD, but the rate was high in both female and male smokers. Therefore, similar, sustained smoking cessation efforts are warranted for both genders.

A history of heart interventions moderates the relationship between psychological variables and the presence of chest pain in older women with self-reported coronary heart disease

Objectives: This study examines the hypothesis that a past history of heart interventions will moderate the relationship between psychosocial factors (stressful life events, social support, perceived stress, having a current partner, having a past diagnosis of depression or anxiety over the past 3 years, time pressure, education level, and the mental health index) and the presence of chest pain in a sample of older women. Design: Longitudinal survey over a 3-year period. Methods: The sample was taken from a prospective cohort study of 10,432 women initially aged between 70 and 75 years, who were surveyed in 1996 and then again in 1999. Two groups of women were identified: those reporting to have heart disease but no past history of heart interventions (i.e., coronary artery bypass graft/angioplasty) and those reporting to have heart disease with a past history of heart interventions. Results: Binary logistic regression analysis was used to show that for the women with self-reported coronary heart disease but without a past history of heart intervention, feelings of time pressure as well as the number of stressful life events experienced in the 12 months prior to 1996 were independent risk factors for the presence of chest pain, even after accounting for a range of traditional risk factors. In comparison, for the women with self-reported coronary heart disease who did report a past history of heart interventions, a diagnosis of depression in the previous 3 years was the significant independent risk factor for chest pain even after accounting for traditional risk factors. Conclusion: The results indicate that it is important to consider a history of heart interventions as a moderator of the associations between psychosocial variables and the frequency of chest pain in older women. Statement of Contribution: What is already known on this subject? Psychological factors have been shown to be independent predictors of a range of health outcomes in individuals with coronary heart disease, including the presence of chest pain. Most research has been conducted with men or with small samples of women; however, the evidence does suggest that these relationships exist in women as well as in men. What does this study add? Most studies have looked at overall relationships between psychological variables and health outcomes. The few studies that have looked at moderators have mainly examined gender as a moderator. To our knowledge, this is the first published study to examine a history of heart interventions as a moderator of the relationship between psychological variables and the presence of chest pain.

Subclinical hyperthyroidism and the risk of coronary heart disease and mortality.

BACKGROUND: Data from prospective cohort studies regarding the association between subclinical hyperthyroidism and cardiovascular outcomes are conflicting.We aimed to assess the risks of total and coronary heart disease (CHD) mortality, CHD events, and atrial fibrillation (AF) associated with endogenous subclinical hyperthyroidism among all available large prospective cohorts. METHODS: Individual data on 52 674 participants were pooled from 10 cohorts. Coronary heart disease events were analyzed in 22 437 participants from 6 cohorts with available data, and incident AF was analyzed in 8711 participants from 5 cohorts. Euthyroidism was defined as thyrotropin level between 0.45 and 4.49 mIU/L and endogenous subclinical hyperthyroidism as thyrotropin level lower than 0.45 mIU/L with normal free thyroxine levels, after excluding those receiving thyroid-altering medications. RESULTS: Of 52 674 participants, 2188 (4.2%) had subclinical hyperthyroidism. During follow-up, 8527 participants died (including 1896 from CHD), 3653 of 22 437 had CHD events, and 785 of 8711 developed AF. In age- and sex-adjusted analyses, subclinical hyperthyroidism was associated with increased total mortality (hazard ratio[HR], 1.24, 95% CI, 1.06-1.46), CHD mortality (HR,1.29; 95% CI, 1.02-1.62), CHD events (HR, 1.21; 95%CI, 0.99-1.46), and AF (HR, 1.68; 95% CI, 1.16-2.43).Risks did not differ significantly by age, sex, or preexisting cardiovascular disease and were similar after further adjustment for cardiovascular risk factors, with attributable risk of 14.5% for total mortality to 41.5% forAF in those with subclinical hyperthyroidism. Risks for CHD mortality and AF (but not other outcomes) were higher for thyrotropin level lower than 0.10 mIU/L compared with thyrotropin level between 0.10 and 0.44 mIU/L(for both, P value for trend, .03). CONCLUSION: Endogenous subclinical hyperthyroidism is associated with increased risks of total, CHD mortality, and incident AF, with highest risks of CHD mortality and AF when thyrotropin level is lower than 0.10 mIU/L.

Values underlying the National Service Framework for coronary heart disease in England : a discourse analysis

OBJECTIVES: The National Service Framework (NSF) for Coronary Heart Disease--published by the English Department of Health in 2000--sets out how those within the health service should seek to prevent and treat coronary heart disease and care for people with the disease. Its prescriptions are partly based on what is known about coronary heart disease and partly on its underlying 'values'. This paper seeks to identify those values.

METHODS:An analysis of the discourses within the text of the NSF based on critical discourse analysis.

RESULTS: Three different discourses can be identified: the managerial, the clinical and the political. The managerial discourse is dominant. Each discourse has its own values. The main 'aspirational' values within the NSF are efficiency, effectiveness, autonomy (choice), universalism and equity. Some aspirational values--particularly equity--appear to be largely rhetorical and lead to few recommendations or prescriptions. Some values that might have been expected to underlie the framework, such as compassion and democracy, are largely absent.

CONCLUSIONS: Discourse analysis provides a more systematic and transparent method of describing the values behind health care policy than the methods that have been used previously.

Depression is a risk factor for incident coronary heart disease in women: an 18-year longitudinal study

BACKGROUND: According to a recent position paper by the American Heart Association, it remains unclear whether depression is a risk factor for incident Coronary Heart Disease (CHD). We assessed whether a depressive disorder independently predicts 18-year incident CHD in women. METHOD: A prospective longitudinal study of 860 women enrolled in the Geelong Osteoporosis Study (1993-2011) was conducted. Participants were derived from an age-stratified, representative sample of women (20-94 years) randomly selected from electoral rolls in South-Eastern Australia. The exposure was a diagnosis of a depressive disorder using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders. Outcomes data were collected from hospital medical records: (1) Primary outcome: a composite measure of cardiac death, non-fatal Myocardial Infarction or coronary intervention. (2) Secondary outcome: any cardiac event (un/stable angina, cardiac event not otherwise defined) occurring over the study period. RESULTS: Seven participants were excluded based on CHD history. Eighty-three participants (9.6%) recorded ≥1 cardiac event over the study period; 47 had a diagnosis that met criteria for inclusion in the primary analysis. Baseline depression predicted 18-year incidence, adjusting for (1) anxiety (adj. OR:2.39; 95% CIs:1.19-4.82), plus (2) typical risk factors (adj. OR:3.22; 95% CIs:1.45-6.93), plus (3) atypical risk factors (adj. OR:3.28; 95% CIs:1.36-7.90). This relationship held when including all cardiac events. No relationship was observed between depression and recurrent cardiac events. CONCLUSION: The results of this study support the contention that depression is an independent risk factor for CHD incidence in women. Moreover, the strength of association between depression and CHD incidence was of a greater magnitude than any typical and atypical risk factor.

Systematic review of genetic risk score in coronary heart disease and other diseases

In order to better take advantage of the abundant results from large-scale genomic association studies, investigators are turning to a genetic risk score (GRS) method in order to combine the information from common modest-effect risk alleles into an efficient risk assessment statistic. The statistical properties of these GRSs are poorly understood. As a first step toward a better understanding of GRSs, a systematic analysis of recent investigations using a GRS was undertaken. GRS studies were searched in the areas of coronary heart disease (CHD), cancer, and other common diseases using bibliographic databases and by hand-searching reference lists and journals. Twenty-one independent case-control studies, cohort studies, and simulation studies (12 in CHD, 9 in other diseases) were identified. The underlying statistical assumptions of the GRS using the experience of the Framingham risk score were investigated. Improvements in the construction of a GRS guided by the concept of composite indicators are discussed. The GRS will be a promising risk assessment tool to improve prediction and diagnosis of common diseases.^

Discordant age and sex-specific trends in the incidence of a first coronary heart disease event in Western Australia from 1996 to 2007

OBJECTIVE: To determine age- and sex-specific population trends in fatal and non-fatal first coronary heart disease (CHD) events in Western Australia from 1996 to 2007. DESIGN: Longitudinal retrospective population study. SETTING: State-wide population. PATIENTS: All residents aged 35-84 years during 1996-2007 who died or were hospitalised with a principal diagnosis of acute CHD. DATA SOURCES: Person-linked file of mortality and morbidity records. MAIN OUTCOME MEASURES: Age-standardised (35-84 years) and age-specific (35-54, 55-69, 70-84 years) rates by gender for a first CHD event were calculated with a 10-year lead-in period to define first events. RESULTS: From 1996 to 2007 there were 36 631 first CHD events, including 8518 (23%) fatal cases in those aged 35-84 years. Overall, age-adjusted rates for fatal first CHD declined 5.3%/year in men (95% CI -6.1% to -4.6%) and 6.5%/year in women (95% CI -7.5% to -5.5%). However, age-specific fatal first CHD rates were neutral in both men aged 35-54 years (0.1%/year; 95% CI -1.8% to 2.1%) and women of the same age, (-1.6%/year; 95% CI -5.6% to 2.5%). Age-specific trends in non-fatal CHD rates reflected the same trends in fatal CHD events in men and women, with rates reportedly increasing in women aged 35-54 years (2.5%/year (95% CI 1.1% to 3.9%). CONCLUSION: The age-specific decline in fatal and non-fatal first CHD rates in older men and women was not observed in those aged 35-54 years. These novel findings provide evidence for a levelling in the CHD incidence rates in younger adults and puts renewed importance on primary prevention in this group.