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Biswajit Chakrabarti1, Sabita Purkait2, Punyabrata Gun2, Vicky C Moore3, Samadrita Choudhuri4, MJ Zaman5,6, Christopher J Warburton1, Peter MA Calverley7, Rahul Mukherjee3 1Aintree Chest Centre, University Hospital Aintree, Liverpool, UK; 2Moitri Swasthya Kendra, Shramajibi Swasthya Udyog, Chengail, West Bengal, India; 3Department of Respiratory Medicine and Physiology, Birmingham Heartlands Hospital, Birmingham, UK; 4National Medical College, Birgunj, Nepal; 5Department of Epidemiology and Public Health, University College, London, UK; 6The George Institute for Global Health, Sydney, Australia; 7Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK Purpose: Respiratory conditions remain a source of morbidity globally. As such, this study aimed to explore factors associated with the development of airflow obstruction (AFO) in a rural Indian setting and, using spirometry, study whether underweight is linked to AFO. Methods: Patients > 35 years old attending a rural clinic in West Bengal, India, took a structured questionnaire, had their body mass index (BMI) measured, and had spirometry performed by an ancillary health care worker. Results: In total, 416 patients completed the study; spirometry was acceptable for analysis of forced expiratory volume in 1 second in 286 cases (69%); 16% were noted to exhibit AFO. Factors associated with AFO were: increasing age (95% confidence interval (CI) 0.004–0.011; P = 0.005), smoking history (95% CI 0.07–0.174; P = 0.006), male gender (95% CI 0.19–0.47; P = 0.012), reduced BMI (95% CI 0.19–0.65; P = 0.02), and occupation (95% CI 0.12–0.84; P = 0.08). The mean BMI in males who currently smoked (n = 60; 19.29 kg/m2; standard deviation [SD] 3.46) was significantly lower than in male never smokers (n = 33; 21.15 kg/m2 SD 3.38; P < 0.001). AFO was observed in 27% of subjects with a BMI

Background: Benefits of cardiac rehabilitation (CR) programme components on attaining risk factor targets post-myocardial infarction (MI) and their predictive strength relative to patient characteristics remain unclear. We aimed to identify organizational and patient-level predictors of risk factor target attainment at one-year post-MI., Methods: In this observational study data on CR organization at 78 Swedish CR centres was collected and merged with patient-level registry data (n = 7549). Orthogonal partial least squares discriminant analysis identified predictors (Variables of Importance for the Projection (VIP) values >0.8) of attaining low-density lipoprotein-cholesterol (LDL-C) <1.8 mmol/L, blood pressure (BP) <140/90 mmHg and smoking abstinence., Results: The strongest predictors (VIP [95% CI]) for attaining LDL-C and BP targets were offering psychosocial management (2.14 [1.78-2.50]; 2.45 [1.91-2.99]), having a psychologist in the CR team (1.62 [1.36-1.87]; 2.05 [1.67-2.44]), extended opening hours (2.13 [2.00-2.27]; 1.50 [0.91-2.10]), adequate facilities (1.54 [0.91-2.18]; 1.89 [1.38-2.40]), and having a medical director (1.70 [0.91-2.48]; 1.46 [1.04-1.88]). The strongest patient-level predictors of attaining LDL-C and/or BP targets were low baseline LDL-C (3.95 [3.39-4.51]) and having no history of hypertension (2.93 [2.60-3.26]), respectively, followed by exercise-based CR participation (1.38 [0.66-2.10]; 1.46 [1.14-1.78]). For smoking abstinence, the strongest organizational predictor was varenicline being prescribed by CR physicians (1.88 [0.95-2.80]) and patient-level predictors were participation in exercise-based CR (2.47 [2.07-2.88]) and group education (1.92 [1.43-2-42]), and no cardiovascular disease history (2.13 [1.78-2.48])., Conclusions: We identified multiple CR organizational and patient-level predictors of attaining risk factor targets post-MI. These results may influence the future design of comprehensive CR programmes., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Many patients with heart failure with preserved ejection fraction (HFpEF) are undiagnosed, and UK general practice registers do not typically record heart failure (HF) subtype. Improvements in management of HFpEF is dependent on improved identification and characterisation of patients in primary care., Aim: To describe a cohort of patients recruited from primary care with suspected HFpEF and compare patients in whom HFpEF was confirmed and refuted., Design & Setting: Baseline data from a longitudinal cohort study of patients with suspected HFpEF recruited from primary care in two areas of England., Method: A screening algorithm and review were used to find patients on HF registers without a record of reduced ejection fraction (EF). Baseline evaluation included cardiac, mental and physical function, clinical characteristics, and patient reported outcomes. Confirmation of HFpEF was clinically adjudicated by a cardiologist., Results: In total, 93 (61%) of 152 patients were confirmed HFpEF. The mean age of patients with HFpEF was 79 years, 46% were female, 80% had hypertension, and 37% took ≥10 medications. Patients with HFpEF were more likely to be obese, pre-frail or frail, report more dyspnoea and fatigue, were more functionally impaired, and less active than patients in whom HFpEF was refuted. Few had attended cardiac rehabilitation., Conclusion: Patients with confirmed HFpEF had frequent multimorbidity, functional impairment, frailty, and polypharmacy. Although comorbid conditions were similar between people with and without HFpEF, the former had more obesity, symptoms, and worse physical function. These findings highlight the potential to optimise wellbeing through comorbidity management, medication rationalisation, rehabilitation, and supported self-management., (Copyright © 2021, The Authors.)

Objective: To assess the impact of heart disease (HD) combined with depression on all-cause mortality in older people living in the community., Design: A population-based cohort study., Participants: We examined the data of 1429 participants aged ≥60 years recruited in rural areas in Anhui province, China. Using a standard method of interview, we documented all types of HD diagnosed by doctors and used the validated Geriatric Mental Status-Automated Geriatric Examination for Computer Assisted Taxonomy algorithm to diagnose any depression for each participant at baseline in 2003. The participants were followed up for 8 years to identify vital status., Measurements: We sought to examine all-cause mortality rates among participants with HD only, depression only and then their combination compared with those without these diseases using multivariate adjusted Cox regression models., Results: 385 deaths occurred in the cohort follow-up. Participants with baseline HD (n=91) had a significantly higher mortality (64.9 per 1000 person-years) than those without HD (42.9). In comparison to those without HD and depression, multivariate adjusted HRs for mortality in the groups of participants who had HD only, depression only and both HD and depression were 1.46 (95% CI 0.98 to 2.17), 1.79 (95% CI 1.28 to 2.48) and 2.59 (95% CI 1.12 to 5.98), respectively., Conclusion: Older people with both HD and depression in China had significantly increased all-cause mortality compared with those with HD or depression only, and without either condition. Psychological interventions should be taken into consideration for older people and those with HD living in the community to improve surviving outcome., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Increased use of invasive coronary strategies in patients admitted to hospitals with on-site cardiac catheter laboratory (CCL) facilities has been reported, but the utilisation of invasive coronary strategies according to types of CCL facilities at the first admitting hospital and clinical outcomes is unknown., Methods: We included 452,216 patients admitted with a diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) in England and Wales from 2007 to 2015. The admitting hospitals were categorized into no-laboratory, diagnostic, and PCI hospitals according to CCL facilities. Multilevel logistic regression models were used to study associations between CCL facilities and in-hospital outcomes., Results: A total of 97,777 (21.6%) of the patients were admitted to no-laboratory hospitals, and 134,381 (29.7%) and 220,058 (48.7%) were admitted to diagnostic and PCI hospitals, respectively. Use of coronary angiography was significantly higher in PCI hospitals (77.3%) than in diagnostic (63.2%) and no-laboratory (61.4%) hospitals. The adjusted odds of in-hospital mortality were similar for diagnostic (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.83-1.04) and PCI hospitals (OR 1.09, 95% CI 0.96-1.24) compared with no-laboratory hospitals. However, in high-risk NSTEMI subgroup (defined as Global Registry of Acute Coronary Events score > 140), an admission to diagnostic hospitals was associated with significantly increased in-hospital mortality (OR 1.36, 95% CI 1.06-1.75) compared with no-laboratory and PCI hospitals., Conclusions: This study highlights important differences in both the utilisation of invasive coronary strategies and subsequent management and outcomes of NSTEMI patients according to admitting hospital CCL facilities. High-risk NSTEMI patients admitted to diagnostic hospitals had greater in-hospital mortality, possibly because of reduced PCI use, which needs to be addressed., (Copyright © 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: While patient performance after participating in cardiac rehabilitation programmes after acute myocardial infarction is regularly reported through registry and survey data, information on cardiac rehabilitation programme characteristics is less well described., Aim: The aim of this study was to evaluate Swedish cardiac rehabilitation programme characteristics and adherence to European Guidelines on Cardiovascular Disease Prevention., Method: Cardiac rehabilitation programme characteristics at all 78 cardiac rehabilitation centres in Sweden in 2016 were surveyed using a web-based questionnaire (100% response rate). The questions were based on core components of cardiac rehabilitation as recommended by European Guidelines., Results: There was a wide variation in programme duration (2-14 months). All programmes reported offering an individual post-discharge visit with a nurse, and 90% ( n  = 70) did so within three weeks from discharge. Most programmes offered centre-based exercise training ( n  = 76, 97%) and group educational sessions ( n  = 61, 78%). All programmes reported to the national audit, SWEDEHEART, and 60% ( n  = 47) reported that performance was regularly assessed using audit data, to improve quality of care. Ninety-six per cent ( n  = 75) had a core team consisting of a cardiologist, a physiotherapist and a nurse and 76% ( n  = 59) reported having a medical director. Having other allied healthcare professionals included in the cardiac rehabilitation team varied. Forty per cent ( n  = 31) reported having regular team meetings where nurses, physiotherapists and cardiologist could discuss patient cases., Conclusion: The overall quality of cardiac rehabilitation programmes provided in Sweden is high. Still, there are several areas of potential improvement. Monitoring programme characteristics as well as patient outcomes might improve programme quality and patient outcomes both at a local and a national level.

Background: The effect of a weekend compared with a weekday hospital admission on patient outcomes after an acute coronary syndrome is unclear. This study aims to determine whether collectively there is a weekend effect in acute coronary syndrome., Method: We conducted a systematic review and meta-analysis of cohort studies examining the association between weekend compared to weekday admission at any time of the day and early mortality (in-hospital or 30-day). A search was performed on Medline and Embase and relevant studies were pooled using random effects meta-analysis for risk of early mortality. Additional analyses were performed considering only more recent studies (conducted after 2005) and by patient group (ST-elevation myocardial infarction [STEMI] or non-STEMI [NSTEMI]), as well as meta-regression according to starting year and mean year of study., Results: A total of 18 studies were included with over 14 million participants incorporating 3 million weekend and over 11.5 million weekday admissions and the rates of mortality were 19.2% and 23.4%, respectively. The pooled results of all 18 studies suggest that weekend admission was associated with a small increased risk of early mortality (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.03-1.09). The results for subgroups of STEMI and NSTEMI cohorts were not statistically significant and timing of admission after 2005 had minimal influence on the results (OR 1.06, 95% CI 0.95-1.17)., Conclusions: There is a small weekend effect for admission with acute coronary syndrome that has persisted over time.

Background: Heart failure with preserved ejection fraction (HFpEF) is under-identified in primary care., Aim: The aim of this study was to determine what information is available in patients' primary care practice records that would identify patients with HFpEF., Design & Setting: Record review in two practices in east of England., Method: Practices completed a case report form on each patient on the heart failure register and sent anonymised echocardiography reports on patients with an ejection fraction (EF) >50%. Reports were reviewed and data analysed using SPSS (version 25)., Results: One hundred and forty-eight patients on the heart failure registers with mean age 77 +12 years were reviewed. Fifty-three patients (36%) had possible HFpEF based on available information. These patients were older and multimorbid, with a high prevalence of overweight and obesity. Confirmation of diagnosis was not possible as recommended HFpEF diagnostic information (natriuretic peptides, echocardiogram parameters of structural heart disease and diastolic function) was widely inconsistent or absent in these patients., Conclusion: Without correct identification of HFpEF, patient management may be suboptimal or inappropriate, and lack the needed focus on comorbidities and lifestyle that can improve patient outcomes. This study describes in detail the characteristics of many of the patients who probably have HFpEF in a real-world sample, and the improvements and diagnostic information required to better identify them. Identifying more than the tip of the iceberg that is the HFpEF population will allow the improvement of the quality of their management, the prevention of ineffective health care, and the recruitment of patients into research.

Italy comprises a high proportion of people who never exercised. Low physical activity levels in adolescents is a risk factor for several disorders. The aim of this cohort epidemiological study was to compare physical fitness profiles between boys and girls with regard to age and gender and to identify health and fitness-related markers that contribute to the make-up of Southern Italian teenagers.Eight hundred eleven teenagers were assessed for anthropometric measurements and completed the 5 ASSO-fitness tests battery. Data were analyzed with a 2-way analysis of variance (ANOVA) for repeated measures to compare the effect of both age and gender on the fitness components.The boys' anthropometric measurements were superior than the girls as expected [weight, height, body mass index (BMI), and waist circumference]; the overall BMI was found in the normality range. The overall teenagers' fitness markers were found to be quite poor with the boys outperforming the girls in all fitness tests. The weak cardiorespiratory performance of the female teenagers was remarkable. The under 16 years old (-16 yrs) girls outperformed the over 16 years old (+16yrs) girls. There were less significant differences when comparing (-16) and (+16) yrs old mixed-gender groups. There were no correlations between the (-16) and (+16) yrs when both genders were considered. The trend analysis showed the younger teenagers might be "catching up" the older ones in both contexts.Gender significantly influenced all variables. Although age did not influence cardiorespiratory fitness, the older the teenagers the worse their health and fitness markers become with the older girls worse than their younger peers., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aims to study the prognostic impact of left ventricular function on mortality and examine the effect of age on the prognostic value of left ventricular function., Methods: We examined the myocardial ischaemia national audit project registry (2006-2010) data with a mean follow-up of 2.1 years. Left ventricular function was categorised into good (ejection fraction ⩾50%), moderate (ejection fraction 30-49%) and poor (ejection fraction <30%) categories. Cox proportional hazards models were constructed to examine the prognostic significance of left ventricular function in different age groups (<65, 65-74, 75-84 and ⩾85 years) on all-cause mortality adjusting for baseline variables., Results: Out of 424,848 patients, left ventricular function data were available for 123,609. Multiple imputations were used to impute missing values of left ventricular function and the final sample for analyses was drawn from 414,305. After controlling for confounders, 339,887 participants were included in the regression models. For any age group, mortality was higher with a worsening degree of left ventricular impairment. Increased age reduced the adverse prognosis associated with reduced left ventricular function (hazard ratios of death comparing poor left ventricular function to good left ventricular function were 2.11, 95% confidence interval 1.88-2.37 for age <65 years and 1.28, 95% confidence interval 1.20-1.36 for age ⩾85 years). Older patients had a high mortality risk even in those with good left ventricular function. Hazard ratios of mortality for ⩾85 compared to <65 years (hazard ratio = 1.00) within good, moderate and poor ejection fraction groups were 5.89, 4.86 and 3.43, respectively., Conclusions: In patients with acute coronary syndrome, clinicians should interpret the prognostic value of left ventricular function taking into account the patient's age.

Background: We aim to determine the prevalence of anemia in acute coronary syndrome (ACS) patients and compare their clinical characteristics, management, and clinical outcomes to those without anemia in an unselected national ACS cohort., Methods and Results: The Myocardial Ischemia National Audit Project (MINAP) registry collects data on all adults admitted to hospital trusts in England and Wales with diagnosis of an ACS. We conducted a retrospective cohort study by analyzing patients in this registry between January 2006 and December 2010 and followed them up until August 2011. Multiple logistic regressions were used to determine factors associated with anemia and the adjusted odds of 30-day mortality with 1 g/dL incremental hemoglobin increase and the 30-day and 1-year mortality for anemic compared to nonanemic groups. Analyses were adjusted for covariates. Our analysis of 422 855 patients with ACS showed that 27.7% of patients presenting with ACS are anemic and that these patients are older, have a greater prevalence of renal disease, peripheral vascular disease, diabetes mellitus, and previous acute myocardial infarction, and are less likely to receive evidence-based therapies shown to improve clinical outcomes. Finally, our analysis suggests that anemia is independently associated with 30-day (OR 1.28, 95% CI 1.22-1.35) and 1-year mortality (OR 1.31, 95% CI 1.27-1.35), and we observed a reverse J-shaped relationship between hemoglobin levels and mortality outcomes., Conclusions: The prevalence of anemia in a contemporary national ACS cohort is clinically significant. Patients with anemia are older and multimorbid and less likely to receive evidence-based therapies shown to improve clinical outcomes, with the presence of anemia independently associated with mortality outcomes., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: observational studies suggest that older patients are less likely to receive secondary prevention medicines following acute coronary syndrome (ACS)., Objectives: to examine the association of increasing age with receipt of specialist care and influence of specialist care on long-term mortality in patients with non-ST elevation myocardial infarction (NSTEMI)., Design: a cohort study., Setting: National ACS registry of England and Wales., Subjects: a total of 85,183 patients admitted with NSTEMI between 2006 and 2010., Methods: logistic regression analyses to assess receipt of secondary prevention medicines (ACE inhibitor, β-blocker, statin, aspirin) by age group; multivariate Cox regression models to examine longitudinal effect of cardiologist care on all-cause mortality by age group., Results: mean age 72.0 years (SD 13.0 years), mean follow-up was 2.13 years. Older patients received less cardiologist care (70.2% of NSTEMI patients ≥85 years compared with 94.7% of patients <65) years and had more co-morbidity. Cardiologists prescribed more secondary prevention in all age groups than generalists, but this was mostly explained away by co-morbidity (receipt of statin crude OR 1.51 (1.27,1.80), fully adjusted OR 1.11 (0.92,1.33) in patients ≥85 years). Receiving cardiologist care compared with generalist care was associated with a decreased risk of death in all even after adjustment for co-morbidity, disease severity and secondary prevention; this benefit reduced incrementally with older age group (adjusted hazard ratio (HR) 0.58 (0.49,0.68) aged <65; 0.87 (0.82,0.92) aged ≥85)., Conclusion: older patients with NSTEMI were less likely to see a cardiologist, but reduced treatment by generalists was explained away by co-morbidity. Cardiologist care was associated with lower mortality in all age groups than a generalist, but this survival benefit was less pronounced in older patients., (© The Author 2015. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Incidentally elevated cardiac troponin I (cTnI) levels are common in acutely unwell older patients. However, little is known about how this impacts on the prognosis of these patients., Objective: We aimed to investigate whether incidentally elevated cTnI levels (group 1) are associated with poorer outcome when compared to age- and sex-matched patients without an elevated cTnI level (group 2), and to patients diagnosed with acute coronary syndrome (group 3)., Patients and Methods: This prospective, matched cohort study placed patients ≥75 years old who were admitted to a University teaching hospital into groups 1-3, based on the cTnI levels and underlying diagnosis. Outcomes were compared between the groups using mixed-effects regression models and adjusted for renal function and C-reactive protein. All-cause mortality at discharge, at 1 month and 3 months, alongside the length of hospital stay (LOS), were recorded., Results: In total, 315 patients were included, with 105 patients in each of the 3 groups. The mean age was 84.8 ± 5.5 years, with 41.9% males. All patients were followed up for 3 months. The percent all-cause mortality at discharge and the LOS for groups 1, 2 and 3 were 12.4, 3.8 and 8.6% and 11.2, 8.5 and 7.7 days, respectively. Group 1 had significantly increased mortality at 3 months [odds ratio (OR) 2.80, 95% confidence interval (CI) 1.12-6.96; p = 0.040] and LOS (OR 1.39, 95% CI 1.08-1.79; p = 0.008) compared to group 2 and did not differ significantly when compared to 3-month mortality (OR 2.39, 95% CI 0.91-6.29; p = 0.079) or LOS (OR 1.26, 95% CI 0.96-1.66; p = 0.097) in group 3., Conclusion: There is a significant association between an incidental rise in cTnI level with mortality and LOS in older patients. Further research is required to evaluate whether a more systematic management of these patients would improve the prognosis., (© 2016 S. Karger AG, Basel.)

Aims: To synthesise the evidence relating influenza and influenza-like symptoms to the risks of myocardial infarction (MI), heart failure (HF) and stroke., Methods: We conducted a systematic review and meta-analysis of the evidence relating influenza and influenza-like symptoms to the risks of MI, HF and stroke. We systematically searched all MEDLINE and EMBASE entries up to August 2014 for studies of influenza vs. the cardiovascular outcomes above. We conducted random effects meta-analysis using inverse variance method for pooled odds ratios (OR) and evaluated statistical heterogeneity using the I(2) statistic., Results: We identified 12 studies with a total of 84,003 participants. The pooled OR for risk of MI vs. influenza (serologically confirmed) was 1.27 (95% CI, confidence interval 0.54-2.95), I(2)  = 47%, which was significant for the only study that adjusted for confounders (OR 5.50, 95% CI 1.31-23.13). The pooled OR for risk of MI vs. influenza-like symptoms was 2.17 (95% CI 1.68-2.80), I(2)  = 0%, which was significant for both unadjusted (OR 2.23, 95% CI 1.65-3.01, five studies) and adjusted studies (OR 2.01, 95% CI 1.24-3.27, two studies). We found one study that evaluated stroke risk, one study in patients with HF, and one that evaluated mortality from MI - all of these studies suggested increased risks of events with influenza-like symptoms., Conclusions: There is an association between influenza-like illness and cardiovascular events, but the relationship is less clear with serologically diagnosed influenza. We recommend renewed efforts to apply current clinical guidelines and maximise the uptake of annual influenza immunisation among patients with cardiovascular diseases, to decrease their risks of MI and stroke., (© 2015 John Wiley & Sons Ltd.)

Background: Clinical decision support systems (CDSS) can modify clinician behaviour, yet the factors influencing their effect remain poorly understood. This study assesses the feasibility and acceptability of a CDSS supporting diagnostic and treatment decisions for patients with suspected stable angina., Methods: Intervention The Optimising Management of Angina (OMA) programme includes a CDSS guiding investigation and medication decisions for clinicians managing patients with new onset stable angina, based on English national guidelines, introduced through an educational intervention. Design and participants A mixed methods study i. A study of outcomes among patients presenting with suspected angina in three chest pain clinics in England before and after introduction of the OMA programme. ii. Observations of clinic processes, interviews and a focus group with health professionals at two chest pain clinics after delivery of the OMA programme., Outcomes: Medication and cardiovascular imaging investigations undertaken within six months of presentation, and concordance of these with the recommendations of the CDSS. Thematic analysis of qualitative data to understand how the CDSS was used., Results: Data were analysed for 285 patients attending chest pain clinics: 106 before and 179 after delivery of the OMA programme. 40 consultations were observed, 5 clinicians interviewed, and a focus group held after the intervention. The proportion of patients appropriate for diagnostic investigation who received one was 50 % (95 CI 34-66 %) of those before OMA and 59 % (95 CI 48-70 %) of those after OMA. Despite high use of the CDSS (84 % of consultations), observations and interviews revealed difficulty with data entry into the CDSS, and structural and practical barriers to its use. In the majority of cases the CDSS was not used to guide real-time decision making, only being consulted after the patient had left the room., Conclusions: The OMA CDSS for the management of chest pain is not feasible in its current form. The CDSS was not used to support decisions about the care of individual patients. A range of barriers to the use of the CDSS were identified, some are easily removed, such as insufficient capture of cardiovascular risk, while others are more deeply embedded in current practice, such as unavailability of some investigations or no prescribing privileges for nurses.

Hypercholesterolemia is common in older adults and less treated, but little is known about correlates of untreated hypercholesterolemia. Using a standard interview method we examined a random sample of 7,572 participants aged ≥60 years in a community-based household survey across 7 provinces of China during 2007-2012, and documented 328 cases of hypercholesterolemia from self-reported doctor diagnosis. Compared to participants with normal cholesterol, older adults with hypercholesterolemia had higher socioeconomic position and larger body mass index. In patients with hypercholesterolemia, 209 were not treated using lipid-lowering medications (63.7%, 95% confidence interval (CI) 58.5%-68.9%). Untreated hypercholesterolemia was significantly associated with female sex (adjusted odds ratio 2.13, 95%CI 1.17-3.89), current smoking (3.48, 1.44-8.44), heavy alcohol drinking (3.13,1.11-8.84), chronic bronchitis (2.37,1.14-4.90) and high level of meat consumptions (2.85,1.22-6.65). Although having coronary heart disease exposed participants for treatment, half of participants with coronary heart disease did not receive lipid-lowering medications. Among hypercholesterolemia participants with stroke, hypertension or diabetes, more than half of them did not receive lipid-lowering medications. The high proportion of untreated hypercholesterolemia in older, high-risk Chinese adults needs to be mitigated through multi-faceted primary and secondary prevention strategies to increase population opportunities of treating hypercholesterolemia.

Aims: Silent myocardial ischaemia occurs commonly in diabetes. Whether altered perception of ischaemia also predisposes to atypical presentations with under-diagnosis of coronary disease is not known. To determine whether (i) patients with diabetes diagnosed with angina are more likely to report atypical symptoms compared with patients without diabetes, and (ii) atypical symptoms in patients with diabetes cause angina to go unrecognized, increasing the risk of coronary events., Methods and Results: Prospective, multicentre cohort study of 8662 ambulatory patients with suspected angina, of whom 906 had diabetes. We recorded detailed chest pain descriptors and fatal and non-fatal coronary events over a median of 3.08 years of follow-up. Proportionately more patients with than without diabetes received a diagnosis of angina (42.7 vs. 25.1%). Among patients with diabetes diagnosed with angina, a greater proportion had atypical chest pain compared with patients without diabetes (21.0 vs. 11.3%), but the hazard of fatal and non-fatal coronary events was similar. However, among patients diagnosed with non-cardiac chest pain, those with diabetes-most of whom had atypical symptoms-remained at greater risk of coronary events [2.29 (95% CI 1.54, 3.41)] and all-cause mortality [1.67 (95% confidence interval, CI 1.04, 2.69)] compared with non-diabetic patients., Conclusion: Patients with diabetes and atypical symptoms are nearly twice as likely to be diagnosed with angina compared with non-diabetic patients. Those diagnosed with non-cardiac pain are at increased risk of coronary events. Our study emphasizes the need for more intensive investigation of diabetic patients with chest pain, particularly those presenting with atypical symptoms.

Objective: This study aims to determine whether the prognostic significance of troponins in acute coronary syndrome in predicting mortality varies by age, and if so, to what extent when other prognostic indicators are considered., Methods: We analysed Myocardial Ischemia National Audit Project registry data collected between January 2006 and December 2010 and followed up this cohort for all-cause mortality until August 2011. Relationships between peak troponin levels (types I and T) and time to death in different age groups, and between age and time to death at different troponin levels were investigated using multiple variable adjusted Cox regression models., Results: Of the 322 617 patients with acute coronary syndromes included, a third (n=106 365, 33%) died during 695 334 person-years of follow-up. Within each troponin category, older age was associated with a higher mortality even in those with a troponin <0.01 ng/mL for both troponin types (HR ~10-12 in ≥85 years cf. HR of 1.0 in <65 years). The relative potency of an elevated troponin to predict an adverse outcome compared with a low troponin attenuated with increased age (for troponin I ≥15.0 compared with troponin I <0.01 in age <65, adjusted HR 2.41 (95% CI 1.80 to 3.24); age ≥85 HR 2.01 (1.62 to 2.52)). Similar but less consistent results were observed with troponin T elevation at the higher levels., Conclusions: Clinicians should interpret the prognostic value of troponin taking into account the patient's age.

Aims: Older people increasingly constitute a large proportion of the acute coronary syndrome (ACS) population. We examined the relationship of age with receipt of more intensive management and secondary prevention medicine. Then, the comparative association of intensive management (reperfusion/angiography) over a conservative strategy on time to death was investigated by age., Methods and Results: Using data from 155 818 patients in the national registry for ACS in England and Wales [the Myocardial Ischaemia National Audit Project (MINAP)], we found that older patients were incrementally less likely to receive secondary prevention medicines and intensive management for both ST-elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). In STEMI patients ≥85 years, 55% received reperfusion compared with 84% in those aged 18 to <65 [odds ratio 0.22 (95% CI 0.21, 0.24)]. Not receiving intensive management was associated with worse survival [mean follow-up 2.29 years (SD 1.42)] in all age groups (adjusted for sex, cardiovascular risk factors, co-morbidities, healthcare factors, and case severity), but there was an incremental reduction in survival benefit from intensive management with increasing age. In STEMI patients aged 18-64, 65-74, 75-84, and ≥85, adjusted hazard ratios (HRs) for all-cause mortality comparing conservative treatment to intensive management were 1.98 (1.78, 2.19), 1.65 (1.51, 1.80), 1.62 (1.52, 1.72), and 1.36 (1.27, 1.47), respectively. In NSTEMI patients, the respective HRs were 4.37 (4.00, 4.78), 3.76 (3.54, 3.99), 2.79 (2.67, 2.91), and 1.90 (1.77, 2.04)., Conclusion: We found an incremental reduction in the use of evidence-based therapies with increasing age using a national ACS registry cohort. While survival benefit from more intensive management reduced with older age, better survival was associated with intensive management at all ages highlighting the requirement to improve standard of care in older patients with ACS., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

Background and Purpose: Anti-inflammatory cytokine and its genetic variations may play an important role in the process of atherosclerosis. We assessed whether serum interleukin-10 (IL-10) and its genetic variations are associated with ischemic stroke in a Chinese general population., Methods: An epidemiological survey on cardiovascular diseases and their risk factors was carried in a general population in Beijing in 2005. Serum IL-10, IL-6, p-selectin, soluble intercellular adhesion molecule-1 and C-reactive protein were analyzed using ELISA kits, while three IL-10 Single Nucleotide Polymorphisms (SNP) (rs1800872, rs1554286 and rs3021094) were genotyped in 1475 participants., Results: A high serum IL-10 (top tertile) was significantly associated with ischemic stroke (multivariable adjusted odds ratio (OR) =0.50; 95%CI 0.31-0.81). Rs1800872 (AA vs. AC+CC genotype, OR=1.60; 1.06-2.39), rs1554286(TT vs. CT+CC genotype, OR=1.59; 1.06-2.39), and rs3021094 (CC/CA vs. AA genotype, OR=1.64; 1.04-2.60) were all significantly associated with ischemic stroke even after controlling for age, sex, smoking, systolic blood pressure, total cholesterol, glucose, body mass index and serum IL-10. The SNP score (a summary index of these SNPs) and IL-10 (top tertile) together significantly improved the discriminative power in predicting ischemic stroke by 3.3% (95%CI: 0.2-6.4, p=0.0398) compared to predictions based on conventional risk factors alone., Conclusions: The lower serum IL-10 concentration and its selected genetic variations were significantly associated with an increased likelihood of ischemic stroke in this cross-sectional study. Our results suggest that more prospective studies should be conducted to provide stronger evidence justifying the use of IL-10 and its SNPs as new biomarkers to identify a predisposition towards ischemic stroke.

Aims: The ADVANCE trial recruited participants from 20 countries worldwide. We analyse here regional variations and causes of hospitalization for people with Type 2 diabetes from Asia, Established Market Economies and Eastern Europe., Methods: A cohort analysis examining the effects of region on causes of first hospitalization, and the association of participant characteristics on all-cause first hospitalization across regions, using multivariable (adjusted for clinical, physiological, behavioural and socio-demographic factors) Cox models., Results: Of 11 140 individuals (6407 men), all-cause hospitalization rates were highest in Established Market Economies, followed by Eastern Europe then Asia. Eastern Europe had rates of hospitalization for diabetic causes four times greater than Established Market Economies [multivariable-adjusted hazard ratio 4.02 (95% CI 2.86-5.63)]. There were no significant regional variations in hospitalization rates for cardiovascular disease (P = 0.534), but much lower rates for musculoskeletal and non-specific causes in Eastern Europe [multivariable-adjusted hazard ratio 0.44 (95% CI 0.32-0.60) and 0.19 (95% CI 0.12-0.29)] and Asia [hazard ratio 0.21 (95% CI 0.16-0.29) and 0.09 (95% CI 0.06-0.14)] compared with Established Market Economies. In all regions, participants hospitalized for any cause were more likely to be older, male, hypertensive, smokers, have higher glycated haemoglobin and a history of macrovascular or macrovascular disease., Conclusions: Across three markedly different regions of the world, regional rates and causes of hospitalization varied widely in patients with Type 2 diabetes. Adjustment for a range of patient characteristics did not explain these regional differences in hospitalization, which appear to be attributable to health system factors., (© 2013 The Authors. Diabetic Medicine © 2013 Diabetes UK.)

Objective: To determine whether the effect of South Asian ethnicity differs between studies of incidence and prognosis of coronary disease., Design: Systematic literature review and meta-analysis, and cohort analysis from a national acute coronary syndrome (ACS) registry linked to mortality (National Institute of Cardiovascular Outcomes Research/Myocardial Infarction National Audit Project)., Setting: International for the review, and England and Wales for the cohort analysis., Patients: The numbers of South Asians included in the meta-analysis were 111 555 (incidence) and 14 531 (prognosis) of whom 8251 were from the ACS cohort., Main Outcome Measures: Incidence studies: non-fatal myocardial infarction or fatal coronary heart disease; prognostic studies: mortality; HRs for 1-year all-cause death in ACS cohort., Results: South Asians had higher incidence of coronary disease compared with white subjects (HR 1.35 95% CI 1.30 to 1.40) based on meta-analysis of nine studies. Among 10 studies on prognosis, South Asians had better prognosis compared with white subjects (HR 0.78 95% CI 0.74 to 0.82). In the ACS cohort, the impact of diabetes (42.4% of South Asians, 16.9% of white subjects) on 1-year mortality was stronger in South Asians than white subjects (age-adjusted HR 1.83 95% CI 1.59 to 2.11 vs 1.53 95% CI 1.49 to 1.57). However, prognosis was better in South Asians even among diabetics, older people and those living in areas of the highest social deprivation., Conclusions: South Asian ethnicity is associated with higher incidence of coronary disease, but lower mortality once coronary disease is manifest. The dissociation between effects on incidence and prognosis suggests that public health initiatives to reduce inequalities in mortality between South Asian and white populations should focus on primary prevention. This is a CALIBER study with ClinicalTrials.gov Identifier: NCT01163513.

Background: There are an estimated 200 million people in China with dyslipidaemia. We sought to explore factors that influence compliance to treatment of dyslipidaemia, using a multi-centre sample in China., Methods: Through review of medical notes and direct interviews at two points in time (2006 and 2007) of 2094 patients in 27 hospitals receiving lipid-lowering therapy since 2004, 1890 patients were recruited who had been on treatment for more than one year. Good compliance (GC) was defined as days taking lipid-lowering drugs/total days of follow-up ≥ 80%. Logistic regression models were used to assess factors associated with GC., Results: In patients with one, two and three years of treatment respectively, GC was greater in those with higher versus lower medical insurance cover - odds ratios 2.8 (95%CI 2.2-3.7), 2.0 (1.5-2.7), 4.3 (2.3-8.1); in patients in province-level versus county-level hospitals-2.0 (1.5-2.6), 2.9 (2.0-4.1), 4.6 (1.8-12.0); in patients treated by non-cardiology physicians compared to cardiologists -1.7 (1.1-2.5), 2.0 (1.3-3.0), 4.0 (1.5-10.3) and in patients using a statin versus other forms of medication for dyslipidaemia -1.7 (1.2-2.2), 1.7 (1.2-2.3), 4.4 (2.3-8.5)., Conclusions: Better medical insurance cover, care in a province-level hospital rather than county-level hospital, treatment by a non-cardiologist and use of a statin were associated with better compliance to lipid-lowering treatment.

Studying ethnic differences in health not only benefits minority groups but is a powerful tool for scientific analysis and for social action in the wider field of health inequalities. Coronary mortality in developed countries is well-known to be higher for men and women born in south Asia compared to other ethnic groups. The aim of this review is to examine how the knowledge of ethnic differences in coronary health in south Asians has advanced in the last decade. We set out to answer the following: Is the high rate of coronary mortality in south Asians a result of high incidence or high case fatality? Why are there ethnic differences, and are they the result of biology, healthcare or social circumstances? Is the cardiovascular health future for south Asians (and especially the UK-born second generation) any brighter than in their parents?

Background: Coronary heart disease (CHD) is the leading cause of morbidity and mortality worldwide. The growth of ageing populations in developing countries with progressively urbanized lifestyles are major contributors. The key risk factors for CHD such as hypercholesterolemia, diabetes mellitus, and obesity are likely to increase in the future. These risk factors are modifiable through lifestyle., Objectives: To review current literature on the potential benefit of cholesterol lowering in CHD risk reduction with a particular focus on the evidence of non-pharmacological/lifestyle management of hypercholesterolemia., Methods: Medline/PubMed systematic search was conducted using a two-tier approach limited to all recent English language papers. Primary search was conducted using key words and phrases and all abstracts were subsequently screened and relevant papers were selected. The next tier of searching was conducted by (1) reviewing the citation lists of the selected papers and (2) by using PubMed weblink for related papers. Over 3600 reports were reviewed., Results: Target cholesterol levels set out in various guidelines could be achieved by lifestyle changes, including diet, weight reduction, and increased physical activity with the goal of reducing total cholesterol to <200 mg/dL and LDL-C<100 mg/dL. Various dietary constituents such as green tea, plant sterols, soy protein have important influences on total cholesterol. Medical intervention should be reserved for those patients who have not reached this goal after 3 months of non-pharmacological approach., Conclusion: CHD remains as a leading cause of death worldwide and hypercholesterolemia is an important cause of CHD. Non-pharmacological methods provide initial as well as long-term measures to address this issue.

Background: To investigate the prevalence, screening and knowledge of cardiovascular risk factors (CVRFs) by socio-economic position (SEP) in rural India., Methods: An age- and sex-stratified random sample of 4535 adults was recruited from rural Andhra Pradesh and a questionnaire was administered to assess prevalence, screening and knowledge of CVRFs and record recent attempts to modify behaviour. Education, income and occupation were used to measure SEP., Results: Lower fruit intake and higher tobacco and alcohol use were found in those with lower SEP. Overweight, physical inactivity, diabetes, hypertension, family history of cardiovascular disease (CVD) and previous CVD (men only) were greater in higher SEP participants. Lower SEP participants had less blood pressure, glucose or cholesterol screening and less knowledge of nine CVRFs. Regardless of SEP, participants knowledgeable of the harms of a CVRF were more likely to have attempted to modify behaviour. For example, knowledge of benefits of smoking cessation was associated with an increased odds ratio (OR) for attempting to quit: in educated participants-OR 3.67, 95% confidence interval (CI) 2.10-6.42; in participants with no education-OR 3.98, 95% CI 2.27-6.97., Conclusions: Some biological CVRFs were worse in higher SEP participants while some behavioural risk factors were worse in lower SEP participants. Lower SEP participants had less CVRF screening and knowledge of CVRFs. Those with knowledge of CVRFs were more likely to make healthy behavioural changes. Our findings suggest equipping rural Indians with knowledge about CVRFs may ameliorate projected future increases in CVD.

Coronary heart disease (CHD) is a leading cause of morbidity and mortality globally. Hypercholesterolemia is one of the major risk factors for CHD. With the increase in aging populations and progressively sedentary lifestyles, the global burden of CHD is likely to increase in the future despite better preventive strategies. It is vitally important to manage hypercholesterolemia effectively because it is a modifiable risk factor. At present, there are several guidelines with differences in recommendations. In this paper the authors present an update on the guidelines on hypercholesterolemia management. The authors have systematically reviewed guidelines in hypercholesterolemia management and discussed a pragmatic approach to follow the most recent guidelines including guidance from NICE in the primary care setting.

Objective: To examine functions of the exercise ECG in the light of the recent National Institute for Health and Clinical Excellence guidelines recommending that it should not be used for the diagnosis or exclusion of stable angina., Design: Qualitative ethnographic study based on interviews and observations of clinical practice., Setting: 3 rapid access chest pain clinics in England., Participants: Observation of 89 consultations in chest pain clinics, 18 patient interviews and 12 clinician interviews., Main Outcome Measure: Accounts and observations of consultations in chest pain clinics., Results: The exercise ECG was observed to have functions that extended beyond diagnosis. It was used to clarify a patient's story and revise the initial account. The act of walking on the treadmill created an additional opportunity for dialogue between clinician and patient and engagement of the patient in the diagnostic process through precipitation of symptoms and further elaboration of symptoms. The exercise ECG facilitated reassurance in relation to exercise capacity and tolerance, providing a platform for behavioural advice particularly when exercise was promoted by the clinician., Conclusions: Many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients and need to be considered in the re-design of services without that test. Through its contribution to the patient's history and to subsequent advice to the patient, the exercise ECG continues to inform the specialist assessment and management of patients with new onset stable chest pain, beyond its now marginalised role in diagnosis.

Background: Whether the higher coronary mortality in South Asians compared with White populations is due to a higher incidence of disease is not known. This study assessed cumulative incidence of chest pain in South Asians and Whites, and prognosis of chest pain., Methods: Over seven phases of 18-year follow-up of the Whitehall-II study (9,775 civil servants: 9,195 White, 580 South Asian), chest pain was assessed using the Rose questionnaire. Coronary death/non-fatal myocardial infarction was examined comparing those with chest pain to those with no chest pain at baseline., Results: South Asians had higher cumulative frequencies of typical angina by Phase 7 (17.0 versus 11.3%, P < 0.001) and exertional chest pain (15.4 versus 8.5%, P < 0.001) compared with Whites. Typical angina and exertional chest pain at baseline were associated with a worse prognosis compared with those with no chest pain in both groups (typical angina, South Asians: HR, 4.67 and 95% CI, 2.12-0.30; Whites: HR, 3.56 95% CI, 2.59-4.88). Baseline non-exertional chest pain did not confer a worse prognosis. Across all types of pain, prognosis was worse in South Asians., Conclusion: South Asians had higher cumulative incidence of angina than Whites. In both, typical angina and exertional chest pain were associated with worse prognosis compared with those with no chest pain.

Background: Rural-to-urban migration in low- and middle-income countries causes an increase in individual cardiovascular risk. Cost-effective interventions at early stages of the natural history of coronary disease such as angina may stem an epidemic of premature coronary deaths in these countries. However, there are few data on the prevalence of angina in developing countries, whilst the understanding the aetiology of angina is complicated by the difficulty in measuring it across differing populations., Methods: The PERU MIGRANT study was designed to investigate differences between rural-to-urban migrant and non-migrant groups in specific cardiovascular disease risk factors. Mass-migration seen in Peru from 1980s onwards was largely driven by politically motivated violence resulting in less 'healthy migrant' selection bias. The Rose angina questionnaire was used to record chest pain, which was classified definite, possible and non-exertional. Mental health was measured using the General Health Questionnaire (GHQ-12). Mantel-Haenszel odds ratios (adjusted for age, sex, cardiovascular disease risk factors and mental health) were used to assess the risk of chest pain in the migrant and urban groups compared to the rural group, and further to assess the relationship (age and sex-adjusted) between risk factors, mental health and chest pain., Results: Compared to the urban group, rural dwellers had a greatly increased likelihood of possible/definite angina (multi-adjusted OR 2.82 (1.68- 4.73)). Urban and migrant groups had higher levels of risk factors (e.g. smoking--20.1% urban, 5.5% rural). No diabetes was seen in the rural dwellers who complained of possible/definite angina. Rural dwellers had a higher prevalence of mood disorder and the presence of a mood disorder was associated with possible/definite angina in all three groups, but not consistently with non-exertional chest pain., Conclusion: Rural groups had a higher prevalence of angina as measured by Rose questionnaire than migrants and urban dwellers, and a higher prevalence of mood disorder. The presence of a mood disorder was associated with angina. The Rose angina questionnaire may not be of relevance to rural populations in developing countries with a low pre-test probability of coronary disease and poor mental health.

By impairing both function and survival, the severe reduction in oxygen availability associated with high-altitude environments is likely to act as an agent of natural selection. We used genomic and candidate gene approaches to search for evidence of such genetic selection. First, a genome-wide allelic differentiation scan (GWADS) comparing indigenous highlanders of the Tibetan Plateau (3,200-3,500 m) with closely related lowland Han revealed a genome-wide significant divergence across eight SNPs located near EPAS1. This gene encodes the transcription factor HIF2alpha, which stimulates production of red blood cells and thus increases the concentration of hemoglobin in blood. Second, in a separate cohort of Tibetans residing at 4,200 m, we identified 31 EPAS1 SNPs in high linkage disequilibrium that correlated significantly with hemoglobin concentration. The sex-adjusted hemoglobin concentration was, on average, 0.8 g/dL lower in the major allele homozygotes compared with the heterozygotes. These findings were replicated in a third cohort of Tibetans residing at 4,300 m. The alleles associating with lower hemoglobin concentrations were correlated with the signal from the GWADS study and were observed at greatly elevated frequencies in the Tibetan cohorts compared with the Han. High hemoglobin concentrations are a cardinal feature of chronic mountain sickness offering one plausible mechanism for selection. Alternatively, as EPAS1 is pleiotropic in its effects, selection may have operated on some other aspect of the phenotype. Whichever of these explanations is correct, the evidence for genetic selection at the EPAS1 locus from the GWADS study is supported by the replicated studies associating function with the allelic variants.

Introduction: Coronary heart disease (CHD) is the leading cause of mortality worldwide. With increasingly urbanized lifestyles in developing countries and the aging populations, the major risk factors for CHD such as obesity, diabetes mellitus, and hypercholesterolemia are likely to increase in the future. In the current report, we reviewed the evidence on the effect of cholesterol lowering using pharmacological agents., Methods: A PubMed/Medline systematic search was performed over the past 12 years (1998-2009 inclusive) and relevant papers written in the English language were selected. We used key phrases including, "risk factors for hypercholesterolemia," "management of hypercholesterolemia," "guidelines for management of hypercholesterolemia," and "pharmacological management of hypercholesterolemia.", Results: There were a total of over 3500 reports. We selected key publications on the effect of cholesterol lowering using different pharmacological agents., Conclusion: Several options exist with regards to pharmacological management of hypercholesterolemia. There is a substantial body of evidence to support the effect of a population shift towards a favorable risk profile, which has huge potential in reducing the burden of CHD globally.

Re-evaluation of adult obesity thresholds in some ethnic groups has led to the questioning of childhood obesity thresholds. An expert group was convened to examine the representativeness of childhood obesity definitions, evidence for ethnic differences in body composition in UK children and the extent of misclassification of adiposity by current body mass index (BMI) thresholds in south Asian and black groups. The group concluded that the current International Obesity Task Force (IOTF) definitions remained the most appropriate for use in the United Kingdom, but further research was needed on the relationship of body shape, fat mass, metabolic markers and ethnicity in children and adolescents.

The '10/90 gap' was first highlighted by the Global Forum for Health Research. It refers to the finding that 90% of worldwide medical research expenditure is targeted at problems affecting only 10% of the world's population. Applying research results from the rich world to the problems of the poor may be a tempting, potentially easy and convenient solution for this gap. This paper had the objective of presenting arguments that such an approach runs the risk of exporting failure. Health interventions that are shown to be effective in the specific context of a Western industrialized setting will not necessarily work in the developing world.