Niamh F. Murphy

An epidemiological study of pulmonary arterial hypertension

All hospitalisations for pulmonary arterial hypertension (PAH) in the Scottish population were examined to determine the epidemiological features of PAH. These data were compared with expert data from the Scottish Pulmonary Vascular Unit (SPVU). Using the linked Scottish Morbidity Record scheme, data from all adults aged 16–65 yrs admitted with PAH (idiopathic PAH, pulmonary hypertension associated with congenital heart abnormalities and pulmonary hypertension associated with connective tissue disorders) during the period 1986–2001 were identified. These data were compared with the most recent data in the SPVU database (2005). Overall, 374 Scottish males and females aged 16–65 yrs were hospitalised with incident PAH during 1986–2001. The annual incidence of PAH was 7.1 cases per million population. On December 31, 2002, there were 165 surviving cases, giving a prevalence of PAH of 52 cases per million population. Data from the SPVU were available for 1997–2006. In 2005, the last year with a complete data set, the incidence of PAH was 7.6 cases per million population and the corresponding prevalence was 26 cases per million population. Hospitalisation data from the Scottish Morbidity Record scheme gave higher prevalences of pulmonary arterial hypertension than data from the expert centres (Scotland and France). The hospitalisation data may overestimate the true frequency of pulmonary arterial hypertension in the population, but it is also possible that the expert centres underestimate the true frequency.

Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK

Objective: To evaluate the cost of atrial fibrillation (AF) to health and social services in the UK in 1995 and, based on epidemiological trends, to project this estimate to 2000. Design, setting, and main outcome measures: Contemporary estimates of health care activity related to AF were applied to the whole population of the UK on an age and sex specific basis for the year 1995. The activities considered (and costs calculated) were hospital admissions, outpatient consultations, general practice consultations, and drug treatment (including the cost of monitoring anticoagulant treatment). By adjusting for the progressive aging of the British population and related increases in hospital admissions, the cost of AF was also projected to the year 2000. Results: There were 534 000 people with AF in the UK during 1995. The “direct” cost of health care for these patients was £244 million (~€350 million) or 0.62% of total National Health Service (NHS) expenditure. Hospitalisations and drug prescriptions accounted for 50% and 20% of this expenditure, respectively. Long term nursing home care after hospital admission cost an additional £46.4 million (~€66 million). The direct cost of AF rose to £459 million (~€655 million) in 2000, equivalent to 0.97% of total NHS expenditure based on 1995 figures. Nursing home costs rose to £111 million (~€160 million). Conclusions: AF is an extremely costly public health problem.

A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland

Objective: To examine the epidemiology, primary care burden and treatment of atrial fibrillation (AF). Design: Cross-sectional data from primary care practices participating in the Scottish Continuous Morbidity Recording scheme between April 2001 and March 2002. Setting: 55 primary care practices (362 155 patients). Participants: 3135 patients with AF. Results: The prevalence of AF in Scotland was 9.4/1000 in men and 7.9/1000 in women (p<0.001) and increased with age (to 71/1000 in individuals aged >85 years). The prevalence of AF decreased with increasing socioeconomic deprivation (9.2/1000 least deprived and 7.5/1000 most deprived category, p = 0.02 for trend). 71% of patients with AF received rate-controlling medication: β-blocker 28%, rate-limiting calcium-channel blocker 42% and digoxin 43%. 42% of patients received warfarin, 44% received aspirin and 78% receeved more than one of these. Multivariable analysis showed that men and women aged ⩾75 years were more likely (than those aged <75 years) to be prescribed digoxin (men OR 1.41, 95% CI 1.14 to 1.74; women OR 1.88, 95% CI 1.50 to 2.37) and aspirin (2.04, 1.66 to 2.51; 1.79, 1.42 to 2.25) and less likely to receive an antiarrhythmic drug (0.62, 0.48 to 0.81; 0.52, 0.39 to 0.70) or warfarin (0.74, 0.60 to 0.91; 0.58, 0.46 to 0.73). Adjusted analysis showed no socioeconomic gradient in prescribing. Conclusions: AF is a common condition, more so in men than in women. Deprived individuals are less likely to have AF, a finding raising concerns about socioeconomic gradients in detection and prognosis. Recommended treatments for AF were underused in women and older people. This is of particular concern, given the current trends in population demographics and the evidence that both groups are at higher risk of stroke.

A comparative study of the palliative care needs of heart failure and cancer patients

Studies suggest that patients with advanced heart failure (HF) have unmet palliative care (PC) needs. However, many of these studies have been retrospective or based on patients receiving poorly coordinated ad hoc care. We aimed to demonstrate whether the PC needs of patients with advanced HF receiving specialist multidisciplinary coordinated care are similar to cancer patients deemed to have specialist PC needs; thereby justifying the extension of specialist PC services to HF patients.

Diagnosis of heart failure with preserved ejection fraction: improved accuracy with the use of markers of collagen turnover

Heart failure with preserved ejection fraction (HF‐PEF) can be difficult to diagnose in clinical practice. Myocardial fibrosis is a major determinant of diastolic dysfunction (DD), potentially contributing to the progression of HF‐PEF. The aim of this study was to analyse whether serological markers of collagen turnover may predict HF‐PEF and DD.

Natural history of markers of collagen turnover in patients with early diastolic dysfunction and impact of eplerenone

OBJECTIVES This study was designed to evaluate the impact of eplerenone on collagen turnover in preserved systolic function heart failure (HFPSF). BACKGROUND Despite growing interest in abnormal collagen metabolism as a feature of HFPSF with diastolic dysfunction, the natural history of markers of collagen turnover and the impact of selective aldosterone antagonism on this natural history remains unknown. METHODS We evaluated 44 patients with HFPSF, randomly assigned to control (n = 20) or eplerenone 25 mg daily (n = 24) for 6 months, increased to 50 mg daily from 6 to 12 months. Serum markers of collagen turnover and inflammation were analyzed at baseline and at 6 and 12 months and included pro-collagen type-I and -III aminoterminal peptides, matrix metalloproteinase type-2, interleukin-6 and -8, and tumor necrosis factor-alpha. Doppler-echocardiographic assessment of diastolic filling indexes and tissue Doppler analyses were also obtained. RESULTS The mean age of the patients was 80 +/- 7.8 years; 46% were male; 64% were receiving an angiotensin-converting enzyme inhibitor, 34% an angiotensin-II receptor blocker, and 68% were receiving beta-blocker therapy. Pro-collagen type-III and -I aminoterminal peptides, matrix metalloproteinase type-2, interleukin-6 and -8, and tumor necrosis factor-alpha increased with time in the control group. Eplerenone treatment had no significant impact on any biomarker at 6 months but attenuated the increase in pro-collagen type-III aminoterminal peptide at 12 months (p = 0.006). Eplerenone therapy was associated with modest effects on diastolic function without any impact on clinical variables or brain natriuretic peptide. CONCLUSIONS This study demonstrates progressive increases in markers of collagen turnover and inflammation in HFPSF with diastolic dysfunction. Despite high background utilization of renin-angiotensin-aldosterone modulators, eplerenone therapy prevents a progressive increase in pro-collagen type-III aminoterminal peptide and may have a role in management of this disease. (The Effect of Eplerenone and Atorvastatin on Markers of Collagen Turnover in Diastolic Heart Failure; NCT00505336).

The current cost of angina pectoris to the National Health Service in the UK

Objective: To calculate the cost of angina pectoris to the UK National Health Service (NHS) in the year 2000. Methods: Calculation of the cost of hospital admissions, revascularisation procedures, hospital outpatient consultations, general practice (GP) consultations, and prescribed drug treatment. Results: 634 000 individuals (1.1% of the UK population) consulted GPs 2.35 million times, costing £60.5 million. They required 16.0 million prescriptions (cost £80.7 million) and 254 000 hospital outpatient referrals (cost £30.4 million). There were 149 000 hospital admissions, 117 000 coronary angiograms, 21 400 coronary artery bypass operations, 17 700 percutaneous coronary interventions, and 516 000 outpatient visits, at a cost of £208.4 million, £69.9 million, £106.2 million, £60.7 million, and £52.2 million, respectively. The direct cost of angina was therefore £669 million (1.3% of total NHS expenditure), with hospital bed occupancy and procedures accounting for 32% and 35% of this total, respectively. Conclusions: Angina is a common and costly public health problem. It consumed over 1% of all NHS expenditure in the year 2000, mainly because of hospital bed occupancy and revascularisation procedures. This is likely to be a conservative estimate of its true cost.

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.

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.