Family Practice Vol. 21, No. 5 © Oxford University Press 2004, all rights reserved.
The challenge of secondary prevention for coronary heart disease in older patients: findings from the British Women's Heart and Health Study and the British Regional Heart Study
a Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, b Department of Public Health Sciences, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE and c Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine, Rowland Hill Street, London NW3 2PF, UK; E-mail: d.a.lawlor{at}bristol.ac.uk
Received 6 June 2003; Revised 7 January 2004; Accepted 17 May 2004.
Lawlor DA, Whincup P, Emberson JR, Rees K, Walker M and Ebrahim S. The challenge of secondary prevention for coronary heart disease in older patients: findings from the British Women's Heart and Health Study and the British Regional Heart Study. Family Practice 2004; 21: 582–586.
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Abstract |
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Background. Secondary prevention of coronary heart disease (CHD) among older individuals is associated with considerable benefit.
Methods. In this study, we have examined the extent of secondary prevention among British women and men aged 60–79 years who were surveyed and examined between 1998 and 2001.
Results. Among 483 women (12.1% of the whole sample) and 831 men (19.5%) with CHD, >90% of both sexes had at least one modifiable risk factor, with over two-fifths having high blood pressure and over three-quarters high cholesterol. For total cholesterol and body mass index, mean values in both male and female subjects were above recommended levels, and a large shift in the population distributions would be required for targets to be met. Less than one-quarter of subjects of either sex were on a statin, and whilst the majority of men were taking an antiplatelet medication, only 40% of women were.
Conclusions. Most older women and men in Britain were failing to meet National Service Framework standards for secondary prevention in the period immediately before its implementation. Large shifts in the population distributions of some risk factors would be required in this group to meet these standards.
Keywords. Coronary heart disease, secondary prevention, aspirin, statin, older age.
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Introduction |
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The absolute benefits of coronary heart disease (CHD) prevention are greatest among subjects with established disease. Whilst a number of studies have assessed the extent of secondary prevention in different populations, no British studies have looked at the levels of modifiable risk factors and treatment in a nationally representative sample of older people. The absolute benefit of secondary prevention in terms of reducing morbidity and disability in older individuals may be greater than that seen in younger individuals.1 The aim of this paper is to describe the standards of secondary prevention in older (60–79 years) British women and men in relation to the National Service Framework (current national Department of Health policy guidance in this area) requirements.2
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Methods |
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The British Regional Heart Study is a prospective study of cardiovascular disease involving 7735 men, selected from the age–sex registers of one group general practice in each of 24 British towns, and followed-up since baseline data collection in 1978–1980. Between February 1998 and February 2000, a clinical re-examination of all surviving members of the British Regional Heart Study, now aged 60–79 years, was undertaken (n = 4252, 76% attendance of survivors). The British Women's Heart and Health Study cohort was established in 1999 to parallel the British Regional Heart Study. The population consisted of women aged 60–79 years, and sampling was stratified by town and by 5 year age group to ensure the distribution proportionately matched that of the men. A total of 4286 women (60% of the 7173 invited) participated and 3994 (56%) had complete data on all variables assessed here. Similar data collection procedures were used for both the women and re-examination of the men and have been described in detail elsewhere.3 Ethics committee approval was obtained for both studies.
Detailed reviews of participants' general practice medical records (including GP notes, hospital letters and computer data) were undertaken to identify all diagnoses of angina and myocardial infarction occurring since 1978. Confirmation of a diagnosis of myocardial infarction was obtained according to WHO criteria. Treatment targets as specified in the National Service Framework were used for the assessment of risk factor control (see Box 1). 2
| BOX 1 UK National Health Service National Service Framework requirements for preventing coronary heart disease in high risk patients in primary care2 GPs and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks:
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Results |
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There were no differences in medical record recordings of CHD between responders and non-responders among the women (P = 0.3). In total, 483 women (12.1%) and 831 men (19.5%) had diagnoses of CHD. The prevalence of GP-recorded angina was similar in women and men (10.1 versus 11.6%), but myocardial infarction was more common in men (2.0 versus 8.0%). Both diagnoses increased with age.
Table 1 shows the extent of secondary prevention. More than 90% of both women and men had at least one poorly controlled modifiable risk factor, with two-fifths of women and men having high blood pressure and >75% of both sexes having high cholesterol levels. Figure 1 shows the distributions of blood pressure, body mass index (BMI) and cholesterol levels in women and men with CHD, together with the thresholds for these risk factors as stipulated in the National Service Framework.2 It can be seen that for total cholesterol and BMI, mean values in both male and female subjects are above recommended levels, and a large shift in the population distributions would be required for targets to be met.
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Only a minority of women (27%) and men (24%) were using statins; use of antiplatelet drugs was low in women. Fifteen of the women had had a myocardial infarction in the 12 months prior to assessment and, of these, five (33%) were taking a ß-blocker. Of 25 men who had a myocardial infarction in the 12 months prior to assessment, 12 (48%) were taking a ß-blocker.
Risk factor control (with the exception of smoking) and treatment tended to be better in younger (60–69 years) patients but, even in this group, >90% had at least one poorly controlled modifiable risk factor and less than one-third were using statins. Both women and men who had angina only, compared with those who had a history of myocardial infarction, were less likely to be using antiplatelet medication (age, social class, area of residence adjusted odds ratio and 95% confidence interval for women 0.32, 0.18–0.57 and for men 0.38, 0.27–0.54) or statins (women 0.33, 0.18–0.59, men 052, 0.37–0.74). Those who had been first diagnosed during or before 1995 compared with those first diagnosed more recently were less likely to be using antiplatelet agents (women 0.90, 0.60–1.35, men 0.51, 0.37–0.71) or statins (women 0.59, 0.37–0.95, men 0.47, 0.33–0.67).
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Discussion |
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Opportunities for improving secondary prevention are present in most older British women and men and our results indicate the considerable challenge required to meet the new National Service Framework for CHD.2
There was no difference in GP-recorded CHD between responders and non-responders in the women's study, and the men's study is of a group of male survivors from a cohort followed for over two decades with high response rates. It is therefore unlikely that any important selection bias has arisen in estimating the prevalence of CHD and use of treatment. Though the studies were carried out in general practices that have been involved in the British Regional Heart Study for >20 years, no attempt has ever been made to influence clinical or preventive practice. Any influence on clinical practice occurring simply through participation might make the results more optimistic than would be the case for the country as a whole.
In older individuals with CHD, treatment with aspirin, statins, smoking cessation and blood pressure control are all effective in reducing future morbidity and disability.1 Our results indicate the considerable shift in population distributions that would be required to meet standards in this group, and achieving compliance with lifestyle factors and medication may be difficult in adults. However, a recent randomized controlled trial has shown that among patients up to 80 years of age, nurse-led clinics in primary care can result in the short-term uptake of secondary prevention and that this is associated with fewer total deaths and CHD events.4 It has been suggested that, because of the repeated findings of poor secondary prevention in primary care patients, secondary prevention should now become the preserve of secondary care (i.e. that this should be undertaken in hospitals rather than primary care).5 Though our results confirm poor levels of secondary prevention in older patients in primary care in 1998–2001, we believe that improvements in this area can only be achieved through primary care services. Older individuals, those with angina but with no history of a myocardial infarction and those with older diagnoses were less likely to be receiving secondary preventive treatments in our study, but these groups form the largest proportion of those with CHD and benefit similarly to others from secondary prevention. To shift the emphasis for identification and initiation of treatment to hospitals would favour new cases of myocardial infarction only and would fail to meet the need of the majority. All primary care teams in the UK were required to begin implementing the National Service Framework criteria in 2002. Thus our study has been conducted immediately before this requirement and with continued follow-up of these cohorts we will be able to examine changes over time in the extent of secondary prevention in older women and men and assess the effect of the National Service Framework in this area.
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Declaration |
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Funding: The British Regional Heart Study and the British Women's Heart and Health Study are funded by the Department of Health. The British Regional Heart Study is a British Heart Foundation Research Group. DAL was funded by a Medical Research Council/Department of Health training fellowship when this work was conducted and is now funded by a Department of Health Career Scientist Award. The views expressed in this publication are those of the authors and not necessarily those of the funding bodies.
Ethical Approval: Both the British Women's Heart and Health Study and the British Regional Heart Study have local (from each of the districts in which the study was based) and multicentre ethical committee approvals.
Conflicts of Interest: None.
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Acknowledgments |
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We thank all of the GPs and their staff who have supported data collection and the women and men who have participated in the studies.
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References |
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1 Hunt D, Young P, Simes J et al. Benefits of pravastatin on cardiovascular events and mortality in older patients with coronary heart disease are equal to or exceed those seen in younger patients: results from the LIPID trial. Ann Intern Med 2001; 134: 931–940.
2 Department of Health. National Service Framework for Coronary Heart Disease. London: Department of Health, 2000.
3 Lawlor DA, Emberson JR, Ebrahim S et al. Is the association between parity and coronary heart disease due to biological effects of pregnancy or adverse lifestyle risk factors associated with childrearing? Findings from the British Women's Heart and Health Study and the British Regional Heart Study. Circulation 2003; 107: 1254–1258.
4 Murchie P, Campbell NC, Richie LD, Simpson JA, Thain J. Secondary prevention clinics for coronary heart disease: four year follow-up of a randomised controlled trial in primary care. B Med J 2003; 326: 84–87.
5 Isles CG. Patients with acute coronary syndrome should start a statin while still in hospital. Heart 2002; 88: 5–6.
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