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Aim: To assess the proportion of patients receiving pharmacological therapy for secondary prevention after an acute coronary syndrome (ACS) in Portugal and to identify age and sex inequalities., Design: Retrospective cohort study., Methods: We studied 747 episodes of ST-segment elevation myocardial infarction (STEMI) and 1364 of non-ST-segment elevation ACS (NSTE-ACS), within a sample of ACS cases consecutively discharged from 10 Portuguese hospitals, in 2008-2009. We estimated adjusted odds ratios (OR) for the association of age and sex with the use of each pharmacological treatment., Results: In STEMI and NSTE-ACS patients, the proportion of patients discharged with aspirin was 96 and 88%, clopidogrel 91 and 78%, aspirin+clopidogrel 88 and 71%, beta-blockers 80 and 76%, angiotensin-converting enzyme (ACE) inhibitors/ARB 82 and 80%, statins 93 and 90%, 3-drug (aspirin/clopidogrel+beta-blocker+statin) 76 and 69%, and 5-drug treatment (aspirin+clopidogrel+beta-blocker+ACE inhibitor/ARB+statin) 61 and 48%, respectively. Among STEMI patients, those aged ≥80 years were substantially less often discharged with clopidogrel (OR 0.22, 95% confidence interval, CI, 0.08-0.56), aspirin+clopidogrel (OR 0.34, 95% CI 0.15-0.76), beta-blockers (OR 0.39, 95% CI 0.18-0.82), 3-drug (OR 0.41, 95% CI 0.21-0.83), and 5-drug treatments (OR 0.44, 95% CI 0.23-0.83) than those <60 years; women were less likely to be discharged with aspirin+clopidogrel (OR 0.52, 95% CI 0.29-0.91). Among NSTE-ACS patients, those aged ≥80 years were much less likely to be discharged with beta-blockers (OR 0.58, 95% CI 0.36-0.93), statins (OR 0.35, 95% CI 0.19-0.64), and 3-drug treatment (OR 0.47, 95% CI 0.30-0.75); sex had no significant effect on treatment prescription., Conclusions: The vast majority of younger patients were discharged on evidence-based secondary preventive medications, but only half received the 5-drug combination. Recommended therapies were substantially underprescribed in older patients., (© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Objective: We studied time trends in acute myocardial infarction (AMI) incidence, including out-of-hospital mortality proportions and hospitalized case-fatality rates. In addition, we compared AMI trends by age, gender and socioeconomic status., Methods: We linked the national Dutch hospital discharge register with the cause of death register to identify first AMI in patients ≥ 35 years between 1998 and 2007. Events were categorized in three groups: 178,322 hospitalized non-fatal, 43,210 hospitalized fatal within 28 days, and 75,520 out-of-hospital fatal AMI events. Time trends were analyzed using Joinpoint and Poisson regression., Results: Since 1998, age-standardized AMI incidence rates decreased from 620 to 380 per 100,000 in 2007 in men and from 323 to 210 per 100,000 in 2007 in women. Out-of-hospital mortality decreased from 24.3% of AMI in 1998 to 20.6% in 2007 in men and from 33.0% to 28.9% in women. Hospitalized case-fatality declined from 2003 onwards. The annual percentage change in incidence was larger in men than women (-4.9% vs. -4.2%, P<0.001). Furthermore, the decline in AMI incidence was smaller in young (35-54 years: -3.8%) and very old (≥ 85 years: -2.6%) men and women compared to middle-aged individuals (55-84 years: -5.3%, P<0.001). Smaller declines in AMI rates were observed in deprived socioeconomic quintiles Q5 and Q4 relative to the most affluent quintile Q1 (P=0.002 and P=0.015)., Conclusions: Substantial improvements were observed in incidence, out-of-hospital mortality and short-term case-fatality after AMI in the Netherlands. Young and female groups tend to fall behind, and socioeconomic inequalities in AMI incidence persisted and have not narrowed., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Socioeconomic status has a profound effect on the risk of having a first acute myocardial infarction (AMI). Information on socioeconomic inequalities in AMI incidence across age-gender-groups is lacking. Our objective was to examine socioeconomic inequalities in the incidence of AMI considering both relative and absolute measures of risk differences, with a particular focus on age and gender., Methods: We identified all patients with a first AMI from 1997 to 2007 through linked hospital discharge and death records covering the Dutch population. Relative risks (RR) of AMI incidence were estimated by mean equivalent household income at neighbourhood-level for strata of age and gender using Poisson regression models. Socioeconomic inequalities were also shown within the stratified age-gender groups by calculating the total number of events attributable to socioeconomic disadvantage., Results: Between 1997 and 2007, 317,564 people had a first AMI. When comparing the most deprived socioeconomic quintile with the most affluent quintile, the overall RR for AMI was 1.34 (95 % confidence interval (CI): 1.32-1.36) in men and 1.44 (95 % CI: 1.42-1.47) in women. The socioeconomic gradient decreased with age. Relative socioeconomic inequalities were most apparent in men under 35 years and in women under 65 years. The largest number of events attributable to socioeconomic inequalities was found in men aged 45-74 years and in women aged 65-84 years. The total proportion of AMIs that was attributable to socioeconomic inequalities in the Dutch population of 1997 to 2007 was 14 % in men and 18 % in women., Conclusions: Neighbourhood socioeconomic inequalities were observed in AMI incidence in the Netherlands, but the magnitude across age-gender groups depended on whether inequality was expressed in relative or absolute terms. Relative socioeconomic inequalities were high in young persons and women, where the absolute burden of AMI was low. Absolute socioeconomic inequalities in AMI were highest in the age-gender groups of middle-aged men and elderly women, where the number of cases was largest.

Background: Both the incidence of myocardial infarction (MI) and short-term case fatality have declined in the UK. However, little is known about trends in longer-term survival following an MI. The aim of the study was to investigate trends in longer-term survival, alongside trends in medication prescribing in primary care., Methods: Data came from 218 general practices contributing to the Health Improvement Network, a UK-wide primary care database. 3-year survival and medication use were determined for 6,586 men and 3,766 women who had an MI between 1991 and 2002 and had already survived 3 months., Results: Adjusting for age and gender, the 3-year post-MI case-fatality rate among 3-month survivors fell by 28% (95% CI 13 to 40), from 83 deaths per 1000 person-years for MI occurring in 1991-2 to 61 deaths per 1000 person-years for MI in 2001-2. Relative declines in the case-fatality rate of 37% (20 to 50) and 14% (-11 to 34) were observed for men and women, respectively (p=0.06 for interaction). Prescribing in the 3 months following the MI of lipid-regulating drugs increased from 3% of patients in 1991 to 79% in 2002, prescribing of beta-blockers increased from 26% to 68%, prescribing of ACE inhibitors increased from 11% to 71% and prescribing of anti-platelet medication increased from 46% to 86%., Conclusion: There has been a moderate improvement in longer-term survival following an MI, distinct from improvements in short-term survival, although men may have benefited more than women. Increased medication prescribing in primary care may be a contributing factor.

Background: The incidence of myocardial infarction (MI) in Britain has fallen markedly in recent years. Few studies have investigated the extent to which this decline can be explained by concurrent changes in major cardiovascular risk factors., Methods and Results: The British Regional Heart Study examined changes in cardiovascular risk factors and MI incidence over 25 years from 1978 in a cohort of 7735 men. During this time, the age-adjusted hazard of MI decreased by 3.8% (95% confidence interval 2.6% to 5.0%) per annum, which corresponds to a 62% decline over the 25 years. At the same time, after adjustment for age, cigarette smoking prevalence, mean systolic blood pressure, and mean non-high-density lipoprotein (HDL) cholesterol decreased, whereas mean HDL cholesterol, mean body mass index, and physical activity levels rose. No significant change occurred in alcohol consumption. The fall in cigarette smoking explained the greatest part of the decline in MI incidence (23%), followed by changes in blood pressure (13%), HDL cholesterol (12%), and non-HDL cholesterol (10%). In combination, 46% (approximate 95% confidence interval 23% to 164%) of the decline in MI could be explained by these risk factor changes. Physical activity and alcohol consumption had little influence, whereas the increase in body mass index would have produced a rise in MI risk., Conclusions: Modest favorable changes in the major cardiovascular risk factors appear to have contributed to considerable reductions in MI incidence. This highlights the potential value of population-wide measures to reduce exposure to these risk factors in the prevention of coronary heart disease.

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.

Objectives: To re-examine interhospital variation in 30 day survival after acute myocardial infarction (AMI) 10 years on to see whether the appointment of new cardiologists and their involvement in emergency care has improved outcome after AMI., Design: Retrospective cohort study., Setting: Acute hospitals in Scotland., Participants: 61,484 patients with a first AMI over two time periods: 1988-1991; and 1998-2001., Main Outcome Measures: 30 day survival., Results: Between 1988 and 1991, median 30 day survival was 79.2% (interhospital range 72.1-85.1%). The difference between highest and lowest was 13.0 percentage points (age and sex adjusted, 12.1 percentage points). Between 1998 and 2001, median survival rose to 81.6% (and range decreased to 78.0-85.6%) with a difference of 7.6 (adjusted 8.8) percentage points. Admission hospital was an independent predictor of outcome at 30 days during the two time periods (p < 0.001). Over the period 1988-1991, the odds ratio for death ranged, between hospitals, from 0.71 (95% confidence interval (CI) 0.58 to 0.88) to 1.50 (95% CI 1.19 to 1.89) and for the period 1998-2001 from 0.82 (95% CI 0.60 to 1.13) to 1.46 (95% CI 1.07 to 1.99). The adjusted risk of death was significantly higher than average in nine of 26 hospitals between 1988 and 1991 but in only two hospitals between 1998 and 2001., Conclusions: The average 30 day case fatality rate after admission with an AMI has fallen substantially over the past 10 years in Scotland. Between-hospital variation is also considerably less notable because of better survival in the previously poorly performing hospitals. This suggests that the greater involvement of cardiologists in the management of AMI has paid dividends.

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.

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.

Objectives: To analyse short- and long-term case-fatality trends following admission to hospital with a first acute myocardial infarction, in men and women between 1986 and 1995, after adjusting for risk factors known to influence survival., Design: A Scottish-wide retrospective cohort study., Setting: The Linked Scottish Morbidity Record Database was analysed. This contains accurate data on all hospital admissions since 1981, for the Scottish population of 5.1 million. It is linked to the Registrar General's death certificate data., Subjects: All 117 718 patients admitted to Scottish hospitals with a principal diagnosis of first acute myocardial infarction (ICD-9 code 410) between 1986 and 1995., Main Outcome Measures: The outcome was death, both in and out of hospital, from any cause, at 30 days, 1 year, 5 and 10 years., Results: Overall case-fatality following hospital admission with acute myocardial infarction was 22. 2%, 31.4%, 51.1% and 64.0% at 1 month, 1 year, 5 and 10 years, respectively. Multivariate analyses identified statistically significant independent prognostic factors. Thirty day mortality increased twofold for each decade of increasing age, and increased with any prior admission to hospital. When comparing the most deprived category to that of the most affluent, men had a 10% increased mortality (P<0.01), whilst women had an increased mortality of 4% (not significant). After adjustment for age, sex, deprivation and prior admission to hospital, case-fatality rates fell significantly between 1986 and 1995. Short-term case-fatality fell by 46% in men (27% in women) and long-term by 34% in men (30% in women) (both P<0.001)., Conclusions: Population-based case-fatality rates in Scotland have fallen dramatically since 1986, particularly in men. The increasing survival in patients admitted to hospital suggests that the trial-based efficacy of modern therapies is now translating into population-based effectiveness. However, an individual's life expectancy still halves after a diagnosis of acute myocardial infarction. Of the variables that we could examine, age was the most powerful predictor of prognosis., (Copyright 2000 The European Society of Cardiology.)

Objective: To examine 30 day survival after acute myocardial infarction as an outcome indicator, and explore the effects of adjusting for available prognostic factors such as age, sex, co-morbidity, deprivation, and deaths outside hospital., Design: Cohort study., Setting: The Scottish Record Linkage System was analysed. This national data-base links inpatient data to death certificate information for a population of 5.1 million., Subjects: All 40,371 admissions to hospital with a principal diagnosis of acute myocardial infarction, plus all 18,452 deaths outside hospital with a principal cause of death registered as acute myocardial infarction (ICD9 code 410) during 1988-1991., Main Outcome Measures: The outcome event was death from any cause, within hospital or elsewhere, within 30 days of admission., Results: During 1988-1991, 30 day survival after acute myocardial infarction was 77% in 40,371 hospital admissions, but only 53% when 18,452 acute myocardial infarction deaths in the community were included (a population-based outcome indicator with many advantages). Using logistic regression at an individual patient level, the odds of dying within 30 days effectively doubled for each decade of age (odds ratio compared with patients aged under 55: 2.3 aged 55-64, 4.4 aged 65-74, 8.2 aged 75-84, 12.0 aged 85 plus); were marginally higher in females than in males (odds ratio 1.07); were almost doubled in patients with a history of previous infarction, coronary heart disease, or other heart disease, and were also significantly increased in patients with circulatory disease, respiratory disease, neoplasm, or diabetes. Socioeconomic deprivation had no significant effect. Marked variations in survival between different hospitals and health board areas persisted, even after adjusting for the above prognostic factors., Conclusion: One month survival after acute myocardial infarction could be a useful means of measuring outcome of hospital care. There was important geographical variation in one month survival. These differences could be accounted for by variations in referral, admission, diagnosis, definition, and coding. These variables merit further research and local clinical audit before one month survival after acute myocardial infarction can be reliably used for detecting differences in quality of care. In addition, it would be essential to take account of infarct severity.

Background: Although most countries face increasing population levels of obesity and diabetes their effect on coronary heart disease (CHD) mortality has not been often studied in small island developing states (SIDs) where obesity rates are among the highest in the world. We estimated the relative contributions of treatments and cardiovascular risk factors to the decline in CHD mortality from 1990 to 2012 in the Caribbean island, Barbados. Methods: We used the IMPACT CHD mortality model to estimate the effect of increased coverage of effective medical/surgical treatments and changes in major CHD risk factors on mortality trends in 2012 compared with 1990. We calculated deaths prevented or postponed (DPPs) for each model risk factor and treatment group. We obtained data from WHO Mortality database, population denominators from the Barbados Statistical Service stratified by 10-year age group (ages 25–34 up to 85 plus), population-based risk factor surveys, Global Burden of Disease and Barbados’ national myocardial infarction registry. Monte Carlo probabilistic sensitivity analysis was performed. Results: In 1990 the age-standardized CHD mortality rate was 109.5 per 100,000 falling to 55.3 in 2012. Implementation of effective treatment accounted for 56% DPPs (95% (Uncertainty Interval (UI) 46%, 68%), mostly due to the introduction of treatments immediately after acute myocardial infarction (AMI) (14%) and unstable angina (14%). Overall, risk factors contributed 19% DPPs (95% UI 6% to 34%) mostly attributed to decline in cholesterol (18% DPPs, 95% UI 12%, 26%). Adverse trends in diabetes: 14% additional deaths(ADs) 95% UI 8% to 21% ADs) and BMI (2% ADs 95%UI 0 to 5% ADs) limited potential for risk factor gains. Conclusions: Given the significant negative impact of obesity/diabetes on mortality in this analysis, research that explores factors affecting implementation of evidenced-based preventive strategies is needed. The fact that most of the decline in CHD mortality in Barbados was due to treatment provides an example for SIDs about the advantages of universal access to care and treatment. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The prognostic impact of heart failure relative to that of 'high-profile' disease states such as cancer, within the whole population, is unknown.Methods: All patients with a first admission to any Scottish hospital in 1991 for heart failure, myocardial infarction or the four most common types of cancer specific to men and women were identified. Five-year survival rates and associated loss of expected life-years were then compared.Results: In 1991, 16224 men had an initial hospitalisation for heart failure (n=3241), myocardial infarction (n=6932) or cancer of the lung, large bowel, prostate or bladder (n=6051). Similarly, 14842 women were admitted for heart failure (n=3606), myocardial infarction (n=4916), or cancer of the breast, lung, large bowel or ovary (n=6320). With the exception of lung cancer, heart failure was associated with the poorest 5-year survival rate (approximately 25% for both sexes). On an adjusted basis, heart failure was associated with worse long-term survival than bowel cancer in men (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97; P<0.01) and breast cancer in women (odds ratio, 0.59; 95% CI, 0.55-0.64; P<0.001). The overall population rate of expected life-years lost due to heart failure in men was 6.7 years/1000 and for women 5.1 years/1000.Conclusion: With the notable exception of lung cancer, heart failure is as 'malignant' as many common types of cancer and is associated with a comparable number of expected life-years lost. [ABSTRACT FROM AUTHOR]

The article examines the reduction in coronary heart disease (CHD) deaths that are potentially achievable through increasing treatment levels in Great Britain. In line with the effort to increase treatment uptakes, the 2003 general medical services contract will now reward the identification of eligible patients and the creation of CHD registers. This article concludes that future national strategies should prioritize secondary prevention and heart failure.

Presents a population based analysis of hospital discharge rates for suspected acute coronary syndromes between 1990 and 2000. Trends in population discharge rates for myocardial infarction, angina and chest pain; Participants, methods and results; Report that the decline in myocardial infarction was greater in men than in women in young and older age groups; Increase in angina in men; Implications for resources, finances and services.

This article focuses on a study that explores recent population trends in the incidence of and survival from cardiogenic shock complicating acute myocardial infarction (AMI). Historically, cardiogenic shock as a result of an AMI has a poor prognosis. Its management and the management of AMI have changed in recent years. Contemporary population studies examining incidence and outcome are lacking. The adjusted incidence of cardiogenic shock has increased in recent years and there has been no improvement in survival. While the risk of developing cardiogenic shock is greater in women than in men there is no difference in survival between men and women.