Prevalence of ischaemic heart disease in middle aged British men

The global prevalence of myocardial infarction: a systematic review and meta-analysis

BACKGROUND

Myocardial infarction (MI) is one of the life-threatening coronary-associated pathologies characterized by sudden cardiac death. The provision of complete insight into MI complications along with designing a preventive program against MI seems necessary.

METHODS

Various databases (PubMed, Web of Science, ScienceDirect, Scopus, Embase, and Google scholar search engine) were hired for comprehensive searching. The keywords of "Prevalence", "Outbreak", "Burden", "Myocardial Infarction", "Myocardial Infarct", and "Heart Attack" were hired with no time/language restrictions. Collected data were imported into the information management software (EndNote v.8x). Also, citations of all relevant articles were screened manually. The search was updated on 2022.9.13 prior to the publication.

RESULTS

Twenty-two eligible studies with a sample size of 2,982,6717 individuals (< 60 years) were included for data analysis. The global prevalence of MI in individuals < 60 years was found 3.8%. Also, following the assessment of 20 eligible investigations with a sample size of 5,071,185 individuals (> 60 years), this value was detected at 9.5%.

CONCLUSION

Due to the accelerated rate of MI prevalence in older ages, precise attention by patients regarding the complications of MI seems critical. Thus, determination of preventive planning along with the application of safe treatment methods is critical.

Spinal cord stimulation: Current applications for treatment of chronic pain

Spinal cord stimulation (SCS) is thought to relieve chronic intractable pain by stimulating nerve fibers in the spinal cord. The resulting impulses in the fibers may inhibit the conduction of pain signals to the brain, according to the pain gate theory proposed by Melzack and Wall in 1965 and the sensation of pain is thus blocked. Although SCS may reduce pain, it will not eliminate it. After a period of concern about safety and efficacy, SCS is now regaining popularity among pain specialists for the treatment of chronic pain. The sympatholytic effect of SCS is one of its most interesting therapeutic properties. This effect is considered responsible for the effectiveness of SCS in peripheral ischemia, and at least some cases of complex regional pain syndrome. The sympatholytic effect has also been considered part of the management of other chronic pain states such as failed back surgery syndrome, phantom pain, diabetic neuropathy, and postherpetic neuralgia. In general, SCS is part of an overall treatment strategy and is used only after the more conservative treatments have failed. The concept of SCS has evolved rapidly following the technological advances that have produced leads with multiple contact electrodes and battery systems. The current prevalence of patients with chronic pain requiring treatment other than conventional medical management has significantly increased and so has been the need for SCS. With the cost benefit analysis showing significant support for SCS, it may be appropriate to offer this as an effective alternative treatment for these patients.

Economic evaluation of the impact of nicorandil in angina (IONA) trial

OBJECTIVE

To estimate the net cost of adding nicorandil to usual treatment for patients with angina and to compare this with indicators of health benefit.

DESIGN

Cost effectiveness analysis.

SETTING

Based on results of the IONA (impact of nicorandil on angina) trial.

PATIENTS

Patients with angina fulfilling the entry criteria for the IONA trial.

INTERVENTIONS

In one arm of the trial nicorandil was added to existing antianginal treatment and compared with existing treatment alone.

MAIN OUTCOME MEASURES

Costs were for use of hospital resources (for cardiovascular, cerebrovascular, and gastrointestinal reasons), nicorandil, and care after hospital discharge. Benefits were assessed in three ways: (1) IONA trial primary outcome (coronary heart disease (CHD) death, non-fatal myocardial infarction, or hospital admission for cardiac chest pain); (2) acute coronary syndrome (CHD death, non-fatal myocardial infarction, or unstable angina); and (3) event-free survivors at the end of the trial.

RESULTS

The net cost for each additional IONA trial end point averted was -5 pounds sterling (-7 euros). The net cost for each case of acute coronary syndrome averted was -8 pounds sterling (-12 euros). The net cost for each event-free survivor was -5 pounds sterling (-7 euros). These figures are based on gastrointestinal events that were judged definitely or probably related to nicorandil. When all gastrointestinal events were included these three ratios rose to 567 pounds sterling (835 euros), 886 pounds sterling (1305 euros), and 516 pounds sterling (760 euros), respectively.

CONCLUSIONS

A substantial amount of the additional cost of nicorandil is offset by reduced use of hospital services. The limited comparisons possible with other CHD interventions suggest that nicorandil compares favourably.

Gender differences in the management and clinical outcome of stable angina

BACKGROUND

We sought to examine the impact of gender on the investigation and subsequent management of stable angina and to assess gender differences in clinical outcome at 1 year.

METHODS AND RESULTS

The Euro Heart Survey of Stable Angina enrolled patients with a clinical diagnosis of stable angina on initial assessment by a cardiologist. Baseline clinical details and cardiac investigations planned or performed within a 4-week period of the assessment were recorded, and follow-up data were collected at 1 year. A total of 3779 patients were included in the survey; 42% were female. Women were less likely to undergo an exercise ECG (odds ratio, 0.81; 95% CI, 0.69 to 0.95) and less likely to be referred for coronary angiography (odds ratio, 0.59; 95% CI, 0.48 to 0.72). Antiplatelet and statin therapies were used significantly less in women than in men, both at initial assessment and at 1 year, even in those in whom coronary disease had been confirmed. Women with confirmed coronary disease were less likely to be revascularized than their male counterparts and were twice as likely to suffer death or nonfatal myocardial infarction during the 1-year follow-up period (hazard ratio, 2.09; 95% CI, 1.13 to 3.85), even after multivariable adjustment for age, abnormal ventricular function, severity of coronary disease, and diabetes.

CONCLUSIONS

Significant gender bias has been identified in the use of investigations and evidence-based medical therapy in stable angina. Women were also less likely to be revascularized. The observed bias is of particular concern in light of the adverse prognosis observed among women with stable angina and confirmed coronary disease.

Prevalence, incidence, primary care burden and medical treatment of angina in Scotland: age, sex and socioeconomic disparities: a population-based study

OBJECTIVE

To examine the epidemiology, primary care burden and treatment of angina in Scotland.

DESIGN

Cross-sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 2001 and 31 March 2002.

SETTING

55 primary care practices (362 155 patients).

PARTICIPANTS

9508 patients with angina.

RESULTS

The prevalence of angina in Scotland was 28/1000 in men and 25/1000 in women (p < 0.05) and increased with age. The prevalence of angina also increased with increasing socioeconomic deprivation from 18/1000 in the least deprived category to 31/1000 in the most deprived group (p < 0.001 for trend). The incidence of angina was higher in men (1.8/1000) than in women (1.4/1000) (p = 0.004) and increased with increasing age and socioeconomic deprivation. Socioeconomically deprived patients (0.48 contacts/patient among the most deprived) were less likely than affluent patients (0.58 contacts/patient among the least deprived) to see their general practitioner on an ongoing basis p = 0.006 for trend). Among men, 52% were prescribed beta blockers, 44% calcium channel blockers, 72% aspirin, 54% statins and 36% angiotensin converting enzyme inhibitors or angiotensin receptor blockers. The corresponding prescription rates for women were 46% (p < 0.001), 41% (p = 0.02), 69% (p < 0.001), 45% (p < 0.001) and 30% (p < 0.001). Among patients < 75 years old 52% were prescribed a beta blocker and 58% a statin. The corresponding figures for patients >or= 75 years were 42% (p < 0.001) and 31% (p < 0.001).

CONCLUSIONS

Angina is a common condition, more so in men than in women. Socioeconomically deprived patients are more likely to have angina but are less likely to consult their general practitioner. Guideline-recommended treatments for angina are underused in women and older patients. These suboptimal practice patterns, which are worst in older women, are of particular concern, as in Scotland more women (and particularly older women) than men have angina.

Overweight and obesity and weight change in middle aged men: impact on cardiovascular disease and diabetes

CONTEXT

The benefit of weight reduction for cardiovascular disease (CVD) outcomes remains uncertain.

OBJECTIVE

To examine the effects of baseline body mass index on major CVD outcomes and diabetes over a 20 year follow up, and of weight change in the first five years over the subsequent 15 years.

DESIGN AND SETTING

A prospective study of British men followed up for 20 years.

PARTICIPANTS

Men aged 40-59 years with no diagnosis of CVD or diabetes (n = 7176) of whom 6798 provided full information on weight change five years later.

OUTCOME MEASURES

Major CVD events (fatal and non-fatal myocardial infarction and stroke, angina, "other" CVD deaths) and diabetes.

RESULTS

During the 20 year follow up there were 1989 major CVD events and 449 incident cases of diabetes in the 7176 men. Risk of major CVD and diabetes increased significantly with increasing overweight and obesity. During the 15 year follow up, weight gain was associated with increased risk of CVD and diabetes. Weight loss was associated with lower risk of diabetes than the stable group irrespective of initial weight. No significant cardiovascular benefit was seen for weight loss in any men, except possibly in considerably overweight (BMI 27.5-29.9 kg/m(2)) younger middle aged men (RR = 0.42; 95% CI 0.22 to 0.81).

CONCLUSION

Long term risk of CVD and diabetes increased significantly with increasing overweight and obesity. Weight loss was associated with significant reduction in risk of diabetes but not CVD, except possibly in considerably overweight younger men. Duration and severity of obesity seem to limit the cardiovascular benefits of weight reduction in older men.

The clinical characteristics and investigations planned in patients with stable angina presenting to cardiologists in Europe: from the Euro Heart Survey of Stable Angina

AIMS

The Euro Heart Survey of Stable Angina set out to prospectively study the presentation and management of patients with stable angina as first seen by a cardiologist in Europe, with particular reference to adherence to existing guidelines and regional variability in patient presentation and initial assessment.

METHODS AND RESULTS

Consecutive outpatients with a clinical diagnosis by a cardiologist of stable angina were enrolled in the study and 3779 patients were included in the analysis. The average age was 61 years and 58% were male. The majority of patients (88%) had mild to moderate angina, CCS class I or II. Despite a high prevalence of recognized risk factors, 27% did not have cholesterol and 33% did not have glucose measured within 4 weeks of assessment. The resting ECG was abnormal in 41% of patients. An exercise ECG was performed or planned as part of initial investigation in 76% of patients and 18% had a stress imaging test such as perfusion scanning or stress echo. A coronary angiogram was performed or planned in 41%, and 64% had an echo. The time from assessment to investigation varied widely, particularly for angiography. One in 10 patients had neither any form of stress test nor angiography, with marked regional variation. Availability of invasive facilities increased the likelihood of both non-invasive and invasive investigations. Those with more severe symptoms or longer duration of symptoms or a positive non-invasive test were more likely to have angiography. In multivariable analysis, a positive stress test was the strongest predictor of the use of angiography, associated with a six-fold increase in the likelihood of invasive investigation. However, gender and availability of facilities were also predictive.

CONCLUSION

Considerable variation in features at presentation and use of investigations has been identified in the stable angina population in Europe. The evaluation of biochemical cardiovascular risk factors was suboptimal. Overall rates of non-invasive investigation for angina and the clinical appropriateness of factors predictive of the use of invasive investigation were broadly in line with guidelines. However, the influence of access to facilities, and marked international variation in rates and timing of investigation suggest that factors unrelated to clinical need are also influential in the management of patients with stable angina.

Resonance-thrombography indices of the haemostatic process in relation to risk of incident coronary heart disease: 9 years follow-up in the Caerphilly Prospective Heart Disease Study

Global assays, such as resonance-thrombography (RTG), which measure the interaction between platelets, coagulation and fibrinolysis have been used as summary measures of risk for over two decades but have not been evaluated in epidemiological studies. We examined whether RTG indices are risk indicators for incident coronary heart disease (CHD). RTG indices, related haematological variables and other risk factors were measured between 1984 and 1988 in a cohort of 2398 British men. Reaction time (r) and amplitude of fibrin leg (AF) were associated with lifestyle risk factors. During 9 years of follow-up, 282 (12%) men developed a major new CHD event, as classified by World Health Organization criteria. On adjustment for age, only r and AF measured at baseline were related to risk of incident CHD. On multivariate adjustment in a multiple logistic regression model that included age, diastolic blood pressure, body mass index, total and high-density lipoprotein cholesterol, lifestyle risk factors and use of prescribed medicine, these associations weakened but remained significant. Additional adjustment for fibrinogen, viscosity, white cell count and fibrin d-dimer either reduced these associations to non-significance (AF) or to borderline significance (r).

Serum albumin and risk of stroke, coronary heart disease, and mortality: the role of cigarette smoking

OBJECTIVE

Lower levels of serum albumin are associated with increased risk of all-cause and cardiovascular mortality as well as with coronary heart disease and stroke incidence. These relationships have been examined with specific focus on the role of cigarette smoking.

STUDY DESIGN AND SETTING

A prospective study of 7,690 British men aged 40-59 years, with 16.8 years mean follow-up.

RESULTS

Cigarette smoking was strongly and inversely associated with serum albumin concentrations that reverted to levels seen in never smokers after 5 years' cessation. Only in current and former smokers were there significant inverse relationships between serum albumin and risk of major CHD and stroke events even after adjustment for potential confounders. Only in current smokers was a significant inverse relationship seen between serum albumin and mortality from cardiovascular disease, cancer, and all causes.

CONCLUSION

The inverse association between serum albumin concentration and disease outcome appears to be related to the effects of cigarette smoking on serum albumin concentration.

Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study

OBJECTIVE

To establish the predictive accuracy of the Framingham risk score for coronary heart disease in a representative British population.

DESIGN

Prospective cohort study.

SETTING

24 towns in the United Kingdom.

PARTICIPANTS

6643 British men aged 40-59 years and free from cardiovascular disease at entry into the British regional heart study.

MAIN OUTCOME MEASURES

Comparison of observed 10 year coronary heart disease mortality and event rates with predicted rates for each individual, using the relevant Framingham risk equation.

RESULTS

Of 6643 men, 2.8% (95% confidence interval 2.4% to 3.2%) died from coronary heart disease compared with 4.1% predicted (relative overestimation 47%, P < 0.0001). A fatal or non-fatal coronary heart disease event occurred in 10.2% (9.5% to 10.9%) of the men compared with 16.0% predicted (relative overestimation 57%, P < 0.0001). These relative degrees of overestimation were similar at all levels of coronary heart disease risk, so that overestimation of absolute risk was greatest for those at highest risk. A simple adjustment provided an improved level of accuracy. In a "high risk score" approach, most cases occur in the low risk group. In this case, 84% of the deaths from coronary heart disease and non-fatal events occurred in the 93% of men classified at low risk (< 30% in 10 years) by the Framingham score.

CONCLUSION

Guidelines for the primary prevention of coronary heart disease advocate offering preventive measures to individuals at high risk. Currently recommended risk scoring methods derived from the Framingham study significantly overestimate the absolute coronary risk assigned to individuals in the United Kingdom.

The current cost of angina pectoris to the National Health Service in the UK

OBJECTIVE

To calculate the cost of angina pectoris to the UK National Health Service (NHS) in the year 2000.

METHODS

Calculation of the cost of hospital admissions, revascularisation procedures, hospital outpatient consultations, general practice (GP) consultations, and prescribed drug treatment.

RESULTS

634 000 individuals (1.1% of the UK population) consulted GPs 2.35 million times, costing pound 60.5 million. They required 16.0 million prescriptions (cost pound 80.7 million) and 254 000 hospital outpatient referrals (cost pound 30.4 million). There were 149 000 hospital admissions, 117 000 coronary angiograms, 21 400 coronary artery bypass operations, 17 700 percutaneous coronary interventions, and 516 000 outpatient visits, at a cost of pound 208.4 million, pound 69.9 million, pound 106.2 million, pound 60.7 million, and pound 52.2 million, respectively. The direct cost of angina was therefore pound 669 million (1.3% of total NHS expenditure), with hospital bed occupancy and procedures accounting for 32% and 35% of this total, respectively.

CONCLUSIONS

Angina is a common and costly public health problem. It consumed over 1% of all NHS expenditure in the year 2000, mainly because of hospital bed occupancy and revascularisation procedures. This is likely to be a conservative estimate of its true cost.

The development of a simulation model of primary prevention strategies for coronary heart disease

This paper describes the present state of development of a discrete-event micro-simulation model for coronary heart disease prevention. The model is intended to support health policy makers in assessing the impacts on health care resources of different primary prevention strategies. For each person, a set of times to disease events, conditional on the individual's risk factor profile, is sampled from a set of probability distributions that are derived from a new analysis of the Framingham cohort study on coronary heart disease. Methods used to model changes in behavioural and physiological risk factors are discussed and a description of the simulation logic is given. The model incorporates POST (Patient Oriented Simulation Technique) simulation routines.

Prevention of coronary heart disease through treatment of infection with Chlamydia pneumoniae? Estimation of possible effectiveness and costs

Evidence has been accumulating for a link between Chlamydia pneumoniae and coronary heart disease (CHD). A spreadsheet model was used to estimate the impact of different strategies for screening and treating C. pneumoniae on the incidence of myocardial infarction and cardiac mortality over a 1-year post-intervention period. It was found that screening would potentially be most cost-effective in men aged over 35 with a history of myocardial infarction (around ł2,000 per life-year saved). Cost-effectiveness would be inferior in those with established heart disease but no history of myocardial infarction (MI), and poor for people at elevated risk of CHD. If causality of the association were proven, the cost-effectiveness of treating C. pneumoniae in post-MI patients would compare favourably with, for example, statins for treating hypercholesterolaemia.

Contemporary management of chronic stable angina

Chronic stable angina is a common condition with a prognosis that is less benign than is generally appreciated. The optimal treatment strategy of this disorder is unclear, and few anti-ischaemic agents have been rigorously tested in prospectively randomised mortality studies. The evidence base for the anti-ischaemic therapy of chronic angina draws upon data 'borrowed' from studies in acute coronary syndromes, and from studies in chronic angina using surrogate endpoints such as ambulatory silent ischaemia. Such evidence leads us to believe that anti-ischaemic therapy with beta-blockers offers a mortality benefit in chronic angina. In contrast, the mortality benefit of lipid lowering therapy and antiplatelet agents is well proven. Angioplasty offers no mortality benefit in the treatment of chronic angina, although it is more effective than medical therapy alone for the relief of symptoms. In a few patients with high order proximal coronary disease, coronary bypass surgery offers a distinct mortality advantage compared with medical treatment alone. Most patients, however, do not warrant such an approach, and only require surgery for when they remain symptomatic despite adequate medical therapy. Alternative strategies such as cardiac transplantation, transmyocardial laser revascularisation and spinal cord stimulation are now accepted in a subgroup of patients for the treatment of chronic angina refractory to standard therapy.

Smoking as a modifiable risk factor for type 2 diabetes in middle-aged men

OBJECTIVE

To examine the effects of cigarette smoking, giving up smoking, and primary or secondary pipe or cigar smoking on the risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS

A prospective study followed 7,735 men aged 40-59 years from general practices in 24 British towns for an average of 16.8 years. Incident cases of physician-diagnosed diabetes were ascertained by repeated postal questionnaires and systematic reviews of primary care records.

RESULTS

A total of 290 incident cases of diabetes were found in 7,124 men with no history of diabetes, coronary heart disease, or stroke. Cigarette smoking was associated with a significant increase in risk of diabetes, even after adjustment for age, BMI, and other potential confounders. The benefit of giving up smoking was only apparent after 5 years of smoking cessation, and risk reverted to that of never-smokers only after 20 years. The risk of diabetes in those who switched from smoking cigarettes to pipe or cigars remained equal to the risk in continuing cigarette smokers. Men who gave up smoking during the first 5 years of follow-up showed significant weight gain and subsequently higher risk of diabetes than continuing smokers.

CONCLUSIONS

Cigarette smoking is an independent and modifiable risk factor for type 2 diabetes. Smoking cessation is associated with weight gain and a subsequent increase in risk of diabetes, but in the long term, the benefits of giving up smoking outweigh the adverse effects of early weight gain.

C-reactive protein, fibrin D-dimer, and incident ischemic heart disease in the Speedwell study: are inflammation and fibrin turnover linked in pathogenesis?

Plasma levels of C-reactive protein (CRP, a marker of the reactant plasma protein component of the inflammatory response) and of fibrin D-dimer (a marker of cross-linked fibrin turnover) have each been associated in recent studies with the risk of future ischemic heart disease (IHD). Previous experimental studies have shown that fibrin degradation products, including D-dimer, have effects on inflammatory processes and acute-phase protein responses. In the Speedwell Prospective Study, we therefore measured CRP and D-dimer levels in stored plasma samples from 1690 men aged 49 to 67 years who were followed-up for incident IHD for an average of 75+/-4 months (mean+/-SD) and studied their associations with each other, with baseline and incident IHD, and with IHD risk factors. CRP and D-dimer levels were each associated with age, plasma fibrinogen, smoking habit, and baseline evidence of IHD. CRP was associated with D-dimer (r=0.21, P<0.00001). On univariate analyses, both CRP and D-dimer were associated with incident IHD. The incidence of IHD increased with CRP independently of the level of D-dimer (P=0.0002) and also increased with D-dimer independently of the level of CRP (P=0.048). In multivariate analyses, inclusion of D-dimer and conventional risk factors reduced the strength of the association between CRP and incident IHD; likewise, inclusion of CRP and conventional risk factors reduced the strength of the association between D-dimer and incident IHD. We conclude that although these respective markers of inflammation and fibrin turnover show modest association with each other in middle-aged men, they may have additive associations with risk of incident IHD. Further larger studies are required to test this hypothesis.

Prevalence of angina pectoris in Spain. PANES Study group

The frequency of coronary heart disease in a community is usually measured by myocardial infarction incidence and mortality rates. The measurement of the prevalence of angina pectoris may, however, become a convenient way of assessing coronary heart disease morbidity in the future. The aim of this study was to determine the prevalence of angina and validity of the Rose questionnaire in the Spanish population aged from 45 to 74 years. A cross-sectional study was conducted in 10,248 subjects (45-74 years), representative of the Spanish population. The WHO Rose questionnaire was used and a construct validation against regional mortality rates and cardiovascular risk factor prevalence was devised. The overall angina prevalence increased with age both in men and women, but was higher in the latter (7.3% and 7.7%, respectively). Angina prevalence also increased with the number of cardiovascular risk factors present and correlated with regional CHD mortality rates (r = 0.66). Sensitivity and specificity results of the Rose questionnaire were low when tested against exercise test (52.9% and 52.1%, respectively). As conclusions, Rose questionnaire is a reliable tool for assessing angina prevalence in the Spanish population which is similar to that of other industrialized countries with higher myocardial infarction morbidity and mortality.

Peri-operative silent myocardial ischaemia in patients undergoing lower limb joint replacement surgery: an indicator of postoperative morbidity or mortality?

One hundred and twenty-seven patients undergoing major lower limb joint replacement surgery were studied to determine the incidence of silent myocardial ischemia and to ascertain any link between pre-operative cardiac risk factors, silent myocardial ischaemia and postoperative morbidity. Patients underwent ambulatory ECG monitoring for 4 days (on the pre-operative night and for 3 days postoperatively). Postoperative cardiorespiratory symptomatology and morbidity was assessed by questionnaire at 3 months. Eighty-seven patients had risk factors for silent myocardial ischaemia; 42 patients (30 with risk factors) had peri-operative silent myocardial ischaemia. The median ischaemic loads (range) were 1.04 (0.32-13.31) min.h-1 pre-operatively and 5.53 (0.26-56.39), 6.69 (0.04-42.71) and 1.23 (0.1-53.74) min.h-1 on postoperative days 1-3, respectively. Risk factors did not predict the occurrence of silent myocardial ischaemia or an increased ischaemic load pre-operatively or overall postoperatively. New symptoms (chest pain, palpitations, breathlessness or fatigue) were associated with both silent myocardial ischaemia and ischaemic load (p < 0.05). Thus cardiac risk factors do not predict the occurrence of silent myocardial ischaemia or adverse outcome. Peri-operative silent myocardial ischaemia was associated with increased postoperative fatigue.

Non-insulin-dependent diabetes in Kuwait: prevalence rates and associated risk factors

Non-insulin-dependent diabetes mellitus (NIDDM) is a major clinical and public health problem in Kuwait. The objective of the study was to determine prevalence rates of NIDDM among a representative sample of the Kuwaiti adult population aged 20 and older in two out of five governorates and identify the associated risk factors for the disease. A total of 3003 subjects (1105 men and 1898 women) were interviewed and examined by the research team during the period September 1995 to June 1996. A specially designed questionnaire was completed and the physical examination included height, weight and blood pressure measurements. Fasting blood samples were withdrawn, centrifuged immediately and refrigerated. Interpretation of oral glucose tolerance tests were based on the World Health Organisation diagnostic criteria for diabetes mellitus (1985). The denominator used for computing the prevalence was obtained from the 1995 Kuwait census. The overall prevalence of NIDDM in this study was found to be 14.8% (14.7% in men, 14.8% in women). Diabetic subjects presented at a relatively young age, prevalence rate in the age group 20-39 was 5.7% (95% confidence interval, 4.4-7.0) and in the age group 40-59 was 18.3% (95% confidence interval, 16.1-20.6). Obesity was found to be a significant risk factor, P < 0.001. The strong association of family history of NIDDM (adjusted odds ratio = 1.80, P < 0.001) suggests a genetic component. Hypertension was markedly associated with NIDDM and IGT (P < 0.001). With the demographic transition which already started among the Kuwaiti population and if the prevalence of NIDDM remains the same, aging of the population will contribute to even more upward trends in prevalence of abnormal glucose tolerance with its serious impact on morbidity and mortality among the Kuwaiti population. The strong association between hypertension and NIDDM may suggest a common approach to the prevention and control of these two conditions.

Aspirin use in middle-aged men with cardiovascular disease: are opportunities being missed?

BACKGROUND

Since the 1980s, clinical trial evidence has supported aspirin use in the secondary prevention of cardiovascular disease (CVD).

AIM

To explore aspirin use among British men with known CVD in a population-based study.

METHOD

Longitudinal study (British Regional Heart Study), in which subjects have been followed up for cardiovascular morbidity and mortality since 1978-1980. Aspirin use was assessed by questionnaires to study participants in November 1992 (Q92); cardiovascular diagnoses are based on general practice notifications to October 1992. A total of 5751 men aged 52-73 years (87% of survivors) completed questions on aspirin use.

RESULTS

Overall, 547 men (9.5%) were taking aspirin daily, of whom 321 (59%) had documented CVD. Among men with pre-existing disease, 153 out of 345 (44%) men with myocardial infarction, 42 out of 109 (39%) with stroke, and 75 out of 247 (29%) with angina were taking aspirin daily. Among men with angina (54% versus 26%) or myocardial infarction (59% versus 42%), those who had undergone coronary artery bypass surgery (CABG) or angioplasty were more likely to be receiving aspirin. Higher rates of aspirin use were also found in those whose last major event occurred after January 1990 (47% versus 34%). There was no association between aspirin use and social class or region of residence.

CONCLUSION

Despite strong evidence of its effectiveness, many patients with established CVD were not receiving aspirin. Daily aspirin treatment was less likely in men with less recent major CVD events and in those who had not received invasive treatment.

Methodology for assessing the prevalence of angina in primary care using practice based information in northern England

OBJECTIVES

The study aimed to consider the value of nitrate prescriptions issued by general practices as an indicator of coronary heart disease and to compare this with the use of coronary heart disease registers.

DESIGN

The study was a cross sectional survey. A self completed questionnaire was used by general practices to indicate an age and gender breakdown of the total practice population, the number of patients taking nitrates, and details of patients recorded on a coronary heart disease register.

SUBJECTS

All 48 general practices registered with Wakefield Family Health Services Authority were sent a questionnaire.

MAIN RESULTS

The prevalence of angina in the sample population of 164796 was 3.1%. The prevalence of angina as assessed by coronary heart disease registers was significantly higher at 4.3%.

CONCLUSIONS

Using questionnaires to assess how many patients are taking nitrates and therefore have angina may provide a quick, "snapshot" view of the prevalence of angina but the methodology is not a robust epidemiological tool. It is likely to provide errors in estimates of true prevalence and risks some under estimation when compared with coronary heart disease registers.

William Heberden revisited: postprandial angina-interval between food and exercise and meal composition are important determinants of time to onset of ischemia and maximal exercise tolerance

OBJECTIVES

This study aimed to explore the hemodynamic responses to ingestion of meals of different composition in patients with chronic stable angina and to assess the effect of these meals on time to onset of > 1-mm ST segment depression and limiting angina pectoris during exercise.

BACKGROUND

To our knowledge, no study has assessed the effect of meal composition and timing of exercise in patients with coronary artery disease.

METHODS

Fifteen patients with chronic stable angina visited our laboratory in the fasted state on three occasions. Measurements of cardiac output, heart rate and blood pressure were taken while patients were standing. A modified Bruce exercise test was then carried out, during which time to onset of > 1-mm ST segment depression and limiting chest pain were recorded. Patients then ate a 2.5-MJ high fat or high carbohydrate meal; on the third occasion, no meal was taken. At 30 min and 1 h after eating the meals, rest hemodynamic measurements and exercise tests were repeated.

RESULTS

The high fat meal did not affect exercise variables, whereas the high carbohydrate meal resulted in a reduction in time to onset of ST segment depression of 74.4 +/- 22.2 s (mean +/- SEM) during exercise at 30 min (p < 0.01), and at both 30 and 60 min after the high carbohydrate meal, limiting chest pain occurred 50 to 90 s earlier than when patients fasted (p < 0.01).

CONCLUSIONS

One hour after a high carbohydrate meal, the onset of angina during exercise occurs earlier than in the fasted state. Despite similar hemodynamic adjustments, a high fat meal does not affect exercise time.

Relation between socioeconomic status, employment, and health during economic change, 1973-93

OBJECTIVE

To investigate the association between the national unemployment rate and class differences in the relation between health and employment during the period 1973-93.

DESIGN

Data from general household surveys, 1973-93. Comparison of rates of employment, unemployment, and economic inactivity among those with and without limiting longstanding illness in different socioeconomic groups and how these varied over 20 years.

SUBJECTS

All men aged 20-59 years in each survey between 1973 and 1993.

MAIN OUTCOME MEASURES

Change over time in class specific rates of employment, unemployment, and economic inactivity in those with and without limiting longstanding illness.

RESULTS

Men in socioeconomic groups 1 and 2 with no longstanding illness experienced little decrease in their chances of being in paid employment as the general unemployment rate rose. Those most affected were men in manual groups with limiting longstanding illness. The likelihood of paid employment was affected far less by such illness in non-manual than in manual groups. In group 1 about 85% of men with such illness were in paid employment in 1979 and 75% by 1993; in group 4 the equivalent proportions were 70% and 40%. In men in manual groups with limiting longstanding illness there was no sign of employment rates rising again as the economy recovered.

CONCLUSION

Socioeconomic status makes a large difference to the impact of illness on the ability to remain in paid employment, and this impact increases as unemployment rises. Men with chronic illness in manual occupations were not drawn back into the labour force during the economic recovery of the late 1980s.

Patterns of alcohol intake and risk of stroke in middle-aged British men

BACKGROUND AND PURPOSE

The relationship between the pattern of alcohol intake and the risk of stroke is unclear, in particular the increased risk observed in abstainers and the possible protective effect of light to moderate drinking. For that reason, we examined in a large prospective study the role of alcohol consumption in the risk of a first major cerebrovascular event (stroke).

METHODS

We prospectively studied 7735 middle-aged men drawn from general practices in 24 British towns. With exclusion of those who had recall of physician diagnosis of ischemic heart disease or stroke, data were available for 7273 men all followed for 13.5 years, with 216 major stroke events (fatal and nonfatal).

RESULTS

Compared with occasional drinkers, nondrinkers (lifelong abstainers plus ex-drinkers) had an increased risk of stroke even after adjustment for age, lifestyle factors, and preexisting cardiovascular disease (relative risk [RR] = 1.6; 95% CI, 1.0 to 2.7). All regular weekend drinkers (1 to 2, 3 to 6, and > 6 drinks/d) and daily 1 to 2 and 3 to 6 drinkers showed no significant difference in adjusted risk of stroke compared with occasional drinkers. Heavy drinkers (daily > 6 drinks) showed significantly increased risk evident within the first 8 years of follow-up only (RR = 1.9; 95% CI, 1.0 to 3.5); however, this finding was attenuated after additional adjustment for systolic blood pressure (RR = 1.5; 95% CI, 0.8 to 2.7). Information obtained 5 years after screening was used to separate lifelong abstainers and ex-drinkers. On subsequent 8.5 years of follow-up, both groups showed similar increased risk (RR = 1.5) compared with occasional drinkers, but the risk in ex-drinkers was reduced after adjustment for lifestyle factors and cardiovascular disease status (RR = 1.2). Lifelong abstainers, however, showed an increase in risk after adjustment of 1.8 (95% CI, 0.7 to 4.6).

CONCLUSIONS

Heavy drinking is associated with an increased risk of total stroke that is largely mediated through blood pressure. The apparent increased risk seen in lifelong abstainers but not in ex-drinkers or occasional drinkers is unexplained but is unlikely to be attributed to abstinence from alcohol. There is no convincing evidence that light or moderate drinking is beneficial for stroke risk compared with occasional drinking.

Prospective relations between Helicobacter pylori infection, coronary heart disease, and stroke in middle aged men

OBJECTIVE

To determine whether Helicobacter pylori, a chronic bacterial infection often acquired in childhood, is associated with increased risk of coronary heart disease and stroke later in life.

DESIGN

Nested case-control study.

SETTING

Prospective study of cardiovascular disease in men aged 40-59 years at entry (1978-1980) in 24 British towns.

SUBJECTS

135 cases of myocardial infarction and 137 cases of stroke occurring before December 1991; 136 controls were identified, frequency matched to cases by town and age group.

METHODS

Serum samples stored at entry were analysed by an enzyme linked immunosorbent assay for the presence of H pylori specific IgG antibodies.

RESULTS

95 of the myocardial infarction cases (70%) and 93 (68%) of the stroke cases were seropositive for H pylori compared with 78 (57%) of the controls (odds ratio for myocardial infarction 1.77, 95% confidence interval (CI) 1.06 to 2.95, P = 0.03; odds ratio for stroke 1.57, 95% CI 0.95 to 2.60, P = 0.07). Helicobacter pylori infection was associated with manual social class, residence in Northern England or Scotland, cigarette smoking, higher systolic pressure and blood glucose, and a lower height-standardised forced expiratory volume in one second. Adjustment for these factors attenuated the relation between H pylori and myocardial infarction (odds ratio = 1.31, 95% CI 0.70 to 2.43, P = 0.40) and effectively abolished the relation with stroke (odds ratio = 0.96, 0.46 to 2.02, P = 0.92). The relation between helicobacter infection and fatal myocardial infarction was slightly stronger (odds ratio 2.41, 95% CI 1.13 to 5.12) but was also markedly attenuated after adjustment (1.56, 95% CI 0.68 to 3.61).

CONCLUSION

In this prospective study the association between Helicobacter pylori infection and increased risk of myocardial infarction and stroke was substantially confounded by the relation between this infection, adult social class, and major cardiovascular risk factors.

Minimising cardiac anaesthetic risk: the tortoise or the hare?

There is no doubt that a group of patients at increased risk of peri-operative cardiac morbidity exists and must be managed with the emphasis on the prevention of myocardial ischaemia. It is also clear that a potentially far larger group are at risk of failing to meet the increased cardiovascular and metabolic demands of surgery and therefore suffering the consequences of a relative hypoperfusion injury. Pre-operative assessment must address both groups and management regimens sought to provide optimal outcome for both. At present there is no consistent strategy for their identification, assessment or management of the high risk surgical population despite the fact that they probably consume a disproportionate share of hospital resources. The first and most important step is the recognition that this high risk group exists. Only then can this population be given similar consideration to those currently thought to be at risk of ischaemia.

Prospective study of serum total homocysteine concentration and risk of stroke in middle-aged British men

Moderate hyperhomocysteinaemia is common in the general population and has been linked with cardiovascular disease. However, there are no data from prospective, population-based studies. We examined the association between serum total homocysteine (tHcy) concentration and stroke in a nested case-control study within the British Regional Heart Study cohort. Between 1978 and 1980 serum was saved from 5661 men, aged 40-59 years, randomly selected from the population of one general practice in each of 18 towns in the UK. During follow-up to December, 1991, there were 141 incident cases of stroke among men with no history of stroke at screening. Serum tHcy was measured in 107 cases and 118 control men (matched for age-group and town, without a history of stroke at screening, who did not develop a stroke or myocardial infarction during follow-up). tHcy concentrations were significantly higher in cases than controls (geometric mean 13.7 [95% CI 12.7-14.8] vs 11.9 [11.3-12.6] mumol/L; p = 0.004). There was a graded increase in the relative risk of stroke in the second, third, and fourth quarters of the tHcy distribution (odds ratios 1.3, 1.9, 2.8; trend p = 0.005) relative to the first. Adjustment for age-group, town, social class, body-mass index, hypertensive status, cigarette smoking, forced expiratory volume, packed-cell volume, alcohol intake, diabetes, high-density-lipoprotein cholesterol, and serum creatinine did not attenuate the association. These findings suggest that tHcy is a strong and independent risk factor for stroke.

Association of Helicobacter pylori and Chlamydia pneumoniae infections with coronary heart disease and cardiovascular risk factors

OBJECTIVE

To investigate the relation between seropositivity to chronic infections with Helicobacter pylori and Chlamydia pneumoniae and both coronary heart disease and cardiovascular risk factors.

DESIGN

Cross sectional study of a population based random sample of men. Coronary heart disease was assessed by electrocardiography, Rose angina questionnaire, and a history of myocardial infarction; serum antibody levels to H pylori and C pneumoniae were measured, risk factor levels determined, and a questionnaire administered.

SETTING

General practices in Merton, Sutton, and Wandsworth, south London.

SUBJECTS

388 white south London men aged 50-69.

MAIN OUTCOME MEASURES

Evidence of coronary risk factors and infection with H pylori or C pneumoniae.

RESULTS

47 men (12.1%) had electrocardiographic evidence of ischaemia or infarction. 36 (76.6%) and 18 (38.3%) were seropositive for H pylori and C pneumoniae, respectively, compared with 155 (45.5%) and 62 (18.2%) men with normal electrocardiograms. Odds ratios for abnormal electrocardiograms were 3.82 (95% confidence interval 1.60 to 9.10) and 3.06 (1.33 to 7.01) in men seropositive for H pylori and C pneumoniae, respectively, after adjustment for a range of socioeconomic indicators and risk factors for coronary heart disease. Cardiovascular risk factors that were independently associated with seropositivity to H pylori included fibrinogen concentration and total leucocyte count. Seropositivity to C pneumoniae was independently associated with raised fibrinogen and malondialdehyde concentrations.

CONCLUSIONS

Both H pylori and C pneumoniae infectins are associated with coronary heart disease. These relations are not explained by a wide range of confounding factors. Possible mechanisms include an increase in risk factor levels due to a low grade chronic inflammatory response.

Cardiorespiratory disease in men and women in urban Scotland: baseline characteristics of the Renfrew/Paisley (midspan) study population

STUDY OBJECTIVE. To describe the distribution of risk factors, risk behaviors, symptoms and the prevalence of cardiorespiratory disease in men and women in an urban area with high levels of socioeconomic deprivation. A cross-sectional survey of 15,411 men and women aged 45-64, comprising an 80% response rate from the general population in Paisley and Renfrew, Scotland.

MAIN RESULTS

The main characteristics of the male Renfrew/Paisley population, compared to previous British studies, were shorter stature, higher blood pressure, a higher proportion of smokers who continue to smoke, lower FEV1 and higher levels of reported angina, breathlessness on effort and chronic bronchitis. In comparison with men, the main characteristics of the female Renfrew/Paisley population were shorter stature, higher plasma cholesterol, lower FEV1, fewer current and ex-smokers, and a higher prevalence of breathlessness on effort. There were only small differences between men and women in the prevalence of angina, ECG evidence of myocardial ischaemia and chronic bronchitis.

CONCLUSIONS

Middle-aged men and women in an urban area with high levels of socio-economic deprivation have different cardio-respiratory risk and disease profiles compared to previous population in the UK, based on occupational groups and random national samples.

The invasive management of angina: issues for consumers and commissioners

OBJECTIVE

To review, from the purchaser's perspective, the current state of knowledge of techniques for investigation and treating coronary artery disease. The study was based on evidence from past and continuing randomised controlled trials (RCTs). CRITERIA FOR INCLUSION OF REPORTS: Articles listed on Medline (1990-3) with the keywords coronary disease, angina, and unstable angina (combined with surgery, economics, therapy, or drug therapy) and percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) were included. Articles published before 1990 were obtained from two comprehensive literature reviews published by the Rand organisation in 1991 and from the papers obtained using the Medline search. A hand search of relevant journals published between July 1993 and June 1994 was also undertaken. Results from more recently published RCTs are included.

RESULTS

CABG provides improved angina relief compared with drug treatment and may prolong life in patients with more severe illness. PTCA is also better than drug treatment, but less so than CABG, and its cost advantages over CABG decrease with time. Repeat intervention for return of symptoms is more frequently required after PTCA, but increasing numbers of patients are also undergoing second and third repeat CABG for graft occlusion in the years after the original operation. Newer PTCA techniques are not, as yet, fully evaluated. One technique, atherectomy, has been shown to be no more effective, and more expensive, than conventional balloon angioplasty. In the short term intracoronary stents reduce the problems associated with vessel occlusion after PTCA and therefore reduce the need for further intervention. PTCA should not be performed without ready access to cardiothoracic support. There is an increasing trend towards the development of coronary catheterisation units at peripheral sites. This may lead to increasing, inappropriate use of this investigation in suboptimal circumstances.

CONCLUSIONS

Ischaemic heart disease is an important cause of morbidity and mortality and invasive management techniques are developing rapidly; some service expansion is occurring without trial evidence. More research is required to determine the optimum balance of PTCA, CABG, and angiography and population requirements for these procedures. In the meantime, in the absence of firm long term evidence of the superior cost effectiveness of PTCA compared with CABG, the rapid expansion of this procedure should be limited. Patients should be fully informed of the benefits and disadvantages of CABG and PTCA, where either procedure is indicated, to enable them to make fully informed choices.

Prospective study of risk factors for development of non-insulin dependent diabetes in middle aged British men

OBJECTIVE

To determine the risk factors for noninsulin dependent diabetes in a cohort representative of middle aged British men.

DESIGN

Prospective study.

SUBJECTS AND SETTINGS

7735 men aged 40-59, drawn from one group practice in each of 24 towns in Britain. Known and probable cases of diabetes at screening (n = 158) were excluded.

MAIN OUTCOME MEASURES

Non-insulin dependent diabetes (doctor diagnosed) over a mean follow up period of 12.8 years.

RESULTS

There were 194 new cases of non-insulin dependent diabetes. Body mass index was the dominant risk factor for diabetes, with an age adjusted relative risk (upper fifth to lower fifth) of 11.6; 95% confidence interval 5.4 to 16.8. Men engaged in moderate levels of physical activity had a substantially reduced risk of diabetes, relative to the physically inactive men, after adjustment for age and body mass index (0.4; 0.2 to 0.7), an association which persisted in full multivariate analysis. A nonlinear relation between alcohol intake and diabetes was observed, with the lowest risk among moderate drinkers (16-42 units/week) relative to the baseline group of occasional drinkers (0.6; 0.4 to 1.0). Additional significant predictors of diabetes in multivariate analysis included serum triglyceride concentration, high density lipoprotein cholesterol concentration (inverse association), heart rate, uric acid concentration, and prevalent coronary heart disease.

CONCLUSION

These findings emphasise the interrelations between risk factors for non-insulin dependent diabetes and coronary heart disease and the potential value of an integrated approach to the prevention of these conditions based on the prevention of obesity and the promotion of physical activity.

Incidence, clinical characteristics, and short-term prognosis of angina pectoris

OBJECTIVES

To estimate the clinical incidence and short-term prognosis of patients presenting with typical angina pectoris in the general population.

DESIGN

Prospective survey of all patients referred by 117 general practitioners from a random sample of 17 general practices serving a population of 191,677 with a median follow up of 16 months.

SETTING

A special open access chest pain clinic, based in the non-invasive cardiology department of a teaching hospital, set up for this study.

PATIENTS

110 consecutive patients < or = 70 years age with no history of coronary heart disease presenting for the first time with typical angina.

MAIN OUTCOME MEASURES

Age and sex specific incidences, persistence of chest pain, revascularisation procedures, myocardial infarction, and death.

RESULTS

The crude annual incidence of angina pectoris (95% confidence interval) was 0.83 (0.66 to 1.0) per thousand population aged 31-70 years; the rates were 1.13 (0.85 to 1.40) for men and 0.53 (0.33 to 0.72) for women. On resting electrocardiography 5% of patients had > or = 1 mm horizontal or downsloping ST depression, 5% had Q/QS patterns, and in one (1%) there was complete left bundle branch block. Among the 103 patients who underwent a Bruce protocol exercise test, 29% had > or = 3 mm ST segment depression induced at a low workload. Of 107 patients at a median (range) follow up of 15.8 (7-30) months, angina remitted spontaneously in 12 patients (11%), 20 (19%) underwent revascularisation, eight (7%) sustained a non-fatal myocardial infarction, and four (4%) died.

CONCLUSION

Incidence of new cases of angina pectoris in the United Kingdom is conservatively estimated from this study to be 22,600 patients per annum. Almost one third of these patients will have positive exercise tests at low workload, so the potential for coronary angiography and revascularisation is considerable. With one in 10 patients experiencing a non-fatal myocardial infarction or coronary death within a year of presentation the prognosis of angina is not benign. Further research is required to identify those patients in the general population who would benefit most from coronary revascularisation.

Weight in infancy and prevalence of coronary heart disease in adult life

OBJECTIVE

To determine whether low birth weight and low weight at 1 year are followed by an increased prevalence of coronary heart disease in adult life.

DESIGN

A follow up study of men born during 1920-30 whose birth weights and weights at 1 year were recorded.

SETTING

Hertfordshire, England.

SUBJECTS

290 men born and still living in East Hertfordshire.

MAIN OUTCOME MEASURE

The prevalence of coronary heart disease, defined by the Rose/WHO chest pain questionnaire, standard electrocardiographic criteria, or history of coronary artery angioplasty or graft surgery.

RESULTS

42 (14%) men had coronary heart disease. Their mean birth weight, 7.9 lb (3600 g), was the same as that of the other men. Their mean weight at 1 year, 21.8 lb (9.9 kg), was 1 lb (454 g) lower (95% confidence interval 0.1 to 1.8, P = 0.02). Percentages of men with coronary heart disease fell from 27% in those who weighed 18 lb (8.2 kg) or less at 1 year to 9% in those who weighed more than 26 lb (11.8 kg) (P value for trend = 0.03). This trend occurred in both smokers and non-smokers and within each social class.

CONCLUSION

These findings add to the evidence that coronary heart disease is "programmed" during early growth.

Management of angina pectoris in general practice: a questionnaire survey of general practitioners

BACKGROUND

Little is known about the current management of angina pectoris in general practice.

AIM

This survey set out to assess general practitioners' perceptions of current investigation and treatment for angina pectoris.

METHOD

A postal questionnaire was sent to all 217 general practitioners listed with the Hampshire Family Health Services Authority who have access to a regional cardiac centre in Southampton.

RESULTS

The response rate was 79% (171 of 217). The majority (80%) of general practitioners reported referring 10% or fewer of their patients with angina to a cardiologist at the regional centre, and 72% reported referring a quarter or fewer of their patients to a hospital physician. Most (77%) considered an exercise test useful for diagnosis of angina, but almost half (47%) were uncertain about its prognostic value. Most respondents (79%) were not confident of interpreting the results of an exercise test. The majority (79%) believed that there was scientific evidence to show that coronary angioplasty relieves symptoms and 21% were of the opinion that it prolongs survival. Ninety six per cent believed coronary artery bypass grafting relieves symptoms and 62% that it prolongs survival.

CONCLUSION

General practitioners do not appear to refer the majority of patients with angina pectoris for hospital investigation, and express divergent and contradictory opinions about exercise testing and the scientific evidence for the benefits of coronary angioplasty and coronary artery bypass surgery. Easier access to cardiological investigation and population based data about the value of exercise testing and survival benefits from coronary intervention are required to optimize selection of patients in the community who are most likely to benefit from coronary revascularization.

Implication of prescriptions for nitrates: 7 year follow up of patients treated for angina in general practice

OBJECTIVE

To determine the demand placed on local cardiological services by patients prescribed nitrates for ischaemic heart disease.

DESIGN

A follow up study of a cohort of patients identified in 1985.

SETTING

Nottingham Health District.

PATIENTS

Four hundred and ninety nine patients prescribed nitrates in 1985 for presumed ischaemic heart disease.

MAIN OUTCOME MEASURES

Referral to medical outpatients, admittance to hospital with chest pain, cardiological investigations, and mortality.

RESULTS

Over the seven year period 26% of patients were admitted urgently with chest pain and 15% were referred to the medical outpatient department--a referral rate of 6% a year. 4% of patients had an exercise test and 6% a coronary angiogram. The death rate was 6% a year and a higher proportion died of cardiovascular causes than would be expected in the general population.

CONCLUSIONS

Prescription of nitrate is useful in the determination of the prevalence of ischaemic heart disease. Most patients with angina are still treated within the community, and the rate of specialist investigation remains low.

The investigation and management of stable angina. Report of a working party of the Joint Audit Committee of the British Cardiac Society and the Royal College of Physicians of London

This paper is a summary of present practices in the investigation and management of angina. The mechanism, incidence, and prevalence of angina are reviewed, the roles of invasive and non-invasive investigations assessed, and the indications for coronary angioplasty and coronary bypass grafting discussed. Basic audit data sets for primary, secondary, and tertiary care are proposed and potential audit initiatives suggested.

Prevalence of coronary heart disease in Turkish adults

The prevalence of coronary heart disease was determined by a conducted survey in a random sample of 3689 subjects 20 years of age or older in 59 communities representing the Turkish adult population. Interview with a questionnaire, physical examination of the cardiovascular system and recording of a 12-lead ECG were performed. The latter was coded according to the Minnesota code. Expressed in age-adjusted rates (for 35-64 years), prevalence rates per 100 men were as follows: typical angina 3.7, atypical angina 0.9, electrocardiographic evidence of myocardial infarction and/or ischemia 3.7, any of the stated findings suggesting coronary heart disease 8. Women had a substantially higher rate of atypical angina, positive ECG findings and of any of the stated manifestations for coronary heart disease, whereas they had a significantly lower rate of Q/QS patterns as well as of a history of myocardial infarction. Based on a probability-related point score, age-adjusted clinical coronary heart disease was estimated to prevail in 5.8% of men and 5% of women (P > 0.4) in the sample of the Turkish population. The respective rates in urban residents was 6% and in rural resident 4.8%. Among participants diagnosed coronary heart disease, 63% presented the form of angina without infarction, 27% had evidence of myocardial infarction, 7% 'silent myocardial ischemia' and 3% cardiac failure alone.

Diet and incident ischaemic heart disease: the Caerphilly Study

The Caerphilly Prospective Ischaemic Heart Disease (IHD) Study is based on a sample of 2512 men aged 45-59 years when first seen. Nutrient intakes, estimated using a self-administered semi-quantitative food frequency questionnaire, are available for 2423 men (96%). Amongst these, 148 major IHD events occurred during the first 5 years of follow-up. Associations were examined between these events and baseline diet. Incident IHD (new events) was negatively associated with total energy intake: men who went on to experience an IHD event had consumed 560 kJ (134 kcal)/d (6%) less at baseline than men who experienced no event (P = 0.01). The relative odds of an IHD event was 1.5 among men in the lowest fifth of energy intake, compared with 1.3, 1.2, 0.9 and 1.0 respectively for the other four fifths (P < 0.05). The difference in energy intake was reflected in lower intakes of every nutrient examined. When expressed as a percentage of total energy, mean intakes of men who experienced an IHD event were virtually identical to those of men who did not. There was some evidence suggesting a positive association between total fat intake and IHD risk, but the trend was not consistent and not statistically significant. There was no association for animal fat. Alcohol consumption was negatively associated with subsequent IHD, but only in men who already had evidence of IHD at baseline (P < 0.05). Dietary fibre, particularly from fruit and vegetables, was 7% lower in men who had an incident IHD event (P < 0.05), but the difference was not independent of total energy. There was a trend of increasing IHD risk with decreasing vitamin C intake, the relative odds of an IHD event being 1.6 among men in the lowest one-fifth of the vitamin C distribution, but this was not statistically significant.

The prevalence of coronary heart disease in the multi-ethnic and high diabetes prevalence population of Mauritius

The prevalence of coronary heart disease (CHD) was determined in a population survey in Mauritius where the prevalence of non-insulin dependent diabetes and mortality from CHD are amongst the highest in the world. Men and women aged 35-74 years of all major ethnic groups were included: Asian Indians (Hindus and Muslims), Creoles and Chinese. ECG abnormalities suggesting either 'probable CHD' or 'possible CHD' were defined using standard criteria. The overall prevalence of probable CHD was 2.7% in men and 0.9% in women, and that of probable or possible CHD together 17.8% in men and 33.3% in women. The prevalence of CHD did not vary significantly between the four ethnic groups. In the multivariate analyses, age and high blood pressure were the most important independent predictors of ECG abnormalities. Neither diabetes nor serum insulin seemed to contribute independently to the prevalence of CHD. This survey confirmed the high ranking of Mauritius in international mortality statistics. The high rates of CHD seen in Asian Indians, African-origin Creoles and Chinese in the rapidly developing country of Mauritius may be a pointer to future problems in their regions of origin.

Provision of services for the diagnosis and treatment of heart disease. Fourth report of a Joint Cardiology Committee of the Royal College of Physicians of London and the Royal College of Surgeons of England

The principal conclusions of the fourth report of the Joint Cardiology Committee are: 1 Cardiovascular disease remains a major cause of death and morbidity in the population and of utilisation of medical services. 2 Reduction in the risk of cardiovascular disease is feasible, and better co-ordination is required of strategies most likely to be effective. 3 Pre-hospital care of cardiac emergencies, in particular the provision of facilities for defibrillation, should continue to be developed. 4 There remains a large shortfall in provision of cardiological services with almost one in five district hospitals in England and Wales having no physician with the appropriate training. Few of the larger districts have two cardiologists to meet the recommendation for populations of over 250,000. One hundred and fifty extra consultant posts (in both district and regional centres) together with adequate supporting staff and facilities are urgently needed to provide modest cover for existing requirements. 5 The provision of coronary bypass grafting has expanded since 1985, but few regions have fulfilled the unambitious objectives stated in the Third Joint Cardiology Report. 6 The development of coronary angioplasty has been slow and haphazard. All regional centres should have at least two cardiologists trained in coronary angioplasty and there should be a designated budget. Surgical cover is still required for most procedures and is best provided on site. 7 Advances in the management of arrhythmias, including the use of specialised pacemakers, implantable defibrillators, and percutaneous or surgical ablation of parts of the cardiac conducting system have resulted in great benefit to patients. Planned development of the emerging sub-specialty of arrhythmology is required. 8 Strategies must be developed to limit the increased exposure of cardiologists to ionising radiation which will result from the expansion and increasing complexity of interventional procedures. 9 Supra-regional funding for infant cardiac surgery and transplantation has been successful and should be continued. 10 Despite advances in non-invasive diagnosis of congenital heart disease the amount of cardiac catheterisation of children has risen due to the increase in number of interventional procedures. Vacant consultant posts in paediatric cardiology and the need for an increase in the number of such posts cannot be filled from existing senior registrar posts. All paediatric cardiac units should have a senior registrar and in the meantime it may be necessary to make proleptic appointments to consultant posts with arrangements for the appointees to complete their training. 11 Provision of care for the increasing number of adolescent and adult survivors of complex congenital heart disease is urgently required. The management of these patients is specialised, and the committee recommends that it should ultimately be undertaken by either adult or pediatric cardiologists with appropriate additional training working in supra-regionally funded centers alongside specially trained surgeons. 12 Cardiac rehabilitation should be available to all patients in the United Kingdom. 13 New recommendations for training in cardiology are for a total of at least five years in the specialty after general professional training, plus a year as senior registrar in general medicine. An additional year may be required for those wishing to work in interventional cardiology and adequate provision must be made for those with an academic interest. 14 It is essential that both basic and clinical research is carried out in cardiac centres but these activities are becoming increasingly limited by the lack of properly funded posts in the basic sciences and restriction in the number of honorary posts for clinical research workers. 15 A joint audit committee of the Royal College of Physicians and the British Cardiac Society has been established to coordinate audit in the specialty. All district and regional cardiac centres should cooperate with the work of the committee, in addition to their participation in local audit activities.

Physical activity and ischaemic heart disease in middle-aged British men

OBJECTIVE

To assess the relation between reported physical activity and the risk of heart attacks in middle aged British men.

DESIGN

Prospective study of middle-aged men followed for a period of eight years (The British Regional Heart Study).

SETTING

One general practice in each of 24 British towns.

PARTICIPANTS

7735 men aged 40-59 years at initial examination.

END POINT

Heart attacks (non-fatal and fatal).

MEASUREMENTS AND MAIN RESULTS

During the follow up period of eight years 488 men suffered at least one major heart attack. A physical activity score used was developed and validated against heart rate and lung function (FEV1) in men without evidence of ischaemic heart disease. Risk of heart attack decreased significantly with increasing physical activity; the groups reporting moderate and moderately vigorous activity experienced less than half the rate seen in inactive men. The benefits of physical activity were seen most consistently in men without preexisting ischaemic heart disease and up to levels of moderately vigorous activity. Vigorously active men had higher rates of heart attack than men with moderate or moderately vigorous activity. The relation between physical activity and the risk of heart attack seemed to be independent of other cardiovascular risk factors. Men with symptomatic ischaemic heart disease showed a reduction in the rate of heart attack at light or moderate levels of physical activity, beyond which the risk of heart attack increased. Men with asymptomatic ischaemic heart disease showed an increasing risk of heart attack with increasing levels of physical activity, but with a progressive decrease in case fatality. Overall, men who engaged in vigorous (sporting) activity of any frequency had significantly lower rates of heart attack than men who reported no sporting activity. However, when all men reporting regular sporting activity at least once a month were excluded from analysis, there remained a strong inverse relation between physical activity and the risk of heart attack in men without pre-existing ischaemic heart disease.

CONCLUSION

This study suggests that the overall level of physical activity is an important independent protective factor in ischaemic heart disease and that vigorous (sporting) exercise, although beneficial in its own right, is not essential in order to obtain such an effect.

Short-term effects of substituting protein for carbohydrate in the diets of moderately hypercholesterolemic human subjects

The short-term effects on plasma lipoprotein lipids of substituting meat and dairy protein for carbohydrate in the diets of 10 free-living moderately hypercholesterolemic human subjects (four men, six women) were studied under closely supervised dietary control during the consumption of constant, low intakes of fat and cholesterol and the maintenance of stable body weight as well as constant fiber consumption. Subjects were randomly allocated to either the high or low protein diets (mean, 23% v 11% of energy as protein, 24% as fat, and 53% v 65% as carbohydrate) and then switched to the other diet for another 4 to 5 weeks. Mean fasting plasma high-density lipoprotein cholesterol (HDL-C) was significantly higher by 12% +/- 4% (0.97 +/- 0.08 v 0.89 +/- 0.08 mmol/L, P less than .01), whereas mean total cholesterol (TC) was lower by 6.5% +/- 1.3% (5.7 +/- 0.3 v 6.1 +/- 0.3 mmol/L, P less than .001), mean low-density lipoprotein-cholesterol (LDL-C) lower by 6.4% +/- 2.0% (4.5 +/- 0.2 v 4.8 +/- 0.2 mmol/L, P less than .02), mean total triglycerides (TG) lower by 23% +/- 5% (1.7 +/- 0.1 v 2.4 +/- 0.3 mmol/L, P less than .02), and mean high versus low protein diet. Mean values for LDL-C were significantly lower during weeks 3 to 5 of the high protein diet than during either weeks 1 to 5 or weeks 1 to 2 of the high protein diet (4.3 +/- 0.3, 4.5 +/- 0.2, and 4.7 +/- 0.3 mmol/L, respectively, P less than .05) and 11% +/- 3% lower than on low protein diet, P less than .005. The ratio of plasma LDL-C to HDL-C was consistently lower by 17% +/- 3% during the high versus low protein diet (4.9 +/- 0.5 v 5.8 +/- 0.5, P less than .001). Lowering plasma TC and LDL-C and total TG and VLDL-TG and increasing HDL-C by chronic isocaloric substitution of dietary for carbohydrate may enhance the cardiovascular risk reduction obtained by restriction of dietary fat and cholesterol.