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1.  Coronary and cardiovascular risk estimation for primary prevention: validation of a new Sheffield table in the 1995 Scottish health survey population 
BMJ : British Medical Journal  2000;320(7236):671-676.
To examine the accuracy of a new version of the Sheffield table designed to aid decisions on lipids screening and detect thresholds for risk of coronary heart disease needed to implement current guidelines for primary prevention of cardiovascular disease.
Comparison of decisions made on the basis of the table with absolute risk of coronary heart disease or cardiovascular disease calculated by the Framingham risk function. The decisions related to statin treatment when coronary risk is ⩾30% over 10 years; aspirin treatment when the risk is ⩾15% over 10 years; and the treatment of mild hypertension when the cardiovascular risk is ⩾20% over 10 years.
The table is designed for use in general practice.
Random sample of 1000 people aged 35-64 years from the 1995 Scottish health survey.
Main outcome measures
Sensitivity, specificity, and positive and negative predictive values of the table.
13% of people had a coronary risk of ⩾15%, and 2.2% a risk of ⩾30%, over 10 years. 22% had mild hypertension (systolic blood pressure 140-159 mm Hg). The table indicated lipids screening for everyone with a coronary risk of ⩾15% over 10 years, for 95% of people with a ratio of total cholesterol to high density lipoprotein cholesterol of ⩾8.0, but for <50% with a coronary risk of <5% over 10 years. Sensitivity and specificity were 97% and 95% respectively for a coronary risk of ⩾15% over 10 years; 82% and 99% for a coronary risk of ⩾30% over 10 years; and 88% and 90% for a cardiovascular risk of ⩾20% over 10 years in mild hypertension.
The table identifies all high risk people for lipids screening, reduces screening of low risk people by more than half, and ensures that treatments are prescribed appropriately to those at high risk, while avoiding inappropriate treatment of people at low risk.
PMCID: PMC27307  PMID: 10710573
2.  Analysing falls in coronary heart disease mortality in the West Bank between 1998 and 2009 
BMJ Open  2012;2(4):e001061.
To analyse coronary heart disease (CHD) mortality and risk factor trends in the West Bank, occupied Palestinian territory between 1998 and 2009.
Modelling study using CHD IMPACT model.
The West Bank, occupied Palestinian territory.
Data on populations, mortality, patient groups and numbers, treatments and cardiovascular risk factor trends were obtained from national and local surveys, routine national and WHO statistics, and critically appraised. Data were then integrated and analysed using a previously validated CHD model.
Primary and secondary outcome measures
CHD deaths prevented or postponed are the main outcome.
CHD death rates fell by 20% in the West Bank, between 1998 and 2009. Smoking prevalence was initially high in men, 51%, but decreased to 42%. Population blood pressure levels and total cholesterol levels also decreased. Conversely, body mass index rose by 1–2 kg/m2 and diabetes increased by 2–8%. Population modelling suggested that more than two-thirds of the mortality fall was attributable to decreases in major risk factors, mainly total cholesterol, blood pressure and smoking. Approximately one-third of the CHD mortality decreases were attributable to treatments, particularly for secondary prevention and heart failure. However, the contributions from statins, surgery and angioplasty were consistently small.
CHD mortality fell by 20% between 1998 and 2009 in the West Bank. More than two-third of this fall was due to decreases in major risk factors, particularly total cholesterol and blood pressure. Our results clearly indicate that risk factor reductions in the general population compared save substantially more lives to specific treatments for individual patients. This emphasizes the importance of population-wide primary prevention strategies.
PMCID: PMC3432845  PMID: 22923626
Cardiology; Cardiac Epidemiology; Cardiology; Myocardial infarction; Epidemiology; Public Health; Surgery; Cardiac surgery
3.  Cost effectiveness of HMG-CoA reductase inhibitor (statin) treatment related to the risk of coronary heart disease and cost of drug treatment 
Heart  1999;82(3):325-332.
OBJECTIVES—To estimate the cost effectiveness of statin treatment in preventing coronary heart disease (CHD) and to examine the effect of the CHD risk level targeted and the cost of statins on the cost effectiveness of treatment.
DESIGN—Cohort life table method using data from outcome trials.
MAIN OUTCOME MEASURES—The cost per life year gained for lifelong statin treatment at annual CHD event risks of 4.5% (secondary prevention) and 3.0%, 2.0%, and 1.5% (all primary prevention), with the cost of statins varied from £100 to £800 per year.
RESULTS—The costs per life year gained according to annual CHD event risk were: for 4.5%, £5100; 3.0%, £8200; 2.0%, £10 700; and 1.5%, £12 500. Reducing the cost of statins increases cost effectiveness, and narrows the difference in cost effectiveness across the range of CHD event risks.
CONCLUSIONS—At current prices statin treatment for secondary prevention, and for primary prevention at a CHD event risk 3.0% per year, is as cost effective as many treatments in wide use. Primary prevention at lower CHD event risks (< 3.0% per year) is less cost effective and unlikely to be affordable at current prices and levels of health service funding. As the cost of statins falls, primary prevention at lower risk levels becomes more cost effective. However, the large volume of treatment needed will remain a major problem.

Keywords: coronary artery disease; cost effectiveness; statins; primary prevention; secondary prevention
PMCID: PMC1729169  PMID: 10455083
4.  Adiposity has differing associations with incident coronary heart disease and mortality in the Scottish population: cross-sectional surveys with follow-up 
Investigation of the association of excess adiposity with three different outcomes: all-cause mortality, coronary heart disease (CHD) mortality and incident CHD.
Cross-sectional surveys linked to hospital admissions and death records.
19 329 adults (aged 18–86 years) from a representative sample of the Scottish population.
Gender-stratified Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause mortality, CHD mortality and incident CHD. Separate models incorporating the anthropometric measurements body mass index (BMI), waist circumference (WC) or waist–hip ratio (WHR) were created adjusted for age, year of survey, smoking status and alcohol consumption.
For both genders, BMI-defined obesity (⩾30 kg m−2) was not associated with either an increased risk of all-cause mortality or CHD mortality. However, there was an increased risk of incident CHD among the obese men (hazard ratio (HR)=1.78; 95% confidence interval=1.37–2.31) and obese women (HR=1.93; 95% confidence interval=1.44–2.59). There was a similar pattern for WC with regard to the three outcomes; for incident CHD, the HR=1.70 (1.35–2.14) for men and 1.71 (1.28–2.29) for women in the highest WC category (men ⩾102 cm, women ⩾88 cm), synonymous with abdominal obesity. For men, the highest category of WHR (⩾1.0) was associated with an increased risk of all-cause mortality (1.29; 1.04–1.60) and incident CHD (1.55; 1.19–2.01). Among women with a high WHR (⩾0.85) there was an increased risk of all outcomes: all-cause mortality (1.56; 1.26–1.94), CHD mortality (2.49; 1.36–4.56) and incident CHD (1.76; 1.31–2.38).
In this study excess adiposity was associated with an increased risk of incident CHD but not necessarily death. One possibility is that modern medical intervention has contributed to improved survival of first CHD events. The future health burden of increased obesity levels may manifest as an increase in the prevalence of individuals living with CHD and its consequences.
PMCID: PMC3647234  PMID: 22751254
body mass index; waist circumference; waist–hip ratio; mortality; coronary heart disease; Scotland
5.  Atorvastatin and cardiovascular risk in the elderly – patient considerations 
Clinical Interventions in Aging  2008;3(2):299-314.
Elderly individuals are at increased risk of coronary heart disease (CHD) and account for a majority of CHD deaths. Several clinical trials have assessed the beneficial effects of statins in individuals with, or at risk of developing, CHD. These trials provide evidence that statins reduce risk and improve clinical outcomes even in older patients; however, statin therapy remains under-utilized among the aged. Atorvastatin has been widely investigated among the older subjects and has the greatest magnitude of favorable effects on clinical outcomes of CHD. The pharmacokinetic properties of atorvastatin allow it to be used every other day, a factor which may decrease adverse events and be especially important in the elderly. The purpose of this article is to review the evidence available from randomized clinical trials regarding the safety and efficacy of atorvastatin in primary and secondary prevention of CHD and stroke in older patients and to discuss issues such as drug interactions, patient compliance and cost-effectiveness, which affect prescription of lipid-lowering therapy among older patients.
PMCID: PMC2546474  PMID: 18686752
atorvastatin; statins; HMG-CoA reductase inhibitors; coronary heart disease; elderly patients
6.  Exercise Training and Cardiac Rehabilitation in Primary and Secondary Prevention of Coronary Heart Disease 
Mayo Clinic Proceedings  2009;84(4):373-383.
Substantial data have established a sedentary lifestyle as a major modifiable risk factor for coronary heart disease (CHD). Increased levels of physical activity, exercise training, and overall cardiorespiratory fitness have provided protection in the primary and secondary prevention of CHD. This review surveys data from observational studies supporting the benefits of physical activity, exercise training, and overall cardiorespiratory fitness in primary prevention. Clearly, cardiac rehabilitation/secondary prevention (CRSP) programs have been greatly underused by patients with CHD. We review the benefits of CRSP programs on CHD risk factors, psychological factors, and overall CHD morbidity and mortality. These data support the routine referral of patients with CHD to CRSP programs. Patients should be vigorously encouraged to attend these programs.
PMCID: PMC2665984  PMID: 19339657
7.  Evidence for inequalities in the management of coronary heart disease in Scotland 
Heart  2005;91(5):630-634.
Objectives: To investigate whether sex, age, and deprivation inequalities existed in the prescription of secondary preventive treatment for coronary heart disease (CHD) in Scottish general practice and whether these differences altered over time.
Design: 6 year cross sectional study based on general practice morbidity and prescribing data.
Setting: 55 primary care practices in Scotland.
Subjects: 14 435 patients with diagnosed CHD.
Main outcome measure: Prescription of various groups of secondary preventive treatment in six study years.
Results: The use of all secondary prevention treatments increased over time (63.6% of patients with CHD in 1997 to 87.6% in 2002). After adjustments for age, sex, deprivation, co-morbidities, and practice where appropriate, women received fewer secondary prevention treatments than men, a difference that increased over time (March 1997: adjusted odds ratio (OR) 0.9, 95% confidence interval (CI) 0.8 to 1.0; March 2002: OR 0.6, 95% CI 0.6 to 0.7). Sex differences were observed within each group of treatments studied. The oldest group of patients was less likely than the youngest group to receive any secondary preventive treatment in the year up to March 1997 (OR 0.6, 95% CI 0.5 to 0.7) but were more likely by 2002 (OR 1.3, 95% CI 1.1 to 1.5) to receive secondary prevention. The most affluent patients with CHD were significantly less likely to receive a statin between March 1998 and 2001 (March 1998 OR 0.6, 95% CI 0.5 to 0.9), a finding that disappeared by 2002 (OR 0.9, 95% CI 0.7 to 1.1).
Conclusion: The results suggest that inequalities exist in the secondary prevention of CHD in Scotland.
PMCID: PMC1768874  PMID: 15831649
coronary heart disease; inequalities; primary care; Scotland; secondary prevention
8.  Small area statistics as markers for personal social status in the Scottish heart health study. 
OBJECTIVE: To evaluate a deprivation index, calculated from small area statistics for postcode sectors, as a measure of individual social status in an epidemiological study of coronary heart disease (CHD). DESIGN: A baseline, cross sectional survey. SETTING: Twenty two local authority districts of Scotland surveyed between 1984 and 1986. SUBJECTS: A total of 10359 men and women aged 40-59 years randomly selected to the Scottish heart health study. MAIN RESULTS: The Scottish deprivation categorisation, derived from small area statistics, exhibits a strong linear trend (p = 0.001 or below) for individual prevalent CHD for men and women, unadjusted, and adjusted for major cardiovascular risk factors. The degree of association with CHD is similar to that for measures of social class based upon occupation. CONCLUSIONS: The Scottish deprivation categorisation is an effective measure of individual social status in the current study, broadly comparable in its effect with the more traditional classification derived from occupations. The latter has important problems in definition, especially for women. Small area statistics may provide a useful marker of individual social status in a more general epidemiological setting.
PMCID: PMC1060352  PMID: 8944867
9.  Statins as Anti-Inflammatory Agents in Atherogenesis: Molecular Mechanisms and Lessons from the Recent Clinical Trials 
Current Pharmaceutical Design  2012;18(11):1519-1530.
Ample evidence exists in support of the potent anti-inflammatory properties of statins. In cell studies and animal models statins exert beneficial cardiovascular effects. By inhibiting intracellular isoprenoids formation, statins suppress vascular and myocardial inflammation, favorably modulate vascular and myocardial redox state and improve nitric oxide bioavailability. Randomized clinical trials have demonstrated that further to their lipid lowering effects, statins are useful in the primary and secondary prevention of coronary heart disease (CHD) due to their anti-inflammatory potential. The landmark JUPITER trial suggested that in subjects without CHD, suppression of low-grade inflammation by statins improves clinical outcome. However, recent trials have failed to document any clinical benefit with statins in high risk groups, such in heart failure or chronic kidney disease patients. In this review, we aim to summarize the existing evidence on statins as an anti-inflammatory agent in atherogenesis. We describe the molecular mechanisms responsible for the anti-inflammatory effects of statins, as well as clinical data on the non lipid-lowering, anti-inflammatory effects of statins on cardiovascular outcomes. Lastly, the controversy of the recent large randomized clinical trials and the issue of statin withdrawal are also discussed.
PMCID: PMC3394171  PMID: 22364136
Atherosclerosis; statins; inflammation; coronary heart disease; heart failure; outcome; endothelial nitric oxide synthase; vascular redox.
10.  Stroke and coronary heart disease: predictive power of standard risk factors into old age—long-term cumulative risk study among men in Gothenburg, Sweden 
European Heart Journal  2013;34(14):1068-1074.
The aim of this study was to examine the short-term and long-term cumulative risk of coronary heart disease (CHD) and stroke separately based on age, sex, smoking status, systolic blood pressure, and total serum cholesterol.
Methods and results
The Primary Prevention Study comprising 7174 men aged between 47 and 55 free from a previous history of CHD, stroke, and diabetes at baseline examination (1970–73) was followed up for 35 years. To estimate the cumulative effect of CHD and stroke, all participants were stratified into one of five risk groups, defined by their number of risk factors. The estimated 10-year risk for high-risk individuals when adjusted for age and competing risk was 18.1% for CHD and 3.2% for stroke which increased to 47.8 and 19.6%, respectively, after 35 years. The estimates based on risk factors performed well throughout the period for CHD but less well for stroke.
The prediction of traditional risk factors (systolic blood pressure, total serum cholesterol, and smoking status) on short-term risk (0–10 years) and long-term risk (0–35 years) of CHD of stroke differs substantially. This indicates that the cumulative risk in middle-aged men based on these traditional risk factors can effectively be used to predict CHD but not stroke to the same extent.
PMCID: PMC3618888  PMID: 23303661
Score models; Stroke; CHD; Risk prediction; Risk factors
11.  Coronary heart disease prevention in clinical practice: are patients with diabetes special? Evidence from two studies of older men and women 
Heart  2005;91(4):451-455.
Objective: To assess whether the extent of primary and secondary coronary heart disease (CHD) prevention in older British men and women differs between patients with and without diabetes.
Design: Two prospective cardiovascular cohort studies.
Setting: 24 British towns.
Patients: 4252 men and 4286 women aged 60–79 years examined between 1998 and 2001.
Main outcome measures: Use of aspirin, statin, and blood pressure lowering treatment and risk factor control, examined by diabetic status and history of established CHD.
Results: About 20% of the men and 12% of the women had established CHD at age 60–79 years and 7% of the men and 5% of the women had diabetes. In primary CHD prevention, patients with diabetes were more likely to receive CHD risk reducing medications than those without diabetes, but the proportions receiving preventive treatments in both groups were low. In secondary prevention, diabetic and non-diabetic patients received similar levels of treatment, with the exception of angiotensin converting enzyme inhibitors and (for women only) blood pressure lowering treatment, which were more widely used among diabetic patients. There were no clear differences in blood pressure control or cigarette smoking by diabetic status in primary or secondary prevention. Mean total cholesterol concentrations were lower in diabetic patients independently of treatment with statins.
Conclusions: Despite their exceptionally high CHD risk, many opportunities to reduce CHD risk among patients with diabetes have not been taken.
PMCID: PMC1768806  PMID: 15772196
diabetes; coronary heart disease; primary prevention; secondary prevention
12.  Cholesterol screening and family history of vascular disease. 
Archives of Disease in Childhood  1994;71(3):239-242.
Hypercholesterolaemia is a major risk factor for the development of coronary heart disease (CHD). Early detection and management of hypercholesterolaemia could retard the atherosclerotic process. Given that CHD and hypercholesterolaemia cluster within families, a screening strategy based on a family history of vascular disease has been advocated. Serum total cholesterol concentrations were measured in a random stratified sample of 1012 children aged from 12-15 years old participating in a coronary risk factor surveillance study in Northern Ireland. Information about vascular disease in close family members was obtained by means of a questionnaire. The study population was divided into two groups according to total cholesterol values: (i) normal, < 5.2 mmol/l (n = 822) and (ii) raised, > or = 5.2 mmol/l (n = 190). A family history identified 63 out of 190 individuals with hypercholesterolaemia yielding a sensitivity of 33.2% and specificity of 71.5%. Our data indicated that a strategy whereby only children from high risk families are screened for hypercholesterolaemia is ineffective. While primary prevention emphasising a healthy diet for all is essential, the role of universal screening deserves further appraisal.
PMCID: PMC1029979  PMID: 7979498
Coronary heart disease (CHD) is the leading cause of death throughout the world. PHC doctors are in a unique position to prevent CHD and promote health in the population. However, the perception of PHC doctors on CHD prevention has not been well documented.
To explore and examine the perception of PHC doctors on the prevention of CHD. Subject and method: A questionnaire survey of all PHC doctors attending a continuing medical education (CME) activity in Riyadh city. The questionnaire was designed and piloted with local PHC doctors before being used in this survey.
All the 77 PHC doctors responded (100%) and almost all the them (97.4%) agreed that the primary prevention of CHD was an essential task. Fifty-two participants (67.53%) confirmed that little attention had been paid to the primary prevention of CHD. While the majority of respondents (71.43%) felt that the primary prevention of CHD was an easy task, a significant minority (23.37%) disagreed. Interestingly, 70 (90.91%) respondents were not aware of any local literature on how to achieve primary prevention of CHD and would like to have the literature made available to them. Finally, participants indicated that the percentage prevalence of CHD risk factors among their patients was high.
the findings of this survey confirm a general feeling that the primary prevention of CHD is not being given enough attention. Participants accepted that the primary prevention of CHD was an essential part of their work, but the lack of local literature and research on this vital area was a major concern.
PMCID: PMC3377029  PMID: 23012190
Opinion of PHC doctors; Prevention and prevalence of CHD
14.  Trends in cardiovascular disease biomarkers and their socioeconomic patterning among adults in the Scottish population 1995 to 2009: cross-sectional surveys 
BMJ Open  2012;2(3):e000771.
To examine secular and socioeconomic changes in biological cardiovascular disease risk factor and biomarker prevalences in the Scottish population. This could contribute to an understanding of why the decline in coronary heart disease mortality in Scotland has recently stalled along with persistence of associated socioeconomic inequalities.
Cross-sectional surveys.
Scottish Health Surveys: 1995, 1998, 2003, 2008 and 2009 (6190, 6656, 5497, 4202 and 4964 respondents, respectively, aged 25–64 years).
Primary outcome measures
Gender-stratified, age-standardised prevalences of obesity, hypertension, hypercholesterolaemia and low high-density lipoprotein cholesterol blood concentration as well as elevated fibrinogen and C reactive protein concentrations according to education and social class groupings. Inequalities were assessed using the slope index of inequality, and time trends were assessed using linear regression.
The prevalence of obesity, including central obesity, increased between 1995 and 2009 among men and women, irrespective of socioeconomic position. In 2009, the prevalence of obesity (defined by body mass index) was 29.8% (95% CI 27.9% to 31.7%) for men and 28.2% (26.3% to 30.2%) for women. The proportion of individuals with hypertension remained relatively unchanged between 1995 and 2008/2009, while the prevalence of hypercholesterolaemia declined in men from 79.6% (78.1% to 81.1%) to 63.8% (59.9% to 67.8%) and in women from 74.1% (72.6% to 75.7%) to 66.3% (62.6% to 70.0%). Socioeconomic inequalities persisted over time among men and women for most of the biomarkers and were particularly striking for the anthropometric measures when stratified by education.
If there are to be further declines in coronary heart disease mortality and reduction in associated inequalities, then there needs to be a favourable step change in the prevalence of cardiovascular disease risk factors. This may require radical population-wide interventions.
Article summary
Article focus
In Scotland, as in other developed countries, coronary heart disease mortality has substantially declined over time.
This decline may have slowed among younger ages and there are still large socioeconomic inequalities in mortality.
Examination of the secular and socioeconomic changes in biological cardiovascular disease risk factor and biomarker prevalences in the Scottish population.
Key messages
In Scotland, over a 14-year period since 1995, there has been a substantial increase in the prevalence of obesity with a persistence of large inequalities.
At the same time, the prevalence of hypertension has changed little, while that of hypercholesterolaemia has declined, albeit from a very high level. Inequalities were generally smaller and, in the case of cholesterol in men, ill defined.
Such trends can only serve to curb any further declines in coronary heart disease mortality and maintain associated inequalities.
Strengths and limitations of this study
This study utilised data from nationally representative surveys conducted over a 14-year period.
Bias may have been introduced by declining survey response levels. Differential non-response by the socioeconomically disadvantaged may lead to an underestimation of the magnitude of inequalities.
PMCID: PMC3364451  PMID: 22619264
15.  Men’s and women’s health beliefs differentially predict coronary heart disease incidence in a population-based sample 
To examine gender differences in the association between beliefs in heart disease preventability and 10-year incidence of coronary heart disease (CHD) in a population-based sample.
2,688 non-institutionalized Nova Scotians without prior CHD enrolled in the Nova Scotia Health Study (NSHS95) and were followed for 10 years. Risk factors, health behaviors and incident CHD were assessed. Participants responded “yes” or “no” to a question about heart disease preventability.Survival models, adjusted for age, income,total and high density lipoprotein (HDL) cholesterol, and systolic blood pressure, were used to estimate the relation between health belief and incident CHD. Gender differences in the relation between health beliefs and health behaviors were assessed.
Gender was a significant moderator of the relation between belief and CHD incidence;specifically,women who believed heart disease could be prevented were less likely to have incident CHD events compared to women who believed heart disease could be not prevented (HR=0.36, 95% CI0.24-0.55, p <.001). This relation was not found for men. Belief was also related to smoking behavior for women (β = −0.70, OR= 0.50, 95% CI = 0.33-0.74, p =.001), but not men. Smoking significantly mediated the relation between health beliefs and incident CHD for women (z = −1.96, p =.05), but not for men.
Health belief in prevention and subsequent smokingwas an important independent predictor of incident coronary heart disease in women, but not men.
PMCID: PMC3676270  PMID: 22991050
health beliefs; gender differences; cardiovascular disease
Over the past decade two informative events in primary prevention of coronary heart disease (CHD) have occurred for women’s health. The first concerns hormone therapy (HT) where data have come full circle from presumed harm to consistency with observational data that HT initiation in close proximity to menopause significantly reduces CHD and overall mortality. The other concerns sex-specific efficacy of CHD primary prevention therapies where lipid-lowering and aspirin therapy have not been conclusively shown to significantly reduce CHD and more importantly where there is lack of evidence that either therapy reduces overall mortality in women. Cumulated data supports a “window-of-opportunity” for maximal reduction of CHD and overall mortality and minimization of risks with HT initiation before 60 years of age and/or within 10 years of menopause and continued for 6 years or more. There is a substantial increase in quality-adjusted life-years over a 5–30 year period in women who initiate HT in close proximity to menopause supporting HT as a highly cost-effective strategy for improving quality-adjusted life. Although primary prevention therapies and HT contrast in their efficacy to significantly reduce CHD and especially overall mortality in postmenopausal women, the magnitude and types of risks associated with HT are similar to those associated with other medications commonly used in women’s health. The cumulated data highlight the importance of studying the HT cardioprotective hypothesis in women representative of those from whom the hypothesis was generated.
PMCID: PMC3631510  PMID: 22612607
Hormone Therapy; Estrogen; Menopause; Women; Coronary Heart Disease; Randomized Controlled Trials; Mortality; Meta-Analysis
17.  Lipid lowering in patients with diabetes mellitus: what coronary heart disease risk threshold should be used? 
Heart  2002;87(5):423-427.
Objective: To examine the impact for the UK population of providing statin treatment for diabetic patients for the primary prevention of coronary heart disease at a coronary event risk lower than currently recommended by the National Service Framework (NSF) for coronary heart disease.
Design: Cross sectional survey.
Setting: England 1998.
Participants: Nationally representative sample of 6879 subjects aged 35–74 years living in private households.
Main outcome measures: The proportion of the UK population recommended for statin treatment according to the NSF for coronary heart disease, and the proportion of the population with diabetes at a coronary disease event risk of ≥ 15% over 10 years.
Results: Of the 6879 subjects with total cholesterol measurements, 218 (3.2%) had diabetes mellitus. In this nationally representative sample, 6.3% of the subjects (95% confidence interval (CI), 5.7% to 6.9%) were candidates for statin treatment for the secondary prevention of coronary heart disease, including 0.7% (95% CI 0.5% to 0.9%) with diabetes. A further 2.4% (95% CI 2.0% to 2.8%), including 0.4% (0.2% to 0.6%) with diabetes, were identified as candidates for primary prevention of coronary heart disease according to the NSF for coronary heart disease. Lowering the primary prevention threshold for statin treatment to a coronary event risk of ≥ 15% over 10 years in diabetic patients identified an additional 0.5% of the population.
Conclusions: Extending statin treatment to diabetic patients at a coronary heart disease risk of ≥ 15% over 10 years would have a relatively small numerical impact in the UK population. Thus patients with diabetes mellitus should, as a minimum, be targeted for statin treatment at this level of risk.
PMCID: PMC1767085  PMID: 11997409
diabetes; coronary heart disease; risk estimate; statins
18.  Implementation of case management to reduce cardiovascular disease risk in the Stanford and San Mateo Heart to Heart randomized controlled trial: study protocol and baseline characteristics 
Case management has emerged as a promising alternative approach to supplement traditional one-on-one sessions between patients and doctors for improving the quality of care in chronic diseases such as coronary heart disease (CHD). However, data are lacking in terms of its efficacy and cost-effectiveness when implemented in ethnic and low-income populations.
The Stanford and San Mateo Heart to Heart (HTH) project is a randomized controlled clinical trial designed to rigorously evaluate the efficacy and cost-effectiveness of a multi-risk cardiovascular case management program in low-income, primarily ethnic minority patients served by a local county health care system in California. Randomization occurred at the patient level. The primary outcome measure is the absolute CHD risk over 10 years. Secondary outcome measures include adherence to guidelines on CHD prevention practice. We documented the study design, methodology, and baseline sociodemographic, clinical and lifestyle characteristics of 419 participants.
We achieved equal distributions of the sociodemographic, biophysical and lifestyle characteristics between the two randomization groups. HTH participants had a mean age of 56 years, 63% were Latinos/Hispanics, 65% female, 61% less educated, and 62% were not employed. Twenty percent of participants reported having a prior cardiovascular event. 10-year CHD risk averaged 18% in men and 13% in women despite a modest low-density lipoprotein cholesterol level and a high on-treatment percentage at baseline. Sixty-three percent of participants were diagnosed with diabetes and an additional 22% had metabolic syndrome. In addition, many participants had depressed high-density lipoprotein (HDL) cholesterol levels and elevated values of total cholesterol-to-HDL ratio, triglycerides, triglyceride-to-HDL ratio, and blood pressure. Furthermore, nearly 70% of participants were obese, 45% had a family history of CHD or stroke, and 16% were current smokers.
We have recruited an ethnically diverse, low-income cohort in which to implement a case management approach and test its efficacy and cost-effectiveness. HTH will advance the scientific understanding of better strategies for CHD prevention among these priority subpopulations and aid in guiding future practice that will reduce health disparities.
PMCID: PMC1592109  PMID: 17005050
19.  Switching to statins: a challenge for primary care. 
In 1997, doctors in England received official guidelines on the use of statins (3-hydroxy-3-methylglutaryl coenzyme A inhibitors) for primary and secondary prevention of coronary heart disease (CHD). Six months later we determined the status of patients who had been discharged from a specialist lipid clinic in 1989. 195 patients received questionnaires, with the consent of their general practitioners, regarding morbidity in, the subsequent decade and present medication, and were asked to have their cholesterol checked. Analysis was confined to the 86 with a current cholesterol measurement. Of 61 patients who had been discharged on a regimen of dietary advice and/or medication for primary prevention of CHD, 8 had been changed to a statin and 6 had been started on one. According to the new guidelines, none of these qualified for treatment. Of 25 patients who had been discharged on drugs for secondary prevention, all qualified for a statin but only 14 were receiving one--in 6 cases without achieving the recommended reductions in cholesterol. In many of the patients reviewed, treatment had not been altered to conform with the new guidelines. If hyperlipidaemic patients are to benefit promptly from advances in treatment, one solution might be a central registry that arranged regular tests and reported back to general practitioners. However, since many patients at risk do not have very high cholesterol levels, a coordinated approach to CHD risk factors would be preferable.
PMCID: PMC1297392  PMID: 10692904
20.  Early detection and treatment of hyperlipidemia: physician practices in Canada. 
We surveyed primary care physicians in Canada to determine their current practices regarding the detection and treatment of hyperlipidemia in asymptomatic adults 20 years of age or more and to determine the role of selected patient characteristics (age, sex and the presence of coronary heart disease [CHD] risk factors) in their management decisions. The self-administered questionnaire was completed by 428 of 804 family physicians and general practitioners. The proportion of physicians who reported having tested at least 50% of their adult patients varied from 29% to 85% and was related to the number of CHD risk factors present and the patient's age. The proportion of respondents who reported starting dietary or drug therapy among patients with a cholesterol level of 6.2 mmol/L or less increased as the number of CHD risk factors increased and was not related to patient age or sex. According to the factors examined our results suggest that primary care physicians in Canada select patients for screening and treatment mainly on the basis of CHD risk factors present and that their approach is more conservative than that recommended by the Canadian and US consensus conferences.
PMCID: PMC1452419  PMID: 2224715
21.  Coronary heart disease: prevalence and dietary sugars in Scotland. 
STUDY OBJECTIVE--The aim was to investigate the effects of dietary intakes of different types of sugars (extrinsic, intrinsic, and lactose) and the dietary fat to sugar ratio on prevalent coronary heart disease (CHD). DESIGN--This was a baseline cross sectional survey of CHD risk factors. SETTING--Twenty two Scottish health districts were surveyed between 1984 and 1986. PARTICIPANTS--A total of 10,359 men and women aged 40-59 years were screened as part of the Scottish Heart Health Study, and a further 1267 men and women aged 25-39 and 60-64 years were screened as part of the Scottish MONICA (monitoring trends and determinants in cardiovascular disease) Study. The response rates were 74% and 64% respectively. METHODS--Subjects completed a questionnaire which included sociodemographic, health, and food frequency information. Medical history, response to the Rose chest pain questionnaire, and results of a 12 lead ECG recording were used to categorize subjects into CHD diagnosed, previously CHD undiagnosed, or no CHD groups. The chi 2 statistic was used to determine whether the CHD groups differed in their sugar consumption, and multiple logistic regression analysis, with adjustment for other potential coronary risk factors, was used to calculate odds ratios for prevalent CHD by intake fifths of dietary sugars. MAIN RESULTS--Men, but not women, differed in their sugar consumption by CHD group. The odds ratios showed a tendency for a U shaped relationship for extrinsic sugar intake with CHD prevalence, but no significant effect of the fat to sugar ratio (possible marker of obesity) on CHD was seen. CONCLUSIONS--The results suggest that neither extrinsic sugar, intrinsic sugar, nor the fat to sugar ratio are significant independent predictors of prevalent CHD in the Scottish population, when the other major risk factors such as cigarette smoking, blood cholesterol concentration, and antioxidant vitamins intake are accounted for. These new data for different sugar types agree with the consensus view that total sugar intake is not a major marker of coronary heart disease.
PMCID: PMC1059918  PMID: 8189163
22.  Guidelines for the detection of high-risk lipoprotein profiles and the treatment of dyslipoproteinemias. Canadian Lipoprotein Conference Ad Hoc Committee on Guidelines for Dyslipoproteinemias. 
Elevated plasma levels of cholesterol and triglycerides, low levels of high-density lipoproteins, hypertension, diabetes mellitus, smoking and abdominal obesity are risk factors for coronary heart disease (CHD) and stroke. Because of the preventable threat to life, well-being and productivity from perturbations of plasma lipoproteins (which affect about 60% of adults), we recommend a population-based strategy with public education on diet, exercise and the hazards of smoking and legislation for better food labelling. This should be combined with the medical guidelines we describe to detect and treat those at highest risk for CHD (including about 15% of adults), who merit priority for the medical, dietetic and laboratory services required. Among people aged 40 years or more this includes those with plasma total cholesterol levels greater than 7 mmol/L, fasting triglyceride levels greater than 3 mmol/L or cholesterol level greater than 6 mmol/L when associated with CHD or other risk factors for CHD. For younger people the criteria for highest risk include cholesterol levels greater than 6.5 mmol/L for those aged 30 to 39 years, greater than 6 mmol/L for those aged 20 to 29 and greater than 5 mmol/L for those under age 20.
PMCID: PMC1451984  PMID: 2190685
23.  Using Stress Testing to Guide Primary Prevention of Coronary Heart Disease among Intermediate-Risk Patients: A Cost-effectiveness Analysis 
Circulation  2011;125(2):260-270.
Non-invasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease (CHD), but it is unclear if such a strategy would be cost-effective.
Methods and Results
We compared the status quo, in which the current national use of aspirin and statins was simulated, with three other strategies; 1) full implementation of Adult Treatment Panel (ATP III) guidelines, 2) a “treat-all” strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only) and 3) a “test and treat strategy,” in which all persons with an intermediate-risk of CHD underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, CHD events, and quality-adjusted life years from 2011 to 2040 were projected. Under a variety of assumptions, the “treat-all” strategy was the most effective and least expensive strategy. Stress electrocardiography was more effective and less expensive than other “test-and-treat” strategies, but it was less expensive than “treat all” only if statin cost exceeded $3.16/pill or if testing increased adherence from below 22% to above 75%. However, stress electrocardiography could be cost-effective in persons initially non-adherent to the “treat all” strategy if it raised their adherence to 5% and cost-saving if it raised their adherence to 13%.
When generic high-potency statins are available, non-invasive cardiac stress testing to target preventive medications is not cost-effective unless it substantially improves adherence.
PMCID: PMC3265963  PMID: 22144567
cost effectiveness; prevention; stress testing; risk factors; lipids
24.  Managing hypercholesterolemia and preventing cardiovascular events in elderly and younger Chinese adults: focus on rosuvastatin 
Coronary heart disease (CHD) is the leading cause of death worldwide. The efficacy and safety of statins in primary and secondary prevention of CHD is confirmed in several large studies, and rosuvastatin is the latest statin on market. We review the published literature on rosuvastatin in Chinese people. The pharmacokinetics of rosuvastatin in Chinese is somewhat different from that in Caucasians, but this does not influence the linear relationship between dosage and efficacy and with no drug accumulation. Rosuvastatin 5–20 mg/day is effective and safe in decreasing low-density lipoprotein cholesterol in both younger and elderly patients with hypercholesterolemia, even in very elderly patients. Rosuvastatin also shows anti-inflammatory and antiatherosclerosis features, such as reducing carotid intima-media thickness and plaque area. Rosuvastatin can also improve the prognosis of Chinese CHD patients, such as in the case of acute myocardial infarction. Its adverse-event rate is low and comparable to other statins. In conclusion, rosuvastatin is effective and safe for younger or elderly Chinese patients.
PMCID: PMC3861292  PMID: 24353409
rosuvastatin; Chinese; younger; elderly
25.  Parental height in relation to offspring coronary heart disease: examining transgenerational influences on health using the west of Scotland Midspan Family Study 
Background Adult height is known to be inversely related to coronary heart disease (CHD) risk. We sought to investigate transgenerational influence of parental height on offspring’s CHD risk.
Methods Parents took part in a cardiorespiratory disease survey in two Scottish towns during the 1970s, in which their physical stature was measured. In 1996, their offspring were invited to participate in a similar survey, which included an electrocardiogram recording and risk factor assessment.
Results A total of 2306 natural offspring aged 30–59 years from 1456 couples were subsequently flagged for notification of mortality and followed for CHD-related hospitalizations. Taller paternal and/or maternal height was associated with socio-economic advantage, heavier birthweight and increased high-density lipoprotein cholesterol in offspring. Increased height in fathers, but more strongly in mothers (risk ratio for 1 SD change in maternal height = 0.85; 95% confidence interval: 0.76 to 0.95), was associated with a lower risk of offspring CHD, adjusting for age, sex, other parental height and CHD risk factors.
Conclusion There is evidence of an association between taller parental, particularly maternal, height and lower offspring CHD risk. This may reflect an influence of early maternal growth on the intrauterine environment provided for her offspring.
PMCID: PMC3535757  PMID: 23087191
Coronary heart disease; mortality; intergenerational; height

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