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Background: Cancer, coronary heart disease, dementia, and stroke are major contributors to morbidity and mortality in England. We aimed to assess the economic burden (including health-care, social care, and informal care costs, as well as productivity losses) of these four conditions in England in 2018, and forecast this cost to 2050 using population projections., Methods: We used individual patient-level data from the Clinical Practice Research Datalink (CPRD) Aurum, which contains primary care electronic health records of patients from 738 general practices in England, to calculate health-care and residential and nursing home resource use, and data from the English Longitudinal Study on Ageing (ELSA) to calculate informal and formal care costs. From CPRD Aurum, we included patients registered on Jan 1, 2018, in a CPRD general practice with Hospital Episode Statistics (HES)-linked records, omitting all children younger than 1 year. From ELSA, we included data collected from wave 9 (2018-19). Aggregate English resource use data on morbidity, mortality, and health-care, social care, and informal care were obtained and apportioned, using multivariable regression analyses, to cancer, coronary heart disease, dementia, and stroke., Findings: We included 4 161 558 patients from CPRD Aurum with HES-linked data (mean age 41 years [SD 23], with 2 079 679 [50·0%] men and 2 081 879 [50·0%] women) and 8736 patients in ELSA (68 years [11], with 4882 [55·9 %] men and 3854 [44·1%] women). In 2018, the total cost was £18·9 billion (95% CI 18·4-19·4) for cancer, £12·7 billion (12·3-13·0) for coronary heart disease, £11·7 billion (9·6-12·7) for dementia, and £8·6 billion (8·2-9·0) for stroke. Using 2050 English population projections, we estimated that costs would rise by 40% (39-41) for cancer, 54% (53-55) for coronary heart disease, 100% (97-102) for dementia, and 85% (84-86) for stroke, for a total of £26·5 billion (25·7-27·3), £19·6 billion (18·9-20·2), £23·5 billion (19·3-25·3), and £16·0 billion (15·3-16·6), respectively., Interpretation: This study provides contemporary estimates of the wide-ranging impact of the most important chronic conditions on all aspects of the economy in England. The data will help to inform evidence-based polices to reduce the impact of chronic disease, promoting care access, better health outcomes, and economic sustainability., Funding: Alzheimer's Research UK., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The evidence that large pay-for-performance schemes improve the health of populations is mixed-evidence regarding locally implemented schemes is limited., Objective: This study evaluates the effects in Stoke-on-Trent of a local, multifaceted Quality Improvement Framework including pay for performance in general practice introduced in 2009 in the context of the national Quality and Outcomes Framework that operated from 2004., Methods: We compared age-standardized mortality data from all 326 local authorities in England with the rates in Stoke-on-Trent using Difference-in-Differences, estimating a fixed-effects linear regression model with an interaction effect., Results: In addition to the existing downward trend in cardiovascular deaths, we find an additional annual reduction of 36 deaths compared with the national mean for coronary heart disease and 13 deaths per 100000 from stroke in Stoke-on-Trent. Compared with the national mean, there was an additional reduction of 9 deaths per 100000 people per annum for coronary heart disease and 14 deaths per 100000 people per annum for stroke following the introduction of the 2009 Stoke-on-Trent Quality Improvement Framework., Conclusion: There are concerns about the unintended consequences of large pay-for-performance schemes in health care, but in a population with a high prevalence of disease, they may at least initially be beneficial. This study also provides evidence that a local, additional scheme may further improve the health of populations. Such schemes, whether national or local, require periodic review to evaluate the balance of their benefits and risks., (© The Author(s) 2018. Published by Oxford University Press.)

Background and Objective: Diagnostic models used in the management of suspected angina provide no explicit information about prognosis. We present a new prognostic model of 10-year coronary mortality in patients presenting for the first time with suspected angina to complement the Diamond-Forrester diagnostic model of disease probability., Methods and Results: A multicentre cohort of 8762 patients with suspected angina was followed up for a median of 10 years during which 233 coronary deaths were observed. Developmental (n=4412) and validation (n=4350) prognostic models based on clinical data available at first presentation showed good performance with close agreement and the final model utilised all 8762 patients to maximise power. The prognostic model showed strong associations with coronary mortality for age, sex, chest pain typicality, smoking status, diabetes, pulse rate, and ECG findings. Model discrimination was good (C statistic 0.83), patients in the highest risk quarter accounting for 173 coronary deaths (10-year risk of death: 8.7%) compared with a total of 60 deaths in the three lower risk quarters. When the model was simplified to incorporate only Diamond-Forrester factors (age, sex and character of symptoms) it underestimated coronary mortality risk, particularly in patients with reversible risk factors., Conclusions: For the first time in patients with suspected angina, a prognostic model is presented based on simple clinical factors available at the initial cardiological assessment. The model discriminated powerfully between patients at high risk and lower risk of coronary death during 10-year follow-up. Clinical utility was reflected in the prognostic value it added to the updated Diamond-Forrester diagnostic model of disease probability., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: There is strong evidence to suggest that social deprivation is linked to health inequalities. In the UK, concerns have been raised regarding disparities in the outcomes of acute cardiac services within the National Health Service (NHS). This study explored whether differences exist in (a) elective hospital presentation time (b) indicators of severity and disease burden and (c) treatment outcomes (hospital stay and mortality) on the basis of the index of multiple deprivation (IMD) status., Design: This study was a retrospective analysis of data from NHS databases for 13,758 patients that had undergone cardiac revascularisation interventions at the Liverpool Heart and Chest Hospital between April 2007-March 2012., Methods: The data was analysed by descriptive, univariate and multivariate statistics to explore the association between the IMD quintiles (Q1-Q5) and revascularisation type, elective presentation time, hospital length of stay and mortality., Results and Conclusions: Univariate analysis indicated that there were significant differences between patients from the most deprived areas (Q5) compared with patients from the least deprived areas (Q1), these included admission volumes, time before presentation to hospital and proportion of non-elective cases. After risk-adjustments, percutaneous coronary intervention patients from Q5 compared with Q1 had significantly greater length of hospital stay and risk of in-hospital major acute cardiovascular events. After multivariate adjustment for baseline risk factors, patients from Q5 were associated with significantly worse five-year survival as compared with Q1 (hazard ratio (HR) 1.52, 95% confidence interval (CI): 1.36-1.71; p < 0.001). In conclusion, there is evidence to suggest that inequalities in cardiac revascularisation choices and outcomes in the UK may be associated with social deprivation., (© The European Society of Cardiology 2015.)

Objectives: To determine health and equity benefits and cost effectiveness of policies to reduce or eliminate trans fatty acids from processed foods, compared with consumption remaining at most recent levels in England., Design: Epidemiological modelling study., Setting: Data from National Diet and Nutrition Survey, Low Income Diet and Nutrition Survey, Office of National Statistics, and health economic data from other published studies, Participants: Adults aged ≥25, stratified by fifths of socioeconomic circumstance., Interventions: Total ban on trans fatty acids in processed foods; improved labelling of trans fatty acids; bans on trans fatty acids in restaurants and takeaways., Main Outcome Measures: Deaths from coronary heart disease prevented or postponed; life years gained; quality adjusted life years gained. Policy costs to government and industry; policy savings from reductions in direct healthcare, informal care, and productivity loss., Results: A total ban on trans fatty acids in processed foods might prevent or postpone about 7200 deaths (2.6%) from coronary heart disease from 2015-20 and reduce inequality in mortality from coronary heart disease by about 3000 deaths (15%). Policies to improve labelling or simply remove trans fatty acids from restaurants/fast food could save between 1800 (0.7%) and 3500 (1.3%) deaths from coronary heart disease and reduce inequalities by 600 (3%) to 1500 (7%) deaths, thus making them at best half as effective. A total ban would have the greatest net cost savings of about £265m (€361m, $415m) excluding reformulation costs, or £64m if substantial reformulation costs are incurred outside the normal cycle., Conclusions: A regulatory policy to eliminate trans fatty acids from processed foods in England would be the most effective and equitable policy option. Intermediate policies would also be beneficial. Simply continuing to rely on industry to voluntary reformulate products, however, could have negative health and economic outcomes., (© Allen et al 2015.)

Objective: To assess the feasibility, strengths and weaknesses of using administrative data to compare hospital performance across countries, using mortality after coronary artery bypass graft (CABG) surgery as an illustrative example., Methods: Country specific and pooled models using individual-level data and logistic regression methods assess individual hospital performance using funnel plots accounting for multiple testing. Outcomes are adjusted for age, sex, comorbidities and indicators of patient severity. Data includes patients from all publicly funded hospitals delivering CABG surgery in England and Spain. Inpatient hospital-level standardized mortality rates within 30 days of CABG surgery are calculated for 83 999 CABG patients between 2007 and 2009., Results: Unadjusted national mortality rates are 5% in Spain and 2.3% in England. Country-specific models identified similar patterns of excess mortality 'alerts' and 'alarms' in hospitals in Spain or England. Pooling data from both countries identifies larger numbers of alerts and alarms in Spanish hospitals, and risk-adjustment increased the already large national mortality difference. This was reduced but not eliminated by accounting for lower volume in Spanish hospitals., Conclusion: Cross-national comparisons potentially add value by providing international performance benchmarks. Hospital-level analysis across countries can illuminate differences in hospital performance, which might not be identified using country-specific data or incomplete registry data, and can test hypotheses that may explain national differences. Difficulties of making data comparable between countries, however, compound the usual within-country measurement problems., (© The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Objective: To analyse the falls in coronary heart disease (CHD) mortality in England between 2000 and 2007 and quantify the relative contributions from preventive medications and population-wide changes in blood pressure (BP) and cholesterol levels, particularly by exploring socioeconomic inequalities., Design: A modelling study., Setting: Sources of data included controlled trials and meta-analyses, national surveys and official statistics., Participants: English population aged 25+ in 2000-2007., Main Outcome Measures: Number of deaths prevented or postponed (DPPs) in 2007 by socioeconomic status. We used the IMPACTSEC model which applies the relative risk reduction quantified in previous randomised controlled trials and meta-analyses to partition the mortality reduction among specific treatments and risk factor changes., Results: Between 2000 and 2007, approximately 20 400 DPPs were attributable to reductions in BP and cholesterol in the English population. The substantial decline in BP was responsible for approximately 13 000 DPPs. Approximately 1800 DPPs came from medications and some 11 200 DPPs from population-wide changes. Reduction in population BP prevented almost twofold more deaths in the most deprived quintile compared with the most affluent. Reduction in cholesterol resulted in approximately 7400 DPPs; approximately 5300 DPPs were attributable to statin use and approximately 2100 DPPs to population-wide changes. Statins prevented almost 50% more deaths in the most affluent quintile compared with the most deprived. Conversely, population-wide changes in cholesterol prevented threefold more deaths in the most deprived quintile compared with the most affluent., Conclusions: Population-wide secular changes in systolic blood pressure (SBP) and cholesterol levels helped to substantially reduce CHD mortality and the associated socioeconomic disparities. Mortality reductions were, in absolute terms, greatest in the most deprived quintiles, mainly reflecting their bigger initial burden of disease. Statins for high-risk individuals also made an important contribution but maintained socioeconomic inequalities. Our results strengthen the case for greater emphasis on preventive approaches, particularly population-based policies to reduce SBP and cholesterol., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: The European Society of Cardiology endorses cardiovascular disease (CVD) risk stratification using the Systematic COronary Risk Evaluation (SCORE) algorithm, with separate algorithms for high-risk and low-risk countries. In the 2012 European Guidelines on CVD Prevention in Clinical Practice, the UK has been reclassified as a low-risk country. However, the performance of the SCORE algorithm has not been validated in the UK., Design: We compared CVD mortality as predicted by SCORE with the observed CVD mortality in the European Prospective Investigation of Cancer-Norfolk (EPIC-Norfolk) prospective population study, a cohort representative of the general population., Methods: Individuals without known CVD or diabetes mellitus, aged 39-65 years at baseline, were included in our analysis. CVD mortality was defined as death due to ischaemic heart disease, cardiac failure, cerebrovascular disease, peripheral artery disease and aortic aneurysm. Predicted CVD mortality was calculated at baseline using the SCORE high-risk and low-risk algorithms., Results: A total of 15,171 individuals (57.1% female) with a mean age of 53.9 (SD 6.2) years were included. Predicted CVD mortality was 2.85% (95% confidence interval (CI) 2.80-2.90) with the SCORE high-risk algorithm and 1.55% (95% CI 1.52-1.58) with the low-risk algorithm. The observed 10-year CVD mortality was 1.25% (95% CI 1.08-1.44). Similar results were observed across sex and age subgroups., Conclusion: In the large EPIC-Norfolk cohort representative of the UK population, the SCORE low-risk algorithm performed better than the high-risk algorithm in predicting 10-year CVD mortality. Our findings indicate that the UK has been correctly reclassified as a low-risk country., (© The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Coronary Heart Disease (CHD) remains a major cause of mortality in the United Kingdom. Yet predictions of future CHD mortality are potentially problematic due to population ageing and increase in obesity and diabetes. Here we explore future projections of CHD mortality in England & Wales under two contrasting future trend assumptions., Methods: In scenario A, we used the conventional counterfactual scenario that the last-observed CHD mortality rates from 2011 would persist unchanged to 2030. The future number of deaths was calculated by applying those rates to the 2012-2030 population estimates. In scenario B, we assumed that the recent falling trend in CHD mortality rates would continue. Using Lee-Carter and Bayesian Age Period Cohort (BAPC) models, we projected the linear trends up to 2030. We validate our methods using past data to predict mortality from 2002-2011. Then, we computed the error between observed and projected values., Results: In scenario A, assuming that 2011 mortality rates stayed constant by 2030, the number of CHD deaths would increase 62% or approximately 39,600 additional deaths. In scenario B, assuming recent declines continued, the BAPC model (the model with lowest error) suggests the number of deaths will decrease by 56%, representing approximately 36,200 fewer deaths by 2030., Conclusions: The decline in CHD mortality has been reasonably continuous since 1979, and there is little reason to believe it will soon halt. The commonly used assumption that mortality will remain constant from 2011 therefore appears slightly dubious. By contrast, using the BAPC model and assuming continuing mortality falls offers a more plausible prediction of future trends. Thus, despite population ageing, the number of CHD deaths might halve again between 2011 and 2030. This has implications for how the potential benefits of future cardiovascular strategies might best be calculated and presented.

Background: There is an ongoing debate about the performance of non-high-density lipoprotein cholesterol (non-HDL-C) compared with apolipoprotein B (apo B) in the prediction of coronary heart disease (CHD) risk. Therefore, we compared the associations between non-HDL-C and apo B in regard to CHD among apparently healthy Western European individuals., Design: In the European Prospective Investigation into Cancer and Nutrition (EPIC)-Norfolk prospective population study, 25,639 men and women aged 45-79 years were followed for 11·4 ± 2·8 years. Those with diabetes or prevalent CHD at baseline were excluded. A total of 2066 (12·1%) participants developed CHD during 195 692 person-years follow-up., Results: The multivariable-adjusted hazard ratio [HR] of future CHD per one standard deviation increase was 1·22 [95% confidence interval (CI): 1·17-1·27] for LDL-C, 1·26 (95% CI 1·20-1·31) for non-HDL-C and 1·19 (95% CI 1·14-1·24) for apo B, respectively. The multivariable-adjusted HR of future CHD in the highest quartile LDL-C was 1·67 (95% CI: 1·47-1·91). For non-HDL-C and apo B, these respective HRs were 1·87 (95% CI: 1·62-2·15) and 1·56 (95% CI: 1·36-1·78). Kaplan-Meier survival analyses showed that there was incremental and comparable increase in risk of CHD with increasing quartiles of both non-HDL-C and apo B., Conclusions: In this prospective study, non-HDL-C and apo B were comparable in their ability to predict risk of future CHD., (© 2013 Stichting European Society for Clinical Investigation Journal Foundation. Published by John Wiley & Sons Ltd.)

Background: Circulatory disease mortality inequalities by country of birth (COB) have been demonstrated for some EU countries but pan-European analyses are lacking. We examine inequalities in circulatory mortality by geographical region/COB for six EU countries., Methods: We obtained national death and population data from Denmark, England and Wales, France, the Netherlands, Scotland and Sweden. Mortality rate ratios (MRRs) were constructed to examine differences in circulatory, ischaemic heart disease (IHD) and cerebrovascular disease mortality by geographical region/COB in 35-74 years old men and women., Results: South Asians in Denmark, England and Wales and France experienced excess circulatory disease mortality (MRRs 1.37-1.91). Similar results were seen for Eastern Europeans in these countries as well as in Sweden (MRRs 1.05-1.51), for those of Middle Eastern origin in Denmark (MRR = 1.49) and France (MRR = 1.15), and for East and West sub-Saharan Africans in England and Wales (MRRs 1.28 and 1.39) and France (MRRs 1.24 and 1.22). Low ratios were observed for East Asians in France, Scotland and Sweden (MRRs 0.64-0.50). Sex-specific analyses showed results of similar direction but different effect sizes. The pattern for IHD mortality was similar to that for circulatory disease mortality. Two- to three-fold excess cerebrovascular disease mortality was found for several foreign-born groups compared with the local-born populations in some countries., Conclusions: Circulatory disease mortality varies by geographical region/COB within six EU countries. Excess mortality was observed for some migrant populations, less for others. Reliable pan-European data are needed for monitoring and understanding mortality inequalities in Europe's multiethnic populations.

Aims: Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) has raised several points of debate. We quantified the proportion of individuals meeting the JUPITER criteria, determined their risk profile, and their risk of coronary heart disease (CHD) events during a long-term follow-up in a contemporary European cohort., Methods and Results: A total of 25 639 participants aged between 45 and 79 years were followed for 11.4 ± 2.8 years in EPIC-Norfolk population cohort. A total of 8397 individuals with complete data available were considered potentially eligible for primary prevention. A total of 846 (10.1%) individuals fulfilled the JUPITER criteria [low-density lipoprotein cholesterol-C (LDL-C) <3.4 mmol/L/C-reactive protein ≥ 2 mg]. This group had a 10-person-year event rate of 14.6% compared with 7.0% for those with LDL-C <3.4 mmol/L/C-reactive protein <2 mg (P = 0.001); the corresponding adjusted hazard ratio for future CHD was 1.70 (95% CI: 1.31-2.21). The group fulfilling JUPITER criteria had significantly higher CHD risk compared with those with LDL-C ≥ 3.4 mmol/L and C-reactive protein <2 mg/L. Among individuals who did not qualify for statin therapy based on the Society of Cardiology Systematic COronary Risk Evaluation (SCORE) (n = 4652) or ATP III criteria (n = 4466), 18.1 and 18.9%, respectively, would have qualified using the JUPITER criteria., Conclusion: In this European cohort, JUPITER-eligible individuals had significantly higher event rates compared with those with LDL-C <3.4 mmol/L/C-reactive protein <2 mg and LDL-C ≥ 3.4 mmol/L/C-reactive protein <2 mg/L. Application of the JUPITER criteria qualified almost one-fifth of the population for statin therapy that otherwise would not have qualified based on SCORE or ATP III criteria.

Background: The purpose of this study was to test whether lower socioeconomic status (SES) augments the effect of psychological distress on mortality from stroke or coronary heart disease (CHD)., Methods: We prospectively linked data from 66,500 participants 35 years or older in the Health Survey for England, selected using stratified random sampling from 1994 to 2004, and free of cardiovascular disease and cancer at baseline, with mortality records. The median follow-up time was 7.9 years. SES was indexed by occupational class, and psychological distress was assessed using the 12-item General Health Questionnaire (GHQ-12)., Results: After adjustment for demographic and clinical variables, both psychological distress and low SES were associated with increased mortality: the hazard ratios (HR) for one-category increase in low SES (three categories in total) were 1.15 for stroke-death (95% confidence interval [CI] = 1.00-1.31, p = .043) and 1.24 for CHD-death (95% CI = 1.09-1.41, p = .001); the HR for one-category increase in GHQ-12 (three categories in total) was 1.18 for stroke-death (95% CI = 1.07-1.30, p = .001) and 1.24 for CHD-death (95% CI = 1.13-1.36, p < .001). In stratified analyses, the strongest associations were found in the lowest SES categories: the HR for GHQ-12 toward stroke-death was 1.15 in high-SES participants (95% CI = 0.97-1.37, p = .107) and 1.31 in low-SES ones (95% CI = 1.13-1.51, p < .001); the HR for GHQ-12 toward CHD-death was 1.10 in high-SES participants (95% CI = 0.97-1.25, p = .129) and 1.33 in low-SES ones (95% CI = 1.19-1.48, p < .001)., Conclusions: People in low socioeconomic circumstances are more vulnerable to the adverse effect of psychological distress. This pattern should be taken into account when evaluating the association between psychosocial variables and health outcomes.

Background: Coronary heart disease (CHD) remains a major public health burden, causing 80,000 deaths annually in England and Wales, with major inequalities. However, there are no recent analyses of age-specific socioeconomic trends in mortality. We analysed annual trends in inequalities in age-specific CHD mortality rates in small areas in England, grouped into deprivation quintiles., Methods: We calculated CHD mortality rates for 10-year age groups (from 35 to ≥ 85 years) using three year moving averages between 1982 and 2006. We used Joinpoint regression to identify significant turning points in age- sex- and deprivation-specific time trends. We also analysed trends in absolute and relative inequalities in age-standardised rates between the least and most deprived areas., Results: Between 1982 and 2006, CHD mortality fell by 62.2% in men and 59.7% in women. Falls were largest for the most deprived areas with the highest initial level of CHD mortality. However, a social gradient in the pace of fall was apparent, being steepest in the least deprived quintile. Thus, while absolute inequalities narrowed over the period, relative inequalities increased. From 2000, declines in mortality rates slowed or levelled off in the youngest groups, notably in women aged 45-54 in the least deprived groups. In contrast, from age 55 years and older, rates of fall in CHD mortality accelerated in the 2000s, likewise falling fastest in the least deprived quintile., Conclusions: Age-standardised CHD mortality rates have declined substantially in England, with the steepest falls in the most affluent quintiles. However, this concealed contrasting patterns in underlying age-specific rates. From 2000, mortality rates levelled off in the youngest groups but accelerated in middle aged and older groups. Mortality analyses by small areas could provide potentially valuable insights into possible drivers of inequalities, and thus inform future strategies to reduce CHD mortality across all social groups.

Background: The aims of this study were to assess whether deprivation inequality at small area level in England is associated with coronary heart disease (CHD) mortality rates and to assess whether this provides evidence of an association between area-level and individual-level risk., Methods: Mortality rates for all wards in England were calculated using all CHD deaths between 2001 and 2006. Ward-level deprivation was measured using the Carstairs Index. Deprivation inequality within local authorities (LAs) was measured by the IQR of deprivation for wards within the LA. Relative deprivation for wards was measured as the modulus of the difference between deprivation for the ward and average deprivation for all neighbouring wards., Results: Deprivation inequality within LAs was positively associated with CHD mortality rates per 100000 (eg, all men β; 95% CI=2.7; 1.1 to 4.3) after adjustment for absolute deprivation (p<0.001 for all models). Relative deprivation for wards was positively associated with CHD mortality rates per 100000 (eg, all men 1.4; 0.7 to 2.1) after adjustment for absolute deprivation (p<0.001 for all models). Subgroup analyses showed that relative deprivation was independently associated with CHD mortality rates in both affluent and deprived wards., Conclusions: Rich wards surrounded by poor areas have higher CHD mortality rates than rich wards surrounded by rich areas, and poor wards surrounded by rich areas have worse CHD mortality rates than poor wards surrounded by poor areas. Local deprivation inequality has a similar adverse impact on both rich and poor areas, supporting the hypothesis that income inequality of an area has an impact on individual-level health outcomes.

There are substantial geographic variations in coronary heart disease (CHD) mortality rates in England that may in part be due to differences in climate and air pollution. An ecological cross-sectional multi-level analysis of male and female CHD mortality rates in all wards in England (1999-2004) was conducted to estimate the relative strength of the association between CHD mortality rates and three aspects of the physical environment--temperature, hours of sunshine and air quality. Models were adjusted for deprivation, an index measuring the healthiness of the lifestyle of populations, and urbanicity. In the fully adjusted model, air quality was not significantly associated with CHD mortality rates, but temperature and sunshine were both significantly negatively associated (p<0.05), suggesting that CHD mortality rates were higher in areas with lower average temperature and hours of sunshine. After adjustment for the unhealthy lifestyle of populations and deprivation, the climate variables explained at least 15% of large scale variation in CHD mortality rates. The results suggest that the climate has a small but significant independent association with CHD mortality rates in England.

Background: Coronary heart disease (CHD) mortality in England fell by approximately 6% every year between 2000 and 2007. However, rates fell differentially between social groups with inequalities actually widening. We sought to describe the extent to which this reduction in CHD mortality was attributable to changes in either levels of risk factors or treatment uptake, both across and within socioeconomic groups., Methods and Findings: A widely used and replicated epidemiological model was used to synthesise estimates stratified by age, gender, and area deprivation quintiles for the English population aged 25 and older between 2000 and 2007. Mortality rates fell, with approximately 38,000 fewer CHD deaths in 2007. The model explained about 86% (95% uncertainty interval: 65%-107%) of this mortality fall. Decreases in major cardiovascular risk factors contributed approximately 34% (21%-47%) to the overall decline in CHD mortality: ranging from about 44% (31%-61%) in the most deprived to 29% (16%-42%) in the most affluent quintile. The biggest contribution came from a substantial fall in systolic blood pressure in the population not on hypertension medication (29%; 18%-40%); more so in deprived (37%) than in affluent (25%) areas. Other risk factor contributions were relatively modest across all social groups: total cholesterol (6%), smoking (3%), and physical activity (2%). Furthermore, these benefits were partly negated by mortality increases attributable to rises in body mass index and diabetes (-9%; -17% to -3%), particularly in more deprived quintiles. Treatments accounted for approximately 52% (40%-70%) of the mortality decline, equitably distributed across all social groups. Lipid reduction (14%), chronic angina treatment (13%), and secondary prevention (11%) made the largest medical contributions., Conclusions: The model suggests that approximately half the recent CHD mortality fall in England was attributable to improved treatment uptake. This benefit occurred evenly across all social groups. However, opposing trends in major risk factors meant that their net contribution amounted to just over a third of the CHD deaths averted; these also varied substantially by socioeconomic group. Powerful and equitable evidence-based population-wide policy interventions exist; these should now be urgently implemented to effectively tackle persistent inequalities.

Background: To examine explanations for the higher rates of male mortality in two Scottish cohorts compared with a cohort in south-east England for which similar data were collected., Methodology/principal Findings: We compared three cohort studies which recruited participants in the late 1960s and early 1970s. A total of 13,884 men aged 45-64 years at recruitment in the Whitehall occupational cohort (south-east England), 3,956 men in the Collaborative occupational cohort and 6,813 men in the Renfrew & Paisley population-based study (both central Scotland) were included in analyses of all-cause and cause-specific mortality. All-cause mortality was 25% (age-adjusted hazard ratio 1.25, 95% confidence interval (CI)1.21 to 1.30) and 41% (hazard ratio 1.41 (95% CI 1.36 to 1.45) higher in the Collaborative and Renfrew & Paisley cohorts respectively compared to the Whitehall cohort. The higher mortality rates were substantially attenuated by social class (to 8% and 17% higher respectively), and were effectively eliminated upon the further addition of the other baseline risk factors, such as smoking habit, lung function and pre-existing self-reported morbidity. Despite this, coronary heart disease mortality remained 11% and 16% higher, stroke mortality 45% and 37% higher, mortality from accidents and suicide 51% and 70% higher, and alcohol-related mortality 46% and 73% higher in the Collaborative and Renfrew & Paisley cohorts respectively compared with the Whitehall cohort in the fully adjusted model., Conclusions/significance: The higher all-cause, respiratory, and lung cancer male mortality in the Scottish cohorts was almost entirely explained by social class differences and higher prevalence of known risk factors, but reasons for the excess mortality from stroke, alcohol-related causes, accidents and suicide remained unknown.

Indices of socio-economic deprivation are often used as a proxy for differences in the health behaviours of populations within small areas, but these indices are a measure of the economic environment rather than the health environment. Sets of synthetic estimates of the ward-level prevalence of low fruit and vegetable consumption, obesity, raised blood pressure, raised cholesterol and smoking were combined to develop an index of unhealthy lifestyle. Multi-level regression models showed that this index described about 50% of the large-scale geographic variation in CHD mortality rates in England, and substantially adds to the ability of an index of deprivation to explain geographic variations in CHD mortality rates., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Context: The goal of US health care reform is to extend access. In England, with a universal access health system, coronary heart disease (CHD) mortality rates have decreased by more than two-fifths in the last decade, but variations in rates between local populations persist., Objective: To identify which features of populations and primary health care explain variations in CHD mortality rates between the 152 primary care trust populations in England., Design, Setting, and Participants: A cross-sectional study in England of all 152 primary care trusts (total registered population, 54.3 million in 2008) using a hierarchical regression model with age-standardized CHD mortality rate as the dependent variable, and population characteristics (index of multiple deprivation, smoking, ethnicity, and registers of individuals with diabetes) and service characteristics (level of provision of primary care services, levels of detected hypertension, pay for performance data) as candidate explanatory variables., Main Outcome Measures: Age-standardized CHD mortality rates in 2006, 2007, and 2008., Results: The mean age-standardized CHD mortality rates per 100,000 European Standard Population were 97.9 (95% confidence interval [CI], 94.9-100.9) in 2006, 93.5 (95% CI, 90.4-96.5) in 2007, and 88.4 (95% CI, 85.7-91.1) in 2008. In all 3 years, 4 population characteristics were significantly positively associated with CHD mortality (index of multiple deprivation, smoking, white ethnicity, and registers of individuals with diabetes), and 1 service characteristic (levels of detected hypertension) was significantly negatively associated with CHD mortality (adjusted r(2) = 0.66 in 2006, adjusted r(2) = 0.68 in 2007, and adjusted r(2) = 0.67 in 2008). Other service characteristics did not contribute significantly to the model., Conclusion: In England, variations in CHD mortality are predominantly explained by population characteristics; however, greater detection of hypertension is associated with lower CHD mortality.

Background: To examine the effect of serum testosterone levels on survival in a consecutive series of men with confirmed coronary disease and calculate the prevalence of testosterone deficiency., Design: Longitudinal follow-up study., Setting: Tertiary referral cardiothoracic centre. Patients 930 consecutive men with coronary disease referred for diagnostic angiography recruited between June 2000 and June 2002 and followed up for a mean of 6.9±2.1 years., Outcome: All-cause mortality and vascular mortality. Prevalence of testosterone deficiency., Results: The overall prevalence of biochemical testosterone deficiency in the coronary disease cohort using bio-available testosterone (bio-T) <2.6 nmol/l was 20.9%, using total testosterone <8.1 nmol/l was 16.9% and using either was 24%. Excess mortality was noted in the androgen-deficient group compared with normal (41 (21%) vs 88 (12%), p=0.002). The only parameters found to influence time to all-cause and vascular mortality (HR ± 95% CI) in multivariate analyses were the presence of left ventricular dysfunction (3.85; 1.72 to 8.33), aspirin therapy (0.63; 0.38 to 1.0), β-blocker therapy (0.45; 0.31 to 0.67) and low serum bio-T (2.27; 1.45 to 3.6)., Conclusions: In patients with coronary disease testosterone deficiency is common and impacts significantly negatively on survival. Prospective trials of testosterone replacement are needed to assess the effect of treatment on survival.

Background: Studies reporting outcomes following staged/synchronous carotid revascularisation prior to cardiac surgery have generally concluded that procedural strokes are reduced. However, virtually none have commented specifically on the risk of stroke in patients with bilateral carotid disease who then undergo their cardiac procedure in the presence of an unoperated, contralateral stenosis. If carotid disease really was an important cause of peri-operative stroke, these patients should incur a much higher risk of stroke following their cardiac procedure., Methods: Retrospective audit of prospectively acquired data in 132 consecutive patients undergoing synchronous carotid endarterectomy and cardiac surgery., Results: Overall 30-day rates of mortality, ipsilateral stroke and any stroke were 5.3%, 1.5% and 3% respectively. The 30-day rate of death/stroke was 6.8%. In 51 patients with a prior history of stroke/TIA, the 30-day rate of death/stroke was 5.9%, compared with 7.4% in neurologically asymptomatic patients. The majority (57%) had significant bilateral disease and underwent their combined procedure in the presence of a significant, non-operated (asymptomatic) contralateral stenosis (50-99% = 75, 60-99% = 54, 70-99% = 32). Only one patient (90-99% stenosis) suffered a post-operative stroke in the hemisphere ipsilateral to the non-operated, contralateral stenosis., Conclusions: Patients undergoing synchronous procedures incurred a low rate of procedural stroke, perhaps justifying this management approach. However, an alternative and more critical analysis suggested that the risk of procedural stroke in patients with significant (non-operated) contralateral asymptomatic carotid disease was extremely low. This challenges the assumption that asymptomatic carotid disease is an important cause of stroke during cardiac surgery., (Copyright 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Statins have been shown to reduce the risk of all-cause mortality among individuals with clinical history of coronary heart disease. However, it remains uncertain whether statins have similar mortality benefit in a high-risk primary prevention setting. Notably, all systematic reviews to date included trials that in part incorporated participants with prior cardiovascular disease (CVD) at baseline. Our objective was to reliably determine if statin therapy reduces all-cause mortality among intermediate to high-risk individuals without a history of CVD., Data Sources: Trials were identified through computerized literature searches of MEDLINE and Cochrane databases (January 1970-May 2009) using terms related to statins, clinical trials, and cardiovascular end points and through bibliographies of retrieved studies., Study Selection: Prospective, randomized controlled trials of statin therapy performed in individuals free from CVD at baseline and that reported details, or could supply data, on all-cause mortality., Data Extraction: Relevant data including the number of patients randomized, mean duration of follow-up, and the number of incident deaths were obtained from the principal publication or by correspondence with the investigators., Data Synthesis: Data were combined from 11 studies and effect estimates were pooled using a random-effects model meta-analysis, with heterogeneity assessed with the I(2) statistic. Data were available on 65,229 participants followed for approximately 244,000 person-years, during which 2793 deaths occurred. The use of statins in this high-risk primary prevention setting was not associated with a statistically significant reduction (risk ratio, 0.91; 95% confidence interval, 0.83-1.01) in the risk of all-cause mortality. There was no statistical evidence of heterogeneity among studies (I(2) = 23%; 95% confidence interval, 0%-61% [P = .23])., Conclusion: This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.

Context: Thyroid status affects several aspects of cardiovascular risk profile, including lipid levels and blood pressure. Whether thyroid status affects the risk of coronary heart disease (CHD) and all-cause mortality remains controversial., Design: The EPIC-Norfolk prospective population study. Mean follow-up was 10.6 years., Patients: Study participants were 11 554 men and women aged 45-79 years, who were living in Norfolk, UK., Measurements: Baseline cardiovascular risk factors were recorded and concentrations of thyroid-stimulating hormone (TSH) and free thyroxine (FT4) were measured in baseline samples. Regression analyses were performed to assess the association between thyroid hormone levels and cardiovascular risk factors. A proportional hazards model was used to estimate the risk of CHD and all-cause mortality by baseline thyroid status. No information was available on thyroid treatment during follow-up., Results: Thyroid abnormalities were common, particularly among women. Thyroid abnormalities were associated with an altered cardiovascular risk profile. Even within the normal range, thyroid hormone levels, TSH more strongly than FT4, were associated with lipid levels and blood pressure among both men and women. We did not observe a significant association between subclinical thyroid abnormalities and risk of CHD or all-cause mortality., Conclusions: Despite the association between thyroid hormone levels and cardiovascular risk factors, thyroid status was not statistically significantly associated with the risk of future CHD or all-cause mortality in this large cohort.

Analysis of the epidemiological effects of overall dietary patterns offers an alternative approach to the investigation of the role of diet in CHD. We analysed the role of blood lipid-related dietary patterns using a two-step method to confirm the prospective association of dietary pattern with incident CHD. Analysis is based on 7314 participants of the Whitehall II study. Dietary intake was measured using a 127-item FFQ. Reduced rank regression (RRR) was used to derive dietary pattern scores using baseline serum total and HDL-cholesterol, and TAG levels as dependent variables. Cox proportional hazard regression was used to confirm the association between dietary patterns and incident CHD (n 243) over 15 years of follow-up. Increased CHD risk (hazard ratio (HR) for top quartile: 2.01 (95% CI 1.41, 2.85) adjusted for age, sex, ethnicity and energy misreporting) was observed with a diet characterised by high consumption of white bread, fried potatoes, sugar in tea and coffee, burgers and sausages, soft drinks, and low consumption of French dressing and vegetables. The diet-CHD relationship was attenuated after adjustment for employment grade and health behaviours (HR for top quartile: 1.81; 95% CI 1.26, 2.62), and further adjustment for blood pressure and BMI (HR for top quartile: 1.57; 95% CI 1.08, 2.27). Dietary patterns are associated with serum lipids and predict CHD risk after adjustment for confounders. RRR identifies dietary patterns using prior knowledge and focuses on the pathways through which diet may influence disease. The present study adds to the evidence that diet is an important risk factor for CHD.

Aims: To examine the changes in coronary, all-cause, and cancer mortality in patients with heterozygous familial hypercholesterolaemia (FH) before and after lipid-lowering therapy with statins., Methods and Results: A total of 3382 patients (1650 men) aged <80 years were recruited from 21 lipid clinics in the United Kingdom and followed prospectively between 1980 and 2006 for 46 580 person-years. There were 370 deaths, including 190 from coronary heart disease (CHD) and 90 from cancer. The standardized mortality ratio (compared with the population in England and Wales) was calculated before and from 1 January 1992. In patients aged 20-79 years, CHD mortality fell significantly by 37% (95% CI = 7-56) from 3.4- to 2.1-fold excess. Primary prevention resulted in a 48% reduction in CHD mortality from 2.0-fold excess to none, with a smaller reduction of nearly 25% in patients with established disease. Coronary mortality was reduced more in women than in men. In patients without known CHD at registration, all-cause mortality from 1992 was 33% (21-43), lower than in the general population, mainly due to a 37% (21-50) lower risk of fatal cancer., Conclusion: The results emphasize the importance of early identification of FH and treatment with statins.

Background: There is a need for a new cardiovascular disease model that includes a wider range of relevant risk factors, in particular lifestyle factors, to aid targeting of interventions and improve population models of the impact of cardiovascular disease and preventive strategies. The model needs to be applicable to a wider population including different ethnic groups, different countries and to those with and without cardiovascular disease. This paper describes the construction of the Cardiovascular Health Improvement Model that aims to meet these requirements., Method: An odds model is used. Information was taken from 2003 mortality statistics for England and Wales, the Health Survey for England 2003 and published data on relative risk in those with and without CVD and mean blood pressure values in hypertensives. The odds ratios used were taken from the INTERHEART study., Results: A worked example is given calculating the 10-year coronary heart disease risk for a 57 year-old non-diabetic male with no personal or family history of cardiovascular disease, who smokes 30 cigarettes a day and has a systolic blood pressure of 137 mmHg, a total cholesterol (TC) of 6.2 mmol/l, a high density lipoprotein (HDL) of 1.3 mol/l, and a body mass index of 21. He neither drinks regularly nor exercises. He can give no reliable information about his mental health or fruit and vegetable intake. His 10-year risk of CHD death is 2.47%., Conclusion: This paper demonstrates a method for developing a CHD risk model. Further improvements could be made to the model with additional information. The method is applicable to other causes of death.

Background: Coronary heart disease (CHD) rates in England and Wales between 1950 and 2005 were high and reasonably steady until the mid 1970s, when they began to fall. Recent work suggests that the rate of change in some groups has begun to decrease and may be starting to plateau or even reverse., Methods: Data for all deaths between 1931 and 2005 in England and Wales were grouped by year, sex, age at death and contemporaneous ICD code for CHD as cause of death. CHD mortality rates by calendar year and birth cohort were produced for both sexes and rates of change were examined., Results: The pattern of increased burden of CHD mortality within older age groups has only recently emerged in men, whereas it has been established in women for far longer. CHD mortality rates among younger people showed little variation by birth cohort. For younger women (49 and under), the rate of change in CHD mortality has reversed in the last 20 years, indicating a future plateau and possible reversal of previous improvement in CHD mortality rates. Among younger men the rate of change in CHD mortality has been consistent for the past 15 years indicating that rates in this group have continued to fall steadily., Conclusion: Although CHD mortality rates continue to drop in older age groups the actual burden of coronary heart disease is increasing due to the ageing of the population. The rate of improvement in CHD mortality appears to be beginning to decline and may even be reversing among younger women.

Objective: To examine trends in coronary heart disease and stroke mortality in migrants to England and Wales., Design: Cross-sectional., Outcome Measures: Age-standardised and sex-specific death rates and rate ratios 1979-83, 1989-93 and 1999-2003., Results: Coronary mortality fell among migrants, more so in the second decade than the first. Rate ratios for coronary mortality remained higher for men and women from Scotland, Northern Ireland, Republic of Ireland and South Asia, and lower for men from Jamaica, other Caribbean countries, West Africa, Italy and Spain. Rate ratios increased for men from Jamaica (1979-83: 0.45, 0.40 to 0.50; 1999-2003: 0.81, 0.73 to 0.90), Pakistan (1979-83: 1.14, 1.04 to 1.25; 1999-2003: 1.93, 1.81 to 2.06), Bangladesh (1979-83: 1.36, 1.15 to 1.60; 1999-2003: 2.11, 1.90 to 2.34), Republic of Ireland (1979-1983: 1.18, 1.15 to 1.21; 1999-2003: 1.45, 1.39 to 1.52) and Poland (1979-83: 1.17, 1.09 to 1.25; 1999-2003: 1.97, 1.57 to 2.47), and for women from Jamaica (1979-83: 0.63, 0.52 to 0.77; 1999-2003: 1.23, 1.06 to 1.42) and Pakistan (1979-83: 1.14, 0.88 to 1.47; 1999-2003: 2.45, 2.19 to 2.74), owing to smaller declines in death rates than those born in England and Wales. Rate ratios for stroke mortality remained higher for migrants. As a result of smaller declines, rate ratios increased for men from Pakistan (1979-1983: 0.99, 0.76 to 1.29; 1999-2003: 1.58, 1.35 to 1.85), Scotland (1979-1983: 1.11, 1.04 to 1.19; 1999-2003: 1.30, 1.19 to 1.42) and Republic of Ireland (1979-1983: 1.27, 1.19 to 1.36; 1999-2003: 1.67, 1.52 to 1.84)., Conclusion: For groups with higher mortality than people born in England and Wales, mortality remained higher. Smaller declines led to increasing disparities for some groups and to excess coronary mortality for women from Jamaica. Maximising the coverage of prevention and treatment programmes is critical.

The risk of coronary heart disease (CHD) is strongly linked both to deprivation and ethnicity and so prevalence will vary considerably between areas. Variations in prevalence are important in assessing health care needs and how far CHD service provision and surgical intervention rates match need. This paper uses a regression model of prevalence rates by age, sex, region and ethnicity from the 1999 and 2003 Health Surveys for England to estimate CHD prevalence for 354 English local authority areas. To allow for the impact of social factors on prevalence, survey information on the deprivation quintile in the respondents' micro-area of residence is also used. Allowance is also made for area CHD mortality rates (obtained from aggregated vital statistics data) which are positively correlated with, and hence a proxy for, CHD prevalence rates. An application involves assessment of surgical intervention rates in relation to prevalence at the level of 28 Strategic Health Authorities.

Background: Trends in cardiovascular risk factors among UK adults present a complex picture. Ominous increases in obesity and diabetes among young adults raise concerns about subsequent coronary heart disease (CHD) mortality rates in this group., Objective: To examine recent trends in age-specific mortality rates from CHD, particularly those among younger adults., Methods and Results: Mortality data from 1984 to 2004 were used to calculate age-specific mortality rates for British adults aged 35+ years, and joinpoint regression was used to assess changes in trends. Overall, the age-adjusted mortality rate decreased by 54.7% in men and by 48.3% in women. However, among men aged 35-44 years, CHD mortality rates in 2002 increased for the first time in over two decades. Furthermore, the recent declines in CHD mortality rates seem to be slowing in both men and women aged 45-54. Among older adults, however, mortality rates continued to decrease steadily throughout the period., Conclusions: The flattening mortality rates for CHD among younger adults may represent a sentinel event. Deteriorations in medical management of CHD appear implausible. Thus, unfavourable trends in risk factors for CHD, specifically obesity and diabetes, provide the most likely explanation for the observed trends.

Background: The relationship between coronary heart disease (CHD) incidence and death, and individual sociodemographic status is well established. Our aim was to examine whether neighbourhood deprivation scores predict CHD and death in older men, independently of individual sociodemographic status., Methods: Prospective study of 5049 men, born between 1918 and 1939, recruited from 24 British towns encompassing 969 electoral wards, without documented evidence of previous major CHD when responding to a questionnaire in 1992, and followed up for incidence of major CHD and death., Results: Four hundred and seventy-two new major CHD events (1.08% pa), and 1021 deaths (2.28% pa) occurred over an average of 9.75 years. When men were divided into fifths according to increasing neighbourhood deprivation score, CHD incidences (% pa) were 0.92, 0.89, 0.99, 1.33 and 1.29. When modelling continuous trends, the rate ratio for men in the top fifth compared with the bottom fifth was 1.55 (95% confidence interval 1.19-2.00) for CHD. This rate ratio was, however, no longer statistically significant [1.22 (95% confidence interval 0.92-1.61)] when effects of individual sociodemographic status measures (car ownership, housing, longest held occupation, marital status and social networks) were accounted for., Conclusion: Little evidence of an independent relationship of neighbourhood deprivation with CHD incidence was found once individual measures of sociodemographic status had been adjusted for.

Current orthodoxy states that coronary heart disease results from the unhealthy lifestyles of westernized adults together with a contribution from genetic inheritance. This does not provide a secure basis for prevention of the disease. Geographical studies gave the first clue that the disease originates during intra-uterine development. Variations in mortality from the disease across England and Wales were shown to correlate closely with past differences in death rates among newborn babies. In the past most deaths among newborns were attributed to low birthweight. This led to the hypothesis that undernutrition in utero permanently changes the body's structure, function and metabolism in ways that lead to coronary heart disease in later life. The association between low birthweight and coronary heart disease has been confirmed in longitudinal studies of men and women around the world. The developmental model of the origins of the disease offers a new way forward.

Background: Coronary heart disease (CHD) in the UK affects approximately 3 million people, with >100,000 deaths annually. Mortality rates have halved since the 1980s, but annual NHS treatment costs for CHD exceed 2 billion pounds., Aim: To examine the cost-effectiveness of specific CHD treatments in England and Wales., Methods: The IMPACT CHD model was used to calculate the number of life-years gained (LYG) from specific cardiological interventions from 2000 to 2010. Cost-effectiveness ratios (costs per LYG) were generated for each specific intervention, stratified by age and sex. The robustness of the results was tested using sensitivity analyses., Results: In 2000, medical and surgical treatments together prevented or postponed approximately 25,888 deaths in CHD patients aged 25-84 years, thus generating approximately 194,929 extra life-years between 2000 and 2010 (range 143,131-260,167). Aspirin and beta-blockers for secondary prevention following myocardial infarction or revascularisation, for angina and heart failure were highly cost-effective (< 1000 pounds per LYG). Other secondary prevention therapies, including cardiac rehabilitation, ACE inhibitors and statins, were reasonably cost-effective (1957 pounds, 3398 pounds and 4246 pounds per LYG, respectively), as were CABG surgery (3239 pounds-4601 pounds per LYG) and angioplasty (3845 pounds-5889 pounds per LYG). Primary angioplasty for myocardial infarction was intermediate (6054 pounds-12,057 pounds per LYG, according to age), and statins in primary prevention were much less cost-effective (27,828 pounds per LYG, reaching 69,373 pounds per LYG in men aged 35-44). Results were relatively consistent across a wide range of sensitivity analyses., Discussion: The cost-effectiveness ratios for standard CHD treatments varied by over 100-fold. Large amounts of NHS funding are being spent on relatively less cost-effective interventions, such as statins for primary prevention, angioplasty and CABG surgery. This merits debate.

Objective: To determine whether rapid access chest pain clinics are clinically effective by comparison of coronary event rates in patients diagnosed with angina with rates in patients diagnosed with non-cardiac chest pain and the general population., Design: Multicentre cohort study of consecutive patients with chest pain attending the rapid access chest pain clinics (RACPCs) of six hospitals in England., Participants: 8762 patients diagnosed with either non-cardiac chest pain (n = 6396) or incident angina without prior myocardial infarction (n = 2366) at first cardiological assessment, followed up for a median of 2.57 (interquartile range 1.96-4.15) years., Main Outcome Measures: Primary end point--death due to coronary heart disease (International Classification of Diseases (ICD)10 I20-I25) or acute coronary syndrome (non-fatal myocardial infarction (ICD10 I21-I23), hospital admission with unstable angina (I24.0, I24.8, I24.9)). Secondary end points--all-cause mortality (ICD I20), cardiovascular death (ICD10 I00-I99), or non-fatal myocardial infarction or non-fatal stroke (I60-I69)., Results: The cumulative probability of the primary end point in patients diagnosed with angina was 16.52% (95% confidence interval (CI) 14.88% to 18.32%) after 3 years compared with 2.73% (95% CI 2.29% to 3.25%) in patients with non-cardiac chest pain. Coronary standardised mortality ratios for men and women with angina aged <65 years were 3.52 (95% CI 1.98 to 5.07) and 4.39 (95% CI 1.14 to 7.64). Of the 599 patients who had the primary end point, 194 (32.4%) had been diagnosed with non-cardiac chest pain. These patients were younger, less likely to have typical symptoms, more likely to be south Asian and more likely to have a normal resting electrocardiogram than patients with angina who had the primary end point., Conclusion: RACPCs are successful in identifying patients with incident angina who are at high coronary risk, but there is a need to reduce misdiagnosis and improve outcomes in patients diagnosed with non-cardiac chest pain who accounted for nearly one third of cardiac events during follow-up.

Aims/hypothesis: We examined prospectively whether measured risk factors can explain the higher CHD mortality in South Asians compared with Europeans., Materials and Methods: Conventional CHD risk factors and those associated with insulin resistance were measured in 1,787 European and 1,420 South Asian men aged 40 to 69 years at baseline in the population-based Southall and Brent studies (London) between 1988 and 1990. Participants were followed up for mortality., Results: By February 2006, there were 202 CHD deaths (108 Asian, 94 European). South Asian men had double the CHD mortality of European men in Cox regression analyses adjusted for age, smoking, and cholesterol (hazard ratio [HR] 2.14, 95% CI 1.56-2.94, p<0.001). Nearly half of all South Asian CHD deaths versus 13% of deaths among Europeans were among persons with diabetes. Asian men had greater CHD mortality than Europeans, both in the with- and the without-diabetes categories at baseline. CHD mortality remained significantly higher in South Asian men in multivariable models that adjusted for conventional risk factors and diabetes and/or impaired glucose regulation, features of insulin resistance, or the metabolic syndrome (HR 1.6-1.9). Accounting for co-morbidity and socio-economic status did not materially alter the findings., Conclusions/interpretation: These data confirm that South Asian men have significantly higher CHD mortality than their European counterparts, while indicating that neither conventional risk factors, nor insulin resistance parameters or metabolic syndrome criteria as currently defined can account for this excess risk. The contribution of unmeasured factors to the elevated vascular risk in South Asians should be addressed in future studies.

Background: Among primary coronary heart disease (CHD) risk factors, certain socioeconomic characteristics of individuals and living environments appear to play a central role. The objective of this study was to assess the burden of neighbourhood deprivation-associated excess in mortality and hospital admission from CHD in Plymouth., Methods: A small area ecological study using indices of neighbourhood deprivation and coronary heart disease mortality and hospital admission data aggregated for 1991-2003 for CHD mortality and for 1997-2004 for CHD hospital admission. Locally defined community areas (n = 43) were classified according to the Townsend index, measuring material deprivation., Results: CHD mortality and hospital admission increased with Townsend deprivation score in all ages and gender groups. The age-adjusted deprivation-associated excess CHD hospital admission was 15.4% in men and 27.9% in women higher for most compared to the least deprived group. The age-adjusted deprivation-associated excess CHD mortality was 31.5% and 18.9% for men and women, respectively. Excess mortality in the 13-year period studied accounted for more than 1380 and 670 deaths for men and women. Excess hospital admissions in the 7-year period studied accounted for more than 966 and 769 hospital admissions for men and women. A larger proportion of excess CHD deaths were found among men while excess CHD hospital admissions were found among women. The most deprived areas showed the highest mortality and hospital admission risk., Conclusion: Despite the existence of a system of universal health care, inequalities in CHD mortality and hospital admission persist and need to be taken into account when implementing intervention programmes.

Aims: To examine the hypothesis that coronary heart disease mortality and emergency hospital admission rates are higher in areas with higher outdoor air pollution levels., Methods and Results: Modelled nitrogen oxides (NO(x)), particulate matter (PM(10)), and carbon monoxide (CO) levels were interpolated to 1030 census enumeration districts using an ecological study design. Results, based on 6857 deaths and 11,407 admissions from 1994-98 and a population of 199,682 aged >or=45 years, were adjusted for age, sex, deprivation, and smoking prevalence. Mortality rate ratios were 1.17 (95% CI 1.06-1.29), 1.08 (95% CI 0.96-1.20), and 1.05 (95% CI 0.95-1.16) in the highest relative to the lowest NO(x), PM(10), and CO quintile categories, respectively. Corresponding admission rate ratios were 1.00 (95% CI 0.90-1.10), 1.01 (95% CI 0.90-1.14), and 0.88 (95% CI 0.79-0.98)., Conclusion: The results are consistent with an excess risk of coronary heart disease mortality in areas with high outdoor NO(x), a proxy for traffic-related pollution, but residual confounding cannot be ruled out. If causality were assumed, 6% of coronary heart disease deaths would have been attributable to outdoor NO(x,) and targeting pollution reduction measures at high pollution areas would be an option for coronary mortality prevention.

Objective: To investigate whether population based primary prevention (risk factor reduction in apparently healthy people) might be more powerful than current government initiatives favouring risk factor reduction in patients with coronary heart disease (CHD) (secondary prevention)., Design, Setting, and Participants: The IMPACT model was used to synthesise data for England and Wales 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 healthy people and in CHD patients., Results: Between 1981 and 2000, CHD mortality rates fell by 54%, resulting in 68,230 fewer deaths in 2000. Overall smoking prevalence declined by 35% between 1981 and 2000, resulting in approximately 29,715 (minimum estimate 20 035, maximum estimate 44,675) fewer deaths attributable to smoking cessation: approximately 5035 in known CHD patients and approximately 24,680 in healthy people. Population total cholesterol concentrations fell by 4.2%, resulting in approximately 5770 fewer deaths attributable to dietary changes (1205 in CHD patients and 4565 in healthy people) plus 2135 fewer deaths attributable to statin treatment (1990 in CHD patients, 145 in people without CHD). Mean population blood pressure fell by 7.7%, resulting in approximately 5870 fewer deaths attributable to secular falls in blood pressure (520 in CHD patients and 5345 in healthy people) plus approximately 1890 fewer deaths attributable to antihypertensive treatments in people without CHD. Approximately 45,370 fewer deaths were thus attributable to reductions in the three major risk factors in the population: some 36 625 (81%) in people without recognised CHD and 8745 (19%) in CHD patients., Conclusions: Compared with secondary prevention, primary prevention achieved a fourfold larger reduction in deaths. Future CHD policies should prioritise population-wide tobacco control and healthier diets.

Objective: It is widely held that there will be an epidemic of heart failure in Europe and North America as a result of increased survival from myocardial infarction and other coronary heart disease. The study objective was to discover if the decline in mortality from coronary heart disease has been accompanied by a rise in mortality from heart failure in the study population., Design: Analysis of database of mortality records including all certified causes of death, not just the underlying cause, from 1979-2003., Setting: Former Oxford NHS Region, England., Patients: Data from death certificates of all who died in the population covered., Main Results: Mortality rates for heart failure fell at very similar rates as those from coronary heart disease. In men, the average annual fall in mortality from coronary heart disease was -2.7% (95% confidence intervals -2.8 to -2.5) and that from heart failure was -2.9% (-3.2 to -2.5). In women, the average annual fall in mortality from coronary heart disease was -2.3% (-2.6 to -2.1) and that from heart failure was -2.6% (-3.0 to -2.3)., Conclusions: The decline in mortality from coronary heart disease has not been accompanied by a rise in mortality from heart failure. A future epidemic of heart failure, as a consequence of the decline in mortality from coronary heart disease, seems unlikely.

Background and Objective: The U.K. government recently called for a 40% reduction in cardiovascular disease mortality by 2010. We examined the potential for cardiovascular risk factor changes to achieve that target., Methods: We applied a previously validated mortality model, IMPACT, to an England and Wales population (37.1 million, aged 25-84). The model integrates information on trends in all the major cardiovascular risk factors, plus the uptake and effectiveness of all medical and surgical treatments. The potential reductions in coronary heart disease mortality from the base year, 2000, were calculated for two contrasting scenarios: (a) if recent risk factor trends simply continued to 2010 and (b) if further small reductions in risk factors were achieved, as in Scandinavia and the United States., Results: Continuation of recent risk factor trends should result in approximately 10,685 fewer coronary deaths in 2010 (minimum estimate 10,110; maximum 16,460) than in 2000. Modest additional reductions in cholesterol and smoking could potentially achieve 51,270 fewer deaths (minimum 39,435; maximum 71,510). Optimistic changes in obesity, diabetes, and physical activity, however, would have relatively small effects., Conclusion: Modest additional risk factor reductions in cholesterol and smoking already achieved in the United States and Scandinavia could prevent or postpone > 50,000 deaths by 2010, halving current coronary mortality.

In the Whitehall Study, which followed 17,139 male civil servants over 33 years, the association between tall stature and coronary heart disease (CHD) mortality differed between employment grades. In men without CHD at study entry, the hazard ratio per 15-cm increase in height was 0.77 (95% confidence interval [CI]=0.69, 0.85; P<0.001) for the highest grades, but 0.84 (95% CI=0.69, 1.03; P=.10) for middle and 0.95 (95% CI=0.75, 1.20; P=.65) for low grades, suggesting that childhood and adult social conditions may interact in their influence on coronary risk.

Background: The prognosis from coronary heart disease (CHD) for patients with heterozygous familial hypercholesterolaemia has improved substantially since the introduction of HMG Co-A reductase inhibitors (statins), but the effect of lipid-lowering drug therapy combined with dietary and life style advice on non-coronary mortality and the risk of fatal cancer is unclear., Methods: The cohort of 2871 patients was recruited from 21 outpatient lipid clinics in the UK from 1980 to 1998 and was followed for 22,992 person-years. The standardised mortality ratio (SMR) was calculated from the ratio of the number of deaths observed to the number expected in the general population of England and Wales., Results: There were 169 deaths, including 102 (60.4%) from CHD, and 32 (18.9%) from cancer. The SMR for CHD was 2.5-fold higher than in the general population (95% CI 2.1, 3.1), but the all-cause SMR was not increased (1.1, 95% CI 0.9, 1.3) and non-coronary mortality was significantly lower in men (0.5, 95% CI 0.3, 0.7) and women (0.6, 95% CI 0.4, 0.9). The SMR for all cancers was significantly reduced (0.6, 95% CI 0.4, 0.8) with an 80% reduction in fatal cancers of the respiratory and intra-thoracic organs and a non-significant reduction in fatal cancers of the genitourinary and digestive organs., Conclusions: Although the study cannot exclude the possibility that statins have anti-cancer activity, the results strongly suggest that giving advice to consume a healthy diet, increase physical activity and stop smoking is associated with a substantial reduction in mortality from cancer.

Objectives: To present named surgeon mortality for isolated first time coronary artery surgery and aortic valve surgery., Design: Retrospective analysis of prospectively collected data., Setting: All NHS hospitals undertaking adult cardiac surgery in north west England., Participants: 25 consultant surgeons carrying out coronary artery surgery and aortic valve replacement between April 2001 and March 2004., Main Outcome Measures: Mortality for both operations according to surgeon. EuroSCORE to stratify patients into low and high risk., Results: 10,163 patients underwent surgery under 25 surgeons. The average number of patients per surgeon was 363 for coronary artery surgery and 44 for aortic valve replacement. Seventeen per cent of the patients undergoing coronary artery surgery and half of those undergoing aortic valve surgery were considered high risk. The average mortality was 1.8% (range 0-3.8%) for coronary surgery and 1.9% (0-12.5%) for aortic valve surgery. Mortality for all surgeons fell below 99% control limits of the national mean for both operations., Conclusions: The presented mortality figures for the two cardiac operations fell within accepted limits for all surgeons. The division of outcomes according to low and high risk patients is imperfect but may help to inform the public about the complexities of this type of analysis and prevent surgeons avoiding high risk patents who may benefit from an operation.