A population study of the long-term consequences of Rose angina: 20-year follow-up of the Renfrew-Paisley study

Long-term impact of air pollution on heart failure readmission in unstable angina patients

Cardiovascular disease remains the leading cause of death worldwide, with air pollution's impact on cardiovascular health being closely monitored. However, the specific effects of air pollution on the risk of hospital readmission for heart failure (HF) in patients with unstable angina (UA) have not been fully explored. We conducted a retrospective study involving 12,857 consecutive patients diagnosed with acute coronary syndrome (ACS) between January 2015 and March 2023. After rigorous screening, we included 8,737 patients with UA in the analysis. Furthermore, we used a Cox proportional hazards regression model to examine the relationship between air quality indicators and hospital readmission for HF in patients with UA. Additionally, a decision tree model identified air quality indicators levels that had the most significant impact on readmission for HF risk. After adjusting for confounding factors, we found that elevated levels of PM10 [hazard ratio (HR) = 1.003, 95% confidence interval (CI): 1.000-1.005, p = 0.04453] and CO (HR = 1.013, 95% CI: 1.005-1.021, p = 0.00216) were associated with an increased risk of hospital readmission for HF in UA patients. Specifically, patients exposed to PM10 levels above 112.5 µ g/m3 had a 1.61-fold higher risk of readmission for HF in UA patients. (HR = 1.609, 95% CI: 1.190-2.176, p = 0.00201), and those exposed to CO levels above 37.5 mg/m3 had a 2.70-fold higher risk of readmission for HF in UA patients. (HR = 2.681, 95% CI: 1.731-4.152, p < 0.00001). Higher concentrations of PM10 and CO significantly increased the risk of HF (HF) readmission in patients with UA after discharge, particularly when PM10 levels exceeded 112.5 ug/m3 and CO levels surpassed 37.5 ug/m3. Besides, female patients with UA, with fewer underlying diseases, were more susceptible to the adverse effects of PM10 and CO.

Chest Symptoms and Long-Term Risk of Incident Cardiovascular Disease

BACKGROUND

We sought to evaluate the associations of chest pain and dyspnea with the long-term risk of cardiovascular disease including coronary disease, heart failure, atrial fibrillation, and stroke.

METHODS

In 13,200 participants without cardiovascular disease in the Atherosclerosis Risk in Communities study (1987-1989), chest pain was categorized into definite angina, possible angina, non-anginal chest pain, and no chest pain using the Rose questionnaire. Dyspnea was categorized into grades 3-4, 2, 1, and 0 by the modified Medical Research Council scale. The associations of chest pain and dyspnea with incident myocardial infarction, heart failure, atrial fibrillation, and stroke over a median follow-up of ∼27 years were quantified with multivariable Cox models.

RESULTS

Definite angina and possible angina were associated with myocardial infarction (adjusted hazard ratios [HR] 1.80 [95%CI 1.45-2.13] and 1.65 [1.27-2.15]). Although lesser magnitude than myocardial infarction, both definite and possible angina were associated with heart failure. For atrial fibrillation, possible angina showed higher HR than definite angina. Dyspnea showed similar HRs for myocardial infarction and heart failure in grades 3-4 (2.00 [1.61-2.49] and 1.94 [1.62-2.32]). Stroke was least associated with chest symptoms. Chest pain and dyspnea significantly improved the discrimination of cardiovascular disease except stroke, beyond traditional risk factors.

CONCLUSIONS

In individuals without cardiovascular disease, chest pain and dyspnea were independently associated with incident cardiovascular disease for about 3 decades, suggesting the need for evaluating chest pain from a broader perspective of cardiovascular disease beyond coronary disease and the importance of dyspnea for cardiovascular risk assessment including myocardial infarction.

Effect of chronic lung diseases on angina pectoris among Indian adults: longitudinal ageing study in India

The study aimed to evaluate the effect of chronic lung diseases, namely chronic obstructive pulmonary diseases (COPD) and asthma, on angina pectoris in individuals aged 45 years and above. Identifying vulnerable subpopulations suffering from COPD and asthma at higher risk of future cardiovascular events using the rose angina questionnaire is imperative for tailored primary and secondary prevention approaches. The present study utilizes the data from the Longitudinal Ageing Study in India, wave 1, conducted during 2017-2018. The sample size included 58,830 individuals aged 45 years and above. Angina was measured based on seven questions from Rose's questionnaires. Descriptive statistics and bivariate analysis were employed to examine the prevalence of angina among individuals with COPD and asthma. Further, multivariable logistic regression and propensity score matching (PSM) methods were used to assess the independent effect of COPD and asthma on angina after controlling the selected background characteristics. We employed PSM in two different models and included various additional factors in model 2, such as smoking, chewing tobacco, alcohol use, ADL, IADL, body mass index, physical activity, high cholesterol, hypertension, diabetes, and chronic heart disease. The current study shows that the prevalence of angina pectoris, COPD and asthma was 6.0%, 2.3% and 4.7%, respectively, among individuals aged 45 years and above in India. The prevalence of angina pectoris was higher among individuals with COPD (9.6% vs. 5.8%) and asthma (9.9% vs. 5.7%) than those without COPD and asthma, respectively. Additionally, angina pectoris was more prevalent among females and rural respondents with COPD (10.8% and 11.0%) and asthma (10.3% and 10.3%) compared to males and urban respondents with COPD (8.0% and 5.7%) and asthma (8.9% and 7.9%). Moreover, in the adjusted model, individuals with COPD (AOR 1.43, 95% CI 1.03 1.98) and asthma (AOR 1.44, 95% CI 1.17 1.77) had nearly 1.5-fold higher odds of having angina pectoris than those without COPD and asthma. The PSM estimates showed that individuals with COPD had 8.4% and 5.0% increased risk of angina pectoris compared to those without COPD in model 1 and model 2, respectively. We observed that, after adjusting to lifestyle, health-related and morbidity factors in model 2, both average treatment effect on untreated (ATU) and average treatment effect (ATE) values decreased by nearly 3.5%. Additionally, the PSM estimates demonstrated that individuals with asthma had a 3.4% and 2.9% increased risk of angina pectoris compared to those without asthma in model 1 and model 2, respectively. The study suggests that COPD and asthma are significantly associated with angina pectoris, and individuals with COPD and asthma have a higher risk of developing angina pectoris. Additionally, angina pectoris was more prevalent among females, rural respondents and adults aged 45-54 with COPD compared to males, urban respondents and those aged 65 and above, respectively, with COPD. Moreover, the findings of our study underscore the targeted primary and secondary interventions and team-based care approach among individuals with COPD and asthma to reduce the risk of CVD events in future.

A systematic review and meta-analysis of air pollution and angina pectoris attacks: identification of hazardous pollutant, short-term effect, and vulnerable population

We conducted a systematic review and meta-analysis of global epidemiological studies of air pollution and angina pectoris, aiming to explore the deleterious air pollutant(s) and vulnerable sub-populations. PubMed and Web of Science databases were searched for eligible articles published between database inception and October 2021. Meta-analysis weighted by inverse-variance was utilized to pool effect estimates based on the type of air pollutant, including particulate matters (PM_2.5 and PM₁₀: particulate matter with an aerodynamic diameter ≤ 2.5 µm and ≤ 10 µm), gaseous pollutants (NO₂: nitrogen dioxide; CO: carbon monoxide; SO₂: sulfur dioxide, and O₃: ozone). Study-specific effect estimates were standardized and calculated with percentage change of angina pectoris for each 10 µg/m³ increase in air pollutant concentration. Twelve studies involving 663,276 angina events from Asia, America, Oceania, and Europe were finally included. Meta-analysis showed that each 10 µg/m³ increase in PM_2.5 and PM₁₀ concentration was associated with an increase of 0.66% (95%CI: 0.58%, 0.73%; p < 0.001) and 0.57% (95%CI: 0.20%, 0.94%; p = 0.003) in the risk of angina pectoris on the second day of exposure. Adverse effects were also observed for NO₂ (0.67%, 95%CI: 0.33%, 1.02%; p < v0.001) on the second day, CO (0.010%, 95%CI: 0.006%, 0.014%; p < 0.001). The elderly and patients with coronary artery disease (CAD) appeared to be at higher risk of angina pectoris. Our findings suggest that short-term exposure to PM_2.5, PM₁₀, NO₂, and CO was associated with an increased risk of angina pectoris, which may have implications for cardiologists and patients to prevent negative cardiovascular outcomes.

Long-term prognosis of unheralded myocardial infarction vs chronic angina; role of sex and coronary atherosclerosis burden

Background

Angina pectoris (AP) and unheralded myocardial infarction (MI) are considered random clinical equivalents of ischemic heart disease (IHD). Aim of the study was to evaluate the long-term progression of AP as opposed to unheralded MI as alternative first clinical presentations of IHD and the effect of sex on prognosis.

Methods

The study included 2272 consecutive patients, 1419 MI and 1353 AP, hospitalized from 1995 to 2007 at CNR Clinical Physiology Institute, Pisa, Italy and followed up to December 2013, who fulfilled the following criteria: unheralded MI or AP as first manifestation of IHD; age < = 70 years; known coronary anatomy; at least 10-year follow-up. Fatal and non fatal MI, all-cause, and cardiac deaths were the end-points.

Results

Males were predominant in MI (86%) as compared to AP (77%). Females were predominantly affected by AP (61%, MI 39%), and older than men (61 ± 7 vs 59 ± 8 years, p < 0.001). Coronary stenoses were prevalent in MI. During 115 ± 58 months follow-up, 628 deaths (23%) were observed, including 269 cardiac (43%), and 149 cancer deaths (24%). Long-term prognosis was significantly better in AP than MI group. The lowest prevalence of future MI was recorded in female AP (p < 0.001).

Conclusions

MI as first clinical manifestation of IHD implies a more adverse prognosis than AP; future MI is a rare event in AP; sex influences the first presentation of IHD and its course with possible implications for preventive strategy.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0890-5) contains supplementary material, which is available to authorized users.

Mortality implications of angina and blood pressure in hypertensive patients with coronary artery disease: New data from extended follow-up of the International Verapamil/Trandolapril Study (INVEST)

BACKGROUND

Angina and hypertension are common in patients with coronary artery disease (CAD); however, the effect on mortality is unclear. We conducted this prespecified analysis of the International Verapamil/Trandolapril Study (INVEST) to assess relationships between angina, blood pressure (BP), and mortality among elderly, hypertensive CAD patients.

HYPOTHESIS

Angina and elevated BP will be associated with higher mortality.

METHODS

Extended follow-up was performed using the National Death Index for INVEST patients in the United States (n = 16 951). Based on angina history at enrollment and during follow-up visits, patients were divided into groups: persistent angina (n = 7184), new-onset angina (n = 899), resolved angina (n = 4070), and never angina (n = 4798). Blood pressure was evaluated at baseline, during drug titration, and during follow-up on-treatment. On-treatment systolic BP was classified as tightly controlled (<130 mm Hg), controlled (130-139 mm Hg), or uncontrolled (≥140 mm Hg). A Cox proportional hazards model was created adjusting for age, heart failure, diabetes, renal impairment, myocardial infarction, stroke, and smoking. The angina groups and BP control groups were compared using the never-angina group as the reference.

RESULTS

Only in the persistent-angina group was a significant association with mortality observed, with an apparent protective effect (hazard ratio: 0.82, 95% confidence interval: 0.75-0.89, P < 0.0001). Uncontrolled BP was associated with increased mortality risk (hazard ratio: 1.29, 95% confidence interval: 1.20-1.40, P < 0.0001), as were several other known cardiovascular risk factors.

CONCLUSIONS

In hypertensive CAD patients, persistent angina was associated with lower mortality. The observed effect was small compared with other cardiovascular risk factors, such as BP, which were associated with increased mortality.

Job insecurity and incident coronary heart disease: the Whitehall II prospective cohort study

OBJECTIVE

This study uses a prospective design to examine the association between self-reported job insecurity and incident coronary heart disease; an association which has been little investigated previously.

METHODS

Participants were 4174 British civil servants (1236 women and 2938 men), aged 42 to 56 with self-reported data on job insecurity and free from coronary heart disease at baseline (1995-6). These participants were followed until 2002-4, an average of 8.6 years, for incident fatal coronary heart disease, clinically verified incident non-fatal myocardial infarction, or definite angina (a total of 168 events).

RESULTS

Cox proportional hazard models adjusted for socio-demographic characteristics showed job insecurity to be associated with a 1.42-fold (95% CI, 1.05-1.93) risk of incident coronary heart disease compared with secure employment. Adjustment for physiological and behavioral cardiovascular risk factors had little effect on this estimate; 1.38 (1.01-1.88).

CONCLUSION

This study suggests that job insecurity may adversely affect coronary health.

The effect of doubling the statin dose on pro-inflammatory cytokine in patients with triple-vessel coronary artery disease

Background and Objectives

Statin prevents atherosclerotic progression and helps to stabilize the plaque. According to a recent study, statin reduces inflammation in blood vessels. However, it has not been demonstrated to have any anti-inflammation reaction in patients who have been diagnosed as having a triple-vessel coronary artery disease (CAD).

Subjects and Methods

This study included a total of thirty (30) patients who had been diagnosed by coronary angiogram as having a triple-vessel CAD. Patients who already had been taking statin were given doubled dosage. An interview, physical examination and blood test were performed at the beginning of this study and three months later.

Results

After doubling the dose of statin, there was no statistically significant decrease in total cholesterol, low density lipoprotein-cholesterol, (increase in) high density lipoprotein-cholesterol and triglyceride in the blood test. C-reactive protein (CRP), an acute phase reactant, significantly decreased from 0.34 mg/dL at the beginning of the study to 0.12 mg/dL at the end of study (p<0.01). The interleukin-6 concentration also significantly decreased from 8.55 pg/dL to 4.81 pg/dL (p<0.001). No major cardiovascular events occurred and the dosage regimen was not modified during the close observation period. There was no difference in the symptoms of angina pectoris, established by World Health Organization Angina Questionnaires, before and after the dose increase. Liver enzymes remained within normal range with no significant increase before and after conducting this study.

Conclusion

Doubling the dose of statin alone significantly lowers pro-inflammatory cytokine concentration, which is closely related to the potential acute coronary syndrome, and CRP, a marker of vascular inflammation.

Heart health when life is satisfying: evidence from the Whitehall II cohort study

AIMS

Negative psychological states such as stress and depression are associated with increased risk of coronary heart disease (CHD), but it is unclear whether some positive states are protective. We investigated satisfaction with specific life domains as predictors of incident CHD.

METHODS AND RESULTS

Coronary risk factors and satisfaction within seven life domains (e.g. job and family) were assessed in 7956 initially healthy members of the Whitehall II cohort. Incident CHD (angina, non-fatal myocardial infarction, or death from CHD) was ascertained from medical screening, hospital data, and registry linkage over five person-years of follow-up. Satisfaction averaged across domains was associated with reduced CHD risk (HR: 0.87; 95% CI: 0.78-0.98), controlling for demographic characteristics, health behaviours, blood pressure, and metabolic functioning. Associations with CHD risk were evident for satisfaction in four life domains-one's job, family, sex life, and self, but not one's love relationship, leisure activities, or standard of living. When examining CHD outcomes separately, average domain satisfaction was associated with angina but not myocardial infarction or coronary death.

CONCLUSIONS

Satisfaction in most life domains was associated with reduced CHD risk, with definite angina being mostly responsible for this association. These findings suggest that satisfaction with life may promote heart health. Further research should examine whether interventions to enhance life satisfaction in specific domains reduce CHD risk and whether life satisfaction is primarily associated with atherosclerosis rather than thrombotic factors associated with plaque rupture.

A novel prediction model for all cause emergency department visits in ischemic heart disease

BACKGROUND

Ischemic heart disease (IHD) is the main cause of morbidity and mortality worldwide, and a considerable part of these patients attend to emergency departments, which increases the burden to these busy departments. The aim of this study was to develop a prediction model enabling prediction of all cause emergency department (ED) visits in patients with documented coronary stenosis in a derivation set, and then to determine its accuracy in a validation set.

METHODS

In a prospective study at outpatient setting of Baqiyatallah hospital, Tehran, Iran, 502 patients with IHD were followed for 6 months for observing the outcome of ED visits for all causes. They were divided in two random groups of derivation set (n = 335) and validation set (n = 167). In the derivation set, to achieve an all cause ED visits prediction model, a prediction model was reached by entering demographic data, clinical variables, somatic comorbidity (Ifudu index), level of anxiety and depression (Hospital Anxiety Depression Scale (HADS) questionnaire), and angina grade (WHO Rose Angina) to a logistic regression. Then in the validation set, the sensitivity, specificity, and the accuracy of that model was tested.

RESULTS

A novel model for prediction of all cause ED visits in IHD patients in six months was presented with gender, anxiety, WHO angina grade and somatic comorbidity as inputs. Sensitivity, specificity, and accuracy of the model were 63.0%, 68.6%, and 67.7%, respectively.

CONCLUSIONS

Testing and using the achieved model is suggested to health care providers in other settings.

Prognostic value of the Rose questionnaire: a validation with future coronary events in the SMART study

AIM

The Rose questionnaire was developed in epidemiological studies to obtain a reproducible diagnosis of angina pectoris. We studied the prognostic value of this questionnaire with respect to the occurrence of future coronary events.

METHODS AND RESULTS

We studied 7916 consecutive patients (mean age 56 years; 67% men) with clinically manifest vascular disease or cardiovascular risk factors, enrolled in the Second Manifestations of ARTerial disease (SMART) study from 1996 to 2009. At inclusion, all patients completed the Rose questionnaire. We investigated the prognostic value of four definitions of angina pectoris that were based on the following elements of the questionnaire (1) the full questionnaire; (2) three key questions concerning chest pain; (3) one question about discomfort or pain in the chest; (4) two questions about complaints when slowing down or stopping activities (the definition that is used in the SMART study). All patients were followed for new coronary events and interventions for an average of 4.6 years. Analyses were with multivariable Cox regression models. Discriminatory ability of the four definitions as assessed with areas under the receiver-operator characteristics curves was similar (range 0.708-0.726) for coronary events in isolation as well as in combination with coronary interventions. The models were assessed for their ability to improve risk stratification compared with each other; differences between definitions are small.

CONCLUSION

Our data implicate that the use of a subset of questions of the Rose questionnaire performs equally well compared with the full Rose questionnaire regarding the prediction of coronary events.

The CHD challenge: comparing four cost-effectiveness models

OBJECTIVES

To compare four UK models evaluating the cost-effectiveness of interventions in coronary heart disease (CHD), exploring the relative importance of structure and inputs in accounting for differences, and the scope for consensus on structure and data.

METHODS

We compared published cost-effectiveness results (incremental cost, quality-adjusted life year, and cost-effectiveness ratio) of three models conforming to the National Institute for Health and Clinical Excellence guidelines dealing with three interventions (statins, percutaneous coronary intervention, and clopidogrel) with a model developed in Southampton. Comparisons were made using three separate stages: 1) comparison of published results; 2) comparison of the results using the same data inputs wherever possible; and 3) an in-depth exploration of reasons for differences and the potential for consensus.

RESULTS

Although published results differed by up to 73% (for statins), standardization of inputs (stage 2) narrowed these gaps. Greater understanding of the reasons for differences was achieved, but a consensus on preferred values for all data inputs was not reached.

CONCLUSIONS

We found that published guidance on methods was important to reduce variation in important model inputs. Although the comparison of models did not lead to consensus for all model inputs, it provided a better understanding of the reasons for these differences, and enhanced the transparency and credibility of all models. Similar comparisons would be aided by fuller publication of models, perhaps through detailed web appendices.

Five year prognosis in patients with angina identified in primary care: incident cohort study

OBJECTIVE

To ascertain the risk of acute myocardial infarction, invasive cardiac procedures, and mortality among patients with newly diagnosed angina over five years.

DESIGN

Incident cohort study of patients with primary care data linked to secondary care and mortality data.

SETTING

40 primary care practices in Scotland.

PARTICIPANTS

1785 patients with a diagnosis of angina as their first manifestation of ischaemic heart disease, 1 January 1998 to 31 December 2001.

MAIN OUTCOME MEASURES

Adjusted hazard ratios for acute myocardial infarction, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, death from ischaemic heart disease, and all cause mortality, adjusted for demographics, lifestyle risk factors, and comorbidity at cohort entry.

RESULTS

Mean age was 62.3 (SD 11.3). Male sex was associated with an increased risk of acute myocardial infarction (hazard ratio 2.01, 95% confidence interval 1.35 to 2.97), death from ischaemic heart disease (2.80, 1.73 to 4.53), and all cause mortality (1.82, 1.33 to 2.49). Increasing age was associated with acute myocardial infarction (1.04, 1.02 to 1.06, per year of age increase), death from ischaemic heart disease (1.09, 1.06 to 1.11, per year of age increase), and all cause mortality (1.09, 1.07 to 1.11, per year of age increase). Smoking was associated with subsequent acute myocardial infarction (1.94, 1.31 to 2.89), death from ischaemic heart disease (2.12, 1.32 to 3.39), and all cause mortality (2.11, 1.52 to 2.95). Obesity was associated with death from ischaemic heart disease (2.01, 1.17 to 3.45) and all cause mortality (2.20, 1.52 to 3.19). Previous stroke was associated with all cause mortality (1.78, 1.13 to 2.80) and chronic kidney disease with death from ischaemic heart disease (5.72, 1.74 to 18.79). Men were more likely than women to have coronary artery bypass grafting or percutaneous transluminal coronary angioplasty after a diagnosis of angina; older people were less likely to receive percutaneous transluminal coronary angioplasty. Acute myocardial infarction after a diagnosis of angina was associated with an increased risk of death from ischaemic heart disease and all cause mortality (8.84 (5.31 to 14.71) and 4.23 (2.78 to 6.43), respectively). Neither of the invasive cardiac procedures significantly reduced the subsequent risk of all cause mortality.

CONCLUSIONS

In this sample of people with incident angina from primary care, there were sex differences in survival and age and sex differences in the provision of revascularisation after a diagnosis. Acute myocardial infarction after a diagnosis of angina was strongly predictive of mortality. To minimise adverse outcomes, optimal preventive treatments should be used in patients with angina.

Cardiorespiratory risk factors as predictors of 40-year mortality in women and men

OBJECTIVE

Most historical studies of cardiorespiratory risk factors as predictors of mortality have been based on men. This study examines whether they predict mortality over long periods in women and men.

DESIGN

Prospective cohort study.

SETTING

Participants were employees of the General Post Office.

METHODS

Risk factor data were collected via clinical examination and questionnaire, 1966-7. Associations between cardiorespiratory risk factors and 40-year mortality were determined for 644 women and 1272 men aged 35-70 at examination.

MAIN OUTCOME MEASURES

All-cause, cardiovascular (CVD), cancer and respiratory mortality.

RESULTS

Associations between systolic blood pressure and all-cause and stroke mortality were equally strong for women and men, hazard ratio (95% confidence interval) 1.25 (1.1 to 1.4) and 1.18 (1.1 to 1.3); and 2.17 (1.7 to 2.8) and 1.69 (1.4 to 2.1), respectively. Cholesterol was higher in women and was associated with all-cause 1.22 (1.1 to 1.4) and CVD 1.39 (1.2 to 1.7) mortality, while associations between 2-hour glucose and all-cause 1.15 (1.1 to 1.2), coronary heart disease (CHD) 1.25 (1.1 to 1.4) and respiratory mortality 1.21 (1.0 to 1.5) were observed in men. Obesity was associated with stroke in women (2.42 (1.12 to 5.24)) and CHD in men (1.59 (1.02 to 2.49)), while ECG ischaemia was associated with CVD in both sexes. The strongest, most consistent predictor of mortality was smoking in women and poor lung function in men. However, evidence of sex differences in associations between the cardiorespiratory risk factors measured and mortality was sparse.

CONCLUSIONS

Data from a 40-year follow-up period show remarkably persistent associations between risk factors and cardiorespiratory and all-cause mortality in women and men.

Cost of illness for chronic stable angina patients enrolled in a self-management education trial

BACKGROUND

Chronic stable angina (CSA) is a major debilitating health problem in Canada. A paucity of relevant cardiovascular data sets has precluded a detailed examination of the impact of interventions on CSA-related costs and its broader economic burden.

OBJECTIVES

As part of a larger clinical trial, the authors sought to determine the short-term impact of a standardized self-management training program on CSA-related costs. A secondary objective was to estimate the total annualized cost of CSA per patient from a societal perspective.

METHODS

Pre- and three-month post-test cost data were collected on 117 participants using the Ambulatory Home Care Record. Mean annualized direct, indirect and system-related CSA costs (2003 to 2005) were estimated; total per-patient CSA costs from a societal perspective were calculated as the sum of these costs.

RESULTS

The mean (+/- SD) age of participants was 68+/-11 years; 80% were male. The program did not impact costs in the short-term. Direct annual out-of-pocket costs, including money paid for health care, travel to appointments, medication, equipment and home support totaled $3,267. Indirect costs, reflecting the value of all unpaid time spent by those engaged in angina-related care, were $12,963. System costs, including costs paid by public and private insurers, were $2,979. Total estimated annual CSA costs from a societal perspective were $19,209 per patient.

CONCLUSIONS

These data suggest that CSA imposes a major economic burden, comparable with other prevalent conditions such as chronic noncancer pain. Advancements in self-management training research are needed to help reduce the economic burden of CSA in Canada.

Is fenofibrate a cost-saving treatment for middle-aged individuals with type II diabetes? An economic analysis of the FIELD Study

BACKGROUND

The aim of this study was to determine the impact of fenofibrate therapy on health care costs in middle-aged patients with type II diabetes at high risk of future cardiovascular events.

METHODS

We undertook an economic analysis of the FIELD study conducted from the perspective of the third party payer (direct costs) with all "within trial" health care costs derived from reported clinical outcomes using pooled data from all 9795 study participants. All analyses were performed on an intention-to-treat-basis and items of expenditure were derived from 2001/2002 health economic data: comparing Diagnostic Related Groupings (DRG) costs of major morbid events from an average of unit costs derived from three European countries (UK, France and Germany).

RESULTS

Despite the additional cost of applying fenofibrate therapy, that was off-set slightly by a reduced need for supplementary lipid-lowering therapy (a net cost increase of 20,495 Euros per 1000 person years to apply combined lipid-lowering therapy), fenofibrate was associated with a net saving of 23,607 Euros in health care costs per 1000 person years of follow-up. This represents an approximate 10% net saving in health care costs (total of 227,111 versus 203,415 Euros for the placebo and treatment groups, respectively). As such, based on the 95% CI calculated for observed event rates per 1000 person years at risk, the cost impact of fenofibrate therapy ranged from a 24% net saving to a 4% net increase in health care costs relative to treatment with placebo. When the highest compared to lowest DRG unit costs were applied to observed event rates, the cost impact of fenofibrate therapy varied from a 5% to 12% net saving (low versus high cost health care models) in health care costs relative to usual care.

CONCLUSION

The robust nature of these analyses suggest potential cost advantages in the longer-term by applying fenofibrate in this type of patient cohort (quite possibly in combination with statin therapy) via a marked reduction in costly cardiac events and procedures.

Effectiveness of Psychoeducational Interventions for Improving Symptoms, Health-Related Quality of Life, and Psychological well Being in Patients with Stable Angina

Several primary trials report the adjunctive value of psychoeducational interventions for improving stable angina symptoms, health-related quality of life (HRQL) and psychological well-being; however, few high-quality meta-analyses have examined the overall effectiveness of these interventions. We used meta-analysis in order to determine the effectiveness of psychoeducational interventions for improving symptoms, HRQL and psychological well-being in stable angina patients. Seven trials, involving 949 participants total were included. Those who received psychoeducation experienced nearly 3 less angina episodes per week, delta (Delta)= -2.85, 95% CI, -4.04 to -1.66, and used sublingual (SL) nitrates approximately 4 times less per week, Delta= -3.69, 95% CI -5.50 to -1.89, post-intervention (3-6 months). Significant HRQL improvements (Seattle Angina Questionnaire) were also found for physical limitation, Delta= 8.00, 95% CI 4.23 to 11.77, and disease perception, Delta= 4.46, 95% CI 0.15 to 8.77, but CIs were broad. A pooled estimate of effect on psychological well-being was not possible due to heterogeneity of measures. Psychoeducational interventions may significantly reduce angina frequency and decrease SL nitrate use in the short-term. These encouraging results must be interpreted with caution due to heterogeneity in methods and small samples. Larger, robust trials are needed to further determine the effectiveness of psychoeducation for stable angina management.

Tackling heart disease and poverty

Cardiovascular disease is the leading cause of death worldwide, with a projected increase in incidence in developed and developing countries. This paper will review the literature on the role of poverty and socioeconomic deprivation in cardiovascular disease and outline ways to tackle poverty. The literature acknowledges the individual risk factors for cardiovascular disease, but highlights the negative effects of neighborhood deprivation on the incidence of cardiovascular disease and its mortality rates. The studies show that equitable access to health care is not evident and those in less affluent neighborhoods have greater disease incidence and increased mortality and morbidity rates, particularly for angina, myocardial infarction, and heart failure. The approach to reducing disease rates needs to be conducted from an individual level to the societal level and needs to prevent and treat heart disease (particularly in deprived neighborhoods). Nurses and health professionals must drive health policy so that progress can be achieved in reducing the disease rates.

Prognosis of stable angina pectoris: why we need larger population studies with higher endpoint resolution

The prognosis of angina was described as "unhappy" by the Framingham investigators and as little different from that of 1-year survivors of acute myocardial infarction. Yet recent clinical trials now report that angina has a good prognosis with adverse outcomes reduced to "normal levels". These disparate prognostic assessments may not be incompatible, applying as they do to population cohorts (Framingham) and selected participants in clinical trials. Comparisons between studies are further complicated by the absence of agreed case definitions for stable angina (contrast this with acute coronary syndromes). Our recent data show that for patients with recent onset symptoms attending chest pain clinics, angina remains a high-risk diagnosis and although many patients receive symptomatic benefit from revascularisation, prognosis is usually unaffected. This leaves little room for complacency and, with angina the commonest initial manifestation of coronary artery disease, there is the opportunity for early detection, risk stratification and treatment to modify outcomes. Meanwhile, larger population-based studies are needed to define the patient journey from earliest presentation through the various syndrome transitions to coronary or noncardiac death in order to increase understanding of the aetiological and prognostic differences between the different coronary disease phenotypes.

The impact of angina and cardiac history on health-related quality of life and depression in coronary heart disease patients

OBJECTIVE

To prospectively examine the contribution of angina and cardiac history to health-related quality of life (HRQoL) and depression in cardiac patients, over 6 months post-hospitalization.

METHODS

Participants were myocardial infarction (MI), percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) outpatients under the age of 70 years. One hundred and seventy-one patients consented to participate, with 121 patients being retained 6 months later (71% response rate). The impact of the patient's cardiac history and the presence of angina on physical, social and emotional HRQoL and depression was examined.

RESULTS

At baseline, cardiac history was not significantly related to any of the dimensions of HRQoL or depression. At 6-month follow-up, cardiac history significantly predicted a higher level of depression, and angina was predictive of a significantly worse emotional, physical and social HRQoL and a higher level of depression.

DISCUSSION

The presence of a cardiac history is associated with depression 6 months post-cardiac event, and angina is associated with both an adverse HRQoL and higher levels of depression. As past research has demonstrated that depression is a risk factor for mortality in patients with established heart disease, it is important from both a clinical and a research perspective to address these issues.