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1.  The UPBEAT Nurse-Delivered Personalized Care Intervention for People with Coronary Heart Disease Who Report Current Chest Pain and Depression: A Randomised Controlled Pilot Study 
PLoS ONE  2014;9(6):e98704.
Depression is common in people with coronary heart disease (CHD) and associated with worse outcome. This study explored the acceptability and feasibility of procedures for a trial and for an intervention, including its potential costs, to inform a definitive randomized controlled trial (RCT) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression.
Multi-centre, outcome assessor-blinded, randomized parallel group study. CHD patients reporting chest pain and scoring 8 or more on the HADS were randomized to personalized care (PC) or treatment as usual (TAU) for 6 months and followed for 1 year. Primary outcome was acceptability and feasibility of procedures; secondary outcomes included mood, chest pain, functional status, well being and psychological process variables.
1001 people from 17 General Practice CHD registers in South London consented to be contacted; out of 126 who were potentially eligible, 81 (35% female, mean age = 65 SD11 years) were randomized. PC participants (n = 41) identified wide ranging problems to work on with nurse-case managers. Good acceptability and feasibility was indicated by low attrition (9%), high engagement and minimal nurse time used (mean/SD = 78/19 mins assessment, 125/91 mins telephone follow up). Both groups improved on all outcomes. The largest between group difference was in the proportion no longer reporting chest pain (PC 37% vs TAU 18%; mixed effects model OR 2.21 95% CI 0.69, 7.03). Some evidence was seen that self efficacy (mean scale increase of 2.5 vs 0.9) and illness perceptions (mean scale increase of 7.8 vs 2.5) had improved in PC vs TAU participants at 1 year. PC appeared to be more cost effective up to a QALY threshold of approximately £3,000.
Trial and intervention procedures appeared to be feasible and acceptable. PC allowed patients to work on unaddressed problems and appears cheaper than TAU.
Trial Registration ISRCTN21615909
PMCID: PMC4047012  PMID: 24901956
2.  Occurrence of symptoms and depressive mood among working-aged coronary heart disease patients 
The typical symptoms of coronary heart disease (CHD), chest pain and breathlessness, are well-known. They are considered quite dramatic, and can thus be fairly reliably mapped by a survey. However, people might have other clearly unpleasant symptoms impairing quality of life. The aim of this study is to evaluate the appearance of these complaints of working-aged people with self-reported CHD.
The study consists of a postal questionnaire of randomly selected Finns in age groups 30–34, 40–44 and 50–54, a response rate of 39% (N = 15,477). The subjects were asked whether or not a doctor had told them that they had angina pectoris or had had myocardial infarction. Four randomly selected age and sex matched controls were chosen for every patient. The occurrence of self-reported dyspnoea, chest pain during anger or other kind of emotion, palpitation and perspiration without physical exercise, irregular heartbeats, flushing, trembling of hands and voice, jerking of muscles, depression and day-time sleepiness were examined. Odds ratios (OR) with 95% confidence intervals (CI), between occurrence of symptoms and CHD with and without heart infarction, were computed by multivariate logistic regression analysis.
The sample eventually comprised 319 CHD patients. Dyspnoea, chest pain during anger or other kind of emotion, palpitation, perspiration without physical exercise, irregular heartbeats daily or almost daily, trembling of hands and voice, and jerking of muscles occurred statistically significantly more frequently among CHD patients than among controls. The CHD patients also reported more depressive mood according to Beck's inventory scores and poorer sleep and more frequent day-time sleepiness than controls. In the multivariate logistic regression analysis chest pain during anger or other kind of emotion (ORs 4.12 and 3.61) and dyspnoea (ORs 2.33 and 3.81) were the symptoms most associated with CHD.
Working-aged people with self-reported coronary heart disease evince a number of symptoms limiting the quality of their every day life. This aspect should be paid attention to when evaluating functional capacity of these patients.
PMCID: PMC534791  PMID: 15533254
3.  Impact of socioeconomic status on coronary mortality in people with symptoms, electrocardiographic abnormalities, both or neither: the original Whitehall study 25 year follow up 
OBJECTIVES—To determine the impact of socioeconomic status (SES) on coronary heart disease (CHD) mortality in people with and without prevalent CHD at baseline.
DESIGN—Cohort study with 25 year follow up; prevalent CHD was defined by Q, ST or T wave electrocardiographic (ECG) abnormalities or symptoms (defined by the Rose chest pain questionnaire and self reported doctor diagnosis) or both. SES was defined by four civil service employment grades.
PARTICIPANTS—17 907 male civil servants aged 40-69 years.
MAIN OUTCOME MEASURES—CHD mortality (n=2695 deaths).
RESULTS—The lowest versus highest employment grade was associated with increased CHD mortality (age adjusted hazard ratio 1.56 (95% CI 1.2, 2.1)), prevalence of symptoms and, among symptomatic participants only, the prevalence of Q, ST or T abnormalities. Thirty one per cent of CHD deaths occurred in participants with prevalent CHD at baseline. Among participants without Q, ST or T abnormality employment grade was associated with CHD mortality; the hazard ratios (lowest v highest grade) adjusted for age, systolic and diastolic blood pressure were 1.72 (95% CI 1.4, 2.1) for asymptomatic and 1.52 (95% CI 1.1, 2.1) for symptomatic participants; among participants with Q, ST or T abnormality the corresponding hazard ratios were 1.46 (95% CI 0.7, 2.9) and 1.14 (95% CI 0.6, 2.0) respectively.
CONCLUSIONS—SES was inversely associated with CHD mortality in civil servants with and without prevalent CHD at baseline. Further distinguishing the relative contribution of SES to the initiation and progression of CHD requires repeated measures studies of pre-clinical and clinical measures of CHD.

Keywords: socioeconomic status; coronary mortality
PMCID: PMC1731713  PMID: 10846193
4.  Gender differences in presentation and diagnosis of chest pain in primary care 
BMC Family Practice  2009;10:79.
Chest pain is a common complaint and reason for consultation in primary care. Research related to gender differences in regard to Coronary Heart Disease (CHD) has been mainly conducted in hospital but not in primary care settings. We aimed to analyse gender differences in aetiology and clinical characteristics of chest pain and to provide gender related symptoms and signs associated with CHD.
We included 1212 consecutive patients with chest pain aged 35 years and older attending 74 general practitioners (GPs). GPs recorded symptoms and findings of each patient and provided follow up information. An independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the aetiology of chest pain at the time of patient recruitment. Multivariable regression analysis was performed to identify clinical predictors that help to rule in or out CHD in women and men.
Women showed more psychogenic disorders (women 11,2%, men 7.3%, p = 0.02), men suffered more from CHD (women 13.0%, men 17.2%, p = 0.04), trauma (women 1.8%, men 5.1%, p < 0.001) and pneumonia/pleurisy (women 1.3%, men 3.0%, p = 0.04) Men showed significantly more often chest pain localised on the right side of the chest (women 9.1%, men 25.0%, p = 0.01). For both genders known clinical vascular disease, pain worse with exercise and age were associated positively with CHD. In women pain duration above one hour was associated positively with CHD, while shorter pain durations showed an association with CHD in men. In women negative associations were found for stinging pain and in men for pain depending on inspiration and localised muscle tension.
We found gender differences in regard to aetiology, selected clinical characteristics and association of symptoms and signs with CHD in patients presenting with chest pain in a primary care setting. Further research is necessary to elucidate whether these differences would support recommendations for different diagnostic approaches for CHD according to a patient's gender.
PMCID: PMC2801475  PMID: 20003406
5.  Is the prevalence of coronary heart disease falling in British men? 
Heart  2001;86(5):499-505.
OBJECTIVE—To assess whether long term trends over time in acute coronary heart disease (CHD) event rates have influenced the burden of prevalent CHD in British men.
DESIGN—Longitudinal cohort study.
PARTICIPANTS—7735 men, aged 40-59 at entry (1978-80), selected from 24 British towns.
METHODS—The prevalences of current angina symptoms and history of diagnosed CHD were ascertained by questionnaire in 1978-80, 1983-85, 1992, and 1996. New major CHD events (fatal and non-fatal) were ascertained throughout the study from National Health Service central registers and general practice record reviews. Age adjusted trends in CHD prevalence were compared with trends in major CHD event rates.
RESULTS—From 1978-1996 there was a clear decline in the prevalence of current angina symptoms: the age adjusted annual percentage change in odds was -1.8% (95% confidence interval (CI) -2.8% to -0.8%). However, there was no evidence of a trend in the prevalence of history of diagnosed CHD (annual change in odds 0.1%, 95% CI -1.0% to 1.2%). Over the same period, the CHD mortality rate fell substantially (annual change -4.1%, 95% CI -6.5% to -1.6%); rates of non-fatal myocardial infarction, all major CHD events, and first major CHD event fell by -1.7% (95% CI -3.9% to 0.5%), -2.5% (95% CI -4.1% to -0.8%), and -2.4% (95% CI% -4.3 to -0.4%), respectively.
CONCLUSIONS—These results suggest that middle aged British men are less likely to experience symptoms of angina than in previous decades but are just as likely to have a history of diagnosed CHD. Despite falling rates of new major events and falling symptom prevalence, the need for secondary prevention among middle aged men with established CHD is as great as ever.

Keywords: coronary heart disease; angina; prevalence; trends
PMCID: PMC1729960  PMID: 11602539
6.  A prospective study of the consulting behaviour of older people with knee pain 
Knee pain is common among older adults but only a minority consult their doctor about it.
To determine predictors of new episodes of consultation in primary care among older people with knee pain.
Design of study
Population-based prospective cohort study linking baseline survey to primary care medical records.
Three general practices in North Staffordshire, UK.
Subjects were 1797 people aged >50 years who responded to a general population survey, reported knee pain in the previous 12 months and had no record of a knee disorder consultation in the 18 months prior to the survey. The main outcome measure was a record of a knee disorder consultation in the 18 months following the survey.
The incidence of a new episode of general practice care was approximately 10% per year. Apart from chronicity (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.1 to 2.1), measures of pain severity were not strong influences on future consultation. No social support (measured by having no partner) increased likelihood of future consultation (OR = 1.3; 95% CI = 1.0 to 1.8). Among those with chronic and severe pain, main predictors were previous experiences of health care (use of non-GP services OR = 1.8; previous knee injury OR = 1.7). Current depression reduced likelihood of consulting about the knee problem (OR = 0.6; 95% CI = 0.3 to 0.9).
Knee pain is common in the older population but a minority consult their doctor about it. Severity of pain and disability is not a strong influence on consultation. For those more severely affected, depression may act as a barrier to healthcare use.
PMCID: PMC1832234  PMID: 16611515
health care surveys; knee; medical records; primary health care; utilization
7.  Accuracy of symptoms and signs for coronary heart disease assessed in primary care 
The British Journal of General Practice  2010;60(575):e246-e257.
Diagnosing the aetiology of chest pain is challenging. There is still a lack of data on the diagnostic accuracy of signs and symptoms for acute coronary events in low-prevalence settings.
To evaluate the diagnostic accuracy of symptoms and signs in patients presenting to general practice with chest pain.
Design of study
Cross-sectional diagnostic study with delayed-type reference standard.
Seventy-four general practices in Germany.
The study included 1249 consecutive patients presenting with chest pain. Data were reviewed by an independent reference panel, with coronary heart disease (CHD) and an indication for urgent hospital admission as reference conditions. Main outcome measures were sensitivity, specificity, likelihood ratio, predictive value, and odds ratio (OR) for non-trauma patients with a reference diagnosis.
Several signs and symptoms showed strong associations with CHD, including known vascular disease (OR = 5.13; 95% confidence interval [CI] = 2.83 to 9.30), pain worse on exercise (OR = 4.27; 95% CI = 2.31 to 7.88), patient assumes cardiac origin of pain (OR = 3.20; 95% CI = 1.53 to 6.60), cough present (OR = 0.08; 95% CI = 0.01 to 0.77), and pain reproducible on palpation (OR = 0.27; 95% CI = 0.13 to 0.56). For urgent hospital admission, effective criteria included pain radiating to the left arm (OR = 8.81; 95% CI = 2.58 to 30.05), known clinical vascular disease (OR = 7.50; 95% CI = 2.88 to 19.55), home visit requested (OR = 7.31; 95% CI = 2.27 to 23.57), and known heart failure (OR = 3.53; 95% CI = 1.14 to 10.96).
Although individual criteria were only moderately effective, in combination they can help to decide about further management of patients with chest pain in primary care.
PMCID: PMC2880766  PMID: 20529488
chest pain; medical history taking; myocardial ischaemia; primary health care; sensitivity and specificity
8.  Metabolic syndrome and risk of coronary heart disease in a Pakistani cohort 
Heart  2005;91(8):1003-1007.
Objective: To assess the relation of the metabolic insulin resistance syndrome (M-IRS) with coronary heart disease (CHD) in Pakistani patients.
Subjects: 200 patients with angiographic disease (CHD(+)) matched with 200 patients with chest pain without occlusive disease (CHD(−)).
Design: Prospective case–control study.
Setting: Tertiary referral cardiology unit in Pakistan.
Results: M-IRS was present in 37% of CHD(+) versus 27% of CHD(−) patients by criteria for white patients or 47% versus 42%, respectively, by Asian criteria (p < 0.001). After adjustment for other risk factors, M-IRS was not a significant predictor for CHD or angiographic disease. Age (p  =  0.03), smoking (p < 0.001), diabetes-years (p = 0.003), sialic acid (p  =  0.01), and creatinine (p  =  0.008) accounted for the excess risk of CHD. Similarly, age (p  =  0.005), creatinine (p < 0.001), cigarette pack-years (p  =  0.02), diabetes-years (p  =  0.003), and sialic acid (p  =  0.08) were predictors of greater angiographic disease. M-IRS differed between Pakistani and white patients, as waist circumference correlated weakly (r  =  −0.03–0.08, p  =  0.45–0.52) with triglycerides, high density lipoprotein cholesterol, systolic blood pressure, or glucose. Sialic acid was the only inflammatory marker associated with M-IRS.
Conclusions: Despite strong associations between individual risk factors associated with M-IRS and a univariate association between M-IRS and CHD in native Pakistanis, the principal discriminant risk factors in this group are age, smoking, inflammation, diabetes-years, and impaired renal function. The poor sensitivity of M-IRS for CHD reflects the high underlying prevalence of M-IRS, thus reducing sensitivity, confounding by other urban lifestyle traits, or a lack of association of waist circumference with M-IRS risk factors. The definition of M-IRS may have to be revised to increase its power as a discriminant risk factor for CHD in Pakistani populations.
PMCID: PMC1769029  PMID: 16020583
coronary heart disease; Indian Asian; insulin resistance; metabolic syndrome; risk
9.  Urinary isoflavonoids and risk of coronary heart disease 
Background Whether soy food consumption may protect against coronary heart disease (CHD) remains controversial. No previous study has used biomarkers of soy intake in assessing the relationship between soy consumption and CHD. Biomarkers that reflect both intake and metabolism may be more informative than self-reports of dietary intake.
Methods We examined associations of urinary isoflavonoids, a biomarker of soy or soy isoflavone intake, with risk of CHD in a case–control study nested within two prospective cohort studies of Chinese adults in Shanghai. Cases were defined as subjects with no history of CHD at baseline who developed incident CHD during follow-up. Control subjects were randomly selected from those who remained free of CHD and matched to cases by sex, age, date and time of sample collection and antibiotic use. Baseline urinary isoflavonoids (daidzein, genistein, glycitein, equol, O-desmethylangolensin, dihydrodaidzein and dihydrogenistein) were compared between cases (n = 377) and control subjects (n = 753). Conditional logistic regression was used to evaluate the associations.
Results Total urinary isoflavonoids were not associated with CHD in either women or men. However, urinary equol excretion showed a significant inverse association with CHD in women. The adjusted odds ratios (95% confidence intervals) for CHD across increasing quartiles of equol levels in women were 1 (reference), 0.61 (0.32, 1.15), 0.51 (0.26, 0.98) and 0.46 (0.24, 0.89) (P = 0.02 for trend).
Conclusions Our study suggests for the first time that equol, a bioactive metabolite of soy isoflavone daidzein, may be inversely associated with risk of CHD in women.
PMCID: PMC3465770  PMID: 22927214
coronary disease; isoflavones; soy foods
10.  Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule 
The British Journal of General Practice  2012;62(599):e415-e421.
The Marburg Heart Score (MHS) aims to assist GPs in safely ruling out coronary heart disease (CHD) in patients presenting with chest pain, and to guide management decisions.
To investigate the diagnostic accuracy of the MHS in an independent sample and to evaluate the generalisability to new patients.
Design and setting
Cross-sectional diagnostic study with delayed-type reference standard in general practice in Hesse, Germany.
Fifty-six German GPs recruited 844 males and females aged ≥35 years, presenting between July 2009 and February 2010 with chest pain. Baseline data included the items of the MHS. Data on the subsequent course of chest pain, investigations, hospitalisations, and medication were collected over 6 months and were reviewed by an independent expert panel. CHD was the reference condition. Measures of diagnostic accuracy included the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, likelihood ratios, and predictive values.
The AUC was 0.84 (95% confidence interval [CI] = 0.80 to 0.88). For a cut-off value of 3, the MHS showed a sensitivity of 89.1% (95% CI = 81.1% to 94.0%), a specificity of 63.5% (95% CI = 60.0% to 66.9%), a positive predictive value of 23.3% (95% CI = 19.2% to 28.0%), and a negative predictive value of 97.9% (95% CI = 96.2% to 98.9%).
Considering the diagnostic accuracy of the MHS, its generalisability, and ease of application, its use in clinical practice is recommended.
PMCID: PMC3361121  PMID: 22687234
chest pain; medical history taking; myocardial ischaemia; sensitivity and specificity
11.  Racial/Ethnic and Socioeconomic Disparities in Health-Related Quality of Life Among People With Coronary Heart Disease, 2007 
Preventing Chronic Disease  2011;8(4):A78.
Health-related quality of life (HRQOL) refers to a person's or group's perceived physical and mental health over time. Coronary heart disease (CHD) affects HRQOL and likely varies among groups. This study examined disparities in HRQOL among adults with self-reported CHD.
We examined disparities in HRQOL by using the unhealthy days measurements among adults who self-reported CHD in the 2007 Behavioral Risk Factor Surveillance System state-based telephone survey. CHD was based on self-reported medical history of heart attack, angina, or coronary heart disease. We assessed differences in fair/poor health status, 14 or more physically unhealthy days, 14 or more mentally unhealthy days, 14 or more total unhealthy days (total of physically and mentally unhealthy days), and 14 or more activity-limited days. Multivariate logistic regression models included age, race/ethnicity, sex, education, annual household income, household size, and health insurance coverage.
Of the population surveyed, 35,378 (6.1%) self-reported CHD. Compared with non-Hispanic whites, Native Americans were more likely to report fair/poor health status (adjusted odds ratio [AOR], 1.7), 14 or more total unhealthy days (AOR, 1.6), 14 or more physically unhealthy days (AOR, 1.7), and 14 or more activity-limited days (AOR, 1.9). Hispanics were more likely than non-Hispanic whites to report fair/poor health status (AOR, 1.5) and less likely to report 14 or more activity-limited days (AOR, 0.5), and Asians were less likely to report 14 or more activity-limited days (AOR, 0.2). Non-Hispanic blacks did not differ in unhealthy days measurements from non-Hispanic whites. The proportion reporting 14 or more total unhealthy days increased with increasing age, was higher among women than men, and was lower with increasing levels of education and income.
There are sex, racial/ethnic, and socioeconomic disparities in HRQOL among people with CHD. Tailoring interventions to people who have both with CHD and poor HRQOL may assist in the overall management of CHD.
PMCID: PMC3136984  PMID: 21672402
12.  Use of global coronary heart disease risk assessment in practice: a cross-sectional survey of a sample of U.S. physicians 
Global coronary heart disease (CHD) risk assessment is recommended to guide primary preventive pharmacotherapy. However, little is known about physicians' understanding and use of global CHD risk assessment. Our objective was to examine US physicians' awareness, use, and attitudes regarding global CHD risk assessment in clinical practice, and how these vary by provider specialty.
Using a web-based survey of US family physicians, general internists, and cardiologists, we examined awareness of tools available to calculate CHD risk, method and use of CHD risk assessment, attitudes towards CHD risk assessment, and frequency of using CHD risk assessment to guide recommendations of aspirin, lipid-lowering and blood pressure (BP) lowering therapies for primary prevention. Characteristics of physicians indicating they use CHD risk assessments were compared in unadjusted and adjusted analyses.
A total of 952 physicians completed the questionnaire, with 92% reporting awareness of tools available to calculate CHD global risk. Among those aware of such tools, over 80% agreed that CHD risk calculation is useful, improves patient care, and leads to better decisions about recommending preventive therapies. However, only 41% use CHD risk assessment in practice. The most commonly reported barrier to CHD risk assessment is that it is too time consuming. Among respondents who calculate global CHD risk, 69% indicated they use it to guide lipid lowering therapy recommendations; 54% use it to guide aspirin therapy recommendations; and 48% use it to guide BP lowering therapy. Only 40% of respondents who use global CHD risk routinely tell patients their risk. Use of a personal digital assistant or smart phone was associated with reported use of CHD risk assessment (adjusted OR 1.58; 95% CI 1.17-2.12).
Reported awareness of tools to calculate global CHD risk appears high, but the majority of physicians in this sample do not use CHD risk assessments in practice. A minority of physicians in this sample use global CHD risk to guide prescription decisions or to motivate patients. Educational interventions and system improvements to improve physicians' effective use of global CHD risk assessment should be developed and tested.
PMCID: PMC3292915  PMID: 22273080
13.  Women and Non-Cardiac Chest Pain: Gender Differences in Symptom Presentation 
Archives of women's mental health  2008;11(4):287-293.
A substantial number of individuals evaluated for complaints of chest pain do not suffer from coronary heart disease (CHD). Studies show that many patients who complain of symptoms that might be caused by CHD, such as shortness of breath or chest pain, may actually have an anxiety disorder. Gender differences in how patients present with these symptoms have not been adequately explored. The purpose of this study was to explore possible gender differences in the presentation of patients with CHD-like symptoms. Two groups were examined, one comprising 6,381 individuals self-referred for electron beam tomography (EBT) studies and a subset of these individuals who defined a “low-risk” group based on the absence of risk factors for CHD and low coronary artery calcium (CAC) scores. We explored gender differences in symptom presentation in each group after controlling for relevant variables by using logistic regression models.
These analyses showed that women were significantly more likely than men to endorse CHD symptoms that might also be caused by an anxiety disorder. Women in the low risk group reported CHD symptoms also referable to anxiety more often than men, but unlike men did not complain primarily of chest pain. Women were also more likely to have been prescribed antianxiety or antidepressant medication. In previous studies, non-cardiac chest pain has been considered a hallmark of anxiety in individuals seen in medical settings. This study suggests that in individuals with low risk for CHD chest pain was not related to gender, but other anxiety-related symptoms including heart flutter, lightheadedness, nausea, and shortness of breath were more likely to be reported in women than in men.
PMCID: PMC2574964  PMID: 18592345
Non-cardiac chest pain; anxiety; coronary heart disease; gender; symptom
14.  Social and gender variation in the prevalence, presentation and general practitioner provisional diagnosis of chest pain 
OBJECTIVES—To describe the prevalence of Rose angina and non-exertional chest pain in men and women in socioeconomically contrasting areas; to describe the proportions of men and women who present with the symptom of chest pain and who receive a provisional general practitioner diagnosis of coronary heart disease; to assess the effects of gender and deprivation.
DESIGN—Two random general population samples in socially contrasting areas were surveyed using the Rose angina questionnaire: the case notes of people identified with chest pain were reviewed.
SETTING—Glasgow conurbation.
PARTICIPANTS—1107 men and women, aged 45-64, with chest pain.
OUTCOME MEASURES—Prevalence of Rose angina and non-exertional chest pain; the proportions who had presented with chest pain and received a general practitioner's provisional diagnosis of coronary heart disease.
RESULTS—There was no difference between social groups in the prevalence of all chest pain but a greater proportion of those in deprived groups had Rose angina and a greater proportion of these had the more severe grade. The proportion of people who had presented with chest pain was higher among socioeconomically deprived groups but there was no difference in the proportions receiving a general practitioner provisional diagnosis of coronary heart disease. Men were more likely to present with chest pain than women and were more likely to receive a provisional general practitioner diagnosis of coronary heart disease.
CONCLUSIONS—No evidence was found of social differences in patient presentation or general practitioner diagnosis that might explain reported variations in uptake of cardiology services. In contrast, gender variation may originate in part from differences in patient presentation and general practitioner diagnosis. Further investigation of socioeconomic variations in uptake of cardiology services should focus later in the care pathway, on general practitioner referral patterns and clinical decisions taken in secondary care.

Keywords: angina; social class; gender; primary care; chest pain
PMCID: PMC1731754  PMID: 10942455
15.  Economic Evaluation of Cardio inCode®, a Clinical-Genetic Function for Coronary Heart Disease Risk Assessment 
A clinical–genetic function (Cardio inCode®) was generated using genetic variants associated with coronary heart disease (CHD), but not with classical CHD risk factors, to achieve a more precise estimation of the CHD risk of individuals by incorporating genetics into risk equations [Framingham and REGICOR (Registre Gironí del Cor)].
The objective of this study was to conduct an economic analysis of the CHD risk assessment with Cardio inCode®, which incorporates the patient’s genetic risk into the functions of REGICOR and Framingham, compared with the standard method (using only the functions).
A Markov model was developed with seven states of health (low CHD risk, moderate CHD risk, high CHD risk, CHD event, recurrent CHD, chronic CHD, and death). The reclassification of CHD risk derived from genetic information and transition probabilities between states was obtained from a validation study conducted in cohorts of REGICOR (Spain) and Framingham (USA). It was assumed that patients classified as at moderate risk by the standard method were the best candidates to test the risk reclassification with Cardio inCode®. The utilities and costs (€; year 2011 values) of Markov states were obtained from the literature and Spanish sources. The analysis was performed from the perspective of the Spanish National Health System, for a life expectancy of 82 years in Spain. An annual discount rate of 3.5 % for costs and benefits was applied.
For a Cardio inCode® price of €400, the cost per QALY gained compared with the standard method [incremental cost-effectiveness ratio (ICER)] would be €12,969 and €21,385 in REGICOR and Framingham cohorts, respectively. The threshold price of Cardio inCode® to reach the ICER threshold generally accepted in Spain (€30,000/QALY) would range between €668 and €836. The greatest benefit occurred in the subgroup of patients with moderate–high risk, with a high-risk reclassification of 22.8 % and 12 % of patients and an ICER of €1,652/QALY and €5,884/QALY in the REGICOR and Framingham cohorts, respectively. Sensitivity analyses confirmed the stability of the study results.
Cardio inCode® is a cost-effective risk score option in CHD risk assessment compared with the standard method.
PMCID: PMC3825137  PMID: 24078223
16.  Measuring health-related quality of life in population-based studies of coronary heart disease: comparing six generic indexes and a disease-specific proxy score 
Quality of Life Research  2009;18(9):1239-1247.
To compare HRQoL differences with CHD in generic indexes and a proxy CVD-specific score in a nationally representative sample of U.S. adults.
The National Health Measurement Study, a cross-sectional random-digit-dialed telephone survey of adults aged 35–89, administered the EQ-5D, QWB-SA, HUI2, HUI3, SF-36v2™ (yielding PCS, MCS, and SF-6D), and HALex. Analyses compared 3,350 without CHD (group 1), 265 with CHD not taking chest pain medication (group 2), and 218 with CHD currently taking chest pain medication (group 3), with and without adjustment for demographic variables and comorbidities. Data on 154 patients from heart failure clinics were used to construct a proxy score utilizing generic items probing CVD symptoms.
Mean scores differed between CHD groups for all indexes with and without adjustment (P < 0.0001 for all except MCS P = 0.018). Unadjusted group 3 versus 1 differences were about three times larger than for group 2 versus 1. Standardized differences for the proxy score were similar to those for generic indexes, and were about 1.0 for all except MCS for group 3 versus 1.
Generic indexes capture differences in HRQoL in population-based studies of CHD similarly to a score constructed from questions probing CVD-specific symptoms.
PMCID: PMC2759459  PMID: 19760103
HRQoL; CHD; Generic index; Disease-specific index; SF-36; SF-6D; HUI2; HUI3; QWB-SA; EQ-5D; HALex
17.  Inducible ischemia and the risk of recurrent cardiovascular events in outpatients with stable coronary heart disease: The Heart and Soul Study 
Archives of internal medicine  2008;168(13):1423-1428.
To compare the prognosis of stable coronary heart disease (CHD) patients with self-reported angina symptoms, inducible ischemia, or both.
Current guidelines do not recommend routine cardiac stress testing in patients with stable CHD unless they report symptoms of angina.
We measured self-reported angina by questionnaire and inducible ischemia using treadmill stress echocardiography in 937 outpatients with stable CHD. We used Cox proportional hazards models to evaluate the independent association of angina and inducible ischemia with CHD events (myocardial infarction or CHD death) during an average 3.9 years of follow-up, adjusted for traditional cardiovascular risk factors.
Of the study participants, 129 (14%) had angina alone, 188 (20%) had inducible ischemia alone, and 40 (4%) had both angina and ischemia. Recurrent CHD events occurred in 7% of participants without angina or inducible ischemia, 10% of those with angina alone, 21% of those with inducible ischemia alone, and 23% of those with both angina and inducible ischemia (p<0.0001). The presence of angina alone was not associated with recurrent CHD events (HR 1.4, 95% CI 0.7–2.9; p=.3). However, the presence of inducible ischemia without self-reported angina strongly predicted recurrent CHD events (HR 2.2, 95% CI, 1.4–3.5; p=.001).
We found that 24% of patients with stable CHD have inducible ischemia and over 80% of these do not report angina. The presence of inducible ischemia without self-reported angina is associated with a greater than 2-fold increased rate of recurrent CHD events.
PMCID: PMC2675881  PMID: 18625923
18.  The Association of Self-Reported Coronary Heart Disease with Diabetes Duration in Korea 
Diabetes & Metabolism Journal  2012;36(5):350-356.
This study aimed to investigate the association of diabetes duration with self-reported coronary heart disease (CHD) in Korea.
Among data from 34,145 persons compiled in the third Korean National Health and Nutrition Examination Survey in 2005, laboratory test and nutritional survey data from 5,531 persons were examined. The participants were asked to recall a physician's diagnosis of CHD (angina or myocardial infarction).
Age- and sex-adjusted relative risk for CHD was 1.51 (95% confidence interval [CI], 0.64 to 3.59; not significant) for diabetes with duration of <1 year, 2.27 (95% CI, 1.14 to 4.54; P=0.020) for diabetes with a duration of 1 to 5 years, and 3.29 (95% CI, 1.78 to 6.08; P<0.001) for diabetes with a duration >5 years, compared with non-diabetes as a control. Even after adjusting for age, sex, current smoking status, waist circumference, hypertension, triglycerides, high density lipoprotein cholesterol, and fasting plasma glucose, relative risk for CHD was 2.87 (95% CI, 1.01 to 8.11; P=0.047) in diabetes with a duration of 6 to 10 years and 4.07 (95% CI, 1.73 to 9.63; P=0.001) in diabetes with duration of >10 years with non-diabetes as a control.
CHD prevalence increased with an increase in diabetes duration in Korean men and women. Recently detected diabetes (duration <1 year) was not significantly associated with CHD prevalence compared to non-diabetes. However, diabetes of a duration of >5 years was associated with an increase in CHD compared to non-diabetics after adjusting for several CHD risk factors.
PMCID: PMC3486981  PMID: 23130319
Coronary disease; Diabetes mellitus; Duration
19.  Rose Angina Questionnaire: Validation with cardiologists' diagnoses to detect coronary heart disease in Bangladesh 
Indian Heart Journal  2013;65(1):30-39.
The study aimed to validate the Rose Angina Questionnaire (RAQ) to detect coronary heart disease (CHD) by comparing with cardiologists' diagnoses in Bangladesh.
Patients aged 40–75 years attending to two cardiac hospitals were diagnosed as either CHD positive or CHD negative by cardiologists. The RAQ was used to reclassify them into CHD positive [RAQ] and CHD negative [RAQ].
There were 302 CHD positive [cardiologists] and 302 CHD negative [cardiologists] individuals. The RAQ reclassified 194 individuals as CHD positive [RAQ] and 409 individuals as CHD negative [RAQ]. Therefore, the RAQ had 53% sensitivity and 89% specificity. There was no difference in sensitivity and specificity during subgroup analyzes by age and gender; the sensitivity was higher among people from lower socio-economic status.
The RAQ, having moderate sensitivity but high specificity to detect CHD, can be used to screen individuals at risk of CHD in large-scale epidemiological surveys.
PMCID: PMC3861154  PMID: 23438610
Rose Angina Questionnaire; Coronary heart disease; Bangladesh
20.  A Coronary Heart Disease Risk Score Based on Patient Reported Information 
The American journal of cardiology  2007;99(9):1236-1241.
To develop a simple, patient self-report based coronary heart disease (CHD) risk score for adults without previously diagnosed CHD (Personal HEART score) we used the Atherosclerosis Risk In Communities (ARIC) study, a prospective cohort of individuals 45–64 at baseline, to develop a measure for 10-year risk for CHD (n=14,343). The variables evaluated for inclusion included age, history of diabetes mellitus, history of hypercholesterolemia, history of hypertension, family history of CHD, smoking, physical activity and body mass index (BMI). Ten-year risk for CHD events defined as a myocardial infarction, fatal CHD or cardiac procedure. The new measure was compared to the Framingham Risk Score (FRS) and the European Systematic Coronary Risk Evaluation (SCORE). The Personal HEART score for men included age, diabetes, hypertension, hypercholesterolemia, smoking, physical activity and family history. Among men, the area under the receiver operator characteristic curve for predicting 10-year CHD for the Personal HEART score (0.65) was significantly different from the FRS (0.69) (p=.03) but not the European SCORE (0.62) (p=.12). The Personal HEART score for women included age, diabetes, hypertension, hypercholesterolemia, smoking, and BMI. The area under the curve for the Personal HEART score (0.79) for women was not significantly different from the FRS (0.81) (p=.42) and performed better than the European SCORE (0.69) (p=.01). In conclusion, the Personal HEART score identifies 10-year risk for CHD based on self-report data, is similar in predictive ability to the FRS and the European SCORE and has the potential for easy self-assessment.
PMCID: PMC1931421  PMID: 17478150
Coronary Heart Disease; heart disease risk
21.  Realising the potential of the family history in risk assessment and primary prevention of coronary heart disease in primary care: ADDFAM study protocol 
Coronary heart disease (CHD) is the leading cause of death in the developed world, and its prevention a core activity in current UK general practice. Currently, family history is not systematically integrated into cardiovascular risk assessment in the UK, Europe or the US. Further, primary health care professionals' lack the confidence to interpret family history information and there is a low level of recording of family history information in General Practice (GP) records. Primary prevention of CHD through lifestyle advice has sometimes yielded modest results although, for example, behavioural interventions targeted at "at risk" patients have produced encouraging findings. A family history approach, targeted at those requesting CHD assessment, could motivate lifestyle change. The project will assess the clinical value of incorporating systematic family history information into CHD risk assessment in primary care, from the perspective of the users of this service, the health care practitioners providing this service, and the National Health Service.
The study will include three distinct phases: (1) cross-sectional survey to ascertain baseline information on current recording of family information; (2) through an exploratory matched-pair cluster randomised study, with nested qualitative semi-structured interview and focus group study, to assess the impact of systematic family history recording on participants' and primary care professionals' experience; (3) develop an economic model of the costs and benefits of incorporating family history into CHD risk assessment.
On completion of the project, users and primary care practitioners will be more informed of the value and utility of including family history in CHD risk assessment. Further, this approach will also act as a model of how familial risk information can be integrated within mainstream primary care preventive services for common chronic diseases.
Trial Registration
Current Controlled Trials ISRCTN17943542
PMCID: PMC2765435  PMID: 19821989
22.  New and known type 2 diabetes as coronary heart disease equivalent: results from 7.6 year follow up in a middle east population 
To investigate whether the known diabetes mellitus (KDM) or newly diagnosed diabetes mellitus (NDM) could be regarded as a coronary heart disease (CHD) risk equivalent among a relatively young Middle East population with high prevalence of diabetes mellitus (DM).
A population based cohort study of 2267 men and 2931 women, aged ≥ 30 years. Prior CHD was defined as self-reported or ECG positive CHD at baseline, KDM as subjects using any kind of glucose-lowering medications and NDM according to fasting plasma glucose and 2-h postchallenge glycemia.
Participants were categorized to six groups according to the presence of known or newly diagnosed DM and CHD at baseline (DM-/CHD-, DM-/CHD+, NDM+/CHD-, NDM+/CHD+, KDM+/CHD-, KDM+/CHD+) and Cox regression analysis were used to estimate the hazard ratio (HR) of CHD events for these DM/CHD groups, given DM-/CHD-as the reference.
During 7.6-year follow up, 358 CHD events occurred. After controlling traditional risk factors, HRs of CHD events for DM-/CHD+ group were 2.1 (95% CI: 1.4-3.1) and 5.2 (3.2-8.3) in men and women respectively. Corresponding HRs for NDM+/CHD-were 1.7 (1.1-2.7) and 3.1 (1.8-5.6) and for KDM+/CHD-were 1.7 (0.9-3.3) and 6.2 (3.6-10.6) in men and women respectively. The HRs for NDM+/CHD+ and KDM+/CHD+ groups (i.e. participants with history of both diabetes and CHD) were 6.4 (3.2-12.9) and 8.0 (4.3-14.8) in women and 3.2 (1.9-5.6) and 4.2 (2.2-7.8) in men, respectively.
The hazard of CHD events did not differ between KDM+/CHD-and DM-/CHD+ in both genders using paired homogeneity test, however the HR for NDM+/CHD-was marginally lower than the HR for DM-/CHD+ in women (p = 0.085).
KDM patients in both genders and NDM especially in men exhibited a CHD risk comparable to nondiabetics with a prior CHD, furthermore diabetic subjects with prior CHD had the worst prognosis, by far more harmful in women than men; reinforcing the urgent need for intensive care and prophylactic treatment for cardiovascular diseases.
PMCID: PMC3016329  PMID: 21129219
23.  The frequency and characteristics of chronic widespread pain in general practice: a case–control study 
Chronic widespread pain is common in the community but is not often diagnosed in primary care. One explanation may be that widespread pain is presented and treated in primary care as multiple episodes of regional pain.
To determine whether patients who consult with multiple regional pain syndromes have characteristics consistent with chronic widespread pain.
Design of study
Case–control study.
One general practice in North Staffordshire, UK.
Participants were 148 cases who consulted regularly with different musculoskeletal pains over 5 years, and 524 controls who had not consulted for musculoskeletal pain during the same period. A postal questionnaire survey and medical record review were undertaken.
Cases with musculoskeletal pain reported more health problems and higher levels of fatigue than controls, and significantly worse general health and greater sleep disturbance (odds ratios 3.3. and 3.1, respectively). They generally reported more severe symptoms and consulted more frequently for a range of problems, but this was not explained by a general propensity to consult.
Patients who consult in primary care with multiple regional pain syndromes have similar characteristics to those associated with chronic widespread pain and fibromyalgia. Recognising the need for general approaches to pain management, rather than treating each syndrome as a regional problem of pain, may improve the outcome in such patients.
PMCID: PMC2034170  PMID: 17263927
case–control study; chronic pain; general practice
24.  Periodontal Disease and Coronary Heart Disease Incidence: A Systematic Review and Meta-analysis 
Journal of General Internal Medicine  2008;23(12):2079-2086.
Periodontal disease is common among adults in the US and is a potential source of chronic inflammation. Recent data have suggested an important role for chronic inflammation in the development of coronary heart disease (CHD).
To aid the United States Preventive Services Task Force (USPSTF) in evaluating whether periodontal disease is an independent novel risk factor for incident CHD.
Studies were identified by searching Medline (1966 through March 2008) and reviewing prior systematic reviews, reference lists, and consulting experts. Prospective cohort studies that assessed periodontal disease, Framingham risk factors, and coronary heart disease incidence in the general adult population without known CHD were reviewed and quality rated using criteria developed by the USPSTF. Meta-analysis of good and fair quality studies was conducted to determine summary estimates of the risk of CHD events associated with various categories of periodontal disease.
We identified seven articles of good or fair quality from seven cohorts. Several studies found periodontal disease to be independently associated with increased risk of CHD. Summary relative risk estimates for different categories of periodontal disease (including periodontitis, tooth loss, gingivitis, and bone loss) ranged from 1.24 (95% CI 1.01–1.51) to 1.34 (95% CI 1.10–1.63). Risk estimates were similar in subgroup analyses by gender, outcome, study quality, and method of periodontal disease assessment.
Periodontal disease is a risk factor or marker for CHD that is independent of traditional CHD risk factors, including socioeconomic status. Further research in this important area of public health is warranted.
PMCID: PMC2596495  PMID: 18807098
25.  Patient-Physician Agreement on the Content of CHD Prevention Discussions 
Little is known about agreement between patients and physicians on content and outcomes of clinical discussions. A common perception of content and outcomes may be desirable to optimize decision making and clinical care.
To determine patient-physician agreement on content and outcomes of coronary heart disease (CHD) prevention discussions.
Cross-sectional survey nested within a randomized CHD prevention study.
Setting and participants
University internal medicine clinic; 24 physicians and 157 patients.
Following one clinic visit, we surveyed patients and physicians on discussion content, decision making, and final decisions about CHD prevention. For comparison, we audio-recorded, transcribed, and coded 20 patient-physician visits. We calculated percent agreement between patient/physician reports, patient/transcription reports, and physician/transcription reports. We calculated Cohen’s kappas to compare patient/physician perspectives.
Patients and physicians agreed on whether CHD was discussed in 130 visits (83%; kappa=0.55; 95% CI .40–.70). When discussions occurred, they agreed about discussion content (pros versus cons) in 53% of visits (kappa=0.15; 95% CI −.01–.30), and physicians’ recommendations in 73% (kappa=0.44; 95% CI .28–.66). Patients and physicians agreed on final decisions to take medication in 78% (kappa=.58; 95% CI .45–.71) and change lifestyle in 69% (kappa=.38; 95% CI .24–.53). They agreed less often, 43%, (kappa=.13; 95% CI −.11–.37) about degree of involvement in decision making. Audio-recorded results were similar, but showed very low agreement between transcripts and patients’ and physicians’ self-report on discussion content and decision making.
Disagreements about clinical discussions and decision making may be common. Future work is needed to determine: how widespread such agreements are; whether they impact clinical outcomes; and the relative importance of the subjective experience versus objective steps of shared decision making.
PMCID: PMC4043219  PMID: 20673244
shared decision making; patient-physician agreement

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