Emer Shelley

Explaining the recent decrease in coronary heart disease mortality rates in Ireland, 1985–2000

Study objectives: To examine the proportion of the recent decline in coronary heart disease (CHD) deaths in Ireland attributable to (a) “evidence based” medical and surgical treatments, and (b) changes in major cardiovascular risk factors. Design setting: IMPACT, a previously validated model, was used to combine and analyse data on the use and effectiveness of specific cardiology treatments and risk factor trends, stratified by age and sex. The main data sources were published trials and meta-analyses, official statistics, clinical audits, and observational studies. Results: Between 1985 and 2000, CHD mortality rates in Ireland fell by 47% in those aged 25–84. Some 43.6% of the observed decrease in mortality was attributed to treatment effects and 48.1% to favourable population risk factor trends; specifically declining smoking prevalence (25.6%), mean cholesterol concentrations (30.2%), and blood pressure levels (6.0%), but offset by increases in adverse population trends related to obesity, diabetes, and inactivity (−13.8%). Conclusions: The results emphasise the importance of a comprehensive strategy that maximises population coverage of effective treatments, and that actively promotes primary prevention, particularly tobacco control and a cardioprotective diet.

The clustering of health behaviours in Ireland and their relationship with mental health, self-rated health and quality of life

BackgroundHealth behaviours do not occur in isolation. Rather they cluster together. It is important to examine patterns of health behaviours to inform a more holistic approach to health in both health promotion and illness prevention strategies. Examination of patterns is also important because of the increased risk of mortality, morbidity and synergistic effects of health behaviours. This study examines the clustering of health behaviours in a nationally representative sample of Irish adults and explores the association of these clusters with mental health, self-rated health and quality of life.MethodsTwoStep Cluster analysis using SPSS was carried out on the SLÁN 2007 data (national Survey of Lifestyle, Attitudes and Nutrition, n = 10,364; response rate =62%; food frequency n = 9,223; cluster analysis n = 7,350). Patterns of smoking, drinking alcohol, physical activity and diet were considered. Associations with positive and negative mental health, quality of life and self-rated health were assessed.ResultsSix health behaviour clusters were identified: Former Smokers, 21.3% (n = 1,564), Temperate, 14.6% (n = 1,075), Physically Inactive, 17.8% (n = 1,310), Healthy Lifestyle, 9.3% (n = 681), Multiple Risk Factor, 17% (n = 1248), and Mixed Lifestyle, 20% (n = 1,472). Cluster profiles varied with men aged 18-29 years, in the lower social classes most likely to adopt unhealthy behaviour patterns. In contrast, women from the higher social classes and aged 65 years and over were most likely to be in the Healthy Lifestyle cluster. Having healthier patterns of behaviour was associated with positive lower levels of psychological distress and higher levels of energy vitality.ConclusionThe current study identifies discernible patterns of lifestyle behaviours in the Irish population which are similar to those of our European counterparts. Healthier clusters (Former Smokers, Temperate and Healthy Lifestyle) reported higher levels of energy vitality, lower levels of psychological distress, better self-rated health and better quality of life. In contrast, those in the Multiple Risk Factor cluster had the lowest levels of energy and vitality and the highest levels of psychological distress. Identification of these discernible patterns because of their relationship with mortality, morbidity and longevity is important for identifying national and international health behaviour patterns.

Stroke awareness in the general population: knowledge of stroke risk factors and warning signs in older adults.

BackgroundStroke is a leading cause of death and functional impairment. While older people are particularly vulnerable to stroke, research suggests that they have the poorest awareness of stroke warning signs and risk factors. This study examined knowledge of stroke warning signs and risk factors among community-dwelling older adults.MethodsRandomly selected community-dwelling older people (aged 65+) in Ireland (n = 2,033; 68% response rate). Participants completed home interviews. Questions assessed knowledge of stroke warning signs and risk factors, and personal risk factors for stroke.ResultsOf the overall sample, 6% had previously experienced a stroke or transient ischaemic attack. When asked to identify stroke risk factors from a provided list, less than half of the overall sample identified established risk factors (e.g., smoking, hypercholesterolaemia), hypertension being the only exception (identified by 74%). Similarly, less than half identified established warning signs (e.g., weakness, headache), with slurred speech (54%) as the exception. Overall, there were considerable gaps in awareness with poorest levels evident in those with primary level education only and in those living in Northern Ireland (compared with Republic of Ireland).ConclusionKnowledge deficits in this study suggest that most of the common early symptoms or signs of stroke were recognized as such by less than half of the older adults surveyed. As such, many older adults may not recognise early symptoms of stroke in themselves or others. Thus, they may lose vital time in presenting for medical attention. Lack of public awareness about stroke warning signs and risk factors must be addressed as one important contribution to reducing mortality and morbidity from stroke.

Living longer and feeling better: healthy lifestyle, self-rated health, obesity and depression in Ireland.

BACKGROUND The combination of four protective lifestyle behaviours (being physically active, a non-smoker, a moderate alcohol consumer and having adequate fruit and vegetable intake) has been estimated to increase life expectancy by 14 years. However, the effect of adopting these lifestyle behaviours on general health, obesity and mental health is less defined. We examined the combined effect of these behaviours on self-rated health, overweight/obesity and depression. METHODS Using data from the Survey of Lifestyle Attitudes and Nutrition (SLAN) 2007 (), a protective lifestyle behaviour (PLB) score was constructed for 10,364 men and women (>18 years), and representative of the Republic of Ireland adult population (response rate 62%). Respondents scored a maximum of four points, one point each for being physically active, consuming five or more fruit and vegetable servings daily, a non-smoker and a moderate drinker. RESULTS One-fifth of respondents (20%) adopted four PLBs, 35% adopted three, 29% two, 13% one and 2% adopted none. Compared to those with zero PLBs, those with four were seven times more likely to rate their general health as excellent/very good [OR 6.8 95% CI (3.64-12.82)] and four times more likely to have better mental health [OR 4.4 95% CI (2.34-8.22)]. CONCLUSIONS Adoption of core protective lifestyle factors known to increase life expectancy is associated with positive self-rated health, healthier weight and better mental health. These lifestyles have the potential to add quality and quantity to life.

Trends in hospitalisation for acute myocardial infarction in Ireland, 1997–2008

Objective To study the temporal and gender trends in age-standardised hospitalisation rates, in-hospital mortality rates and indicators of health service use for acute myocardial infarction (AMI), and the sub-categories, ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI), in Ireland, 1997–2008. Design, setting, patients Anonymised data from the hospital inpatient enquiry were studied for the ICD codes covering STEMI and NSTEMI in all 39 acute hospitals in Ireland over a 12-year period. Age standardisation (direct method) was used to study hospitalisation and in-hospital mortality rates. Joinpoint regression analysis was undertaken to identify significant inflection points in hospitalisation trends. Main outcome measures Age-standardised hospitalisation rates, in-hospital mortality and indicators of health service use (length of stay, bed days) for AMI, STEMI and NSTEMI patients. Results From 1997 to 2008, hospitalisation rates for AMI decreased by 27%, and by 68% for STEMI patients (test for trend p<0.001), and increased by 122% for NSTEMI, (test for trend p<0.001). The mean age of male STEMI patients decreased (p<0.01), while those for the remaining groupings of AMI and subcategories increased. The proportion of males increased significantly for STEMI and NSTEMI (p<0.001). In-hospital mortality decreased steadily (p=0.01 STEMI, p=0.02 NSTEMI), as did median length of stay. Conclusions The authors found a steady decrease in hospitalisation rates with AMI, and a shift away from STEMI towards rising rates of NSTEMI patients who are increasingly older. In an ageing population, and with increasing survival rates, surveillance of acute coronary syndrome and allied conditions is necessary to inform clinicians and policy makers.

Knowledge of stroke risk factors and warning signs in Ireland: development and application of the Stroke Awareness Questionnaire (SAQ)

Background Inability to recognize stroke warning signs and delay in seeking medical attention for recognized symptoms contribute to treatment delay, thus limiting the potential for intervention and impacting negatively on potential stroke outcome. Aim To examine knowledge of stroke risk factors and warning signs in the adult population in Ireland. Methods In 2009, 1000 members of the general public were interviewed by telephone using quota-based population sampling of adults (≥18 years). Information was gathered using the Stroke Awareness Questionnaire (SAQ). Results 71% of participants could correctly list two or more risk factors for stroke, typically generic lifestyle risk factors. Two-thirds could not identify two warning signs for stroke. While 31% could identify two or more stroke warning signs, there was no consistency in warning signs identified. Less than 50% stated they would call an ambulance if having a stroke. Overall, there were significant gaps in knowledge, with poorest levels evident in those aged ≥65 years. Conclusions Survey findings provide first evidence on levels of knowledge of stroke risk factors and warning signs in the Irish adult population. Awareness of stroke warning signs was poor, as was awareness of the need to call emergency services and the potential for acute stroke intervention. These factors contribute to delay in seeking medical attention following stroke, with resulting implications for stroke outcome.

Quality of life assessment in heart failure interventions: a 10-year (1996–2005) review:

The increasing prevalence and poor prognosis associated with heart failure have prompted research to focus on improving quality of life (QoL) for heart failure patients. Research from 1996–2005 was systematically reviewed to identify randomized controlled trials that assessed QoL in heart failure. In 120 studies, 44 were medication trials; 19 surgical/procedural interventions; and 57 patient care/service delivery interventions. Studies were summarized in terms of aim, population, QoL measures used and QoL findings. Studies used 47 different measures of QoL-generic, health-related, condition-specific, domain-specific and utility measures. Most used a single QoL measure. In 87%, a condition specific QoL measure was used, with the Minnesota Living with Heart Failure Questionnaire being the favoured assessment tool. The range of QoL measures in use poses challenges for development of cumulative knowledge. Although comparability across studies is important, this must be informed by the responsiveness of the instrument selected. As carried out in other cardiac groups, comparative evaluations of instrument responsiveness are needed in heart failure. Eur J Cardiovasc Prev Rehabil 14:589-607

Impact of briefly-assessed depression on secondary prevention outcomes after acute coronary syndrome: a one-year longitudinal survey

BackgroundPatients with acute coronary syndromes (ACS) are at increased risk of further acute cardiac events. Secondary prevention aims to decrease morbidity and mortality post-ACS. Depression is related to increased risk in this population, and to poorer secondary prevention activities. However, lengthy depression assessment techniques preclude depression assessment in routine care. The present study investigated the relationship of briefly-assessed depression with secondary prevention outcomes one year post-ACS.MethodsFollowing ethics committee approval, hospitals recruited patients for a national survey of ACS. Consenting patients with ACS completed a brief depression scale during hospitalisation. The predictive validity of two brief scales was independently assessed, with groups combined for the overall sample. Participants then completed a one-year longitudinal follow-up postal survey of secondary prevention activities.ResultsThe response rate for follow-up was 86% (n = 681). Proportions taking anti-platelet (88% v 87%; p = 0.334) and lipid-lowering (83% v 84%; p = 0.437) therapies remained unchanged. Prevalence of smoking (40% v 22%; p < 0.001), and median number of cigarettes smoked (20 v 10; p < 0.001) were significantly reduced at one year. Fifty-six per cent of patients reported attending cardiac rehabilitation programmes. Of those aged <65 years at baseline, 54% had returned to work at one year. A majority (56%) reported feeling physically better. Prevalence of depression was unchanged in those who completed a depression scale at both time points (15% v 17%; p = 0.434). Baseline depression did not predict taking anti-platelet, blood pressure or cholesterol medications (all p > 0.05), but did predict continuation of smoking (OR = 2.3, 95% CI 1.3–4.0, p = 0.003), a higher (above median) number of general practitioner visits (OR = 2.1, 95% CI 1.3–3.4, p = 0.005), failure to return to work (OR = 0.4, 95% CI 0.2–0.8, p = 0.015), and not feeling better (OR = 0.6, 95% CI 0.3–1.0, p = 0.05) at one year.ConclusionRapid depression assessment can be used to help identify patients with ACS at risk of a range of poorer secondary prevention outcomes. The results provide support for the routine screening of depression in acute settings. Strategies to increase rates of smoking cessation, return to work, general well-being and decrease health service use by depressed patients may need to incorporate some element of treatment for depression.

Comparing primary prevention with secondary prevention to explain decreasing Coronary Heart Disease death rates in Ireland, 1985–2000

BackgroundTo investigate whether primary prevention might be more favourable than secondary prevention (risk factor reduction in patients with coronary heart disease(CHD)).MethodsThe cell-based IMPACT CHD mortality model was used to integrate data for Ireland describing CHD patient numbers, uptake of specific treatments, trends in major cardiovascular risk factors, and the mortality benefits of these specific risk factor changes in CHD patients and in healthy people without recognised CHD.ResultsBetween 1985 and 2000, approximately 2,530 fewer deaths were attributable to reductions in the three major risk factors in Ireland. Overall smoking prevalence declined by 14% between 1985 and 2000, resulting in about 685 fewer deaths (minimum estimate 330, maximum estimate 1,285) attributable to smoking cessation: about 275 in healthy people and 410 in known CHD patients. Population total cholesterol concentrations fell by 4.6%, resultingin approximately 1,300 (minimum estimate 1,115, maximum estimate 1,660) fewer deaths attributable to dietary changes(1,185 in healthy people and 115 in CHD patients) plus 305 fewer deaths attributable to statin treatment (45 in people without CHD and 260 in CHD patients). Mean population diastolic blood pressure fell by 7.2%, resulting in approximately 170 (minimum estimate 105, maximum estimate 300) fewer deaths attributable to secular falls in blood pressure (140 in healthy people and 30 in CHD patients), plus approximately 70 fewer deaths attributable to antihypertensive treatments in people without CHD.Of all the deaths attributable to risk factor falls, some 1,715 (68%) occurred in people without recognized CHD and 815(32%) in CHD patients.ConclusionCompared with secondary prevention, primary prevention achieved a two-fold larger reduction in CHD deaths. Future national CHD policies should therefore prioritize nationwide interventions to promote healthy diets and reduce smoking.

Gender differences in the presentation and management of acute coronary syndromes: a national sample of 1365 admissions

Background Gender differences in presentation and management of acute coronary syndromes (ACS) are well established internationally. This study investigated differences in a national Irish sample. Design Cross-sectional survey. Methods All centres (n = 39) admitting cardiac patients to intensive/coronary care provided information on 25 consecutive acute myocardial infarction patients and other ACS patients admitted concurrently (n = 1365 episodes). Patient data was analyzed in terms of those with prior ACS/revascularization, and those without. Results Men with prior established ACS/revascularization were twice as likely to have received revascularization procedures (coronary artery bypass graft or percutaneous coronary intervention) prior to admission when controlling for age, total cholesterol and insurance status [odds ratio (OR) 1.97, 95% confidence interval (CI) 1.18–3.29, P=0.011]. No gender differences were seen in acute-phase reperfusion (OR 0.96, 95% CI 0.76–1.24, P>0.05) or antiplatelet therapy (OR 0.99, 95% CI 0.69–1.41, P>0.05). For patients with prior ACS/revascularization, men were twice as likely to receive statins on discharge after adjustment for age and total cholesterol (OR 1.94, 95% CI 1.02–3.71, P=0.045). Conclusions Women were treated differently to men. Fewer women with a positive history of ACS received revascularization prior to current admission and fewer women were prescribed lipid-lowering medications on discharge. Acute phase hospital treatment was not gender determined. These findings have implications for secondary prevention in Ireland.