Alan Finlayson

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.

Impact of changing diagnostic criteria on incidence, management, and outcome of acute myocardial infarction: retrospective cohort study

Acute myocardial infarction used to be defined by criteria based on symptoms, changes in electrocardiograms and the concentrations of cardiac enzymes, as recommended by the World Health Organization.1 Specific markers of myocardial damage, including troponin T, are more sensitive indicators than total creatine kinase concentration for ischaemic myocardial necrosis and prognosis.2 In 2000, the European Society of Cardiology and the American College of Cardiology recommended changing the diagnostic criteria for acute myocardial infarction to include raised troponin T concentrations in addition to changes in electrocardiograms or coronary intervention.3 Some patients with acute coronary syndrome who had been diagnosed as having unstable angina are now classified as having myocardial infarction. We investigated the impact of using the new criteria on the incidence, management, and outcome of myocardial infarction. Since 1997, all patients admitted with chest pain to Monklands Hospital, Airdrie, had their troponin T concentrations measured. We identified patients …

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 …

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.

Trends in case-fatality in 22 968 patients admitted for the first time with atrial fibrillation in Scotland, 1986–1995

BACKGROUND Although atrial fibrillation (AF) is an important cause of cardiovascular morbidity and mortality there is a paucity of data describing hospitalisation rates and case-fatality associated with this common arrhythmia. This study examines recent trends in first-ever hospitalisations for AF in Scotland. METHODS Using the linked Scottish Morbidity Record Scheme, we identified all 22968 patients admitted to Scottish hospitals for the first time with a principal diagnosis of AF between 1986 and 1995. For each calendar year we calculated short (30-day) and medium (31 day to 2 years) case-fatality rates. Adjusting for each patients age, sex, deprivation status, concurrent diagnoses and prior hospitalisation status, we examined whether case-fatality rates had significantly improved during this 10-year period. RESULTS Between 1986 and 1995 the number of men hospitalised for the first time with AF increased by 926 (125%) to 1730 per annum and the number of women and by 875 (105%) to 1712 (both P<0.001). Hospitalisation rates increased from 0.31 to 0.70/1000 men and from 0.32 to 0.65/1000 women (both P<0.001). By the end of this period the proportion of men had increased from 48 to 50%. In both sexes, the median age of patients rose--in men from 66 to 68 years and in women from 74 to 75 years (both P<0.01). Despite the increasing age of patients and greater comorbidity, short-term (30-day) case-fatality declined from 4.0 to 3.1% in men (P<0.001) and 4.1 to 3.8% (P<0.01) in women. Similarly, medium-term (31-day to 2-year) case-fatality fell from 25 to 22% in men and 27 to 25% (both P<0.001) in women. Adjusting for the age, sex, extent of deprivation, secondary diagnoses and prior hospitalisation of hospitalised patients, we found that the risk of short-term case-fatality in the 1995 male and female cohort significantly declined by 21% (P<0.05) and 24% (P<0.05), respectively, in comparison to the 1986 cohort. The adjusted risk of case-fatality in the medium term also declined significantly in men by 30% (P<0.05) over this period and by 20% (P<0.05) in women relative to 1986. CONCLUSION The number of first-ever hospitalisations for AF has increased twofold during the 10-year period 1986-1995. Although the age of patients has progressively increased during this period, short and medium case-fatality rates have declined, especially in men. This may partly reflect better treatment of AF. However, changing admission thresholds and other factors could also have led to an apparent improvement in prognosis. Nevertheless, medium-term case fatality remains substantial after a first ever admission to hospital with AF.

Is the Scottish population living dangerously? Prevalence of multiple risk factors: the Scottish Health Survey 2003

BackgroundRisk factors are often considered individually, we aimed to investigate the prevalence of combinations of multiple behavioural risk factors and their association with socioeconomic determinants.MethodsMultinomial logistic regression was used to model the associations between socioeconomic factors and multiple risk factors from data in the Scottish Health Survey 2003. Prevalence of five key risk - smoking, alcohol, diet, overweight/obesity, and physical inactivity, and their risk in relation to demographic, individual and area socioeconomic factors were assessed.ResultsFull data were available on 6,574 subjects (80.7% of the survey sample). Nearly the whole adult population (97.5%) reported to have at least one behavioural risk factor; while 55% have three or more risk factors; and nearly 20% have four or all five risk factors. The most important determinants for having four or five multiple risk factors were low educational attainment which conferred over a 3-fold increased risk compared to high education; and residence in the most deprived communities (relative to least deprived) which had greater than 3-fold increased risk.ConclusionsThe prevalence of multiple behavioural risk factors was high and the prevalence of absence of all risk factors very low. These behavioural patterns were strongly associated with poorer socioeconomic circumstances. Policy to address factors needs to be joined up and better consider underlying socioeconomic circumstances.

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.

Time trends in survival and readmission following coronary artery bypass grafting in Scotland, 1981-96: retrospective observational study

Improvements in coronary revascularisation techniques and an increase in the use of percutaneous interventions1 have led to a rise in the number of coronary artery bypass grafting operations in older patients with more severe cardiac disease and worse comorbidity and who have previously undergone revascularisation procedures. 2 3 Advances in surgical and anaesthetic techniques have prevented a worsening risk profile from being translated into an increase in perioperative deaths. 2 3 The aim of our study was to examine time trends in major outcomes up to two years after coronary artery bypass grafting. We used the Scottish morbidity record (SMR1) system to identify all operations for coronary artery bypass grafting performed in Scottish NHS hospitals from 1981 to 1996. We excluded operations that included other procedures. Information was obtained on age, sex, urgency of the operation, and Carstairs …