Adam Redpath

Long-term trends in first hospitalization for heart failure and subsequent survival between 1986 and 2003: a population study of 5.1 million people.

Background— We examined whether population-level hospitalization rates for heart failure (HF) and subsequent survival have continued to improve since the turn of the century. We also examined trends in the prescribing of evidence-based pharmacological treatment for HF. Methods and Results— All patients in Scotland hospitalized with a first episode of HF between 1986 and 2003 were followed up until death or the end of 2004. Prescriptions of evidence-based treatments issued from 1997 to 2003 by a sample of primary care practices were also examined. A total of 116 556 individuals (52.6% women) had a first hospital discharge for HF. Age-adjusted first hospitalization rates for HF (per 100 000; 95% CI in parentheses) rose from 124 (119 to 129) in 1986 to 162 (157 to 168) in 1994 and then fell to 105 (101 to 109) in 2003 in men; in women, they rose from 128 (123 to 132) in 1986 to 160 (155 to 165) in 1993, falling to 101 (97 to 105) in 2003. Case-fatality rates fell steadily over the period. Adjusted 30-day case-fatality rates fell after discharge (adjusted odds [2003 versus 1986] 0.59 [95% CI 0.45 to 0.63] in men and 0.77 [95% CI 0.67 to 0.88] in women). Adjusted 1- and 5-year survival improved similarly. Median survival increased from 1.33 to 2.34 years in men and from 1.32 to 1.79 years in women. Age-adjusted prescribing rates for angiotensin-converting enzyme inhibitors, β-blockers, and spironolactone increased from 1997 to 2003 (all P<0.0001 for trend). Conclusions— After rising between 1986 and 1994, rates of first hospitalization for HF declined. Case-fatality rates also fell. Prescribing rates for HF therapies increased from 1997 to 2003. These findings suggest that improvements in the prevention and treatment of HF may have had progressive, sustained effects on outcomes at the population level; however, prognosis remains poor in HF.

Evidence of Improving Prognosis in Heart Failure Trends in Case Fatality in 66 547 Patients Hospitalized Between 1986 and 1995

BackgroundContemporary survival in unselected patients with heart failure and the population impact of newer therapies have not been widely studied. Therefore, we have documented case-fatality rates (CFRs) over a recent 10-year period. Methods and ResultsIn Scotland, all hospitalizations and deaths are captured on a single database. We have studied case fatality in all patients admitted with a principal diagnosis of heart failure from 1986 to 1995. A total of 66 547 patients (47% male) were studied. Median age was 72 years in men and 78 years in women. Crude CFRs at 30 days and at 1, 5, and 10 years were 19.9%, 44.5%, 76.5%, and 87.6%, respectively. Median survival was 1.47 years in men and 1.39 years in women (2.47 and 2.36 years, respectively, in those surviving 30 days). Age had a powerful effect on survival, and sex, comorbidity, and deprivation had modest effects. One-year CF was 24.2% in those aged <55 years and 58.1% in those aged >84 years. After adjustment, 30-day CFRs fell between 1986 and 1995, by 26% (95% CI 15 to 35, P <0.0001) in men and 17% (95% CI 6 to 26, P <0.0001) in women. Longer term CFRs fell by 18% (95% CI 13 to 24, P <0.0001) in men and 15% (95% CI 10 to 20, P <0.0001) in women. Median survival increased from 1.23 to 1.64 years. ConclusionsHeart failure CF is much higher in the general population than in clinical trials, especially in the elderly. Although survival has increased significantly over the last decade, there is still much room for improvement.

Gender and survival: A population-based study of 201,114 men and women following a first acute myocardial infarction

OBJECTIVES We tested the hypotheses that the effect of gender on short-term case fatality following a first admission for acute myocardial infarction (AMI) varies with age, and that this effect is offset by differences in the proportion of men and women who survive to reach hospital. BACKGROUND Evidence is conflicting regarding the effect of gender on prognosis after AMI. METHODS All 201,114 first AMIs between 1986 and 1995 were studied. Both 30-day and 1-year case fatality were analyzed for the 117,749 patients hospitalized and for all first AMIs, including deaths before hospitalization. The effect of gender and its interaction with age on survival was examined using multivariate modeling. RESULTS Gender-based differences in survival varied according to age in hospitalized patients, with younger women having higher 30-day case fatality than men (e.g., <55 years, women 6.5% vs. 4.8% men, p < 0.0001). When deaths from first AMI before hospitalization were included in 30-day case fatality, women were less likely to die (adjusted odds ratio 0.9, confidence interval 0.89 to 0.93). Gender was not an independent predictor of one-year survival (p = 0.16). CONCLUSIONS Female gender increases the probability of surviving to reach hospital, and this outweighs the excess risk of death occurring in younger women following hospitalization. Overall, men have a higher 30-day case fatality than women. Women do not fare worse than men after AMI when age and other factors are taken into account. However, men are more likely to die before hospitalization.

Age, sex, and social trends in out-of-hospital cardiac deaths in Scotland 1986–95: a retrospective cohort study

BACKGROUND Most deaths from coronary heart disease occur out of hospital. Hospital patients face social, age, and sex inequalities. Our aim was to examine inequalities and trends in out-of-hospital cardiac deaths. METHODS We used the Scottish record linked database to identify all deaths from acute myocardial infarction that occurred in Scotland (population 5.1 million), in 1986-95. We have compared population-based death rates for men and women across age and social groups. FINDINGS Between 1986 and 1995, 83365 people died from acute myocardial infarction, out of hospital and without previous hospital admission (44655 men, 38710 women); and 117749 were admitted with a first acute myocardial infarction, of whom 37020 died within 1 year. Thus, out-of-hospital deaths accounted for 69.2% (95% CI 69.0-69.5) of all 120385 deaths. Out-of-hospital deaths, measured as a proportion of all acute myocardial infarction events (deaths plus first hospital admissions), increased with age, from 20.1% (19.2-21.0) in people younger than 55 years, to 62.1% (61.3-62.9) in those older than 85 years. Population-based out-of-hospital mortality rates fell by a third in men and by a quarter in women. Mean yearly falls were larger in people aged 55-64 years (5.6% per year in men, 3.7% in women), than in those older than 85 years (2.5% in men and women). Mortality rates were substantially higher in deprived socioeconomic groups than in affluent groups, especially in people younger than 65 years. INTERPRETATION These inequalities in age, sex, and socioeconomic class should be actively addressed by prevention strategies for coronary heart disease.

Coronary heart disease mortality among young adults in Scotland in relation to social inequalities: time trend study

Objective To examine recent trends and social inequalities in age specific coronary heart disease mortality. Design Time trend analysis using joinpoint regression. Setting Scotland, 1986-2006. Participants Men and women aged 35 years and over. Main outcome measures Age adjusted and age, sex, and deprivation specific coronary heart disease mortality. Results Persistent sixfold social differentials in coronary heart disease mortality were seen between the most deprived and the most affluent groups aged 35-44 years. These differentials diminished with increasing age but equalised only above 85 years. Between 1986 and 2006, overall, age adjusted coronary heart disease mortality decreased by 61% in men and by 56% in women. Among middle aged and older adults, mortality continued to decrease fairly steadily throughout the period. However, coronary heart disease mortality levelled from 1994 onwards among young men and women aged 35-44 years. Rates in men and women aged 45-54 showed similar flattening from about 2003. Rates in women aged 55-64 may also now be flattening. The flattening of coronary heart disease mortality in younger men and women was confined to the two most deprived fifths. Conclusions Premature death from coronary heart disease remains a major contributor to social inequalities. Furthermore, the flattening of the decline in mortality for coronary heart disease among younger adults may represent an early warning sign. The observed trends were confined to the most deprived groups. Marked deterioration in medical management of coronary heart disease seems implausible. Unfavourable trends in the major risk factors for coronary heart disease (smoking and poor diet) thus provide the most likely explanation for these inequalities.

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

Abstract ObjectiveTo examine whether there are socioeconomic gradients in the incidence, prevalence, treatment, and follow up of patients with heart failure in primary care. DesignPopulation based study. Setting53 general practices (307 741 patients) participating in the Scottish continuous morbidity recording project between 1April 1999 and 31 March 2000. Participants2186 adults with heart failure. Main outcome measuresComorbid diagnoses, frequency of visits to general practitioner, and prescribed drugs. Results2186 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%)βblockers, 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.

Relation between socioeconomic deprivation and death from a first myocardial infarction in Scotland: population based analysis

Health policy now explicitly addresses the increasing inequalities arising within many countries.1 Although it is generally accepted that socioeconomic factors influence the overall rates of coronary heart disease events,2 studies of case fatality after admission to hospital for acute myocardial infarction show only modest socioeconomic gradients.3 By focusing on those who survive to reach hospital, however, such studies may underestimate the true influence of socioeconomic deprivation. Reports suggest that around 70-80% of deaths within 30 days of a myocardial infarction occur before admission to hospital, and this proportion increases with age.4 We therefore examined the effect of socioeconomic deprivation not only on case fatality in patients admitted with myocardial infarction but also on the risk of death before admission. Data were obtained from the Scottish Morbidity Record and General Register Office on all Scottish residents for whom a first myocardial …

Sex differences in incidence, mortality, and survival in individuals with stroke in Scotland, 1986 to 2005.

Background and Purpose— The aim of this study was to examine the effect of sex across different age groups and over time for stroke incidence, 30-day case-fatality, and mortality. Methods— All first hospitalizations for stroke in Scotland (1986 to 2005) were identified using linked morbidity and mortality data. Age-specific rate ratios (RRs) for comparing women with men for both incidence and mortality were modeled with adjustment for study year and socioeconomic deprivation. Logistic regression was used to model 30-day case-fatality. Results— Women had a lower incidence of first hospitalization than men and size of effect varied with age (55 to 64 years, RR=0.65, 95% CI 0.63 to 0.66; ≥85 years, RR=0.94, 95% CI 0.91 to 0.96). Women aged 55 to 84 years had lower mortality than men and again size of effect varied with age (65 to 74 years, RR=0.79, 95% CI 0.76 to 0.81); 75 to 84 years, RR=0.94, 95% CI 0.92 to 0.95). Conversely, women aged ≥85 years had 15% higher stroke mortality than men (RR=1.15, 95% CI 1.12 to 1.18). Adjusted risk of death within 30 days was significantly higher in women than men, and this difference increased over the 20-year period in all age groups (adjusted OR in 55 to 64 year olds 1.23, 95% CI 1.14 to 1.33 in 1986 and 1.51, 95% CI 1.39 to 1.63 in 2005). Conclusions— We observed lower rates of incidence and mortality in younger women than men. However, higher numbers of older women in the population mean that the absolute burden of stroke is greater in women. Short-term case-fatality is greater in women of all ages and, worryingly, these differences have increased from 1986 to 2005.

Hospital discharge rates for suspected acute coronary syndromes between 1990 and 2000: population based analysis.

Although hospital discharge rates for acute myocardial infarction are falling,1–4 no contemporary studies compare temporal trends in these rates for angina and other types of chest pain. We examined recent trends in population discharge rates for myocardial infarction, angina, and chest pain (“suspected acute coronary syndromes”) between 1990 and 2000. We got data from the Scottish morbidity record for Scottish residents aged at least 18 years with a “first” emergency hospitalisation for myocardial infarction (codes ICD-9 (international classification of diseases, ninth revision) 410, ICD-10 I21 or I22), angina (ICD-9 411 or 413; ICD-10 I20 or I24.9) or “other chest pain” (ICD-9 786.5; ICD-10 R07), between 1990 and 2000.5 We analysed discharges coded only in the principal position. A “first” hospitalisation was one with no discharge diagnosis of coronary heart disease or chest pain in the previous 10 years. We calculated rates using annual official age and sex specific population estimates for 1990-2000 and tested the significance of …

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 ⩾ 85 years. The incidence of heart failure was 2.0 in 1000, increasing with age to 22.4 in 1000 among patients ⩾ 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 β 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 β blocker, 11% spironolactone, and 50% an angiotensin converting enzyme inhibitor. The corresponding figures for patients ⩾ 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.