Homocysteine is associated with both myocardial infarction and arterial wall inflammation. To establish whether homocysteine is associated with myocardial infarction after adjusting for age, sex, the major cardiovascular risk factors and inflammatory risk predictors (fibrinogen, C-reactive protein and interleukin-6). A case-control study, using 364 myocardial infarction cases drawn from the north Glasgow MONICA study, 3-9 months after their event, and 383 controls drawn from the general population of the same geographical area. The odds ratio for myocardial infarction increased progressively across the four quarters of the homocysteine distribution, after adjusting for only age and sex or for the full adjustment (age, sex, smoking, systolic blood pressure, total cholesterol, fibrinogen, C-reactive protein and interleukin-6). The odds ratios produced by the two adjustments were similar. Comparing the top quarter with the bottom quarter of homocysteine, the odds ratio was 2.21 (95% confidence interval: 1.30-3.76) after the full adjustment. The odds ratio for a 5 mu mol/l increase in homocysteine was 1.12 (95% confidence interval: 1.01 - 1.24) after the full adjustment.

BACKGROUND:The association of plasma fibrinogen with myocardial infarction (MI) may (like that of C-reactive protein, CRP) be a marker of subclinical inflammation, mediated by cytokines such as interleukin-6 (IL-6). There are well-recognized discrepancies between commonly performed fibrinogen assays. Increased ratio of clottable fibrinogen to intact fibrinogen (measured by a recently developed immunoassay) has been proposed as a measure of hyperfunctional fibrinogen, and is elevated in acute MI.OBJECTIVE:To compare the associations of intact fibrinogen and four routine fibrinogen assays (two von Clauss assays; one prothrombin-time derived; and one immunonephelometric) in a case-control study of previous MI.PATIENTS/METHODS:Cases (n=399) were recruited 3-9 months after their event; 413 controls were age- and sex- matched from the case-control study local population. Intact fibrinogen was measured in 50% of subjects.RESULTS:All routine fibrinogen assays showed high intercorrelations (r=0.82-0.93) and significant (P<0.0001) increased mean levels in cases vs. controls. These four routine assays correlated only moderately with intact fibrinogen (r=0.45-0.62), while intact fibrinogen showed only a small, nonsignificant increase in cases vs. controls. Consequently, the ratio of each of the four routine assays to the intact fibrinogen assay was significantly higher (P<0.0003) in cases vs. controls. Each fibrinogen assay correlated with plasma levels of CRP and IL-6 (which were also elevated in cases vs. controls). Each routine fibrinogen assay remained significantly elevated in cases vs. controls after further adjustment for C-reactive protein and interleukin-6.CONCLUSIONS:These data provide evidence for acquired, increased hyperfunctional plasma fibrinogen in MI survivors, which is not associated with markers of inflammatory reactions. The causes and significance of these results remain to be established in prospective studies.

The prevalence and trends of coronary heart disease in British men are discussed. In Britain, approximately 150 000 deaths each year are attributed to coronary heart disease (CHD).1 CHD has been estimated to cost around £10 billion per annum, much of this through lost earnings.1 For some time, CHD has been a national priority, with targets set for reducing CHD mortality.2 Mortality rates from CHD have declined steadily in Britain over the past two decades.3 However, the reduction in CHD mortality has been more dramatic in other countries including the USA and Australia. The prevalence of CHD in the community is determined by a number of factors including the incidence of new disease, survival thereafter, and demographic trends. A fall in CHD incidence would reduce prevalence, while improved survival and an aging population would increase it. Therefore, the net effect will depend on the balance of these influences. Until now, data on population prevalence trends have been sparse. …

AIMSHospital activity represents the major component of health care expenditure related to heart failure. This study evaluated the economic impact of applying specialist nurse management programmes that limit heart failure-related hospital readmissions within a whole population.METHODSUsing a reliable and validated estimate of the current level and cost of heart failure-related hospital activity in the U.K., we determined the thresholds at which the actual cost of establishing and applying a national service based on three different models of specialist nurse management would be equal to the 'cost' of bed utilization associated with preventable hospital readmissions in the year 2000. The three models of care examined were home-based, clinic-based or a combination of home plus clinic-based, post-discharge follow-up. The potential impact of this service was based on a U.K.-wide caseload of 122,000 patients discharged to home with a discharge diagnosis of congestive heart failure in that year.RESULTSBased on heart failure-specific patterns of hospital activity, we estimate that 47,000 of these 122,000 patients would normally accumulate a total of 594000 days of associated hospital stay from 49,000 readmissions (for any reason) within 1 year of hospital discharge. The cost of these admissions to the National Health Service was calculated at 166.2 million pounds sterling. Taking into account other costs associated with such hospital activity (e.g. general practice and hospital outpatient visits) each 10% reduction in recurrent bed utilization would be associated with 18.0 million ponds sterling in cost savings. Alternatively, the cost of applying a U.K.-wide programme of home-, clinic- or home plus clinic-based follow-up was calculated to be 69.4 pounds sterling, 73.1 pounds sterling and 72.5 million pounds sterling per annum, respectively. The relative thresholds at which generated 'cost-savings' would equal the cost of applying these programmes of care would therefore be a 38.5%, 40.6% and 40.3% reduction in recurrent bed utilization, respectively. If, as expected, a home-based programme of specialist nurse management reduced recurrent bed utilization by 50% or more, annual savings equivalent to 169,000 pounds sterling per 1000 patients treated would be generated.CONCLUSIONSThis is the first study to examine the economic consequences of applying a specialist nurse-mediated, post-discharge management service for heart failure within a whole population. Our findings suggest that such a service will not only improve quality of life and reduce readmissions in patients with congestive heart failure, but also reduce costs and improve the efficiency of the health care system in doing so.

OBJECTIVETo report the mortality of left ventricular systolic dysfunction (LVD), assessed objectively by echocardiography, and its association with natriuretic peptide hormones in a random sample of 1640 men and women aged 25–74 years from a geographical, urban population.METHODSLeft ventricular function was measured by echocardiography in 1640 attendees studied in 1992–3. LVD was defined as a left ventricular ejection fraction (LVEF) ⩽ 30%. Plasma concentrations of N-terminal atrial natriuretic peptide (N-ANP) and brain natriuretic peptide (BNP) were measured by standard radioimmunoassays. Mortality was documented at four years.RESULTSThe four year all cause mortality rate in the whole cohort was 4.9% (80 deaths). It was 21% (nine deaths) in those with an LVEF ⩽ 30% and 4% in those whose LVEF was > 30% (p < 0.001). The median (interquartile range) BNP concentration in those who died was 16.9 pg/ml (8.8–27) and 7.8 pg/ml (3.4–13) in survivors (p < 0.0001). Similarly, N-ANP had a median concentration of 2.35 ng/ml (1.32–3.36) in those with a fatal outcome and 1.27 ng/ml (0.9–2.0) in those alive at four years (p < 0.0001). Subjects with an LVEF ⩽ 40% also had a significant mortality rate of 17% if they also had a BNP concentration ⩾ 17.9 pg/ml compared with 6.8% if their BNP was below this concentration (p = 0.013). Multivariate analysis revealed the independent predictors of four year all cause mortality to be increasing age (p < 0.001), a BNP concentration ⩾ 17.9 pg/ml (p = 0.006), the presence of ischaemic heart disease (p = 0.03), and male sex (p = 0.04).CONCLUSIONSLVD is associated with a considerable mortality rate in this population. BNP also independently predicts outcome. In addition to its role as a diagnostic aid in chronic heart failure and LVD, it provides prognostic information and clarifies the meaning of a given degree of LVD.

Objectives To determine whether specialist nurse intervention improves outcome in patients with chronic heart failure. Design Randomised controlled trial.Setting Acute medical admissions unit in a teaching hospital.Participants 165 patients admitted with heart failure due to left ventricular systolic dysfunction. The intervention started before discharge and continued thereafter with home visits for up to 1 year.Main outcome measures Time to first event analysis of death from all causes or readmission to hospital with worsening heart failure.Results 31 patients (37%) in the intervention group died or were readmitted with heart failure compared with 45 (53%) in the usual care group (hazard ratio= 0.61, 95% confidence interval 0.33 to 0.96). Compared with usual care, patients in the intervention group had fewer readmissions for any reason (86 v 114, P=0.018), fewer admissions for heart failure (19 v 45, P<0.001) and spent fewer days in hospital for heart failure (mean 3.43 v 7.46 days, P=0.0051).Conclusions Specially trained nurses can improve the outcome of patients admitted to hospital with heart failure.

OBJECTIVETo determine the reasons for delay in calling for help during acute myocardial infarction and the reasons for choice of first medical contact.DESIGNReview of routine medical records and one to one semi-structured interviews.SETTINGCommunity survey in city of Glasgow, north of the river Clyde.PATIENTS228 men and 85 women aged between 25 and 65 years, respectively, who survived acute myocardial infarction between October 1994 and December 1996.RESULTSOnly 25% of the subjects made a call for help within one hour of the onset of coronary symptoms; in 40% the delay was greater than four hours. Symptoms were not recognised as coronary in origin in the majority of cases. In all cases where delay was more than one hour the main reasons for the delay were thinking that symptoms would go away or that they were not serious. Requesting the attendance of a general practitioner was the first course of action in the majority of cases (55%); the main reason given was that the patient believed this should always be the first course of action. Reluctance to call the emergency services reflected the belief that the symptoms were not serious enough to warrant an ambulance.CONCLUSIONSStrategies to reduce patient delay times in this deprived urban population must focus on educating the public on the recognition and diversity of coronary symptoms and the benefits of presenting promptly to hospital by way of the emergency ambulance service.

OBJECTIVE:To evaluate the costs and benefits of alternative systems of coronary heart disease monitoring in Scotland.DESIGN:An option appraisal was conducted to evaluate the costs and benefits of implementing a coronary heart disease monitoring system. This involved a review of existing Scottish datasets and relevant reports, specification of options, definition and weighting of benefit criteria by key stakeholders, assessment of options by experts, and costing of options. The options were assessed by 33 stakeholders (grouped as cardiologists, patient representatives, general practitioners, public health physicians, and policy makers), plus 13 topic experts.SETTING:Scotland (population 5.1 million).RESULTS:Between group mean benefit weights were: mortality rates and case fatality (10.6), quality of life (9.8), patient function (8.8), hospital activity (7.8), primary care activity (9.25), prescribing (5.72), socioeconomic impact (4.0), risk factors (7.4), prevalence (5.0), incidence (6.0), case registration (6.82), international comparability (4.2), breadth of coverage (8.8), and frequency (5.8). Differences between group weights were significant for prevalence (p = 0.048) and international comparability (p = 0.032). Four monitoring options were identified: a community epidemiology model, based on MONICA (monitoring trends and determinants in cardiovascular disease) study methodology applied to a series of eight representative communities, had the highest benefits, at an average annual discounted cost of approximately pound 360,000; models based on the Australian cardiovascular disease monitoring scheme and on enhanced routine data offered fewer benefits at discounted average annual costs ranging from pound 165,000 to pound 195,000; finally, a coronary heart disease registry modelled on the Scottish Cancer Registry scheme would have had fewer benefits and substantially higher costs than the other options.CONCLUSIONS:The most beneficial coronary heart disease monitoring system is the community epidemiology model, based on MONICA methodology. Option appraisal potentially offers an explicit and transparent methodology for evidence based policy development.

OBJECTIVE To estimate the fall in coronary heart disease (CHD) mortality in Scotland attributable to medical and surgical treatments, and risk factor changes, between 1975 and 1994. DESIGN A cohort model combining effectiveness data from meta-analyses with information on treatment uptake in all patient categories in Scotland. SETTING AND PATIENTS The whole Scottish population of 5.1 million, including all patients with recognised CHD. INTERVENTIONS All cardiological, medical, and surgical treatments, and all risk factor changes between 1975 and 1994. Data were obtained from epidemiological surveys, routine National Health Service sources, and local audits. MAIN OUTCOME MEASURES Deaths from CHD in 1975 and 1994. RESULTS There were 15 234 deaths from CHD in 1994, 6205 fewer deaths than expected if there had been no decline from 1975 mortality rates. In 1994, the total number of deaths prevented or postponed by all treatments and risk factor reductions was estimated at 6747 (minimum 4790, maximum 10 695). Forty per cent of this benefit was attributed to treatments (initial treatments for acute myocardial infarction 10%, treatments for hypertension 9%, for secondary prevention 8%, for heart failure 8%, aspirin for angina 2%, coronary artery bypass grafting surgery 2%, and angioplasty 0.1%). Fifty one per cent of the reduction in deaths was attributed to measurable risk factor reductions (smoking 36%, cholesterol 6%, secular fall in blood pressure 6%, and changes in deprivation 3%). Other, unquantified factors apparently accounted for the remaining 9%. These proportions remained relatively consistent across a wide range of assumptions and estimates in a sensitivity analysis. CONCLUSIONS Medical treatments and risk factor changes apparently prevented or postponed about 6750 coronary deaths in Scotland in 1994. Modest gains from individual treatments produced a large cumulative survival benefit. Reductions in major risk factors explained about half the fall in coronary mortality, emphasising the importance and future potential of prevention strategies.

Aims: To determine the prevalence of dyspepsia and associated antisecretory medication usage, and their associations with H. pylori infection in the general population. In addition, to compare the importance of H. pylori infection relative to other potential causes of dyspepsia: alcohol, smoking and obesity.Methods: The study examined a random population sample of 784 men and 827 women from Glasgow. They completed a validated dyspepsia questionnaire and had their H. pylori status determined by serology.Results: The overall prevalence of dyspepsia was 12%; prescribed antisecretory medication had been used over the last 6 months by 7%. The odds ratio (95% CI) for dyspepsia, comparing H. pylori‐positives to negatives was 1.79 (1.03, 3.09) for men and 1.11 (0.70, 1.78) for women. Ever‐smoking (both sexes) and obesity (women) had higher odds ratios for dyspepsia than did H. pylori. Adjustment for age, social class, ever‐smoking, ever‐drinking and obesity reduced the H. pylori odds ratios for dyspepsia to 1.38 (0.73, 2.60) for men and 0.99 (0.57, 1.73) for women. The association between H. pylori and antisecretory medication usage was similar to that for dyspepsia.Conclusion: Obesity and smoking are more important risk factors, for dyspepsia and antisecretory medication usage, than is H. pylori. Reducing the burden and cost of dyspepsia will require lifestyle modification and not merely H. pylori eradication.

BACKGROUND:We sought to determine whether there is an association between the rate of prescription of angiotensin-converting enzyme (ACE) inhibitors and the rate of hospitalization for heart failure.METHODS AND RESULTS:We conducted a cross-sectional study linking prescribing data with hospital admission data from 215 primary health care practices in Greater Glasgow, United Kingdom. We obtained numbers of prescriptions of diuretics. ACE inhibitors, and digoxin and numbers of admissions for heart failure. The mean practice rate of diuretic prescription was 0.7 per patient per year, the mean practice rate of ACE inhibitor prescription was 0.06 per patient per year, the mean practice rate of digoxin prescription was 0.09 per patient per year, and the mean practice rate of admission for heart failure was 3.29 per 1,000 patients per year. There was a strong and significant association between the rate of diuretic prescription and the rate of digoxin prescription. There was only a moderate inverse association between the ratio of ACE inhibitor to diuretic prescriptions and the rate of admissions for heart failure.CONCLUSIONS:ACE inhibitors are underused. Rates of diuretic and digoxin prescriptions correlate strongly and are presumably both markers for similar cardiovascular morbidity. There was no evidence that ACE inhibitors modulated the rate of heart failure admissions.

BackgroundIn previous studies on the use of natriuretic peptides to detect left-ventricular systolic dysfunction, a higher rate of cardiac disorders in the control groups than in the study groups could have led to bias. We investigated the effectiveness of plasma N-terminal atrial natriuretic peptide (NT-ANP) and brain natriuretic peptide (BNP) concentrations to show left-ventricular systolic dysfunction in a random sample of the general population.MethodsWe randomly selected 2000 participants aged 25–74 years from family physicians' lists in Glasgow, UK. We sent all participants questionnaires. 1653 respondents underwent echocardiography and electrocardiography. We took a left-ventricular ejection fraction of 30% or less to show left-ventricular systolic dysfunction. NT-ANP and BNP were measured in plasma by RIAs.Findings1252 participants had analysable electrocardiograms and echocardiograms, completed questionnaires, and available blood samples. Median concentrations of NT-ANP and BNP were significantly higher in participants with left-ventricular systolic dysfunction (2·8 ng/mL [IQR 1·8–4·6] and 24·0 pg/mL [18·0–33·0]) than in those without (1·3 ng/mL [0·9–1·8] and 7·7 pg/mL [3·4–13·0]; each p<0·001). Among participants with left-ventricular systolic dysfunction, both symptomatic and asymptomatic subgroups had raised NT-ANP and BNP concentrations. A BNP concentration of 17·9 pg/mL or more gave a sensitivity of 77% and specificity of 87% in all participants, and 92% and 72% in participants aged 55 years or older.InterpretationMeasurement of BNP could be a cost-effective method of screening for left-ventricular systolic dysfunction in the general population, especially if its use were targeted to individuals at high risk.

Aims As heart failure is a syndrome arising from another condition, such as coronary heart disease, it is rarely officially coded as the underlying cause of death regardless of the cause recorded by the physician at the time of certification. We sought to assess the true contribution of heart failure to overall mortality and coronary heart disease mortality and to examine how this contribution has changed over time.Methods and Results We carried out a retrospective analysis of all death certificates in Scotland between 1979 and 1992 for which heart failure was coded as the underlying or a contributory cause of death. From a total of 833 622 deaths in Scotland between 1979 and 1992, heart failure was coded as the underlying cause in only 1.5% (13 695), but as a contributory cause in a further 14.3% (126 073). In 1979, 28.5% of male and 40.4% of female deaths attributed to coronary heart disease (coded as the underlying cause of death) also had a coding for heart failure. In 1992 these percentages had risen significantly to 34.1% and 44.8%, respectively (both P < 0.001). Mortality rates for heart failure as the underlying or contributory cause of death, standardized by age and sex, fell significantly over the period studied in all ages and in both sexes: by 31% in men and 41% in women <65 years and 15.8% in men and 5.1% in women greater than or equal to 65 years, respectively (P < 0.01 for all changes).Conclusions Death from heart failure is substantially underestimated by official statistics. Furthermore, one third or more of deaths currently attributed to coronary heart disease may be related to heart failure and this proportion appears to be increasing. While the absolute numbers of deaths caused by heart failure remains constant, this study is the first to show that standardized mortality rates are declining.