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Introduction: Individuals with Long Covid represent a new and growing patient population. In England, fewer than 90 Long Covid clinics deliver assessment and treatment informed by NICE guidelines. However, a paucity of clinical trials or longitudinal cohort studies means that the epidemiology, clinical trajectory, healthcare utilisation and effectiveness of current Long Covid care are poorly documented, and that neither evidence-based treatments nor rehabilitation strategies exist. In addition, and in part due to pre-pandemic health inequalities, access to referral and care varies, and patient experience of the Long Covid care pathways can be poor. In a mixed methods study, we therefore aim to: (1) describe the usual healthcare, outcomes and resource utilisation of individuals with Long Covid; (2) assess the extent of inequalities in access to Long Covid care, and specifically to understand Long Covid patients' experiences of stigma and discrimination. Methods and analysis: A mixed methods study will address our aims. Qualitative data collection from patients and health professionals will be achieved through surveys, interviews and focus group discussions, to understand their experience and document the function of clinics. A patient cohort study will provide an understanding of outcomes and costs of care. Accessible data will be further analysed to understand the nature of Long Covid, and the care received. Ethics and dissemination: Ethical approval was obtained from South Central—Berkshire Research Ethics Committee (reference 303958). The dissemination plan will be decided by the patient and public involvement and engagement (PPIE) group members and study Co-Is, but will target 1) policy makers, and those responsible for commissioning and delivering Long Covid services, 2) patients and the public, and 3) academics. [ABSTRACT FROM AUTHOR]

Objectives: to examine the use of antithrombotic therapy and predictors of stroke and death in very elderly (≥85 years) atrial fibrillation (AF) patients in a general practice cohort from the UK. Design: retrospective, observational cohort study; 12-month follow-up period. Setting: eleven general practices serving the town of Darlington, England representing a population of 105,000 patients. Patients: two thousand two hundred and fifty-nine patients with a history of AF, 561 (24.8%) aged ≥85 years. Main outcome measures: use of antithrombotic therapy by age group and predictors of stroke and death. Results: five hundred and sixty-one (24.8%) AF patients aged ≥85 years (mean (SD) age 89 (4) years; 66% female) identified with a mean CHA2DS2-VASc score of 4.6 (SD 1.4). Thirty-six per cent received oral anticoagulation (OAC) compared with 57% in the 75-84 years age group. Forty-nine per cent of the very elderly received antiplatelet (AP) monotherapy; recorded OAC contraindications and declines were greatest among those aged ≥85 years. Stroke risk was highest among the very elderly (5.2% per annum), despite anticoagulation (3.9%). Multivariate analyses demonstrated an increased risk of stroke with AP monotherapy (odds ratio (OR) 2.45, 95% confidence intervals (CIs) 1.05-5.70) and a significant reduction in all-cause mortality with OAC therapy (OR 0.59, 95% CI 0.36-0.99). Conclusion: the majority of very elderly AF patients in general practice do not receive OAC despite their higher stroke risk; almost half received AP monotherapy. AP use independently increased the risk of stroke, signifying that effective stroke prevention requires OAC regardless of age, except where true contraindications exist. [ABSTRACT FROM AUTHOR]

Aims: Supervised exercise can benefit selected patients with heart failure, however the effectiveness of home-based exercise remains uncertain. We aimed to assess the effectiveness of a home-based exercise programme in addition to specialist heart failure nurse care. [ABSTRACT FROM PUBLISHER]

The article focuses on the study regarding patients with nonvalvular atrial fibrillation (AF) receiving percutaneous coronary intervention (PCI) in West Midlands, England. The study used data of patients who were diagnosed with AF associated with acute coronary syndrome or PCI. It was found that 25 patients were prescribed with aspirin and clopidogrel, six patients with triple therapy, two patients with clopidogrel only and two patients receiving warfarin plus antiplatelet drug upon discharge.

The article examines the compliance and treatment of patients with hypertension by researchers from Birmingham, England. It is stated that treatment and control of hypertension reduces cardiovascular risk and delays target-organ damage. Therefore, the researchers assert that it is essential for physicians to try various options to increase compliance with antihypertensive medications.

Background: Stroke prevention is central to the management of atrial fibrillation (AF), but there remains a residual risk of adverse outcomes in anticoagulated AF patients. Hence, current guidelines have proposed a more holistic or integrated approach to AF management, based on the Atrial fibrillation Better Care (ABC) pathway, as follows: (A) avoid stroke with anticoagulation; (B) better symptom control with patient-centred symptom directed decisions on rate or rhythm control; and (C) cardiovascular and comorbidity management, including lifestyle factors. There has been no formal healthcare cost analysis from the UK National Health Service (NHS) perspective of ABC pathway implementation to optimize the management of AF. Our aim was to estimate the number of patients with AF in the UK each year up to 2040, their morbidity and mortality, and the associated healthcare costs, and secondly, to estimate improvements in morbidity and mortality of implementing an ABC pathway, and the impact on costs., Results: In 2020, there were an estimated 1 463 538 AF patients, resulting in £286 million of stroke care and £191 million of care related to bleeds annually. By 2030, it is expected that there will be 2 115 332 AF patients, resulting in £666 million of stroke healthcare and £444 million of healthcare related to bleeds. By 2040, this is expected to rise to 2 856 489 AF patients, with £1096 million of stroke healthcare and £731 million of healthcare related to bleeds for that year. If in 2040 patients are managed on an ABC pathway, this could prevent between 3724 and 18 622 strokes and between 5378 and 26 890 bleeds, and save between 16 131 and 80 653 lives depending on the proportion of patients managed on the pathway. This would equate to cost reductions of between £143.9 million and £719.6 million for the year., Conclusion: We estimate that there will be a substantial healthcare burden in the UK NHS associated with AF, from strokes, bleeds, and mortality over the next decades. If patients are managed with a holistic or integrated care approach based on the ABC pathway, this could prevent strokes and bleeds that equate to substantial NHS healthcare cost reductions, and save lives., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Atrial fibrillation (AF) increases the risk of death, stroke, heart failure, cognitive decline, and healthcare costs but is often asymptomatic and undiagnosed. There is currently no national screening program for AF. The advent of validated hand-held devices allows AF to be detected in non-healthcare settings, enabling screening to be undertaken within the community., Method and Results: In this novel observational study, we embedded a MyDiagnostick single lead ECG sensor into the handles of shopping trolleys in four supermarkets in the Northwest of England: 2155 participants were recruited. Of these, 231 participants either activated the sensor or had an irregular pulse, suggesting AF. Some participants agreed to use the sensor but refused to provide their contact details, or consent to pulse assessment. In addition, some data were missing, resulting in 203 participants being included in the final analyses. Fifty-nine participants (mean age 73.6 years, 43% female) were confirmed or suspected of having AF; 20 were known to have AF and 39 were previously undiagnosed. There was no evidence of AF in 115 participants and the remaining 46 recordings were non-diagnostic, mainly due to artefact. Men and older participants were significantly more likely to have newly diagnosed AF. Due to the number of non-diagnostic ECGs (n = 46), we completed three levels of analyses, excluding all non-diagnostic ECGs, assuming all non-diagnostic ECGs were masking AF, and assuming all non-diagnostic ECGs were not AF. Based on the results of the three analyses, the sensor's sensitivity (95% CI) ranged from 0.70 to 0.93; specificity from 0.15 to 0.97; positive predictive values (PPV) and negative predictive values (NPV) ranged from 0.24 to 0.56 and 0.55 to 1.00, respectively. These values should be interpreted with caution, as the ideal reference standard on 1934 participants was imperfect., Conclusion: The study demonstrates that the public will engage with AF screening undertaken as part of their daily routines using hand-held devices. Sensors can play a key role in identifying asymptomatic patients in this way, but the technology must be further developed to reduce the quantity of non-diagnostic ECGs., Competing Interests: Disclosures The study is independently led by the academic team and is supported by educational grant funding from Bristol Myers Squibb. Deirdre Lane received investigator-initiated educational grants from Bristol-Myers Squibb (BMS) and Pfizer, has been a speaker for Bayer, Boehringer Ingelheim, and BMS/Pfizer and has consulted for BMS and Boehringer Ingelheim; all outside the submitted work. Peter Penson owns four shares in AstraZeneca PLC and has received honoraria and/or travel reimbursement for events sponsored by AKCEA, Amgen, AMRYT, Link Medical, Mylan, Napp, Sanofi. Lis Neubeck has received an investigator-initiated grant from Daiichi Sankyo, payment from Bristol Myers Squib for participation in a Global Medical Advisory Board and is the Former President of the Association for Cardiovascular Nursing and Allied Professionals of the ESC. Gregory Lip has been Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, Anthos. No fees are received personally. He is co-principal investigator of the AFFIRMO project on multimorbidity in AF, which has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement No 899871. No further conflicts of interest declared., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: There is a lack of evidence that the benefits of screening for atrial fibrillation (AF) outweigh the harms. Following the completion of the Screening for Atrial Fibrillation with ECG to Reduce stroke (SAFER) pilot trial, the aim of the main SAFER trial is to establish whether population screening for AF reduces incidence of stroke risk., Methods and Analysis: Approximately 82 000 people aged 70 years and over and not on oral anticoagulation are being recruited from general practices in England. Patients on the palliative care register or residents in a nursing home are excluded. Eligible people are identified using electronic patient records from general practices and sent an invitation and consent form to participate by post. Consenting participants are randomised at a ratio of 2:1 (control:intervention) with clustering by household. Those randomised to the intervention arm are sent an information leaflet inviting them to participate in screening, which involves use of a handheld single-lead ECG four times a day for 3 weeks. ECG traces identified by an algorithm as possible AF are reviewed by cardiologists. Participants with AF are seen by a general practitioner for consideration of anticoagulation. The primary outcome is stroke. Major secondary outcomes are: death, major bleeding and cardiovascular events. Follow-up will be via electronic health records for an average of 4 years. The primary analysis will be by intention-to-treat using time-to-event modelling. Results from this trial will be combined with follow-up data from the cluster-randomised pilot trial by fixed-effects meta-analysis., Ethics and Dissemination: The London-Central National Health Service Research Ethics Committee (19/LO/1597) provided ethical approval. Dissemination will include public-friendly summaries, reports and engagement with the UK National Screening Committee., Trial Registration Number: ISRCTN72104369., Competing Interests: Competing interests: JM has performed consultancy work for BMS/Pfizer and Omron. FDRH reports occasional consultancy for BMS/Pfizer, Bayer and BI over the past 5 years. NA is a member of the UK National Screening Committee. MC and MS are employed by AstraZeneca, but at the time of involvement with the trial were employed by universities (King's College London and University of Leicester, respectively), for which they still hold honorary contracts. RJM’s employer, the University of Oxford, receives consultancy and licensing payments from Omron and Sensyne for BP telemonitoring interventions. GYHL is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo and Anthos. No fees are received personally. SJG has received honoraria from AstraZeneca for lectures at postgraduate educational meetings for primary care teams about type 2 diabetes. BF has received speaker fees, honoraria and non-financial support from BMS and Pfizer Alliance; grants to the institution for investigator-initiated studies from BMS and Pfizer Alliance; and loan devices for investigator-initiated studies from Alivecor, all were unrelated to the present trial but related to screening for AF., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Hypertension is the key modifiable cardiovascular risk factor but is underdiagnosed, and its scale in South Asian and African-Caribbean communities is unknown. Left ventricular hypertrophy (LVH) is a measure of target organ damage in uncontrolled hypertension. The study assesses LVH prevalence in South Asian and African-Caribbean communities and its impact on mortality., Method: This study is based on the large prospective UK community Ethnic-Echocardiographic Heart of England Screening Study (E-ECHOES, age ≥45 years). Left ventricular mass index (LVMI) was calculated using echocardiography to establish LVH. The predictive value of LVH all-cause and cardiovascular mortality was assessed using Cox regression., Results: The study included 3200 South Asians (age 59 ± 10 years, 52% women, 45% had a history of hypertension, 5.8 ± 1.0-year follow-up). LVH was found in 1568 (49%), of whom 45% did not have hypertension diagnosis. On Cox regression, LVH was independently associated with all-cause mortality [hazard ratio 1.38, 95% confidence interval (95% CI) 1.01-1.88], cardiovascular mortality (hazard ratio 2.64, 95% CI 1.21-3.73). The projected overall hypertension prevalence was 82%, undiagnosed hypertension prevalence 37%. The study included 1858 African-Caribbeans (age 62 ± 12, 45% women, 45% had history of hypertension, 5.1 ± 0.9-year follow-up). LVH was found in 1186 (64%), of whom 32% did not have hypertension diagnosis. LVH was borderline associated with all-cause mortality (hazard ratio 1.57, 95% CI 1.01-2.44), but not cardiovascular mortality (hazard ratio 1.82, 95% CI 0.80-4.16). The projected overall hypertension prevalence was 78.5%, and undiagnosed hypertension prevalence was 20.8%., Conclusion: UK South Asians and African-Caribbeans have a high prevalence of hypertension, which is often underdiagnosed and poorly controlled., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Previous studies, mainly from the United States, have reported worse outcomes from lower limb bypass procedures in ethnic minority populations. Limited nationwide data are available from ethnic minority populations from Europe. The aim of this study is to investigate outcomes from lower limb bypass procedures in ethnic minorities from England., Methods: We enquired the "Hospital Episode Statistics" database, using ICD-10 codes to identify all cases of femoral-popliteal bypass operations from English NHS Hospitals from 01/01/2006 to 31/12/2015. Every case was followed up for 2 years for subsequent events. The primary outcomes were mortality and major leg amputation. Patients were broadly categorised according to Black, Asian and White ethnicity. Chi-square test was used to the ethnic groups and odds ratios (OR) were calculated using White ethnic group with the largest numbers of participants as a reference category., Results: In the examined 10-year period, 20825 femoral-popliteal bypass procedures (250 of Black, 167 of Asian, and 20.408 of White ethnicity) were recorded. Thirty-day and 2-year mortality were 2.8% and 16.8% with no significant ethnic differences. Patients of Black ethnicity had higher risk of limb loss compared to Whites (23.2% vs. 15.6%, OR = 1.63, 95% confidence interval (CI) 1.21-2.19, P < 0.01). There was no significant difference in amputation rates between Asians and Whites (16.2% vs.. 15.6%, P = 0.94)., Conclusions: Patients of Black ethnicity are at higher risk of limb loss after a femoropopliteal bypass procedure. Further research is needed to identify the causes of this discrepancy., (Copyright © 2021. Published by Elsevier Inc.)

Background/objectives: Stroke-related visual impairment and atrial fibrillation are both common following stroke. This study explores whether presence of visual impairment following stroke is associated with presence of atrial fibrillation (AF)., Subjects/methods: The Impact of Visual Impairment after Stroke (IVIS) study is a multi-centre, acute stroke unit, prospective epidemiology study. Standardised visual assessments included visual acuity, reading, visual fields, eye movements and visual perception. AF and blood pressure (BP) were measured on admission. Further data capture included stroke type, age, gender, stroke severity. Analysis included descriptive statistics, independent samples analysis and multivariate analysis for comparison of AF and visual impairment against covariates., Results: 1500 stroke admissions were recruited of which 1204 stroke survivors had visual assessment. New onset stroke-related visual impairment (n = 703) was significantly associated with older age and stoke severity. AF and BP data were available for 889 stroke survivors. AF was present on admission for 258 stroke survivors and significantly associated with older age, stroke severity and discharge destination. A significant association was found for presence of AF and presence of visual impairment. However, stroke severity was a contributing factor for this association. High systolic BP (>140 mmHg) was present in 62% and high diastolic BP (>90 mmHg) in 29%, but not associated with presence of visual impairment., Conclusions: AF and visual impairment, independently, occur commonly in stroke. Although our results show an association between AF and visual impairment, this appears to be independently influenced by stroke severity. AF was not associated with type of visual impairment or extent of visual recovery. It remains unknown if AF causes more severe visual impairment., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Malignant hypertension represents a high-risk condition and there are scarce data on current clinical patterns of this condition. The aim of the study is to identify the clinical and demographic factors associated with poor outcome., Methods: The data collected from 1958 to May 2016 included a total of 351 patients whose 5-year survival status was known: 221 white Caucasians (63%, age 51 ± 13 years, 64% male), 83 African-Caribbeans (24%, 45 ± 11 years, 61% male), and 47 South Asians (13%, 42 ± 11 years, 74% male)., Results: During the 5-year follow-up 119 (34%) patients suffered a primary outcome, defined as the composite endpoint of death or dialysis. The 5-year mortality ranged from 76% in patients diagnosed before 1967 to 7% in patients diagnosed between 1997 and 2006. The independent predictors of outcome were advanced age (vs. a reference group of < 40-year-old; P = 0.01 for age at presentation 51-60 years, P < 0.001 for age > 60 years), prior use of antihypertensive medications (P = 0.002), higher serum creatinine (P = 0.006), and proteinuria (P < 0.01). Also, white Caucasian (odds ratio12.02, 95% confidence interval 1.64-88.15, P = 0.01) and African-Caribbean (odds ratio 15.55, 95% confidence interval 2.06-117.29, P = 0.008) origins were associated with higher mortality vs. South Asians. The years of the diagnosis after 1977 were significantly associated with lower composite endpoint of death or dialysis, all P < 0.01., Conclusion: There has been a major improvement in 5-year survival in patients with malignant hypertension over recent decades. Abnormal renal function at presentation still predicts worse outcome. South Asian ethnicity is also associated with better outcome, although mechanisms involved are yet to be established.

Background: People of South Asian (SAs) and African Caribbean (AC) origin have increased cardiovascular morbidity, but underlying mechanisms are poorly understood. Aging is the key predictor of deterioration in diastolic function, which can be assessed by echocardiography using E/e' ratio as a surrogate of left ventricular (LV) filling pressure. The study aimed to assess a possibility of premature cardiac aging in SA and AC subjects., Methods and Results: We studied 4540 subjects: 2880 SA and 1660 AC subjects. All participants underwent detailed echocardiography, including LV ejection fraction, average septal-lateral E/e', and LV mass index (LVMI). When compared to ACs, SAs were younger, with lower mean LVMI, systolic blood pressure (BP), diastolic BP, and body mass index (BMI), as well as a lower prevalence of hypertension and smoking (P≤0.001 for all). In a multivariate linear regression model including age, sex, ethnicity, BP, heart rate, BMI, waist circumference, LVMI, history of smoking, hypertension, coronary artery disease, diabetes mellitus, medications, SA origin was independently associated with higher E/e' (regression coefficient±standard error, -0.66±0.10; P<0.001, adjusted R 2 for the model 0.21; P<0.001). Furthermore, SAs had significantly accelerated age-dependent increase in E/e' compared to ACs. On multivariable Cox regression analysis without adjustment for E/e', SA ethnicity was independently predictive of mortality (P=0.04). After additional adjustment for E/e', the ethnicity lost its significance value, whereas E/e' was independently predictive of higher risk of death (P=0.008)., Conclusions: Premature cardiac aging is evident in SAs and may contribute to high cardiovascular morbidity in this ethnic group, compared to ACs., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Studies have shown higher in-hospital mortality for female patients and ethnic minorities admitted to hospital with acute ST elevation myocardial infarction (STEMI). Pre-hospital delay is thought to be associated with increased in-hospital mortality., Aim: To assess the impact of gender and ethnicity on symptom-to-door time (STDT) in patients presenting with STEMI., Design: Retrospective survey of consecutive patients receiving primary percutaneous coronary intervention between January 2008 and January 2013. A multivariate model was used to adjust for confounders., Main Outcome Measure: Influence of gender and ethnicity on STDT., Results: We analysed 1020 patients (75% male, 263 South Asians, 38 Afro Caribbeans and 719 White Europeans.) There was a trend towards longer unadjusted median STDT in women compared with men (132 min vs. 113 min P = 0.07) which disappeared after correction for age and ethnicity (P = 0.15). There was no gender difference in hospital mortality after correction for age (odds ratio 0.69, 95% confidence interval 0.40-1.18, P = 0.17). On linear regression analysis South Asians showed a trend towards longer STDT than other ethnic groups (P = 0.08) however after adjustment for diabetes there was no association between South Asian ethnicity and hospital mortality., Conclusions: Neither female gender nor ethnicity were shown to be associated with significant pre-hospital delay., (© The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Elevated low-density lipoprotein (LDL) concentration in mid-life increases the risk of developing Alzheimer's disease (AD) in later life. Increased oxidized LDL (oxLDL) modification and nitration is observed during dementia and hypercholesterolaemia. We investigated the hypothesis that statin intervention in mid-life mitigates the inflammatory effects of oxLDL on the microvasculature. Human microvascular endothelial cells (HMVECs) were maintained in transwells to mimic the microvasculature and exposed to patient and control LDL. Blood was obtained from statin-naive, normo- and hyper-lipidaemic subjects, AD with vascular dementia (AD-plus) and AD subjects (n=10/group) at baseline. Only hyperlipidaemic subjects with normal cognitive function received 40 mg of simvastatin intervention/day for 3 months. Blood was re-analysed from normo- and hyper-lipidaemic subjects after 3 months. LDL isolated from statin-naive hyperlipidaemic, AD and AD-plus subjects was more oxidized (agarose gel electrophoretic mobility, protein carbonyl content and 8-isoprostane F2α) compared with control subjects. Statin intervention decreased protein carbonyls (2.5±0.4 compared with 3.95±0.2 nmol/mg; P<0.001) and 8-isoprostane F2α (30.4±4.0 pg/ml compared with 43.5±8.42 pg/ml; P<0.05). HMVEC treatment with LDL-lipids (LDL-L) from hyperlipidaemic, AD and AD-plus subjects impaired endothelial tight junction expression and decreased total glutathione levels (AD; 18.61±1.3, AD-plus; 16.5±0.7 nmol/mg of protein) compared with untreated cells (23.8±1.2 compared with nmol/mg of protein). Basolateral interleukin (IL)-6 secretion was increased by LDL-L from hyperlipidaemic (78.4±1.9 pg/ml), AD (63.2±5.9 pg/ml) and AD-plus (80.8±0.9 pg/ml) groups compared with healthy subject lipids (18.6±3.6 pg/ml). LDL-L isolated after statin intervention did not affect endothelial function. In summary, LDL-L from hypercholesterolaemic, AD and AD-plus patients are inflammatory to HMVECs. In vivo intervention with statins reduces the damaging effects of LDL-L on HMVECs., (© 2015 Authors; published by Portland Press Limited.)

Background: Atrial fibrillation (AF) is associated with a high risk of mortality and morbidity and it commonly coexists with chronic kidney disease. A biomarker of renal function, β-trace protein (BTP), has been implicated in the progression of cardiovascular disease. The aim of our study was to evaluate the association of BTP with adverse cardiovascular events, bleeding, and mortality in patients with AF., Methods: In a consecutive cohort of patients with nonvalvular AF receiving anticoagulation treatment, plasma BTP was determined using an automated nephelometer BN ProSpec System (Siemens) and related to estimated glomerular filtration rate (eGFR). We recorded adverse cardiovascular events (stroke, acute coronary syndrome, and acute pulmonary edema), major bleeding, and mortality., Results: We included 1,279 patients (48.6% men), aged 76 years (IQR, 71-81 years), who were followed up for 996 days (IQR, 802-1,254 days). During the follow-up, there were 150 cardiovascular events (annual rate, 3.99%), 57 embolisms (annual rate, 1.54%), and 114 major bleeding events (annual rate, 3.04%), and 161 patients died (annual rate, 4.32%). BTP levels were inversely associated with eGFR (P &lt; .001). High BTP concentrations were significantly associated with embolic events (hazard ratio [HR], 4.64 [1.98-10.86]; P &lt; .001), composite adverse cardiovascular events (HR, 1.93 [1.31-2.85]; P = .001), and mortality (HR, 2.08 [1.49-2.90]; P &lt; .001), even after adjusting for CHAD2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes mellitus, stroke [doubled], vascular disease, age 65 to 74 years, sex category) score and renal function. High BTP was associated with major bleeding events (HR, 1.88 [1.18-3.00]; P = .008), even after adjusting for the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or redisposition, labile international normalized ratio, elderly [&gt; 65 years], drugs/alcohol concomitantly) score., Conclusions: We suggest that BTP, a proposed renal damage biomarker, may be a novel predictor of adverse cardiovascular events, major bleeding, and mortality in patients with AF. BTP may help refine clinical risk stratification in these patients.

Background: South Asians presenting with chest pain in the UK experience disproportionately greater delays with respect to diagnosis and treatment for acute myocardial infarction (AMI). The duration of time between symptom onset and hospital intervention is a critical delay for AMI but there are limited data amongst South Asians. The objectives of this study were to investigate ethnic differences in hospital delay and to look at short-term outcomes in South Asian and White patients presenting with AMI., Methods: Between 2004 and 2009, data were collected from 672 AMI patients with ST elevation who subsequently received percutaneous coronary intervention at Sandwell and West Birmingham Hospitals NHS Trust (UK). The hospital delay between the onset of symptoms and arrival time (pre-hospital), and between arrival time and intervention (post-hospital) was calculated., Results: South Asians were more likely to be in the upper tertile of hospital delay (pre-hospital odds ratio, OR, 1.44, 95% CI 0.93-2.24, p = 0.06; post-hospital OR 1.83, 95% CI 1.05-3.21, p = 0.015), contributing to an overall hospital delay that was longer (median 314, interquartile range, IQR, 195-679 min) than in Whites (median 240, IQR 182-468 min). Women were more likely to be in the upper tertile for pre-hospital delay than men (p = 0.01) and South Asian ethnicity was an independent predictor of post-hospital delay (p = 0.003)., Conclusions: While the reasons for ethnic differences in AMI-related hospital delay are likely to be multifactorial and complex, there is an urgent need to promote change in both the South Asian patient (delays in arrival) and their treatment (delays in intervention).

Background: Coronary heart disease (CHD) is highly prevalent amongst the South Asian communities in Britain. The reasons for this excess CHD risk are multifactorial, but in part relate to a susceptibility to diabetes mellitus - where the aberrant metabolism of non-esterified fatty acids (NEFA) and glucose are likely to underpin vascular disease in this population. Dietary intervention is an important and first line approach to manage increased CHD risk. However, there is limited information on the impact of the South Asian diet on CHD risk., Methods/design: The Diabetes Health, Residence & Metabolism in Asians (DHRMA) study is a blinded, randomised, placebo controlled trial that analyses the efficacy of reduced glycaemic index (GI) staples of the South Asian diet, in relation to cardio-metabolic risk factors that are commonly perturbed amongst South Asian populations - primarily glucose, fatty acid and lipoprotein metabolism and central adiposity. Using a 10-week dietary intervention study, 50 healthy South Asians will be randomised to receive either a DHRMA (reduced GI) supply of chapatti (bread), stone ground, high protein wheat flour and white basmati rice (high bran, unpolished) or commercially available (leading brand) versions chapatti wheat flour and basmati rice. Volunteers will be asked to complete a 75g oral glucose tolerance test at baseline and at 10-weeks follow-up, where blood metabolites and hormones, blood pressure and anthropometry will also be assessed in a standardised manner., Discussion: It is anticipated that the information collected from this study help develop healthy diet options specific (but not exclusive) for South Asian ethnic communities. Trial registration Current Controlled Trials ISRCTN02839188.

Background: Limited data exists on the prevalence of heart failure amongst minority groups in the UK. To document the community prevalence and severity of left ventricular systolic dysfunction, heart failure, and atrial fibrillation, amongst the South Asian and Black African-Caribbean groups in the UK., Methods and Results: We conducted a cross-sectional study recruiting from September 2006 to July 2009 from 20 primary care centres in Birmingham, UK. 10,902 eligible subjects invited, 5,408 participated (49.6%) and 5,354 had complete data (49.1%). Subjects had median age 58.2 years (interquartile range 51.0 to 70.0), and 2544 (47.5%) were male. Of these, 1933 (36.3%) had BMI>30 kg/m(2), 1,563 (29.2%) had diabetes, 2676 (50.0%) had hypertension, 307 (5.7%) had a history of myocardial infarction, and 104 (1.9%) had history of arrhythmia. Overall, 59 (1.1%) had an Ejection Fraction<40%, and of these 40 (0.75%) were NYHA class ≥2; 51 subjects (0.95%) had atrial fibrillation. Of the remaining 19 patients with an EF<40%, only 4 patients were treated with furosemide. A further 54 subjects had heart failure with preserved ejection fraction., Conclusions: This is the largest study of the prevalence of left ventricular systolic dysfunction, heart failure and atrial fibrillation in under-researched minority communities in the UK. The prevalence of heart failure in these minority communities appears comparable to that of the general population but less than anticipated given the high rates of cardiovascular disease in these groups. Heart failure continues to be a major cause of morbidity in all ethnic groups and preventive strategies need to be identified and implemented.

Background: Recruitment targets of patients to multi-centre primary care-based randomized controlled trials (RCT) are often not met. A critical step in the pathway is whether an eligible patient will give consent., Objective: To assess whether patient, practice or practitioner characteristics are associated with a patient's likelihood of giving consent to participation in a large primary care-based RCT., Methods: A cross-sectional study of patients from 260 practices in England and Wales who met the eligibility criteria for an RCT of aspirin versus warfarin for stroke prevention and attended an appointment with their GP to consider trial participation. Logistic regression analysis was used to determine which patient and practitioner factors independently predicted whether or not a patient would give consent to take part in the trial., Results: Of the 1740 patients, 973 (55.9%) gave consent. On multivariable analysis, patient factors associated with increased likelihood of giving consent were younger age, current use of warfarin and year of recruitment to the trial. Patients with a history of transient ischaemic attack, angina or valve disease were less likely to give consent. Practice/practitioner factors that were associated with increased likelihood of consent were smaller practice size (practices with greater than eight GPs as compared with those with one to two GPs, odds ratio 0.40, 95% confidence interval 0.21-0.75) and older GPs., Conclusions: The strong association of consent with year of recruitment may be due to changes in trial procedures and investigator training. If so, this has important implications for the conduct of future trials.

Background: Cardiac rehabilitation (CR) has been shown to improve prognosis and function following an acute myocardial infarction or revascularization. However, participation in CR programmes is low and adherence is poor., Objective: To explore patients' reasons for non-participation in or non-adherence to a home- or hospital-based CR programme., Methods: Individual semi-structured interviews were conducted with 49 patients participating in the Birmingham Rehabilitation Uptake Maximisation Study of home-based compared with hospital-based CR trial who had not completed their CR programme. Participants included 16 women, 11 aged 70 years or over with 15 from ethnic minority groups., Results: Patients gave a wide range of reasons for not completing their rehabilitation programme. Many patients had other health problems, such as arthritis, and continuing cardiac problems which prevented them from exercising as much as expected. The majority of non-adherers found some aspects of their CR programme helpful and had made lifestyle changes. Lack of motivation to exercise was the main reason for patients not adhering to the home programme, particularly in the women. Domestic duties in women and ill health in ethnic minority patients were also common reasons for non-adherence., Conclusions: Reasons for non-participation/non-adherence were generally multifactorial and individualistic. Many patients who had not attended or not adhered to their CR programme had participated in rehabilitative activities in other ways. Social characteristics, individual patient needs and preferences and the location of CR programmes need to be taken into account in programme design to maximize participation.

Objectives: To assess whether screening improves the detection of atrial fibrillation (cluster randomisation) and to compare systematic and opportunistic screening., Design: Multicentred cluster randomised controlled trial, with subsidiary trial embedded within the intervention arm., Setting: 50 primary care centres in England, with further individual randomisation of patients in the intervention practices., Participants: 14,802 patients aged 65 or over in 25 intervention and 25 control practices., Interventions: Patients in intervention practices were randomly allocated to systematic screening (invitation for electrocardiography) or opportunistic screening (pulse taking and invitation for electrocardiography if the pulse was irregular). Screening took place over 12 months in each practice from October 2001 to February 2003. No active screening took place in control practices., Main Outcome Measure: Newly identified atrial fibrillation., Results: The detection rate of new cases of atrial fibrillation was 1.63% a year in the intervention practices and 1.04% in control practices (difference 0.59%, 95% confidence interval 0.20% to 0.98%). Systematic and opportunistic screening detected similar numbers of new cases (1.62% v 1.64%, difference 0.02%, -0.5% to 0.5%)., Conclusion: Active screening for atrial fibrillation detects additional cases over current practice. The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography., Trial Registration: Current Controlled Trials ISRCTN19633732 [controlled-trials.com].

Objective: To assess the accuracy of general practitioners, practice nurses, and interpretative software in the use of different types of electrocardiogram to diagnose atrial fibrillation., Design: Prospective comparison with reference standard of assessment of electrocardiograms by two independent specialists., Setting: 49 general practices in central England., Participants: 2595 patients aged 65 or over screened for atrial fibrillation as part of the screening for atrial fibrillation in the elderly (SAFE) study; 49 general practitioners and 49 practice nurses., Interventions: All electrocardiograms were read with the Biolog interpretative software, and a random sample of 12 lead, limb lead, and single lead thoracic placement electrocardiograms were assessed by general practitioners and practice nurses independently of each other and of the Biolog assessment., Main Outcome Measures: Sensitivity, specificity, and positive and negative predictive values., Results: General practitioners detected 79 out of 99 cases of atrial fibrillation on a 12 lead electrocardiogram (sensitivity 80%, 95% confidence interval 71% to 87%) and misinterpreted 114 out of 1355 cases of sinus rhythm as atrial fibrillation (specificity 92%, 90% to 93%). Practice nurses detected a similar proportion of cases of atrial fibrillation (sensitivity 77%, 67% to 85%), but had a lower specificity (85%, 83% to 87%). The interpretative software was significantly more accurate, with a specificity of 99%, but missed 36 of 215 cases of atrial fibrillation (sensitivity 83%). Combining general practitioners' interpretation with the interpretative software led to a sensitivity of 92% and a specificity of 91%. Use of limb lead or single lead thoracic placement electrocardiograms resulted in some loss of specificity., Conclusions: Many primary care professionals cannot accurately detect atrial fibrillation on an electrocardiogram, and interpretative software is not sufficiently accurate to circumvent this problem, even when combined with interpretation by a general practitioner. Diagnosis of atrial fibrillation in the community needs to factor in the reading of electrocardiograms by appropriately trained people.

Background: Although aspirin is useful in reducing platelet activation and cardiovascular events, its effects on platelet levels of angiogenic factors, such as vascular endothelial growth factor (VEGF) and angiopoietin-1 (Ang-1), and markers of platelet activation in hypertension are unknown. The aim of this study was to study the effects of aspirin on the platelet morphology, plasma and platelet levels of VEGF (sVEGF and pVEGF respectively), Ang-1 (sAng-1 and pAng-1 respectively), and P-selectin (sPsel and pPsel respectively) in patients with well controlled hypertension., Methods: A total of 35 aspirin-naive, hypertensive patients (29 male and six female; mean age 64 years) were compared with 30 (23 male, seven female, mean age 59 years) normotensive control subjects. Blood was collected for plasma VEGF, P-selectin, and Ang-1 (enzyme-linked immunoassay), intra-platelet levels of VEGF, Ang-1, and P-selectin, and platelet volume and mass. Research indices in hypertensive patients were studied before and after 3 months treatment with aspirin 75 mg daily., Results: Hypertensive patients had significantly higher plasma levels of VEGF (P=.04), Ang-1 (P<.001), as well as pVEGF (P=.008), pAng-1(P=.001), sPsel (P=.02), pPsel (P<.001), and mean platelet mass (P=.01) when compared with control subjects. After treatment with aspirin for 3 months, there were significant reductions in plasma VEGF (P=.01), pAng-1 (P=.04), sPsel (P=.001), and pPsel (P<.001) levels, but not levels of platelet VEGF and plasma Ang-1. Neither pVEGF nor pAng-1 correlated with blood pressure or with their respective plasma levels., Conclusions: The use of aspirin in high-risk hypertensive patients leads to a reduction in intra-platelet angiogenic growth factors and platelet activation. This may have implications for the use of aspirin in conditions (such as vascular disease) that have been associated with an increase in angiogenesis and platelet activation.

Objectives: To compare cardiovascular and all-cause mortality, among white Europeans, African-Caribbeans and South-Asians, in relation to baseline demographic characteristics and blood pressure variables., Design: Observational follow-up study., Setting: Community settings in Birmingham, UK., Participants: Two thousand and eighty-nine white European and 340 African-Caribbean men and women, and 195 South-Asian men whose survival status on 31 December 2003 was known., Interventions: Follow-up for assessment of all-cause and cardiovascular mortality over a mean (SD) 20.3 (4.2) years., Main Outcome Measures: All-cause and cardiovascular mortality., Results: There were no significant ethnic differences in all-cause or cardiovascular mortality for men [adjusted hazard ratio (HR) = 1.02; 95% confidence interval (CI), 0.80-1.28 and HR = 1.33; 95% CI, 0.99-1.79, respectively] or women (adjusted HR = 0.61; 95% CI, 0.29-1.32 and HR = 1.19; 95% CI, 0.41-3.45, respectively) in either univariate or multivariate analyses. The only independent predictors of both all-cause and cardiovascular mortality were age, sex, smoking and mean systolic blood pressure or hypertension., Conclusions: It appears that ethnicity per se is not an independent risk factor for all-cause and cardiovascular mortality between white Europeans and African-Caribbeans in the present study. The data concerning ethnic differences in all-cause and cardiovascular mortality for South-Asians is limited, given that significantly fewer South-Asian men could be traced by the Office for National Statistics (ONS), hence we do not know their survival status, and the total lack of data on South-Asian women.

We hypothesised that ethnicity may influence the circadian pattern in acute myocardial infarction (MI), in view of the potential differences in genetic background, cardiovascular risk factors and cultural habits. To test our hypothesis, we studied 340 consecutive acute MI patients (268 males; mean age 61.6+/-12.3 years) from two different city-centre teaching hospitals in Birmingham (United Kingdom) and Alicante (Spain). A different circadian rhythm in MI onset was observed between the ethnic groups (p=0.001), with a significantly higher number of acute MI onset occurring between midnight and noon in British Caucasians and Indo-Asians. In contrast, Mediterranean Caucasians showed the converse circadian pattern, with most of the acute MI events happened between noon and midnight. Indo-Asian patients were the youngest patient group and showed the highest prevalence of diabetes and increased body mass index. Mediterranean patients had the highest prevalence of smokers but their mean serum cholesterol was the lowest. No differences in sex, blood pressure, height and weight were observed. In conclusion, this study has shown a different circadian rhythm in acute MI onset between 3 ethnic groups from two different city-centre teaching hospitals in Birmingham (United Kingdom) and Alicante (Spain) and, for the first time, provide data in the Indo-Asian population. Further studies are required to determine the pathophysiological mechanism(s) underlying these differences.

To investigate whether knowledge and perceptions of antithrombotic therapy differ between ethnic groups in the UK, we conducted a cross-sectional questionnaire survey of patients attending anticoagulation clinics in three Birmingham teaching hospitals. 180 consecutive patients were recruited-135 white European, 29 Indo-Asian, 16 Afro-Caribbean. The average knowledge score was 5.5 out of 9, with no significant differences between the groups. Indo-Asians were significantly less likely than the other groups to know the name of the anticoagulant they were taking (warfarin) and Afro-Caribbeans to know the condition for which they were being anticoagulated. Few patients of any group were able to specify more than one side-effect of warfarin or the dose they were on. In logistic regression analysis the factors associated with a low score were age >61 years, having been born outside the UK, and the perception of difficulty in comprehension. Nearly half the Indo-Asians felt unable to understand what was said to them in the clinic, and 62% expressed a preference for a doctor of the same ethnic group. Although there were no significant between-group differences, this study points to gaps in the knowledge of patients from ethnic minorities and to deficiencies in the provision of information. In patient education, these groups should receive special attention.

Background: The main aim of this study was to examine the relationship between symptoms of depression following myocardial infarction (MI) and 3-year survival status., Methods: The Beck Depression Inventory was completed by 288 patients hospitalized for MI. Patients' cardiological status, including indices of disease severity, were recorded or derived from hospital notes. Three-year survival status was determined using patient information systems and cause of death ascertained from death certificates., Results: During the 3 years of follow-up, 38 patients (13%) died, 33 (11%) from cardiac causes. Symptoms of depression did not predict either cardiac-specific or all-cause mortality. Similarly, in-hospital levels of anxiety were not associated with prognosis. In contrast, measures of disease severity and discharge medication status were strong prognostic indicators. Depression was not related to measures of disease severity at entry to the study., Conclusions: Symptoms of depression following MI do not predict longer-term survival, although measures of disease severity and discharge medication status do. Previous positive results for depression and cardiac mortality in MI patients could reflect the occasional confounding of depression with disease severity.

Background and Purpose: We hypothesized that different ethnic groups would have different levels of knowledge and perceptions of atrial fibrillation (AF) and of their antithrombotic therapy. To investigate this further, we conducted a cross-sectional survey of patients with documented chronic AF who were attending the anticoagulation clinic in our city center teaching hospital, serving a multiethnic population., Methods: We surveyed 119 patients (77 male; mean age 69+/-9 years [mean+/-SD]); of these, 39 were Indo-Asian (33%), 27 Afro-Caribbean (23%), and 53 white (44%)., Results: Only 63% of patients in the overall study cohort were aware of their cardiac condition, with Indo-Asians and Afro-Caribbeans significantly less aware of AF compared with the white patients (P<0.001). When questioned about the perception of the severity of the underlying condition, the majority (61%) felt that AF was "not serious." A large proportion were unaware that AF predisposed to thrombosis and stroke; among the ethnic groups, Indo-Asians appeared to be the least aware of the stroke and thromboembolic associations of AF. Only 52% in the whole cohort were aware of the reason(s) for commencing their warfarin, whereas the remainder began warfarin therapy simply because their "doctor told them to." Most patients in the whole cohort were aware of warfarin being used to prevent blood clots (65%) or stroke (66%), but Indo-Asians and Afro-Caribbeans were less so. Only 45% of the study cohort believed that there was some risk associated with warfarin therapy in the form of either "bleeding" or "poisoning." Only a minority of Indo-Asians and Afro-Caribbeans with AF felt that their doctor had given them enough information about their warfarin therapy, and many from these ethnic groups felt that they were careless about taking their warfarin., Conclusions: In conclusion, many patients with AF possess very limited knowledge of AF as well as its consequences and therapy. In particular, our study has highlighted significant differences between different ethnic groups in terms of their knowledge of the risks, actions, and benefits of warfarin as well as of AF itself.