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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.)

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: 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: 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.

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: Studies have found associations between psychological distress (PD) and increased risk of myocardial infarction (MI). However, it is not clear whether the relationship reflects the subtle influence of pre-existing illness on both PD and MI. This study examines the association between PD and MI in a prospective epidemiological study of 1864 middle-aged men to examine if the association is explained by existing illness., Method: This study was a prospective cohort study modelling the association between PD, measured using the 30-item General Health Questionnaire (GHQ) and non-fatal myocardial infarction (NFMI) and fatal/non-fatal myocardial infarction (FNFMI). The relationship was modelled in a series of logistic regression models adjusted for age, then cigarette smoking, then social position, and finally for all sociodemographic characteristics, coronary heart disease (CHD) risk factors, and baseline CHD., Results: PD was associated with a 70% and 68% increased risk of NFMI and FNFMI in fully adjusted analysis. However, PD was not associated with an increased risk of NFMI and FNFMI in analyses excluding those with baseline CHD. Further, being psychologically distressed and physically ill was associated with a greater than twofold risk of NFMI and FNFMI, 2.37 (95% CI 1.33-4.20) and 2.33 (95% CI 1.32-4.12) respectively., Conclusions: This study suggests that PD is a moderator of the increased risk of MI associated with existing physical illness. PD in men who are physically ill is a marker of an underlying chronic physical illness. The prospective association of PD with MI is not independent of baseline physical illness.

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 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.

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.

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: We estimated life-years gained from cardiological treatments and cardiovascular risk factor changes in England and Wales between 1981 and 2000., Methods: We used the IMPACT model to integrate data on the number of coronary heart disease patients, treatment uptake and effectiveness, risk factor trends, and median survival in coronary heart disease patients., Results: Compared with 1981, there were 68230 fewer coronary deaths in 2000. Approximately 925415 life-years were gained among people aged 25-84 years (range: 745 195-1 138 655). Cardiological treatments for patients accounted for approximately 194145 life-years gained (range: 142505-259225), and population risk factor changes accounted for approximately 731270 life-years gained (range; 602695-879430)., Conclusions: Modest reductions in major risk factors led to gains in life-years 4 times higher than did cardiological treatments. Effective policies to promote healthy diets and physical activity might achieve even greater gains.

Background: Coronary heart disease mortality rates have been decreasing in the United Kingdom since the 1970s. Our study aimed to examine how much of the decrease in England and Wales between 1981 and 2000 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors., Methods and Results: The IMPACT mortality model was used to combine and analyze data on uptake and effectiveness of cardiological treatments and risk factor trends in England and Wales. The main data sources were published trials and meta-analyses, official statistics, clinical audits, and national surveys. Between 1981 and 2000, coronary heart disease mortality rates in England and Wales decreased by 62% in men and 45% in women 25 to 84 years old. This resulted in 68 230 fewer deaths in 2000. Some 42% of this decrease was attributed to treatments in individuals (including 11% to secondary prevention, 13% to heart failure treatments, 8% to initial treatments of acute myocardial infarction, and 3% to hypertension treatments) and 58% to population risk factor reductions (principally smoking, 48%; blood pressure, 9.5%; and cholesterol, 9.5%). Adverse trends were seen for physical activity, obesity and diabetes., Conclusions: More than half the coronary heart disease mortality decrease in Britain between 1981 and 2000 was attributable to reductions in major risk factors, principally smoking. This emphasizes the importance of a comprehensive strategy that promotes primary prevention, particularly for tobacco and diet, and that maximizes population coverage of effective treatments, especially for secondary prevention and heart failure. These findings may be cautiously generalizable to the United States and other developed countries.

Study Objective: Coronary heart disease (CHD) is the commonest cause of death in the UK. However, there is no single comprehensive source of information to support CHD prevention and treatment strategies. Therefore this study evaluated the availability and quality of UK CHD data sources since 1981., Design: Data sources for England and Wales were identified and appraised on: (1) CHD patient numbers (myocardial infarction, angina, hypertension, and heart failure); (2) uptake of medical and surgical CHD treatments, and (3) population trends in major cardiovascular risk factors., Setting: England and Wales (population 53 million)., Main Results: Population and mortality data were easily accessible from Office for National Statistics and British Heart Foundation Annual CHD Statistics; population based risk factor data came principally from the British Regional Heart Study, the General Household Survey, and the Health Survey for England. They were limited for 1981, but more extensive by 2000. Hospital admissions information since 1998 was available online from HES; but trend data and details of interventions were scant. Limited primary care data on consultation rates, prescribing, and treatment uptake were available from published audits and studies., Conclusions: Information on CHD in the UK is fragmented, patchy, and mixed in quality. Data for women, the elderly populatiom, and ethnic minorities were particularly scarce, exacerbating inequalities. Future CHD disease monitoring and evaluation will require comprehensive and accurate population based information on trends in patient numbers, treatment uptake, and risk factors.

Objective: To examine the optimal intensity of leisure time physical activity (LTPA) to decrease the risk of all cause, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality in a population sample of middle aged British men., Design: Prospective study of middle aged men with an 11 year follow up., Setting: A whole population sample of men from Caerphilly, South Wales, UK., Subjects: 1975 men aged 49-64 years without historical or clinical evidence of CHD at baseline examination., Main Outcome Measures: All cause, CVD, and CHD mortality., Results: Total (cumulative) LTPA had a graded, significant relation with all cause, CVD, and CHD mortality but no trend with cancer deaths. When different intensities of activity were considered, light and moderate intensity LTPA had inconsistent and non-significant relations with all cause, CVD, or CHD mortality whether adjusted only for age or for other cardiovascular risk factors. In contrast a significant dose-response relation was found for heavy intensity LTPA for all cause, CVD, and CHD mortality fully adjusted for other risk factors., Conclusions: These data suggest that, in a population of men without evidence of CHD at baseline, only leisure exercise classified as heavy or vigorous was independently associated with reduced risk of premature death from CVD.

Background: Few studies have examined mortality of migrants by duration of residence in the country of destination., Methods: I examined mortality of South Asian migrants by duration of residence in England and Wales. The cohort (N = 2,272, age 25-54 years in 1971) was followed from 1971 to 2000., Results: All-cause mortality of South Asian migrants increased with increasing duration of residence in England and Wales. A yearly increase in duration of residence was associated with a hazard ratio of 1.07 (95% confidence interval [CI] = 1.02-1.13) among persons ages 25-34 years in 1971, 1.03 (1.00-1.07) among those ages 35-44 years, and 1.02 (1.00-1.05) among those ages 45-54. Cardiovascular disease mortality was the main component of this trend. Yearly increases in duration of residence were associated with cardiovascular disease mortality hazard ratios of 1.09 (1.03-1.16), 1.04 (1.00-1.09) and 1.02 (1.00-1.05) for the youngest, middle and oldest age groups, respectively. Comparable results were seen for coronary heart disease and for cancer mortality. Age at migration was positively related to mortality independent of duration of residence but the confidence intervals were wide. Adjusting for socioeconomic position did not alter these patterns., Conclusions: Cardiovascular and cancer mortality of South Asian migrants increased with duration of residence in England and Wales.

Objective: (1) To compare mortality estimates based on clinicopathological diagnoses of death from acute coronary heart disease with official estimates of coronary heart disease mortality; (2) to compare present day mortality figures with those from earlier reports., Design: Prospective community study over the two years 1994 and 1995., Setting: The health districts of Brighton, South Glamorgan, and York., Subjects: 1589 men and women under 75 years of age who, based on our study criteria, died from acute coronary events were compared with certified cases of coronary death in the same age group., Main Outcome Measures: (1) Comparison of the underlying cause recorded on death certificates with the diagnosis of acute coronary death defined by our study criteria; (2) comparison of age specific mortality figures of the present with earlier studies., Results: Up to age 65, age specific mortality for coronary heart disease, using study criteria, was similar to official estimates. However, at ages 65-74 years there was a shortfall in study deaths of about 20% compared with official figures. One reason for this was that many death certificates in elderly people attributed death to coronary disease in the absence of confirmatory evidence. Despite this, deaths in the under 65 age group in the 1990s appear to be occurring in people who are about 10 years older than was the case during the 1970s., Conclusions: There are differences, most noticeable in elderly subjects, between estimates of coronary mortality made according to strict clinical and pathological definitions and official rates based on death certification. Recognition of these differences will be important for future epidemiological studies.

Objective: To examine the relation between frequency of orgasm and mortality., Study Design: Cohort study with a 10 year follow up., Setting: The town of Caerphilly, South Wales, and five adjacent villages., Subjects: 918 men aged 45-59 at time of recruitment between 1979 and 1983., Main Outcome Measures: All deaths and deaths from coronary heart disease., Results: Mortality risk was 50% lower in the group with high orgasmic frequency than in the group with low orgasmic frequency, with evidence of a dose-response relation across the groups. Age adjusted odds ratio for all cause mortality was 2.0 for the group with low frequency of orgasm (95% confidence interval 1.1 to 3.5, test for trend P = 0.02). With adjustment for risk factors this became 1.9 (1.0 to 3.4, test for trend P = 0.04). Death from coronary heart disease and from other causes showed similar associations with frequency of orgasm, although the gradient was most marked for deaths from coronary heart disease. Analysed in terms of actual frequency of orgasm, the odds ratio for total mortality associated with an increase in 100 orgasms per year was 0.64 (0.44 to 0.95)., Conclusion: Sexual activity seems to have a protective effect on men's health.

Objective: To investigate the use of computer models as tools for policy makers in evaluating physical activity interventions aimed at reducing deaths from coronary heart disease (CHD)., Design: The cell-based computer model Prevent, adapted to simulate risk factor interventions for an English and Welsh population, was used to simulate the effect of two strategies for increasing physical activity levels in respect of CHD mortality over 25 years. The first strategy involved a 25% increase in the proportion of 15-64 year olds who were moderately active, while the second strategy involved a similar increase in the proportion who were vigorously active. The effects of focusing on narrower age ranges and on people at different initial activity levels were also explored., Main Results: The simulations showed a small reduction in the CHD death rates--less than 0.15% and 0.06% for men and women respectively. The strategies would postpone up to 12,100 deaths over 25 years, comparable to the effect of a 2% reduction in smoking prevalence. The strategies seemed as if they would be more effective if they concentrated on men rather than women, on those over 45 years of age as opposed to all or younger age groups, and on the least active members of the population rather than those already taking some exercise., Conclusion: The use of computer modelling for stimulating physical activity strategies has shown that concentrating these interventions on older sedentary men will produce the greatest health gain, but efforts to encourage smoking cessation may be more effective in terms of years of life saved.

Background: The 'programming' hypothesis for the causation of heart disease suggests that there are critical periods of development in early life during which a stimulus or insult has permanent effects on the subject's organ or tissue structure and physiology. Exposure to such effects might be expected to be linked to year of birth and produce cohort (generation) effects in heart disease death rates. Evidence is sought for such effects in data from England and Wales., Methods: The age- and period-specific heart disease death rates for men and women aged 30-69 in England and Wales have declined recently in both men and women. The trends have two components. The first is described by a peak in rates during 1977-1981 that applies to both sexes and all age-groups. This is consistent with risk conferred by adult diet and lifestyle. The second component required to explain the trends also applies to both sexes and is described by a risk that is lower in each successive year of birth. This is consistent with risk linked to poor growth in early life., Conclusion: Poor early growth has become less common as maternal health, physique and nutritional status have improved through the century. The trends are therefore consistent with the'programming' hypothesis for the causation of coronary heart disease.

The variations in the Health of the Nation (HoN) key areas among ethnic minorities living in England and Wales are examined, based on a national mortality study by country of birth for the latest possible period (1988-1992). It addresses the 10 mortality indicators in the HoN White Paper (covering coronary heart disease [CHD] and stroke, cancers, mental illness and accidents), using age-standardised rates adjusted to the European Standard Population. The findings establish variations in the recent health experience of ethnic minorities born outside England and Wales who are now living in England and Wales. CHD among persons aged under 65 years was highest in those born in the Indian Subcontinent, 55% above the normal rate in England and Wales. Caribbeans, and African groups experienced the lowest rates. Stroke mortality under 65 years-of-age was highest in Bangladeshis, followed by other Commonwealth Africans, and then by Caribbeans. Patterns of cancer deaths also varied, with breast cancer mortality rates being lower in all ethnic groups, and lowest in those born in the Indian Subcontinent. By contrast, lung cancer deaths were higher in Irish men and women; lung cancer mortality among Bangladeshi men was significantly higher than Indians and Pakistanis, being only 15% less than that of the rates in England and Wales. Suicides were lowest in Bangladeshis and Pakistanis and highest among Indians and the Irish. Accidental deaths in children were highest in Pakistanis followed by the Irish, who also experienced higher rates among young persons. It is suggested that the HoN strategy should consider setting appropriate and achievable targets, including ones in new areas of relevance to these groups. The National Health Service purchaser/provider framework should respond to the needs of its populations, including ethnic groups.

Study Objective: This study aims to apply economic principles and techniques in evaluating a health promotion programme., Design: This study is an economic appraisal of the Heartbeat Wales no smoking intervention programme. The costs incurred over the four year period 1985-89 have been identified and estimates have been made of the likely future impact of the reduced smoking prevalence within Wales in terms of reduced morbidity and displaced mortality in three disease groups--coronary heart disease, lung cancer, and chronic bronchitis., Setting: Wales, UK., Results: The net present value of benefits is considerably greater than costs in terms of both the NHS and the economy as a whole in Wales. In addition, the net costs per life year saved shows that the programme generates additional working life years at relatively low cost. Because not all the benefits can be fully attributed to the programme 'impact rates' ranging from 100 to 10% have been applied to the level of benefits. The evidence suggests that even if only 10% of the benefits could be attributed to the programme there is still a positive net present value of benefits. The relative efficiency of this programme has not been considered here., Conclusion: Large scale benefits to the NHS and the economy as a whole can be derived from reductions in smoking.

Coronary mortality rates are significantly higher in Newcastle than Perth. In this paper we examine the extent to which this might be due to differences in medical treatment and case fatality. Population-based disease registers were used to identify all cases of non-fatal definite myocardial infarction (MI) and coronary death in people aged 25-64 years in the study populations between July 1988 and June 1990. Case fatality (at 28 days from onset of symptoms) was not significantly different between the centres. Thrombolytic therapy was used for one third of all hospitalised events in both centres. Other drugs of proven benefit were, however, used more often in Perth than in Newcastle. For example, during hospitalisation 74% of patients in Perth received beta-blockers compared with 41% in Newcastle (difference = 33%, 95% confidence interval (CI): 28%, 37%) and 85% of patients in Perth compared with 72% in Newcastle received aspirin (difference = 13%, 95% CI: 9%, 17%). Median lengths of stay in a coronary care unit (CCU) and total hospital stay were one day shorter in Perth. As case fatality was similar, the differences in mortality rates can be attributed mainly to differences in attack rates. Greater use of cardio-active drugs in Perth apparently did not result in improved short-term outcome although potential long-term benefits cannot be judged yet.

Objective: To examine mortality from ischaemic heart disease and cerebrovascular disease in England and Wales by country of birth of the deceased., Design: Standardised mortality ratios were computed by country of birth groups for ischaemic heart disease and cerebrovascular disease for 1979-83 and 1970-2 by using the five year age-sex specific rates for England and Wales for 1979-83 as standard., Setting: England and Wales 1970-2 and 1979-83., Results: In 1979-83 mortality from ischaemic heart disease was highest in men and women born in the Indian subcontinent (standardised mortality ratio 136 and 146 respectively). Young Indian men suffered the greatest excess (313 at ages 20-29). Other groups with raised mortality included Irish, Scottish, and Polish born immigrants. Those born in the Caribbean, the old Commonwealth, west Europe, and the United States had low death rates. In England and Wales mortality from ischaemic heart disease declined by 5% in men and 1% in women between 1970-2 and 1979-83, with greatest percentage declines in immigrants born in the United States, South Africa, the old Commonwealth, the Caribbean, and France. immigrant groups with raised mortality in the earlier period showed little improvement, and mortality from ischaemic heart disease increased among Indians (6% in men and 13% in women). In 1979-83 mortality from cerebrovascular disease was highest in Caribbeans (standardised mortality ratios 176 in men and 210 in women), followed by Africans, Indians, and Irish. Rates were low in west Europeans. Mortality from stroke declined by 28% overall in this period, a rate of decline shared by most groups. Men from the Indian subcontinent showed a decline of only 3%., Conclusion: In the 1980s mortality from ischaemic heart disease and cerebrovascular disease differed significantly between ethnic groups in England and Wales. In general, ethnic groups that experienced lower mortality from ischaemic heart disease in the 1970s showed the greatest improvement over the following decade.

Previous ecological studies have suggested that early life factors are important causes of adult cardiovascular and respiratory disease, by showing geographic correlations between past infant mortality rates and present adult mortality rates. However, these studies inadequately take account of the fact that areas which were severely deprived earlier this century remain the most deprived today. Thus the ecological relation between infant and adult mortality rates could simply reflect persistence in the geographic distribution of poor socioeconomic circumstances. To explore this hypothesis further infant mortality rates for 1895-1908 for 43 counties in England and Wales were correlated with cause-specific adult mortality for 1969-73 in people aged 65-74 years, with and without adjustment for present-day social deprivation and social class. The strong simple correlations found between infant mortality in 1895-1908 and adult mortality from various causes in 1969-73 were generally much attenuated or abolished by controlling for indices of present-day socioeconomic circumstances. Our results suggest that previous studies give no strong support for any direct influence of factors acting in early life on adult coronary heart disease mortality risk. Studies which gather data about infancy, childhood, and the full course of adult life are required to clarify this issue.

Study Objective: The aim was to predict death rates from ischaemic heart disease in England and Wales during the next 20 years., Study Design: Age and sex specific death rates for 1968-1987 were used to predict national and regional trends until 2007., Setting: The nine standard regions of England and Wales., Results: There will be a large fall in deaths from ischaemic heart disease. The fall will be greater in men and women below 65 years of age. There will, however, be a sharp worsening of the north/south divide. The largest fall in any region will be in Wales., Conclusion: The campaign to change the national diet should give highest priority to the norther regions. Because infant growth is inversely related to adult risk of ischaemic heart disease, the poor growth of young children in some northern areas is a cause for concern.

It has been claimed that unemployment affects the health and thus the mortality of the unemployed, their families, and other members of their communities. This paper examines the relation between mortality and the unemployment experiences of small areas which vary in the extent to which their unemployment levels have changed in recent years. Quarterly numbers of unemployed, classified by age, sex, duration of unemployment, and unemployment office for 1977-81, have been aggregated to correspond to Family Practitioner Committee areas (FPCs), for which population and mortality data had been collected for a different study. There was little variation in long term (greater than 6 months) unemployment trends prior to July 1980, but subsequently there were large variations between FPCs in the rate of increase in unemployment rates. Mortality data for suicide, ischaemic heart disease, cerebrovascular disease, and all causes were examined for the period 1975-83. When the mortality trends of FPCs with different unemployment experiences were compared, no statistically significant differences in trends were found, although areas with greater increases in unemployment appeared to have slightly worse mortality trends for suicide, ischaemic heart disease, cerebrovascular disease, and total mortality for men in the younger age groups. If changes in the level of unemployment do have an effect on changes in trends in mortality levels, this effect is not of sufficient magnitude to be statistically significant with the sample available, in spite of the fact that it included the whole of England and Wales.

In middle-aged men and women, mortality from ischaemic heart disease and cerebrovascular disease is highest in the north and west of Britain. The worst region is West Central Scotland. Statistical analysis using a linear logistic model shows that the differences between the regions are significant and the yearly fluctuation in numbers of deaths contributes little to the overall variation.

The history of myocardial infarction ('coronary thrombosis'), a condition which was only recognised as a clinical entity in the 20th century, is reviewed up to the time of the introduction of the intensive coronary care units. Early observations of presentations, complications, diagnosis and treatment of the disease are emphasised. The increase in incidence of myocardial infarction, real or relative, is discussed and the remarkable variation shown in earlier reports on the mortality rate of myocardial infarction is explained. Many of the important principles which revolutionised the management of the disease through coronary care units, are evident in the earlier reports.

Changes in the type and quantity of cigarettes smoked in the United Kingdom from 1956 to 1971 are compared with changes in the dealth-rates due to lung cancer and coronary heart-disease (C.H.D.) from 1956 to 1973. Associated with a change in filter cigarettes there has been a decrease in lung-cancer mortality among men aged less than sixty years despite little change in the number of cigarettes smoked. In contrast, lung-cancer mortality has increased in women along with their cigarette consumption. C.H.D. mortality has continued to increase in both sexes, but to a greater extent in women. These changes are consistent with the hypothesis that, in tobacco smoke, tar is the principal aetiological factor in lung cancer, whereas carbon monoxide or other gaseous constituents are involved in the development of C.H.D.

A cohort study has been carried out of 2876 men and women with potential exposure to ethylene oxide. Subjects were identified from employment records at four companies that have produced or used ethylene oxide since the 1950s and at eight hospitals which have had ethylene oxide sterilising units since the 1960s. The cohort represents a substantial proportion of the British workforce with a history of occupational exposure to ethylene oxide. Industrial hygiene data were not available before 1977, but since then time weighted average exposures have been less than 5 ppm in almost all jobs and less than 1 ppm in many. Past exposures were probably somewhat higher. In contrast to some previous studies, no clear excess of leukaemia (three deaths observed, 2.09 expected) and no increase in stomach cancer (five deaths observed, 5.95 expected) were found. This discrepancy with earlier reports may be due in part to differences in levels of exposure. Total cancer mortality was similar to that expected from national and local death rates. Some specific cancers showed small excesses but their relevance to ethylene oxide exposure is doubtful. Again, contrary to some earlier reports, no excess of cardiovascular disease was found. This study does not exclude the possibility that ethylene oxide is a human carcinogen but suggests that any risk of cancer from currently permitted occupational exposures is small.

Examination of the Registrar General's mortality data suggested that women do not lose protection from coronary heart disease (CHD) after the menopause. Apparently, at around the age of 50 men begin to lose a factor that had previously put them at increased risk of developing CHD compared with women. Male sex hormones may be risk factors for CHD, and further studies are needed to clarify their role in the aetiology of CHD in men.

Geographical differences in maternal mortality in England and Wales during 1911-4 correlate closely with death rates from stroke in the generation born around that time. The geographical distribution of stroke is more closely related to past maternal mortality than to any leading cause of death, past or present, except ischaemic heart disease, for which correlation coefficients with stroke are similar. This relation is new evidence that poor health and physique of mothers are important determinants of the risk of stroke among their offspring.

Consumptions of chemically modified hydrogenated fat are estimated for the United Kingdom standard regions, conurbations, and urban/rural aggregates as well as for the social classes. Consumptions are shown to correlate satisfactorily with mortality from arteriosclerotic disease and account reasonably well for certain peculiarities in the ratio of female to male death rates and for secular changes in mortality patterns.

Many publications have claimed that oral contraceptives (OCs) are associated with an increased risk of circulatory disease, yet between the years 1962 and 1976, when OCs became widely used in the United Kingdom, death rates from circulatory disease in women of reproductive age fell steadily. This decreased mortality was greater in young women than in men of comparable age, and did not occur in older women. These data tend strongly to refute the belief that OCs are causative of circulatory disease. The possibility that the decreased mortality rate is due to a protective effect of OCs was examined. It was concluded that they could not be completely responsible, although a partial effect could not be ruled out with certainty. It is suggested that, when mortality trends are opposed to the results of case-control or cohort studies, serious doubts are cast on the conclusions about causal relationships.