Mild to moderate renal impairment is associated with increased left ventricular mass

BACKGROUND

Mild to moderate renal impairment (MMRI) is associated with an excess cardiovascular mortality but the reason for this is unclear. Increased left ventricular mass (LVM) is associated with severe renal dysfunction and a higher cardiovascular mortality. However, whether increased LVM also occurs in patients with milder renal dysfunction is unknown.

METHODS

336 consecutive patients under investigation for chest pain who underwent concurrent coronary angiography, serum creatinine (Cr) and LVM assessment, were recruited from a university hospital in Shanghai, China. The main outcome measures were: LVM normalised for body surface area (NLVM), renal function determined by Cr, creatinine clearance (CrCl) (Cockroft-Gault equation) and glomerular filtration rate (GFR) (Modification of Diet in Renal Disease equation).

RESULTS

Mean+/-SD age was 56.8+/-9.5 years, 282 (84%) were male, mean NLVM 107.1+/-36.8 g/m(2), Cr 0.94+/-0.22 mg/dL, CrCl 82.7+/-21.7 mL/min/1.73 m(2) and GFR 89.4+/-24.6 mL/min/1.73 m(2). NLVM was related to Cr (r=-0.30), CrCl (r=0.19) and GFR (r=0.24) (all p<0.001). A multiple logistic regression model using quartile analysis of renal function showed that those patients with a Cr 1.06-2.00 mg/dL, CrCl 34.8-67.5 mL/min/1.73 m(2) and a GFR 36.2-73.4 mL/min/1.73 m(2) were significantly associated with increased NLVM, independent of other variables. Using definitions derived from the National Kidney Foundation Guidelines multiple regression analysis showed MMRI to be independently associated with increased NLVM: Cr 1.2-1.9 mg/dL, odds ratio (OR) 2.77 (CI 1.04-7.40) (p=0.04); CrCl 30-89.9 mL/min/1.73 m(2), OR 1.63 (CI 0.91-2.93) (p=0.11); GFR 30-89.9 mL/min/1.73 m(2), OR 1.76 (CI 1.07-2.90) (p=0.03).

CONCLUSION

In patients being investigated for chest pain, MMRI is significantly and independently associated with increased LVM.

Weight Change and the Onset of Cardiovascular Diseases: Emulating Trials Using Electronic Health Records

BACKGROUND

Cross-sectional measures of body mass index (BMI) are associated with cardiovascular disease (CVD) incidence, but less is known about whether weight change affects the risk of CVD.

METHODS

We estimated the effect of 2-y weight change interventions on 7-y risk of CVD (CVD death, myocardial infarction, stroke, hospitalization from coronary heart disease, and heart failure) by emulating hypothetical interventions using electronic health records. We identified 138,567 individuals with 45-69 years of age without chronic disease in England from 1998 to 2016. We performed pooled logistic regression, using inverse-probability weighting to adjust for baseline and time-varying confounders. We categorized each individual into a weight loss, maintenance, or gain group.

RESULTS

Among those of normal weight, both weight loss [risk difference (RD) vs. weight maintenance = 1.5% (0.3% to 3.0%)] and gain [RD = 1.3% (0.5% to 2.2%)] were associated with increased risk for CVD compared with weight maintenance. Among overweight individuals, we observed moderately higher risk of CVD in both the weight loss [RD = 0.7% (-0.2% to 1.7%)] and the weight gain group [RD = 0.7% (-0.1% to 1.7%)], compared with maintenance. In the obese, those losing weight showed lower risk of coronary heart disease [RD = -1.4% (-2.4% to -0.6%)] but not of stroke. When we assumed that chronic disease occurred 1-3 years before the recorded date, estimates for weight loss and gain were attenuated among overweight individuals; estimates for loss were lower among obese individuals.

CONCLUSION

Among individuals with obesity, the weight-loss group had a lower risk of coronary heart disease but not of stroke. Weight gain was associated with increased risk of CVD across BMI groups. See video abstract at, http://links.lww.com/EDE/B838.

Job strain and symptoms of angina pectoris among British and Finnish middle-aged employees

BACKGROUND

High job strain has been linked with cardiovascular outcomes. This study aimed to examine whether job strain is associated with angina pectoris symptoms among British and Finnish non-manual employees.

METHODS

Postal questionnaire survey data among 40-60-year-old employees of the British Whitehall II Study (n = 4551, 27% women) and the Finnish Helsinki Health Study (n = 7605, 83% women) cohort were analysed. Angina pectoris symptoms were the outcome in logistic regression analysis. Karasek's job strain was examined. Models were adjusted first for age, second for occupational class and finally for smoking, heavy drinking, physical inactivity, unhealthy food habits and obesity.

RESULTS

Angina pectoris symptoms were reported by 5% of women and 3% of men in Britain, and by 6% of women and 4% of men in Finland. High job strain was associated with angina pectoris symptoms among men in Britain (OR 2.08; CI 95% 1.07 to 4.02) and women in Finland (OR 1.90; CI 95% 1.36 to 2.63) independent of age, occupational class, and behavioural risk factors. However, similar associations between job strain and angina pectoris symptoms were not observed among men in Finland or women in Britain.

CONCLUSION

The results yielded partial support for the association between job strain and angina pectoris symptoms across national contexts.

The determinants and effect of shared care on patient outcomes and psychiatric admissions - an inner city primary care cohort study

OBJECTIVE

The aim of this study was to determine the factors associated with receipt of different levels of shared care, and the effect of shared care on patient outcomes.

METHOD

A total of 349 patients with severe mental illness were selected from general practice lists. Patient functioning was assessed using standardised questionnaires, and GPs completed a questionnaire about patients' shared care arrangements at baseline (response-rate 79%). Patients were followed up at 12 months.

RESULTS

Receipt of high shared care was associated with greater patient satisfaction with services and social functioning at baseline (p < 0.005). Patients receiving high shared care showed greater improvements in SF-12 mental health scores at follow-up compared to low shared care groups (p = 0.02). This effect was abolished after adjustment for age, sex and psychiatric diagnosis.

CONCLUSION

Receipt of high shared care was not associated with demographic or clinical characteristics. High shared care had limited value for patients in terms of improved clinical, social or general health functioning over one year.

An informatics consult approach for generating clinical evidence for treatment decisions

BACKGROUND

An Informatics Consult has been proposed in which clinicians request novel evidence from large scale health data resources, tailored to the treatment of a specific patient. However, the availability of such consultations is lacking. We seek to provide an Informatics Consult for a situation where a treatment indication and contraindication coexist in the same patient, i.e., anti-coagulation use for stroke prevention in a patient with both atrial fibrillation (AF) and liver cirrhosis.

METHODS

We examined four sources of evidence for the effect of warfarin on stroke risk or all-cause mortality from: (1) randomised controlled trials (RCTs), (2) meta-analysis of prior observational studies, (3) trial emulation (using population electronic health records (N = 3,854,710) and (4) genetic evidence (Mendelian randomisation). We developed prototype forms to request an Informatics Consult and return of results in electronic health record systems.

RESULTS

We found 0 RCT reports and 0 trials recruiting for patients with AF and cirrhosis. We found broad concordance across the three new sources of evidence we generated. Meta-analysis of prior observational studies showed that warfarin use was associated with lower stroke risk (hazard ratio [HR] = 0.71, CI 0.39-1.29). In a target trial emulation, warfarin was associated with lower all-cause mortality (HR = 0.61, CI 0.49-0.76) and ischaemic stroke (HR = 0.27, CI 0.08-0.91). Mendelian randomisation served as a drug target validation where we found that lower levels of vitamin K1 (warfarin is a vitamin K1 antagonist) are associated with lower stroke risk. A pilot survey with an independent sample of 34 clinicians revealed that 85% of clinicians found information on prognosis useful and that 79% thought that they should have access to the Informatics Consult as a service within their healthcare systems. We identified candidate steps for automation to scale evidence generation and to accelerate the return of results.

CONCLUSION

We performed a proof-of-concept Informatics Consult for evidence generation, which may inform treatment decisions in situations where there is dearth of randomised trials. Patients are surprised to know that their clinicians are currently not able to learn in clinic from data on 'patients like me'. We identify the key challenges in offering such an Informatics Consult as a service.

Global health competencies in UK postgraduate medical training: a scoping review and curricular content analysis

OBJECTIVE

To assess global health (GH) training in all postgraduate medical education in the UK.

DESIGN

Mixed methodology: scoping review and curricular content analysis using two GH competency frameworks.

SETTING AND PARTICIPANTS

A scoping review (until December 2017) was used to develop a framework of GH competencies for doctors. National postgraduate medical training curricula were analysed against this and a prior framework for GH competencies. The number of core competencies addressed and/or appearing in each programme was recorded.

OUTCOMES

The scoping review identified eight relevant publications. A 16-competency framework was developed and, with a prior 5-competency framework, used to analyse each of 71 postgraduate medical curricula. Curricula were examined by a team of researchers and relevant learning outcomes were coded as one of the 5 or 16 core competencies. The number of core competencies in each programme was recorded.

RESULTS

Using the 5-competency and 16-competency frameworks, 23 and 20, respectively, out of 71 programmes contained no global health competencies, most notably the Foundation Programme (equivalent to internship), a compulsory programme for UK medical graduates. Of a possible 16 competencies, the mean number across all 71 programmes was 1.73 (95% CI 1.42 to 2.04) and the highest number were in paediatrics and infectious diseases, each with five competencies. Of the 16 core competencies, global burden of disease and socioeconomic determinants of health were the two most cited with 47 and 35 citations, respectively. 8/16 competencies were not cited in any curriculum.

CONCLUSIONS

Equity of care and the challenges of practising in an increasingly globalised world necessitate GH competencies for all doctors. Across the whole of postgraduate training, the majority of UK doctors are receiving minimal or no training in GH. Our GH competency framework can be used to map and plan integration across postgraduate programmes.

A national initiative in data science for health: an evaluation of the UK Farr Institute

OBJECTIVE

To evaluate the extent to which the inter-institutional, inter-disciplinary mobilisation of data and skills in the Farr Institute contributed to establishing the emerging field of data science for health in the UK.

DESIGN AND OUTCOME MEASURES

We evaluated evidence of six domains characterising a new field of science:defining central scientific challenges,demonstrating how the central challenges might be solved,creating novel interactions among groups of scientists,training new types of experts,re-organising universities,demonstrating impacts in society.We carried out citation, network and time trend analyses of publications, and a narrative review of infrastructure, methods and tools.

SETTING

Four UK centres in London, North England, Scotland and Wales (23 university partners), 2013-2018.

RESULTS

1. The Farr Institute helped define a central scientific challenge publishing a research corpus, demonstrating insights from electronic health record (EHR) and administrative data at each stage of the translational cycle in 593 papers with at least one Farr Institute author affiliation on PubMed. 2. The Farr Institute offered some demonstrations of how these scientific challenges might be solved: it established the first four ISO27001 certified trusted research environments in the UK, and approved more than 1000 research users, published on 102 unique EHR and administrative data sources, although there was no clear evidence of an increase in novel, sustained record linkages. The Farr Institute established open platforms for the EHR phenotyping algorithms and validations (>70 diseases, CALIBER). Sample sizes showed some evidence of increase but remained less than 10% of the UK population in primary care-hospital care linked studies. 3.The Farr Institute created novel interactions among researchers: the co-author publication network expanded from 944 unique co-authors (based on 67 publications in the first 30 months) to 3839 unique co-authors (545 papers in the final 30 months). 4. Training expanded substantially with 3 new masters courses, training >400 people at masters, short-course and leadership level and 48 PhD students. 5. Universities reorganised with 4/5 Centres established 27 new faculty (tenured) positions, 3 new university institutes. 6. Emerging evidence of impacts included: > 3200 citations for the 10 most cited papers and Farr research informed eight practice-changing clinical guidelines and policies relevant to the health of millions of UK citizens.

CONCLUSION

The Farr Institute played a major role in establishing and growing the field of data science for health in the UK, with some initial evidence of benefits for health and healthcare. The Farr Institute has now expanded into Health Data Research (HDR) UK but key challenges remain including, how to network such activities internationally.

Aligning the planets: The role of nurses in the care of patients with non-ST elevation myocardial infarction

Background

Studies have shown variation in care for patients with non‐ST elevation myocardial infarction (NSTEMI), including in the roles of specialist and advanced practice nurses in diagnosis, treatment and coordination of care.

Aim

The aim of this study was to describe the roles and responsibilities of specialist and advanced practice nurses in providing care for patients with NSTEMI.

Methods

Secondary analysis of observational field notes and interviews from an ethnographic study of variation in care for NSTEMI patients in 10 UK hospitals conducted 2011–2012. Data were thematically analysed to identify key concepts and themes related to the roles of specialist nurses.

Results

Seven of 10 hospitals had roles for specialist nurses in NSTEMI care. The major theme related to high demand and the complexity of patients and organizations (‘Aligning the planets’). In this theme, nurses contributed to improving services or compensating for deficiencies (‘Making the system work versus making up for the system’). Data collection for audit could take precedence over time with patients (‘Paying worship to the paper’). Nurses expressed a sense of ownership of cardiovascular patients that drove their desire to provide quality of care (‘They are our patients’).

Appropriateness of VATS and bedside thoracostomy talc pleurodesis as judged by a panel using the RAND/UCLA appropriateness method (RAM)

We sought formal consensus on the appropriateness of Video-assisted Thoracoscopic Surgery (VATS) talc pleurodesis and bedside thoracostomy talc slurry by use of a well established method - the RAND/UCLA appropriateness method (RAM). We recruited an expert panel of respiratory physicians, oncologists, and surgeons under the leadership of experts in health services research. The panellists were provided with evidence from a systematic review and then were taken through two rounds of opinion gathering, the first individually, the second as a group. The purpose is not to force consensus, but to find scenarios where there is agreement on the appropriateness or inappropriateness of a treatment and scenarios where there is disagreement. In scenarios where the diagnosis was proven and expectation of life beyond six months, pleurodesis was deemed appropriate. If there was no tissue diagnosis surgical VATS was preferred. The response to a trial aspiration played a major part in the recommendation for or against pleurodesis. The attitude to breathlessness was incongruous; it is the target of palliation yet some interpreted it as performance status and thus a contraindication. Although the RAM is well developed and in widespread use, we found it worryingly unreliable and to be used with caution.

Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise ECG in evaluating stable chest pain

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.

Discussion of "Combining Health Data Uses to Ignite Health System Learning"

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Combining Health Data Uses to Ignite Health System Learning" written by John D. Ainsworth and Iain E. Buchan [1]. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the paper of Ainsworth and Buchan. In subsequent issues the discussion can continue through letters to the editor. With these comments on the paper "Combining Health Data Uses to Ignite Health System Learning", written by John D. Ainsworth and Iain E. Buchan [1], the journal seeks to stimulate a broad discussion on new ways for combining data sources for the reuse of health data in order to identify new opportunities for health system learning. An international group of experts has been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.

Survival in relation to angina symptoms and diagnosis among men aged 70-90 years: the Whitehall Study

BACKGROUND

While the excess mortality associated with a diagnosis of angina, myocardial infarction in middle-aged individuals is well established, there is little available evidence on the natural history of angina in population-based studies of older people.

DESIGN

We conducted a 5-year follow-up of 6655 older men aged 67-90 years (mean age 77 years) who participated in the Whitehall Study of London Civil Servants.

METHODS

Survival was examined in relation to a diagnosis of angina or myocardial infarction and to angina symptoms in a population-based study of older men living in the United Kingdom in the late 1990s.

RESULTS

Compared with men without a diagnosis of myocardial ischaemia (n=5219), a diagnosis of angina alone (n=617), myocardial infarction alone (n=421) or both (n=398) were associated with about a threefold, fourfold and sixfold higher risk of death from coronary heart disease, respectively. Median expectation of life at age 70 years was reduced by about 2, 5 and 6 years for those with angina, myocardial infarction, or both, respectively. Current symptoms of angina among those without previously diagnosed angina, was associated with a 2-fold higher risk of coronary heart disease mortality than those without either diagnosis or symptoms.

CONCLUSIONS

Both angina symptoms and diagnosis have a significant adverse effect on survival among men aged 70-90 years highlighting the importance of diagnosis and appropriate treatment of angina in old age.

Phenotyping UK Electronic Health Records from 15 Million Individuals for Precision Medicine: The CALIBER Resource

Electronic health records (EHR) are increasingly being used for observational research at scale. In the UK, we have established the CALIBER research resource which utilizes national primary and hospital EHR data sources and enables researchers to create and validate longitudinal disease phenotypes at scale. In this work, we will describe the core components of the resource and provide results from three exemplar research studies on high-resolution epidemiology, disease risk prediction and subtype discovery which demonstrate both the opportunities and challenges of using EHR for research.

Incidence of 12 common cardiovascular diseases and subsequent mortality risk in the general population

BACKGROUND

Incident events of cardiovascular diseases (CVDs) are heterogenous and may result in different mortality risks. Such evidence may help inform patient and physician decisions in CVD prevention and risk factor management.

AIMS

This study aimed to determine the extent to which incident events of common CVD show heterogeneous associations with subsequent mortality risk in the general population.

METHODS AND RESULTS

Based on England-wide linked electronic health records, we established a cohort of 1 310 518 people ≥30 years of age initially free of CVD and followed up for non-fatal events of 12 common CVD and cause-specific mortality. The 12 CVDs were considered as time-varying exposures in Cox's proportional hazards models to estimate hazard rate ratios (HRRs) with 95% confidence intervals (CIs). Over the median follow-up of 4.2 years (2010-16), 81 516 non-fatal CVD, 10 906 cardiovascular deaths, and 40 843 non-cardiovascular deaths occurred. All 12 CVDs were associated with increased risk of cardiovascular mortality, with HRR (95% CI) ranging from 1.67 (1.47-1.89) for stable angina to 7.85 (6.62-9.31) for haemorrhagic stroke. All 12 CVDs were also associated with increased non-cardiovascular and all-cause mortality risk but to a lesser extent: HRR (95% CI) ranged from 1.10 (1.00-1.22) to 4.55 (4.03-5.13) and from 1.24 (1.13-1.35) to 4.92 (4.44-5.46) for transient ischaemic attack and sudden cardiac arrest, respectively.

CONCLUSION

Incident events of 12 common CVD show significant adverse and markedly differential associations with subsequent cardiovascular, non-cardiovascular, and all-cause mortality risk in the general population.

Long-Term Cardiovascular Risk and Management of Patients Recorded in Primary Care With Unattributed Chest Pain: An Electronic Health Record Study

Background Most adults presenting with chest pain will not receive a diagnosis and be recorded with unattributed chest pain. The objective was to assess if they have increased risk of cardiovascular disease compared with those with noncoronary chest pain and determine whether investigations and interventions are targeted at those at highest risk. Methods and Results We used records from general practices in England linked to hospitalization and mortality information. The study population included patients aged 18 years or over with a new record of chest pain with a noncoronary cause or unattributed between 2002 and 2018, and no cardiovascular disease recorded up to 6 months (diagnostic window) afterward. We compared risk of a future cardiovascular event by type of chest pain, adjusting for cardiovascular risk factors and alternative explanations for chest pain. We determined prevalence of cardiac diagnostic investigations and preventative medication during the diagnostic window in patients with estimated cardiovascular risk ≥10%. There were 375 240 patients with unattributed chest pain (245 329 noncoronary chest pain). There was an increased risk of cardiovascular events for patients with unattributed chest pain, highest in the first year (hazard ratio, 1.25 [95% CI, 1.21-1.29]), persistent up to 10 years. Patients with unattributed chest pain had consistently increased risk of myocardial infarction over time but no increased risk of stroke. Thirty percent of patients at higher risk were prescribed lipid-lowering medication. Conclusions Patients presenting to primary care with unattributed chest pain are at increased risk of cardiovascular events. Primary prevention to reduce cardiovascular events appears suboptimal in those at higher risk.

'What is the risk to me from COVID-19?': Public involvement in providing mortality risk information for people with 'high-risk' conditions for COVID-19 (OurRisk.CoV)

Patients and public have sought mortality risk information throughout the pandemic, but their needs may not be served by current risk prediction tools. Our mixed methods study involved: (1) systematic review of published risk tools for prognosis, (2) provision and patient testing of new mortality risk estimates for people with high-risk conditions and (3) iterative patient and public involvement and engagement with qualitative analysis. Only one of 53 (2%) previously published risk tools involved patients or the public, while 11/53 (21%) had publicly accessible portals, but all for use by clinicians and researchers.Among people with a wide range of underlying conditions, there has been sustained interest and engagement in accessible and tailored, pre- and postpandemic mortality information. Informed by patient feedback, we provide such information in 'five clicks' (https://covid19-phenomics.org/OurRiskCoV.html), as context for decision making and discussions with health professionals and family members. Further development requires curation and regular updating of NHS data and wider patient and public engagement.

Prognostic Significance of Ventricular Arrhythmias in 13 444 Patients With Acute Coronary Syndrome: A Retrospective Cohort Study Based on Routine Clinical Data (NIHR Health Informatics Collaborative VA-ACS Study)

Background A minority of acute coronary syndrome (ACS) cases are associated with ventricular arrhythmias (VA) and/or cardiac arrest (CA). We investigated the effect of VA/CA at the time of ACS on long-term outcomes. Methods and Results We analyzed routine clinical data from 5 National Health Service trusts in the United Kingdom, collected between 2010 and 2017 by the National Institute for Health Research Health Informatics Collaborative. A total of 13 444 patients with ACS, 376 (2.8%) of whom had concurrent VA, survived to hospital discharge and were followed up for a median of 3.42 years. Patients with VA or CA at index presentation had significantly increased risks of subsequent VA during follow-up (VA group: adjusted hazard ratio [HR], 4.15 [95% CI, 2.42-7.09]; CA group: adjusted HR, 2.60 [95% CI, 1.23-5.48]). Patients who suffered a CA in the context of ACS and survived to discharge also had a 36% increase in long-term mortality (adjusted HR, 1.36 [95% CI, 1.04-1.78]), although the concurrent diagnosis of VA alone during ACS did not affect all-cause mortality (adjusted HR, 1.03 [95% CI, 0.80-1.33]). Conclusions Patients who develop VA or CA during ACS who survive to discharge have increased risks of subsequent VA, whereas those who have CA during ACS also have an increase in long-term mortality. These individuals may represent a subgroup at greater risk of subsequent arrhythmic events as a result of intrinsically lower thresholds for developing VA.