Missing, mediocre, or merely obsolete? An evaluation of UK data sources for coronary heart disease

Explaining the Decline in Coronary Heart Disease Mortality Rate Using IMPACT Model: Estimation of the Changes in Risk Factors and Treatment Uptake in Iran between 2007 and 2016

INTRODUCTION

Coronary heart disease (CHD) contributes significantly to mortality and morbidity in Iran. A model was fitted in this study to determine changes in risk factors and treatment uptake to CHD mortality rate reduction in Isfahan between 2007 and 2016.

METHOD

The IMPACT model was fitted to determine how much the decrease in CHD death can be explained by treatment uptake and significant risk factors included in the analyses for adults aged 35 to 84 years. Body mass index (BMI), diabetes, and smoking were considered as the CHD risk factors in the model. Medical and interventional treatments were studied in four different groups of patients. The primary data sources were obtained from the Persian registry of cardiovascular disease (PROVE), The Isfahan healthy heart program (IHHP), and the impact of self-care management and adopted Iranian guidelines for hypertension treatment on improving the control rate of hypertension (IMPROVE CARE) study, death registration system, and the Isfahan province Cemetery.

RESULTS

The CHD mortality rate decreased by 14% between 2007 and 2016 in Iran for adults aged 35 to 84 years and prevented or delayed 212 CHD deaths in 2016. Treatment uptakes caused 99% postponed or prevented death. Treatment for heart failure in hospitals explained approximately half of the death prevented by treatment. Risk factors caused about 15% of excess death. It appears that the prevalence of CHD is increasing while the death rate is decreasing because of these observed changes.

CONCLUSION

Risk factors worsened in 2016 and, without treatment, could lead to an increase in CHD mortality in Iran. Preventive policies should control the risk factor and contribute to the decrease in CHD death.

Vessel graft fabricated by the on-site differentiation of human mesenchymal stem cells towards vascular cells on vascular extracellular matrix scaffold under mechanical stimulation in a rotary bioreactor

Although a significant number of studies on vascular tissue engineering have been reported, the current availability of vessel substitutes in the clinic remains limited mainly due to the mismatch of their mechanical properties and biological functions with native vessels. In this study, a novel approach to fabricating a vessel graft for vascular tissue engineering was developed by promoting differentiation of human bone marrow mesenchymal stem cells (MSCs) into endothelial cells (ECs) and vascular smooth muscle cells (VSMCs) on a native vascular extracellular matrix (ECM) scaffold in a rotary bioreactor. The expression levels of CD31 and vWF, and the LDL uptake capacity as well as the angiogenesis capability of the EC-like cells in the dynamic culture system were significantly enhanced compared to the static system. In addition, α-actin and smoothelin expression, and contractility of VSMC-like cells harvested from the dynamic model were much higher than those in a static culture system. The combination of on-site differentiation of stem cells towards vascular cells in the natural vessel ECM scaffold and maturation of the resulting vessel construct in a dynamic cell culture environment provides a promising approach to fabricating a clinically applicable vessel graft with similar mechanical properties and physiological functions to those of native blood vessels.

General Characteristics and Quality of Stroke-Related Online Information – A Cross-Sectional Assessment of the Romanian and Hungarian Websites

Background: The quality of online health-related information may affect users’ understanding and medical decision-making with dramatic impact, particularly in case of stroke. Objective: The objective of this study was to assess the quality of information about stroke on the Romanian and Hungarian websites in terms of completeness and accuracy. Methods: The research was designed as an observational cross-sectional study. The sample included 25 Romanian and 25 Hungarian websites presenting information about stroke for the general public. General characteristics such as website ownership, main goal, website genre and medical approach were identified by the evaluators using a predetermined set of common instructions. The completeness and accuracy of the information were assessed by two independent assessors against a quality benchmark. Results: Overall, most of the websites were owned by private commercial companies (42%), had educational goal (66%), were designed as medical web-portals (46%) and had a conventional medicine approach (72%). Mean completeness score was 5.6 points (SD± 1.9) for Romanian sites and 4.1 points (SD ± 2.4) for Hungarian sites (p = 0.017). Mean accuracy score was 6.2 points (SD ± 1.1) for Romanian sites and 7.0 points (SD ± 0.7) for Hungarian sites (p = 0.02). Conclusions: The information about stroke on the Romanian and Hungarian websites had poor quality. Although we found statistically significant differences between the quality scores of the two language sub-samples and two site characteristics associated with significantly higher quality, the practical relevance of these findings for online health information seekers should be interpreted with caution.

The Quality of Online Health-Related Information – an Emergent Consumer Health Issue

The Internet has become one of the main means of communication used by people who search for health-related information. The quality of online health-related information affects the users’ knowledge, their attitude, and their risk or health behaviour in complex ways and influences a substantial number of users in their decisions regarding diagnostic and treatment procedures.

The aim of this review is to explore the benefits and risks associated with using the Internet as a source of health-related information; the relationship between the quality of the health-related information available on the Internet and the potential risks; the multiple conceptual components of the quality of health-related information; the evaluation criteria for quality health-related information; and the main approaches and initiatives that have been implemented worldwide to help improve users’ access to high-quality health-related information.

A Review of the Use of Routine Data on CHD in General Practice Research in Scotland

Background: The primary aim of the Platform Project is to maximise the use of routine data for-primary care research in Scotland. Aims: To assess the extent to which routine data ts available and has been used in studies on CHD in General Practice research in Scotland. To assess the advantages and limitations of using routine data in this setting Methods: Literature review using a variety of databases catalogues and websites, bibliographies of articles retrieved and searching through journals by hand not available electronically. Results: This review has found that the use of routine data in CHD studies in General Practice research in Scotland remains small. There has been little work undertaken which has combined the use of routine data with other research methods. Limitations with routine data exist particularly with regard to risk factors and ethnicity. However, despite such limitations there exists an increasingly extensive range of data, which exists to help explain tends in CHD, which so far has been largely underused.

Continued improvement of cardiovascular mortality in Hungary--impact of increased cardio-metabolic prescriptions

Background

During the last 35 years the poor ranking of Hungary on the list of life expectancy at birth among European countries, has not changed. In 1970 our lag behind the leading European countries was the smallest. The gap was growing between 1970 and 1993 but from 1994 onwards the life expectancy at birth in Hungary has increased continuously and somewhat faster than in other European countries. The aim of this study was to analyze the association between decreasing cardiovascular mortality rates, as a main cause of death and the increase in cardio-metabolic prescriptions and possible changes in lifestyle behavior.

Methods

Analyses were conducted on national data concerning cardiovascular mortality and the number of cardio-metabolic drug prescription per capita. The association between yearly rates of cardiovascular events and changes in antihypertensive, antilipidemic and antidiabetic prescription rates was analyzed. The changes in other cardiovascular risk factors, like lifestyle were also considered.

Results

We observed a remarkable decline of mortality due to stroke and acute myocardial infarction (AMI). The fall was significantly associated with all prescription rates. The proportion of each treatment type responsible for suppression of specific mortality rates is different. All treatment types comparably improved stroke mortality, while antilipidemic therapy improved AMI outcome.

Conclusions

These results emphasize the importance of a comprehensive strategy that maximizes the population coverage of effective treatments. Hungary appears to be at the beginning of the fourth stage of epidemiologic transition, i.e. it has entered the stage of delayed chronic noninfectious diseases.

Potential reductions in United States coronary heart disease mortality by treating more patients

Approximately one half of the recent decline observed in age-adjusted coronary heart disease (CHD) mortality rates can be attributed to the use of modern medical and surgical interventions. In 2000, however, only about 30% to 60% of eligible patients actually received the appropriate treatment. To examine the reduction in CHD mortality potentially achievable by increasing the provision of specific medical and surgical treatment to eligible patients with CHD in the United States, we integrated the data on CHD patient numbers, medical and surgical treatment uptake levels, and treatment effectiveness using a previously validated CHD policy model. We estimated the number of deaths prevented or postponed for 2000 (baseline) and for an alternative scenario (60% of eligible patients). In 2000, the treatment levels in the United States were generally poor; only 30% to 60% of eligible patients received the appropriate therapy. These treatments resulted in approximately 159,330 fewer deaths. By treating 60% of eligible patients, 297,470 fewer deaths would have been obtained (minimum 118,360; maximum 628,120), representing 134,635 less than in 2000, with approximately 32% from heart failure therapy, 30% from secondary prevention therapy, 19% from acute coronary syndrome treatment, 15% from primary prevention with statins, 0.5% from hypertension treatment, and 1% from coronary bypass surgery for chronic angina. These findings remained stable in the sensitivity analysis. In conclusion, increasing the proportion of eligible patients with CHD who received the appropriate treatment could have achieved approximately 135,000 fewer deaths in 2000, almost doubling the benefit actually achieved. Future strategies should maximize the delivery of appropriate therapies to all eligible patients with CHD and prioritize medical therapies for secondary prevention and heart failure.

Large-scale epidemiological data on cardiovascular diseases and diabetes in migrant and ethnic minority groups in Europe

BACKGROUND

Data on differences by ethnicity in cardiovascular diseases (CVDs) and diabetes, reflecting the influence of diverse cultural, social and religious factors, are important to providing clues to disease aetiology and directing public health interventions and health care resources.

METHODS

Through a network of European public health researchers and searches of bibliographic databases and internet sites, we determined the availability and characteristics of ethnically relevant data on mortality and morbidity from coronary heart disease (CHD), stroke and diabetes, in current European Union countries; data from the four countries comprising the UK were assessed separately.

RESULTS

In total, 25 countries had one or more relevant data sets (72 in total); however, two-thirds (n = 47) of the data sources came from only eight Nordic and Western European countries. For several countries, no data could be identified. Ethnically relevant, national death registers were available in 24 countries. Country of birth was the most common indicator of ethnicity. Data on CHD, stroke and diabetes morbidity among migrant and ethnic minority populations are currently scarce; both between and within countries, there are important differences in how ethnicity as well as disease outcomes are defined and measured which limits data comparability.

CONCLUSION

Reliable routine data are key to evidence-based public health policies at both national and EU level. EU countries have a relatively weak base for assessing needs and planning health care interventions for its migrant and ethnic minority populations. The lack of ethnically relevant data on CVD and diabetes across the EU needs to be addressed urgently.

Validity and utilization of epidemiological data: a study of ischaemic heart disease and coronary risk factors in a local population

OBJECTIVES

To calculate the burden of ischaemic heart disease (IHD) and coronary risk factors in a defined population using data from all public providers of health care, i.e. inpatient and outpatient care in all settings.

STUDY DESIGN

Cross-sectional, 1-year retrospective study.

METHODS

The main outcome measures were the number of individuals by diagnosis and by care setting, and gender- and age-specific event rates by diagnosis.

RESULTS

Less than half of the individuals who visited any care provider for IHD or coronary risk factors were identified in the hospital discharge register. Calculation of the actual burden of disease in the population showed that when hospital discharge data were combined with outpatient data, there were no or slight differences in the age-specific rates of acute myocardial infarction (AMI), while the rates of angina were between two-fold and four-fold higher, and unspecified IHD was between three-fold and ten-fold higher in individuals aged > or =50 years compared with using hospital discharge data alone. The rates of hypertension, diabetes and lipid disorders increased in all age groups when outpatient data were added to hospital discharge data. The differences in the rates were more pronounced in women aged 50-79 years. However, the age-specific rates were higher in men except for hypertension which was higher in older women.

CONCLUSION

Data for epidemiological analyses of diseases are often based on hospital discharge data. This study found that hospital discharge data provide limited information on patients treated for IHD and coronary risk factors, except for AMI. These findings suggest that hospital discharge data should be combined with outpatient care data to provide a more comprehensive estimate of the burden of IHD and its risk factors.

Disease prevalence in the English population: a comparison of primary care registers and prevalence models

The Quality and Outcomes Framework (QOF) is a UK system for monitoring general practitioner (GP) activity and performance, introduced in 2004. The objective of this paper is to explore the potential of QOF datasets as a basis for better understanding geographical variations in disease prevalence in England. In an ecological study, prevalence estimates for four common disease domains (coronary heart disease (CHD), asthma, hypertension and diabetes) were derived from the 2004-2005 QOF primary care disease registers for 354 English Local Authority Districts (LADs). These were compared with synthetic estimates from four prevalence models and with self-reported measures of general health from the 2001 census. Prevalence models were recalculated for LADs using demographic and deprivation data from the census. Results were mapped spatially and cross-tabulated against a national classification of local authorities. The four disease domains display different spatial distributions and different spatial relationships with the corresponding prevalence model. For example, the prevalence model for CHD under-estimated QOF cases in northern England, but this north-south pattern was not evident for the other disease domains. The census-derived health measures were strongly correlated with CHD, but not with the other disease domains. The relationship between modelled prevalence and QOF disease registers differs by disease domain, implying that there is no simple cross-domain effect of the QOF process on prevalence figures. Given reliable synthetic estimates of small area prevalence for the QOF disease domains, one potential application of the QOF dataset may be in assessing the geographical extent of under-diagnosis for each domain.

An evaluation of UK secondary data sources for the study of childhood obesity, physical activity and diet

BACKGROUND

This study assesses the potential of secondary datasets for measuring recent and future trends in childhood obesity, physical activity and diet in the UK, at national, regional and sub-regional levels, and in relation to inequalities.

METHODS

Relevant datasets were identified using online searches; they were excluded if they had low sample sizes, were assembled prior to 1990 or on only one occasion, were not potentially accessible, or were limited to a specific population. Remaining datasets were assessed according to content, sampling frame and size, timing and ability to be used to assess inequalities and regional trends.

RESULTS

A total of 96 datasets were identified, but only 11 had the potential to be used to assess trends. Eight of these contained data on physical activity, 8 on diet and 3 on obesity. The period over which trends might be assessed varied from 2 years to over 10, with over half of the datasets expected to continue data collection into the future. Most had the potential to be used to assess inequalities and also regional and sub-regional level trends, albeit with relatively small sample sizes. There were some limitations to the datasets, such as non-objective measures of diet and physical activity and, in some, low response rates, which would require further consideration when utilizing individual datasets.

CONCLUSIONS

Awareness of the potential of secondary datasets for monitoring trends in childhood obesity should be raised, alongside the financial and intellectual capacity to enhance and exploit them.

A novel small-diameter vascular graft: in vivo behavior of biodegradable three-layered tubular scaffolds

Small-diameter vascular grafts are potential substitutes for damaged vessels in patients, but most biodegradable grafts available now are not strong enough. The present study examined the burst strength, radial compliance, suture retention strength for a novel biodegradable tubular scaffold and investigated its behavior in vivo. The tubular scaffold (6-mm i.d., 4 cm long) has three layers including porous polylacticglycolic- acid in both inner and outer layers, a compact polyurethanes layer in midst. Bone marrow stromal cells (bMSCs) were seeded on the scaffolds and cultured for 7 days in vitro to construct tissue engineered vascular grafts which were then implanted in canine abdominal aorta. After 1, 3, 6, 12 and 24 weeks, the grafts were retrieved and evaluated histologically, angiographically and immunohistochemically. The biodegradable tubular scaffolds showed wall thickness of 0.295 mm to 0.432 mm; radial compliance of 3.80%/100 mmHg approximately 0.57%/100 mmHg, burst strength of 160 kPa approximately 183 kPa, and suture retention strength of 1959 N/cm(2) approximately 3228N/cm(2). The implanted grafts were fully patent without any signs of dilation or obstruction after 3 months' implantation. Scanning electron microscopy revealed a confluence endothelial cell layer spreading on the inner surface of the grafts. Immunohistochemistry of the retrieved grafts showed that vWF-stainin, alphaSMA-staining were positive in the inner and medium layer respectively. Masson's trichrome staining showed that amount of collagen fibers existed in the grafts wall. Overall, these novel three-layered scaffolds exhibited favourable mechanical strength, long term patency and good remodeling in vivo.

The cost of cardiovascular disease: rising, declining or staying still?

Epidemiological, demographic and health technology factors combined are likely to inflate future healthcare CVD costs, with an older and healthier population consuming higher levels of resources required for treatment.

Population impact of stricter adherence to recommendations for pharmacological and lifestyle interventions over one year in patients with coronary heart disease

STUDY OBJECTIVE

To assess the potential number of lives saved associated with the full implementation of aspects of the National Service Framework (NSF) for coronary heart disease (CHD) in England using recently developed population impact measures.

DESIGN

Modelling study.

SETTING

Primary care.

DATA SOURCES

Published data on prevalence of acute myocardial infarction and heart failure, baseline risk of mortality, the relative risk reduction associated with different interventions and the proportion treated, eligible for treatment and adhering to each intervention.

MAIN RESULTS

Adopting the NSF recommendations for pharmacological interventions would prevent an extra 1027 (95% CI 418 to 1994) deaths in post-acute myocardial infarction (AMI) patients and an extra 37 899 (95% CI 25 690 to 52 503) deaths in heart failure patients in the first year after diagnosis. Lifestyle based interventions would prevent an extra 848 (95% CI 71 to 1 614) deaths in post-AMI patients and an extra 7249 (95% CI 995 to 16 696) deaths in heart failure patients.

CONCLUSIONS

Moving from current to "best" practice as recommended in the NSF will have a much greater impact on one year mortality rates among heart failure patients compared with post-AMI patients. Meeting pharmacological based recommendations for heart failure patients will prevent more deaths than meeting lifestyle based recommendations. Population impact numbers can help communicate the impact on a population of the implementation of guidelines and, when created using local data, could help policy makers assess the local impact of implementing a range of health care targets.

Urban-rural inequalities in ischemic heart disease in Scotland, 1981-1999

OBJECTIVES

We sought to describe the pattern and magnitude of urban-rural variation in ischemic heart disease (IHD) in Scotland and to examine the associations among IHD health indicators, level of rurality, and degree of socioeconomic deprivation.

METHODS

We used routine population and health data on the population aged 40-74 years between 1981 and 1999 and living in 826 small areas (average population=5600) in Scotland. Three IHD health indicators-mortality rates (deaths per 100,000 population), rates of continuous hospital stays (discharges per 100,000 population), and rates of mortality in the hospital or within 28 days of discharge (MH+) were analyzed with multilevel Poisson models. A 4-level rurality classification was used: urban areas, remote small towns, accessible rural areas, and remote rural areas.

RESULTS

Rates of mortality, continuous hospital stays, and MH+ increased with area socioeconomic deprivation. After adjustment for population age, gender, and deprivation, the relative risk of IHD mortality in remote rural areas was similar to that of urban areas in 1981; the relative risk of a continuous hospital stay was significantly lower (relative risk [RR] = 0.70; 95% confidence interval [CI] = 0.64, 0.76) and the relative risk of MH+ was higher (RR=1.18; 95% CI=1.04, 1.35) in remote rural areas. Mortality and MH+ declined for all ruralities over time. However, MH+ remains highest in remote rural areas and remote towns.

CONCLUSIONS

Low standardized ratios of IHD continuous hospital stays and mortality in remote rural areas mask health problems among rural populations. Although absolute and relative differences between urban and rural rates of MH+ have diminished, the relative risk of MH+ remains high in remote rural areas.

Advancing vascular tissue engineering: the role of stem cell technology

Atherosclerosis and heart disease are still the leading causes of morbidity and mortality worldwide. The lack of suitable autologous grafts has produced a need for artificial grafts but the patency of such grafts is limited compared to natural materials. Tissue engineering, whereby living tissue replacements can be constructed, has emerged as a solution to some of these difficulties. This, in turn, is limited by the availability of suitable cells from which to construct the vessels. The development of prosthesis using progenitor cells and switching these into endothelial cells is an important and exciting advance in the field of tissue engineering. Here, we describe recent developments in the use of stem cells for the development of replacement vessels. These paradigm shifts in vascular engineering now offer a new route for effective clinical therapy.

First myocardial infarction in a Dutch general practice population: trends in incidence from 1975-2003

BACKGROUND

As morbidity registrations generally do not make distinct first and following myocardial infarctions, it is still unclear as to what extent the falling rates of myocardial infarctions are caused by lower incidences of first myocardial infarctions.

AIM

To investigate the incidence of first myocardial infarctions in a general practice population.

METHOD

Data were taken from the Continuous Morbidity Registration (CMR) Nijmegen, which has been collecting data from four general practices since 1971. For the 1975-2003 period, sex-specific and age-specific yearly incidence rates were obtained from the registration data of the CMR. Trends were studied with Poisson regression.

RESULTS

During the study period, 827 patients with a first myocardial infarction were identified. The incidence of first myocardial infarctions has declined since 1986 to 2.1 per 1000 for men and to 1.5 per 1000 for women. The average age of getting a first myocardial infarction increased with 3 years for men and slightly decreased for women. Since 1986, the incidence of sudden cardiac death from a first myocardial infarction has considerably declined for men and women to 0.9 and 0.7 per 1000 respectively.

CONCLUSION

A slight, significant, decline in incidence of first myocardial infarctions was found. From the mid eighties a mean annual decline of 3.5% in death from first myocardial infarction was observed. Though the variance in rates of coronary heart diseases is not unambiguous, this may indicate an effect of primary prevention. The decline was more pronounced in men, with an increasing age of getting a first myocardial infarction.

Explaining the decline in coronary heart disease mortality in Finland between 1982 and 1997

In Finland since the 1980s, coronary heart disease mortality has declined more than might be predicted by risk factor reductions alone. The aim of this study was to assess how much of the decline could be attributed to improved treatments and risk factor reductions. The authors used the cell-based IMPACT mortality model to synthesize effectiveness of treatments and risk factor reductions with data on treatments administered to patients and trends in cardiovascular risk factors in the population. Cardiovascular risk factors were measured in random samples of patients in 1982 (n=8,501) and 1997 (n=4,500). Mortality and treatment data were obtained from the National Causes of Death Register, Hospital Discharge Register, social insurance data, and medical records. Estimated and observed changes in coronary heart disease mortality were used as main outcome measures. Between 1982 and 1997, coronary heart disease mortality rates declined by 63%, with 373 fewer deaths in 1997 than expected from baseline mortality rates in 1982. Improved treatments explained approximately 23% of the mortality reduction, and risk factors explained some 53-72% of the reduction. These findings highlight the value of a comprehensive strategy that promotes primary prevention programs and actively supports secondary prevention. It also emphasizes the importance of maximizing population coverage of effective treatments.

Life-years gained from modern cardiological treatments and population risk factor changes in England and Wales, 1981-2000

OBJECTIVES

We estimated life-years gained from cardiological treatments and cardiovascular risk factor changes in England and Wales between 1981 and 2000.

METHODS

We used the IMPACT model to integrate data on the number of coronary heart disease patients, treatment uptake and effectiveness, risk factor trends, and median survival in coronary heart disease patients.

RESULTS

Compared with 1981, there were 68230 fewer coronary deaths in 2000. Approximately 925415 life-years were gained among people aged 25-84 years (range: 745 195-1 138 655). Cardiological treatments for patients accounted for approximately 194145 life-years gained (range: 142505-259225), and population risk factor changes accounted for approximately 731270 life-years gained (range; 602695-879430).

CONCLUSIONS

Modest reductions in major risk factors led to gains in life-years 4 times higher than did cardiological treatments. Effective policies to promote healthy diets and physical activity might achieve even greater gains.

Assessing the impact of heart failure specialist services on patient populations

Background

The assessment of the impact of healthcare interventions may help commissioners of healthcare services to make optimal decisions. This can be particularly the case if the impact assessment relates to specific patient populations and uses timely local data. We examined the potential impact on readmissions and mortality of specialist heart failure services capable of delivering treatments such as b-blockers and Nurse-Led Educational Intervention (N-LEI).

Methods

Statistical modelling of prevented or postponed events among previously hospitalised patients, using estimates of: treatment uptake and contraindications (based on local audit data); treatment effectiveness and intolerance (based on literature); and annual number of hospitalization per patient and annual risk of death (based on routine data).

Results

Optimal treatment uptake among eligible but untreated patients would over one year prevent or postpone 11% of all expected readmissions and 18% of all expected deaths for spironolactone, 13% of all expected readmisisons and 22% of all expected deaths for b-blockers (carvedilol) and 20% of all expected readmissions and an uncertain number of deaths for N-LEI. Optimal combined treatment uptake for all three interventions during one year among all eligible but untreated patients would prevent or postpone 37% of all expected readmissions and a minimum of 36% of all expected deaths.

Conclusion

In a population of previously hospitalised patients with low previous uptake of b-blockers and no uptake of N-LEI, optimal combined uptake of interventions through specialist heart failure services can potentially help prevent or postpone approximately four times as many readmissions and a minimum of twice as many deaths compared with simply optimising uptake of spironolactone (not necessarily requiring specialist services). Examination of the impact of different heart failure interventions can inform rational planning of relevant healthcare services.

Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000

BACKGROUND

Coronary heart disease mortality rates have been decreasing in the United Kingdom since the 1970s. Our study aimed to examine how much of the decrease in England and Wales between 1981 and 2000 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors.

METHODS AND RESULTS

The IMPACT mortality model was used to combine and analyze data on uptake and effectiveness of cardiological treatments and risk factor trends in England and Wales. The main data sources were published trials and meta-analyses, official statistics, clinical audits, and national surveys. Between 1981 and 2000, coronary heart disease mortality rates in England and Wales decreased by 62% in men and 45% in women 25 to 84 years old. This resulted in 68 230 fewer deaths in 2000. Some 42% of this decrease was attributed to treatments in individuals (including 11% to secondary prevention, 13% to heart failure treatments, 8% to initial treatments of acute myocardial infarction, and 3% to hypertension treatments) and 58% to population risk factor reductions (principally smoking, 48%; blood pressure, 9.5%; and cholesterol, 9.5%). Adverse trends were seen for physical activity, obesity and diabetes.

CONCLUSIONS

More than half the coronary heart disease mortality decrease in Britain between 1981 and 2000 was attributable to reductions in major risk factors, principally smoking. This emphasizes the importance of a comprehensive strategy that promotes primary prevention, particularly for tobacco and diet, and that maximizes population coverage of effective treatments, especially for secondary prevention and heart failure. These findings may be cautiously generalizable to the United States and other developed countries.