5191Recurrent coronary heart disease in the year following myocardial infarction among US men and women between 2008 and 2015

Background

Although the risk of recurrent events among adults with coronary heart disease (CHD) has declined considerably from the 1970's in the US and many Western countries, studies from the 2000's show that rates remain high. Women have lower rates of incident CHD but little is known about sex differences in recurrent events in adults with CHD.

Purpose

To examine trends in rates of recurrent myocardial infarction (MI), recurrent CHD, and all-cause mortality following a MI hospitalization between 2008 and 2015 among US men and women. Also, we compared sex differences in event rates among individuals with a MI hospitalization versus their counterparts without a history of CHD.

Methods

Data were used from 1,232,024 (53% women) US adults <65 years of age with commercial health insurance in the MarketScan database and US adults ≥66 years of age with government health insurance through Medicare who had a MI hospitalization between January 1, 2008 and December 31, 2015. For each calendar year, age-standardized sex-specific rates of recurrent MI, recurrent CHD (i.e., recurrent MI or coronary revascularization), and all-cause mortality (in Medicare only) were calculated through 365 days following the hospital discharge date for MI. In a secondary analyses, we assessed the rate of recurrent MI, CHD events and all-cause mortality among women versus men with a history of MI (n=324,283) and without a history of CHD (n=1,297,132) in 2014–2015. For these analyses, adjusted hazard ratios (95% confidence intervals) were calculated using follow-up through December 31, 2016.

Results

From 2008 to 2015, age-standardized rates over 365 days of follow-up for recurrent MI declined by 15%, from 94 to 80 per 1000 person-years, in men and by 14%, from 89 to 77 per 1000 person-years, in women. Age-standardized recurrent CHD rates decreased by 16%, from 163 to 138 per 1000 person-years, in men and by 17%, from 142 to 118 per 1000 person-years, in women. In the Medicare population, age-standardized all-cause mortality rates following MI decreased by 6%, from 446 to 421 per 1000 person-years, in men and by 3%, from 412 to 398 per 1000 person-years, in women. In the secondary analyses, the women-to-men hazard ratios for those with a history of MI and those without prior CHD were 0.97 (0.94–0.99) and 0.67 (0.65–0.69), respectively, for MI, 0.89 (0.87–0.91) and 0.52 (0.51–0.54), respectively, for CHD, and 0.84 (0.83–0.85) and 0.74 (0.73–0.75) respectively, for all-cause mortality.

Conclusion

Reductions in rates of recurrent MI, recurrent CHD, and all-cause mortality within 365 days after hospitalization for MI have been similar for US women and men. The lower risk for events comparing women versus men without prior CHD is attenuated after a MI.

Acknowledgement/Funding

The design and conduct of the study was supported through a research grant from Amgen, Inc.

P3422Contrasting the risk for atherosclerotic cardiovascular disease events among individuals with lower extremity peripheral artery disease, coronary heart disease and cerebrovascular disease

Background

Having more vascular conditions, including coronary heart disease (CHD), cerebrovascular disease and lower extremity artery disease (LEAD), may increase the risk for atherosclerosis cardiovascular disease (ASCVD) events. Specific vascular conditions may increase the ASCVD event rate more than others.

Purpose

To compare the risk for future ASCVD events associated with the number and type of vascular conditions among adults with a history of CHD, cerebrovascular disease and/or LEAD.

Methods

We analyzed data from US adults ≥19 years of age with commercial or Medicare health insurance who had a history of CHD, cerebrovascular disease and/or LEAD as of December 31, 2014 (N=901,391). Individuals were followed through December 31, 2016 (median follow-up: 2 years) for ASCVD events, including myocardial infarction, coronary revascularization, stroke, carotid revascularization and lower extremity amputation or revascularization.

Results

Among individuals included in the current analysis (mean age 63 years, 45% female), 70%, 23% and 7% had 1, 2 and 3 vascular conditions, respectively. After adjustment for sociodemographic and cardiovascular risk factors, the hazard ratio for ASCVD among individuals with 2 and 3 versus 1 vascular conditions was 1.88 (1.85, 1.92) and 2.93 (2.86, 3.00), respectively. Among individuals with 1 vascular condition, the rate of ASCVD events per 1,000 person-years was 46.5 (95% CI 44.1, 49.0), 29.6 (95% CI 29.0, 30.1) and 19.9 (95% CI 19.2, 20.8) for those with LEAD, CHD and cerebrovascular disease, respectively. The multivariable-adjusted hazard ratio (95% CI) for ASCVD events comparing individuals with LEAD only and CHD only versus those with cerebrovascular disease only was 1.84 (1.77, 1.92) and 1.12 (1.08, 1.16), respectively. Among individuals with 2 vascular conditions, the ASCVD event rate per 1,000 person-years was higher in those with LEAD and CHD (122.0, 95% CI 112.5, 132.2) and with LEAD and cerebrovascular disease (92.4, 95% CI 79.9, 106.4), versus those with CHD and cerebrovascular disease (59.1, 95% CI 54.8, 63.6). The multivariable-adjusted hazard ratio (95% CI) comparing individuals with LEAD and CHD and those with LEAD and cerebrovascular disease versus those with CHD and cerebrovascular disease was 1.48 (1.44, 1.53) and 1.49 (1.41, 1.58), respectively.

Conclusion

Among adults with vascular disease, having LEAD confers a higher risk for future ASCVD events than CHD or cerebrovascular disease and this group may benefit from more intensive risk reduction treatment.

Acknowledgement/Funding

Amgen Inc.

P1691Impact of dose and duration of dietary salt reduction on blood pressure levels: systematic review and meta-analysis of randomised trials

Background

Authoritative medical and public health agencies in most countries advise to reduce population dietary salt intake to under 5–6 g/day as a strategy for preventing high blood pressure and cardiovascular disease. However, there is still dispute about whether salt reduction should be adopted by all populations. In addition, the effect of duration of dietary salt reduction has not been sufficiently investigated.

Purpose

To understand the effect of dietary salt reduction on blood pressure and the impact of intervention duration.

Methods

A systematic review and meta-analysis was conducted. Randomized controlled trials that allocated participants to low and high salt intake, without confounding from unequal concomitant interventions, were included. We excluded studies done in individuals younger than 18 years, pregnant women, individuals with renal disease or heart failure, and studies with sodium excretion estimated from spot urine. Random effect meta-analysis was used to generate pooled estimates of the effect on 24-hour urinary sodium excretion, systolic and diastolic blood pressure. Multivariate meta-regression was used to quantify the dose response effect of dietary salt on blood pressure change and to understand the impact of the intervention duration.

Results

125 studies were included with 162 data points extracted. Ninety-nine data points (61%) had interventions under 4 weeks. Overall, 24-hour urinary sodium excretion changed by −141 mmol (95% CI: −156; −126), systolic blood pressure changed by −4.4 mm Hg (95% CI: −5.2; −3.7) and diastolic blood pressure changed by −2.4 mm Hg (95% CI: −2.9; −1.9). Sodium reduction resulted in a significant decrease of systolic blood pressure in all subgroups except in participants with low baseline sodium intake (<109 mmol) (Figure 1). Each 100 mmol reduction of sodium was associated with 2.7 mm Hg (95% CI: 1.0; 4.4; p=0.002) reduction of systolic blood pressure and 1.2 mm Hg (95% CI: 0.0; 2.4; p=0.046) reduction of diastolic blood pressure after adjusting for intervention duration, age, sex, race, baseline blood pressure, baseline sodium intake and interaction between age and baseline blood pressure. For the same amount of salt reduction, a 10 mm Hg higher baseline systolic blood pressure would result in 2.5 mm Hg greater reduction of systolic blood pressure. There is not enough evidence to show the impact of intervention duration.

Figure 1

Conclusions

Our meta-analysis showed that sodium reduction could reduce blood pressure in all adult populations regardless of age, sex and race. The effect of salt reduction on systolic blood pressure increases with higher baseline blood pressure. Further studies, designed to investigate the impact of intervention duration, are needed to understand the significance of the duration.

Acknowledgement/Funding

None

P652Lower use of statins among patients with peripheral artery disease compared with those with coronary heart disease

Background

Adults with atherosclerotic cardiovascular disease are recommended to take a statin to reduce their risk for future cardiovascular events. Prior studies suggest that statins are being taken by most adults with coronary heart disease (CHD). However, there are few data on the use of statins among adults with peripheral artery disease (PAD).

Purpose

To compare the use of statins among US adults with a history of PAD versus those with a history of CHD.

Methods

We conducted a retrospective cohort study among US adults ≥19 years of age with commercial or government health insurance who had a history of CHD or PAD as of December 31, 2014 (n=1,006,451, mean age 63 years, 47% male). We used pharmacy claims between January 1 and December 31, 2014 to identify use of any statin and of a high-intensity statin (i.e., atorvastatin 40–80 mg, rosuvastatin 20–40 mg, simvastatin 80 mg). Patients with a history of CHD without PAD (CHD only), both CHD and PAD, and PAD without CHD (PAD only) were analysed. Prevalence ratios for use of any statin and a high-intensity statin among those taking a statin were calculated after multivariable adjustment for sociodemographics and cardiovascular risk factors.

Results

Overall, 69.1% of patients included in the current analysis had CHD only, 21.4% had both CHD and PAD, and 9.5% had PAD only. Overall, 66.0%, 68.2% and 47.5% of patients with CHD only, CHD and PAD, and PAD only were taking a statin. After multivariable adjustment and compared to patients with CHD only, the prevalence ratio for statin use was 1.02 (95% CI 1.01, 1.02) for those with both CHD and PAD and 0.82 (95% CI 0.82, 0.83) for those with PAD only. Among patients taking a statin, 29.4% of those with CHD only, 28.6% of those with both CHD and PAD, and 17.3% of those with PAD only were taking a high-intensity dosage. Compared to patients with CHD only, the multivariable adjusted prevalence ratio for taking a high-intensity dosage was 1.05 (95% CI 1.04, 1.06) for those with both CHD and PAD and 0.71 (95% CI 0.70, 0.73) for those with PAD only.

Conclusion

Adults with PAD receive less intensive statin therapy compared with their counterparts who have CHD. Interventions aimed to increase statin use among patients with PAD are warranted.

Acknowledgement/Funding

This study was supported through a research grant from Amgen, Inc. (Thousand Oaks, CA, USA).

Improving emergency surgical care for patients with right iliac fossa pain at a regional scale: A quality improvement study using the Supported Champions implementation strategy

INTRODUCTION

Methods to improve clinical systems safety suffer from significant difficulties in implementation and scaling up. We used an upscaling implementation strategy entitled Supported Champions in a quality and safety improvement programme for emergency surgery at regional level, focusing on patients with right iliac fossa pain.

METHODS

A before-after study was conducted across four acute NHS Trusts: A 6 month intervention phase was preceded and followed by 3 months of data collection. An established Human Factors intervention was led at each Trust by a small group of staff selected as Champions. Champions received training in teamwork and systems improvement and were supported by Human Factors experts. The primary improvement aim was to expedite surgery for patients with sepsis, using Royal College of Surgeons emergency surgery guidelines as the measure. Additional outcomes studied included length of inpatient stay and 30-day readmission rates.

RESULTS

Breaches of RCS urgency guidelines decreased markedly from 13.7% of operated patients pre-intervention to 3.5% post-intervention (p = 0.000). Mean time from booking to incision decreased in three of the four sites, whilst median length of stay increased in 3 of 4. Overall 30-day readmission rate remained stable (7.84% pre-intervention versus 7.31% post-intervention, p = 0.959).

DISCUSSION

The Supported Champions model allowed all surgical teams to reduce delay for septic patients by more than 50%, using distinct Quality Improvement strategies to address local issues. Improvement was implemented in 4 diverse settings with a quarter of the level of expert input previously used in a single hospital.

The association of the dietary approach to stop hypertension (DASH) diet with blood pressure, glucose and lipid profiles in Malaysian and Philippines populations

BACKGROUND AND AIM

Despite a growing body of evidence from Western populations on the health benefits of Dietary Approaches to Stop Hypertension (DASH) diets, their applicability in South East Asian settings is not clear. We examined cross-sectional associations between DASH diet and cardio-metabolic risk factors among 1837 Malaysian and 2898 Philippines participants in a multi-national cohort.

METHODS AND RESULTS

Blood pressures, fasting lipid profile and fasting glucose were measured, and DASH score was computed based on a 22-item food frequency questionnaire. Older individuals, women, those not consuming alcohol and those undertaking regular physical activity were more likely to have higher DASH scores. In the Malaysian cohort, while total DASH score was not significantly associated with cardio-metabolic risk factors after adjusting for confounders, significant associations were observed for intake of green vegetable [0.011, standard error (SE): 0.004], and red and processed meat (-0.009, SE: 0.004) with total cholesterol. In the Philippines cohort, a 5-unit increase in total DASH score was significantly and inversely associated with systolic blood pressure (-1.41, SE: 0.40), diastolic blood pressure (-1.09, SE: 0.28), total cholesterol (-0.015, SE: 0.005), low-density lipoprotein cholesterol (-0.025, SE: 0.008), and triglyceride (-0.034, SE: 0.012) after adjusting for socio-demographic and lifestyle groups. Intake of milk and dairy products, red and processed meat, and sugared drinks were found to significantly associated with most risk factors.

CONCLUSIONS

Differential associations of DASH diet and dietary components with cardio-metabolic risk factors by country suggest the need for country-specific tailoring of dietary interventions to improve cardio-metabolic risk profiles.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

More holes than cheese. What prevents the delivery of effective, high quality and safe health care in England?

What prevents the delivery of effective, high quality and safe health care in the National Health Service (NHS) in England? This paper presents 760 challenges which 330 NHS staff reported as preventing the delivery of effective, high quality and safe care. Some problems have been known for over 25 years (staff shortages, finance and patient complexity) but other challenges raise questions about the commitment of the NHS to patient and staff safety. For example, Organisational Culture leading to 'stifling bureaucracy', 'odds stacked against smooth […] working' and Workload resulting in 'firefighting daily' and 'perpetual crisis mode'. The role of Human Factors/Ergonomics professional input (engagement with safety scientists) is discussed in the context of success stories and examples of Human Factors Integration from other safety critical industries (Defence, Nuclear and Rail). Practitioner Summary: 760 challenges to the quality, effectiveness and safety of health care were identified at Human Factors/Ergonomics taster workshops in England. These are used to challenge health care providers to think about a Human Factors Integration (HFI systems) approach for safety, well-being and performance for all people involved in providing and receiving health care.

The impact of level of education on vascular events and mortality in patients with type 2 diabetes mellitus: Results from the ADVANCE study

AIMS

The relationship between educational level and the risk of all-cause mortality is well established, whereas the association with vascular events in individuals with type 2 diabetes is not well described. Any association may reflect a link with common cardiovascular or lifestyle-based risk factors.

METHODS

The relationships between the highest level of educational attainment and major cardiovascular events, microvascular complications and all-cause mortality were explored in a cohort of 11,140 individuals with type 2 diabetes. Completion of formal education before the age of 16 was categorized as a low level of education. Regional differences between Asia, East Europe and Established Market Economies were also assessed.

RESULTS

During a median of 5years of follow up, 1031 (9%) patients died, 1147 (10%) experienced a major cardiovascular event and 1136 (10%) a microvascular event. After adjustment for baseline characteristics and risk factors, individuals with lower education had an increased risk of cardiovascular events (hazard ratio (HR) 1.31, 95% CI 1.16-1.48, p<0.0001), microvascular events (HR 1.23, 95% CI 1.08-1.39, p=0.0013) and all-cause mortality (HR 1.34, 95% CI 1.18-1.52, p<0.0001). In regional analyses the increased risk of studied outcomes associated with lower education was weakest in Established Market Economies and strongest in East Europe.

CONCLUSIONS

A low level of education is associated with an increased risk of vascular events and death in patients with type 2 diabetes, independently of common lifestyle associated cardiovascular risk factors. The effect size varies between geographical regions.

Constitutive expression of the anti-apoptotic Bcl-2 family member A1 in murine endothelial cells leads to transplant tolerance

Anti-apoptotic genes, including those of the Bcl-2 family, have been shown to have dual functionality inasmuch as they inhibit cell death but also regulate inflammation. Several anti-apoptotic molecules have been associated with endothelial cell (EC) survival following transplantation; however, their exact role has yet to be elucidated in respect to controlling inflammation. In this study we created mice expressing murine A1 (Bfl-1), a Bcl-2 family member, under the control of the human intercellular adhesion molecule 2 (ICAM-2) promoter. Constitutive expression of A1 in murine vascular ECs conferred protection from cell death induced by the proinflammatory cytokine tumour necrosis factor (TNF)-α. Importantly, in a mouse model of heart allograft transplantation, expression of A1 in vascular endothelium increased survival in the absence of CD8⁺ T cells. Better graft outcome in mice receiving an A1 transgenic heart correlated with a reduced immune infiltration, which may be related to increased EC survival and reduced expression of adhesion molecules on ECs. In conclusion, constitutive expression of the anti-apoptotic molecule Bfl1 (A1) in murine vascular ECs leads to prolonged allograft survival due to modifying inflammation.