M. Justin Zaman

The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP)

AIMS Older people increasingly constitute a large proportion of the acute coronary syndrome (ACS) population. We examined the relationship of age with receipt of more intensive management and secondary prevention medicine. Then, the comparative association of intensive management (reperfusion/angiography) over a conservative strategy on time to death was investigated by age. METHODS AND RESULTS Using data from 155 818 patients in the national registry for ACS in England and Wales [the Myocardial Ischaemia National Audit Project (MINAP)], we found that older patients were incrementally less likely to receive secondary prevention medicines and intensive management for both ST-elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). In STEMI patients ≥85 years, 55% received reperfusion compared with 84% in those aged 18 to <65 [odds ratio 0.22 (95% CI 0.21, 0.24)]. Not receiving intensive management was associated with worse survival [mean follow-up 2.29 years (SD 1.42)] in all age groups (adjusted for sex, cardiovascular risk factors, co-morbidities, healthcare factors, and case severity), but there was an incremental reduction in survival benefit from intensive management with increasing age. In STEMI patients aged 18-64, 65-74, 75-84, and ≥85, adjusted hazard ratios (HRs) for all-cause mortality comparing conservative treatment to intensive management were 1.98 (1.78, 2.19), 1.65 (1.51, 1.80), 1.62 (1.52, 1.72), and 1.36 (1.27, 1.47), respectively. In NSTEMI patients, the respective HRs were 4.37 (4.00, 4.78), 3.76 (3.54, 3.99), 2.79 (2.67, 2.91), and 1.90 (1.77, 2.04). CONCLUSION We found an incremental reduction in the use of evidence-based therapies with increasing age using a national ACS registry cohort. While survival benefit from more intensive management reduced with older age, better survival was associated with intensive management at all ages highlighting the requirement to improve standard of care in older patients with ACS.

Presentation of stable angina pectoris among women and South Asian people

Background: There is speculation that women and South Asian people are more likely than men and white people to report atypical angina and that they are less likely to undergo invasive management of angina. We sought to determine whether atypical symptoms of angina pectoris in women and South Asians impacted clinically important outcomes and clinical management. Methods: We prospectively identified 2189 South Asian people and 5605 white people with recent-onset chest pain at 6 chest-pain clinics in the United Kingdom. We documented hospital admissions for acute coronary syndromes, coronary deaths as well as coronary angiography and revascularization procedures. Results: Atypical chest pain was reported by more women than men (56.5% vs 54.5%, p < 0.054) and by more South Asian patients than white patients (59.9% vs 52.5%, p < 0.001). Typical symptoms were associated with coronary death or acute coronary syndromes among women (hazard ratio [HR] 2.30, 95% CI 1.70–3.11, p < 0.001) but not among men (HR 1.23, 95% CI 0.96–1.57, p = 0.10). Typical symptoms were associated with coronary outcomes in both South Asian and white patients. Among those with typical symptoms, women (HR 0.76, 95% CI 0.63–0.92, p = 0.004) and South Asian patients (HR 0.52, 95% CI 0.41–0.67, p < 0.001) were less likely than men and white patients to receive angiography. Interpretation: Compared to those with atypical chest pain, women and South Asian patients with typical pain had worse clinical outcomes. However, sex and ethnic background did not explain differences in the use of invasive procedures.

Relationship of serum interleukin-10 and its genetic variations with ischemic stroke in a Chinese general population

Background and Purpose Anti-inflammatory cytokine and its genetic variations may play an important role in the process of atherosclerosis. We assessed whether serum interleukin-10 (IL-10) and its genetic variations are associated with ischemic stroke in a Chinese general population. Methods An epidemiological survey on cardiovascular diseases and their risk factors was carried in a general population in Beijing in 2005. Serum IL-10, IL-6, p-selectin, soluble intercellular adhesion molecule-1 and C-reactive protein were analyzed using ELISA kits, while three IL-10 Single Nucleotide Polymorphisms (SNP) (rs1800872, rs1554286 and rs3021094) were genotyped in 1475 participants. Results A high serum IL-10 (top tertile) was significantly associated with ischemic stroke (multivariable adjusted odds ratio (OR) =0.50; 95%CI 0.31-0.81). Rs1800872 (AA vs. AC+CC genotype, OR=1.60; 1.06-2.39), rs1554286(TT vs. CT+CC genotype, OR=1.59; 1.06-2.39), and rs3021094 (CC/CA vs. AA genotype, OR=1.64; 1.04-2.60) were all significantly associated with ischemic stroke even after controlling for age, sex, smoking, systolic blood pressure, total cholesterol, glucose, body mass index and serum IL-10. The SNP score (a summary index of these SNPs) and IL-10 (top tertile) together significantly improved the discriminative power in predicting ischemic stroke by 3.3% (95%CI: 0.2-6.4, p=0.0398) compared to predictions based on conventional risk factors alone. Conclusions The lower serum IL-10 concentration and its selected genetic variations were significantly associated with an increased likelihood of ischemic stroke in this cross-sectional study. Our results suggest that more prospective studies should be conducted to provide stronger evidence justifying the use of IL-10 and its SNPs as new biomarkers to identify a predisposition towards ischemic stroke.

New answers to three questions on the epidemic of coronary mortality in south Asians: Incidence or case fatality? Biology or environment? Will the next generation be affected?

Studying ethnic differences in health not only benefits minority groups but is a powerful tool for scientific analysis and for social action in the wider field of health inequalities. Coronary mortality in developed countries is well-known to be higher for men and women born in south Asia compared to other ethnic groups. The aim of this review is to examine how the knowledge of ethnic differences in coronary health in south Asians has advanced in the last decade. We set out to answer the following: Is the high rate of coronary mortality in south Asians a result of high incidence or high case fatality? Why are there ethnic differences, and are they the result of biology, healthcare or social circumstances? Is the cardiovascular health future for south Asians (and especially the UK-born second generation) any brighter than in their parents?

Cardiothoracic ratio within the 'normal' range independently predicts mortality in patients undergoing coronary angiography

Objective: To determine whether cardiothoracic ratio (CTR), within the range conventionally considered normal, predicted prognosis in patients undergoing coronary angiography. Design: Cohort study with a median of 7-years follow-up. Setting: Consecutive patients undergoing coronary angiography at Barts and The London National Health Service (NHS) Trust. Subjects: 1005 patients with CTRs measured by chest radiography, and who subsequently underwent coronary angiography. Of these patients, 7.3% had a CTR ⩾0.5 and were excluded from the analyses. Outcomes: All-cause mortality and coronary event (non-fatal myocardial infarction or coronary death). Adjustments were made for age, left ventricular dysfunction, ACE inhibitor treatment, body mass index, number of diseased coronary vessels and past coronary artery bypass graft. Results: The risk of death was increased among patients with a CTR in the upper part of the normal range. In total, 94 (18.9%) of those with a CTR below the median of 0.42 died compared with 120 (27.8%) of those with a CTR between 0.42 and 0.49 (log rank test p<0.001). After adjusting for potential confounders, this increased risk remained (adjusted HR 1.45, 95% CI 1.03 to 2.05). CTR, at values below 0.5, was linearly related to the risk of coronary event (test for trend p = 0.024). Conclusion: : In patients undergoing coronary angiography, CTR between 0.42 and 0.49 was associated with higher mortality than in patients with smaller hearts. There was evidence of a continuous increase in risk with higher CTR. These findings, along with those in healthy populations, question the conventional textbook cut-off point of ⩾0.5 being an abnormal CTR.

Relationship between anemia and mortality outcomes in a national acute coronary syndrome cohort: Insights from the UK Myocardial Ischemia National Audit Project registry

Background We aim to determine the prevalence of anemia in acute coronary syndrome (ACS) patients and compare their clinical characteristics, management, and clinical outcomes to those without anemia in an unselected national ACS cohort. Methods and Results The Myocardial Ischemia National Audit Project (MINAP) registry collects data on all adults admitted to hospital trusts in England and Wales with diagnosis of an ACS. We conducted a retrospective cohort study by analyzing patients in this registry between January 2006 and December 2010 and followed them up until August 2011. Multiple logistic regressions were used to determine factors associated with anemia and the adjusted odds of 30‐day mortality with 1 g/dL incremental hemoglobin increase and the 30‐day and 1‐year mortality for anemic compared to nonanemic groups. Analyses were adjusted for covariates. Our analysis of 422 855 patients with ACS showed that 27.7% of patients presenting with ACS are anemic and that these patients are older, have a greater prevalence of renal disease, peripheral vascular disease, diabetes mellitus, and previous acute myocardial infarction, and are less likely to receive evidence‐based therapies shown to improve clinical outcomes. Finally, our analysis suggests that anemia is independently associated with 30‐day (OR 1.28, 95% CI 1.22‐1.35) and 1‐year mortality (OR 1.31, 95% CI 1.27‐1.35), and we observed a reverse J‐shaped relationship between hemoglobin levels and mortality outcomes. Conclusions The prevalence of anemia in a contemporary national ACS cohort is clinically significant. Patients with anemia are older and multimorbid and less likely to receive evidence‐based therapies shown to improve clinical outcomes, with the presence of anemia independently associated with mortality outcomes.

Prognostic value of troponins in acute coronary syndrome depends upon patient age

Objective This study aims to determine whether the prognostic significance of troponins in acute coronary syndrome in predicting mortality varies by age, and if so, to what extent when other prognostic indicators are considered. Methods We analysed Myocardial Ischemia National Audit Project registry data collected between January 2006 and December 2010 and followed up this cohort for all-cause mortality until August 2011. Relationships between peak troponin levels (types I and T) and time to death in different age groups, and between age and time to death at different troponin levels were investigated using multiple variable adjusted Cox regression models. Results Of the 322 617 patients with acute coronary syndromes included, a third (n=106 365, 33%) died during 695 334 person-years of follow-up. Within each troponin category, older age was associated with a higher mortality even in those with a troponin <0.01 ng/mL for both troponin types (HR ∼10–12 in ≥85 years cf. HR of 1.0 in <65 years). The relative potency of an elevated troponin to predict an adverse outcome compared with a low troponin attenuated with increased age (for troponin I ≥15.0 compared with troponin I <0.01 in age <65, adjusted HR 2.41 (95% CI 1.80 to 3.24); age ≥85 HR 2.01 (1.62 to 2.52)). Similar but less consistent results were observed with troponin T elevation at the higher levels. Conclusions Clinicians should interpret the prognostic value of troponin taking into account the patients age.

Update on guidelines for management of hypercholesterolemia

Coronary heart disease (CHD) is a leading cause of morbidity and mortality globally. Hypercholesterolemia is one of the major risk factors for CHD. With the increase in aging populations and progressively sedentary lifestyles, the global burden of CHD is likely to increase in the future despite better preventive strategies. It is vitally important to manage hypercholesterolemia effectively because it is a modifiable risk factor. At present, there are several guidelines with differences in recommendations. In this paper the authors present an update on the guidelines on hypercholesterolemia management. The authors have systematically reviewed guidelines in hypercholesterolemia management and discussed a pragmatic approach to follow the most recent guidelines including guidance from NICE in the primary care setting.

Effect of age on the prognostic value of left ventricular function in patients with acute coronary syndrome: A prospective registry study.

Objective: This study aims to study the prognostic impact of left ventricular function on mortality and examine the effect of age on the prognostic value of left ventricular function. Methods: We examined the myocardial ischaemia national audit project registry (2006–2010) data with a mean follow-up of 2.1 years. Left ventricular function was categorised into good (ejection fraction ⩾50%), moderate (ejection fraction 30–49%) and poor (ejection fraction <30%) categories. Cox proportional hazards models were constructed to examine the prognostic significance of left ventricular function in different age groups (<65, 65–74, 75–84 and ⩾85 years) on all-cause mortality adjusting for baseline variables. Results: Out of 424,848 patients, left ventricular function data were available for 123,609. Multiple imputations were used to impute missing values of left ventricular function and the final sample for analyses was drawn from 414,305. After controlling for confounders, 339,887 participants were included in the regression models. For any age group, mortality was higher with a worsening degree of left ventricular impairment. Increased age reduced the adverse prognosis associated with reduced left ventricular function (hazard ratios of death comparing poor left ventricular function to good left ventricular function were 2.11, 95% confidence interval 1.88–2.37 for age <65 years and 1.28, 95% confidence interval 1.20–1.36 for age ⩾85 years). Older patients had a high mortality risk even in those with good left ventricular function. Hazard ratios of mortality for ⩾85 compared to <65 years (hazard ratio = 1.00) within good, moderate and poor ejection fraction groups were 5.89, 4.86 and 3.43, respectively. Conclusions: In patients with acute coronary syndrome, clinicians should interpret the prognostic value of left ventricular function taking into account the patient’s age.

Association of increasing age with receipt of specialist care and long-term mortality in patients with non-ST elevation myocardial infarction

BACKGROUND observational studies suggest that older patients are less likely to receive secondary prevention medicines following acute coronary syndrome (ACS). OBJECTIVES to examine the association of increasing age with receipt of specialist care and influence of specialist care on long-term mortality in patients with non-ST elevation myocardial infarction (NSTEMI). DESIGN a cohort study. SETTING National ACS registry of England and Wales. SUBJECTS a total of 85,183 patients admitted with NSTEMI between 2006 and 2010. METHODS logistic regression analyses to assess receipt of secondary prevention medicines (ACE inhibitor, β-blocker, statin, aspirin) by age group; multivariate Cox regression models to examine longitudinal effect of cardiologist care on all-cause mortality by age group. RESULTS mean age 72.0 years (SD 13.0 years), mean follow-up was 2.13 years. Older patients received less cardiologist care (70.2% of NSTEMI patients ≥85 years compared with 94.7% of patients <65) years and had more co-morbidity. Cardiologists prescribed more secondary prevention in all age groups than generalists, but this was mostly explained away by co-morbidity (receipt of statin crude OR 1.51 (1.27,1.80), fully adjusted OR 1.11 (0.92,1.33) in patients ≥85 years). Receiving cardiologist care compared with generalist care was associated with a decreased risk of death in all even after adjustment for co-morbidity, disease severity and secondary prevention; this benefit reduced incrementally with older age group (adjusted hazard ratio (HR) 0.58 (0.49,0.68) aged <65; 0.87 (0.82,0.92) aged ≥85). CONCLUSION older patients with NSTEMI were less likely to see a cardiologist, but reduced treatment by generalists was explained away by co-morbidity. Cardiologist care was associated with lower mortality in all age groups than a generalist, but this survival benefit was less pronounced in older patients.