Hospital burden of suspected acute coronary syndromes: recent trends
TL;DR: The objective of this study was to describe the changing burden of suspected ACS on the hospital sector of the National Health Service in Scotland over the period 1990–2000.
Abstract: No study has described the burden to a health service of the complete spectrum of possible acute coronary syndromes (ACS). The objective of this study was to describe the changing burden of suspected ACS on the hospital sector of the National Health Service in Scotland over the period 1990–2000.
The record linkage system for discharges from Scottish hospitals and deaths has been described previously.1 We identified all emergency hospitalisations of patients ⩾ 18 years old in Scotland between January 1990 and December 2000 where acute myocardial infarction (AMI; International classification of diseases , (ICD), ninth revision, code 410, ICD-10 I21, 22), angina (ICD-9 411, 413, ICD-10 I20, I249), or chest pain (ICD-9 786.5, ICD-10 R07) was coded as the principal diagnosis on discharge. Numbers and age and sex specific rates of discharges (and patients discharged), length of stay, revascularisation procedures, and deaths were studied. We used linear regression to examine trends in population hospitalisation rates, hospitalisation numbers, and …
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Dissertation•
28 Aug 2012
TL;DR: The principal findings are that favourable time trends in major modifiable aetiological exposures (smoking, blood pressure and HDL and non-HDL cholesterol) may explain half of a 62% decline in major CHD incidence in men over 25 years, and unfavourable rising adiposity levels limited the scale of the decline.
Abstract: Coronary heart disease (CHD) mortality rates have fallen since the 1960s in the UK. The prevalence of type 2 diabetes (T2DM), in contrast, has increased markedly in recent decades. Few attempts have been made to examine the reasons for these striking, divergent time trends. The CHD mortality and T2DM prevalence trends likely reflect in part contemporaneous trends in incidence of these conditions. The broad aim of this thesis is therefore to analyse recent trends in CHD and T2DM incidence in the UK, in relation to trends in aetiological exposures and treatment use, and in relation to each other. This epidemiological research involves statistical analysis of pre-collected data from different UK-based observational data sources, each used according to their strengths: the British Regional Heart Study cohort, The Health Improvement Network primary care database, and the Whitehall II cohort. The principal findings are that favourable time trends in major modifiable aetiological exposures (smoking, blood pressure and HDL and non-HDL cholesterol) may explain half of a 62% decline in major CHD incidence in men over 25 years. Findings for women are similar. Much of the blood pressure decline, and a third of the non-HDL cholesterol decline was associated with increased preventive medication use. Conversely, unfavourable rising adiposity levels limited the scale of the decline in major CHD incidence, and explain an estimated one quarter of a rise in T2DM incidence since the 1980s. Major CHD incidence declined faster among those with T2DM, than without, corresponding to an attenuation of excess risk of CHD associated with T2DM. By highlighting what can be achieved in terms of reducing CHD, while showing the adverse impact of rising obesity levels, the results provide evidence to help inform future efforts to reduce CHD further and curb the rise in T2DM, in the UK and in other locations.
3 citations
TL;DR: An analysis of myocardial infarction mortality in England before and after the introduction of smoke-free legislation in July 2007 concludes that the second model is to be preferred.
Abstract: Background: Numerous studies have investigated the impact of smoke-free laws on health outcomes. Large differences in estimates are in part attributable to how the long-term trend is modelled. However, the choice of appropriate trend is not always straightforward. We explore these complexities in an analysis of myocardial infarction (MI) mortality in England before and after the introduction of smoke-free legislation in July 2007. Methods: Weekly rates of MI mortality among men aged 40+ between July 2002 and December 2010 were analysed using quasi-Poisson generalised additive models. We explore two ways of modelling the long-term trend: (1) a parametric approach, where we fix the shape of the trend, and (2) a penalised spline approach, in which we allow the model to decide on the shape of the trend. Results: While both models have similar measures of fit and near identical fitted values, they have different interpretations of the legislation effect. The parametric approach estimates a significant immediate reduction in mortality rate of 13.7% (95% CI: 7.5, 19.5), whereas the penalised spline approach estimates a non-significant reduction of 2% (95% CI:-0.9, 4.8). After considering the implications of the models, evidence from sensitivity analyses and other studies, we conclude that the second model is to be preferred. Conclusions: When there is a strong long-term trend and the intervention of interest also varies over time, it is difficult for models to separate out the two components. Our recommendations will help further studies determine the best way of modelling their data.
3 citations
Cites background from "Hospital burden of suspected acute ..."
...Hospital admissions and mortality rates for coronary heart disease have been declining across Europe and North America [15-18]....
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TL;DR: Indications for PCI other than ACS have a greater likelihood of readmission with angina or non‐specific chest pain at 30‐days, and readmissions are more common in patients with modifiable risk factors, previous history of IHD and anaemia.
Abstract: Percutaneous coronary intervention (PCI) improves anginal chest pain in most, but not all, treated patients. PCI is associated with unplanned readmission for angina and non‐specific chest pain within 30‐days of index PCI. Patients with an index hospitalization for PCI between January–November in each of the years 2010–2014 were included from the United States Nationwide Readmissions Database. Of 2 723 455 included patients, the 30‐day unplanned readmission rate was 7.2% (n = 196 581, 42.3% female). This included 9.8% (n = 19 183) with angina and 11.1% (n = 21 714) with non‐specific chest pain. The unplanned readmission group were younger (62.2 vs 65.1 years; P < 0.001), more likely to be females (41.0% vs 34.2%; P < 0.001), from the lowest quartile of household income (32.9% vs 31.2%; P < 0.001), have higher prevalence of cardiovascular risk factors or have index PCI performed for non‐acute coronary syndromes (ACS) (OR:3.46, 95%CI 3.39–3.54). Factors associated with angina readmissions included female sex (OR:1.28, 95%CI 1.25–1.32), history of ischemic heart disease (IHD) (OR:3.28, 95%CI 2.95–3.66), coronary artery bypass grafts (OR:1.79, 95%CI 1.72–2.86), anaemia (OR:1.16, 95%CI 1.11–1.21), hypertension (OR:1.13, 95%CI 1.09, 1.17), and dyslipidemia (OR:1.10, 95%CI 1.06–1.14). Non‐specific chest pain compared with angina readmissions were younger (mean difference 1.25 years, 95% CI 0.99, 1.50), more likely to be females (RR:1.13, 95%CI 1.10, 1.15) and have undergone PCI for non‐ACS (RR:2.17, 95%CI 2.13, 2.21). Indications for PCI other than ACS have a greater likelihood of readmission with angina or non‐specific chest pain at 30‐days. Readmissions are more common in patients with modifiable risk factors, previous history of IHD and anaemia.
2 citations
TL;DR: The underlying mechanisms of the most common causes of chest pain in cancer patients are described with an emphasis on how their management may differ to that of non-cancer patients with chest pain and the role of the cardio-oncology team is highlighted.
Abstract: Chest pain is one of the most common presenting symptoms in patients seeking care from a physician. Risk assessment tools and scores have facilitated prompt diagnosis and optimal management in these patients; however, it is unclear as to whether a standardised approach can adequately triage chest pain in cancer patients and survivors. This is of concern because cancer patients are often at an increased risk of cardiovascular mortality and morbidity given the shared risk factors between cancer and cardiovascular disease, compounded by the fact that certain anti-cancer therapies are associated with an increased risk of cardiovascular events that can persist for weeks and even years after treatment. This article describes the underlying mechanisms of the most common causes of chest pain in cancer patients with an emphasis on how their management may differ to that of non-cancer patients with chest pain. It will also highlight the role of the cardio-oncology team, who can aid in identifying cancer therapy-related cardiovascular side-effects and provide optimal multidisciplinary care for these patients.
1 citations
TL;DR: A 43-year-old man is referred to a cardiologist with near-syncopal episodes during exercise, and an exercise electrocardiogram shows no signs of ischaemia.
Abstract: A 43-year-old man is referred to a cardiologist with near-syncopal episodes during exercise. The patient has an intermediate cardiovascular risk profile, and an exercise electrocardiogram shows no signs of ischaemia. To further rule out coronary artery disease, cardiac …
References
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TL;DR: A CPU located in the emergency department can be a safe, effective, and cost-saving means of ensuring that patients with unstable angina who are considered to be at intermediate risk for cardiovascular events receive appropriate care.
Abstract: Background Nearly half of patients hospitalized with unstable angina eventually receive a non–cardiac-related diagnosis, yet 5 percent of patients with myocardial infarction are inappropriately discharged from the emergency department. We evaluated the safety, efficacy, and cost of admission to a chest-pain observation unit (CPU) located in the emergency department for such patients. Methods We performed a community-based, prospective, randomized trial of the safety, efficacy, and cost of admission to a CPU as compared with those of regular hospital admission for patients with unstable angina who were considered to be at intermediate risk for cardiovascular events in the short term. A total of 424 eligible patients were randomly assigned to routine hospital admission (a monitored bed under the care of the cardiology service) or admission to the CPU (where patients were cared for according to a strict protocol including aspirin, heparin, continuous ST-segment monitoring, determination of creatine kinase is...
532 citations
Journal Article•
TL;DR: Howard Newcombe, pioneer and founder of probability matching techniques, has illustrated the continuing dialectic between the theory and the practical craft of linkage by being guided by the characteristics and structure of the data sets in question and close empirical attention to the emergent qualities of each linkage.
Abstract: Howard Newcombe, pioneer and founder of probability matching techniques, has illustrated the continuing dialectic between the theory and the practical craft of linkage. From the point of view of the development of record linkage in Scotland his most valuable contribution, beyond his initial formulation of the principles of probability matching, has been his emphasis on being guided by the characteristics and structure of the data sets in question and close empirical attention to the emergent qualities of each linkage (Newcombe et al. 1959; Newcombe, 1988). Particularly inspiring has been his insistence that probability matching is at heart a simple and intuitive process and should not be turned into a highly specialised procedure isolated from the day to day concerns of the organisation in which it is carried out (Newcombe et al. 1986).
383 citations
TL;DR: Care in a chest pain observation unit seems to be more effective and more cost effective than routine care for patients with acute, undifferentiated chest pain.
Abstract: Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain. Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing
254 citations
TL;DR: Any scheme which safely avoided these unnecessary admissions might save resources, reduce stress for patients, and, crucially, reduce the worrying false negatives—those missed cases of high risk coronary heart disease.
Abstract: Emergency medical admissions are important. They continue to rise year after year; consume substantial NHS resources; disrupt other NHS activities; and generate winter bed crises.1 2 Patients with acute central chest pain account for 20-30% of emergency medical admissions.3 4 Most are admitted because of concern about unstable coronary heart disease. Yet fewer than half will have a final diagnosis of acute myocardial infarction or unstable angina.4 Patients without high risk coronary heart disease thus account for over half those presenting with chest pain and over 10% of all emergency medical admissions. Such patients could be safely managed without admission, and most would prefer it. The current system is therefore both ineffective and inefficient. Any scheme which safely avoided these unnecessary admissions might save resources, reduce stress for patients, and, crucially, reduce the worrying false negatives—those missed cases of high risk coronary heart disease. …
70 citations
TL;DR: The Chest Pain Clinic service has a higher diagnostic yield for ischaemic heart disease than open access exercise electrocardiography, provides the General Practitioner with a firm clinical diagnosis in over 90% of cases, and identifies those patients requiring further treatment and invasive investigation.
Abstract: The aims of the Chest Pain Clinic were: to establish rapid-access, 'same-day', referral and attendance without a waiting list; to provide a diagnosis, treatment and follow-up plan for each patient; and to optimize the use of hospitalization for appropriate patients. Prospective data were collected from 1001 consecutive General Practitioner referrals to the Chest Pain Clinic over a 22-month period. Hospital admissions were reduced from an estimated 268 to 145 patients. Without a Chest Pain Clinic service, 213 (21%) would have been admitted inappropriately, and 89 (9%) with unstable angina or myocardial infarction would potentially have been managed in the community. A firm diagnosis was provided in 92% of cases (919 patients) with 42% (418) diagnosed as having ischaemic heart disease. The provision of a Chest Pain Clinic reduces the hospitalization of patients with benign non-cardiac chest pain whilst facilitating the identification of those patients with acute coronary syndromes requiring in-patient care. The Chest Pain Clinic service has a higher diagnostic yield for ischaemic heart disease than open access exercise electrocardiography, provides the General Practitioner with a firm clinical diagnosis in over 90% of cases, and identifies those patients requiring further treatment and invasive investigation.
54 citations