Coronary Heart Disease Cohort Research Articles

Temporal trends in myocardial infarction case fatality: methodological challenges and prevention targets

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council of AustraliaHealy Medical Research Foundation Background Case fatality is an important indicator of severity and quality of care for myocardial infarction (MI). Most studies focus on hospitalised case fatality, which does not capture the total burden of MI deaths. Additionally, changes in diagnostic criteria and acute clinical care, and evidence that identifying all coronary heart disease (CHD) events better captures this patient group,1 have led to suggestions that a different definition of case fatality is required. Purpose The aim of the study was to determine the impact of different definitions of case fatality on the composition of fatal cases, and to measure trends in case fatality across a range of case definitions. Methods A whole-state linked hospital/death dataset was used to identify all MI, acute coronary syndromes (ACS) and CHD events (fatal + nonfatal) from 1997-2015. The traditional MI case fatality definition included all MI deaths as the numerator, stratified as MI hospitalisation with death ≤28 days, non-MI hospitalisation with MI death ≤28 days, or pre-hospital MI deaths. The denominator was all MIs (fatal plus nonfatal MI). ACS and a broader CHD definition were trialled, with ACS or CHD deaths as the numerator respectively, stratified in a similar manner as MI. Case fatality was age-standardised by 5-year age group using the internal age distribution of each definition as the standard. Results From 1997 to 2015, there were 76,928 MI events, 126,470 ACS events, and 235,100 CHD events. Of the MI cohort, 64.1% were men, and 13.0% had a prior MI, with a similar pattern in the ACS and CHD cohorts. For the traditional definition of MI case fatality, 10,819 deaths (53.9%) occurred pre-hospital, 4990 deaths in those hospitalised for MI and dying ≤28 days (24.8%), and 4271 MI deaths (21.3%) ≤28 days of a non-MI hospitalisation (Figure). Using the broadest CHD definition of case fatality, there was a similar proportion of pre-hospital deaths, but a higher proportion of CHD deaths in those with a non-CHD hospitalisation. In men, age-standardised MI case fatality declined from 40.0% in 1997 to 17.3% by 2015; in women, the decline was from 41.9% to 18.2%. In contrast, using the ACS and broad CHD definitions, age-standardised case fatality was lower than for MI throughout the study period, with a smaller temporal decline (ACS: men 22.2% to 13.1%, women 20.5% to 13.0%; CHD: men 20.6% to 12.4%, women 19.3% to 12.3%). Conclusion Despite substantial falls in MI case fatality, the fatal burden remains high. Regardless of the case fatality definition, pre-hospital deaths from acute or all CHD have remained high over time, highlighting the need to target the pre-hospital setting. Caution is needed when using different definitions of case fatality to ensure relevant statistics are used, particularly for temporal trends. Figure Legend. Proportion of MI deaths occurring ≤28 days after MI hospitalisation (2), ≤28 days after non-MI hospitalisation (3), and pre-hospital (4).

Cost-effectiveness of a cardiovascular polypill strategy (aspirin, atorvastatin, ramipril) for the secondary prevention of cardiovascular disease based on real life improvement in risk factor control

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Ferrer Internacional Background The cardiovascular (CV) polypill has consistently demonstrated cost-effectives in decreasing the risk of CV disease in patients in secondary prevention. Previous pharmacoeconomic studies addressed improvements in adherence as a driver of health gains. This economic assessment focuses on the implications of improved control of risk factors with the polypill as observed in clinical practice. Purpose To assess the cost-effectiveness of a fixed-dose combination polypill (ASA 100mg, atorvastatin 20/40mg, ramipril 2.5/5/10mg) strategy for the secondary prevention of CV and cerebrovascular events in adults with a history of coronary heart disease (CHD) or stroke compared to usual care with monocomponents. Methods A Markov cost-effectiveness model (1-year cycles; 4 health states: stable disease, subsequent CHD, subsequent stroke, death; payer perspective; direct medical costs; lifetime horizon; 4% discount rate) based on changes in CV risk factors (total cholesterol, 18.3% reduction; high density lipoprotein cholesterol, 2.1% increment; systolic blood pressure, 11.46% reduction) obtained from a real-life effectiveness study was set for Portugal. The probability of transition between health states was based on the SMART risk equation. Cost-effectiveness was calculated for two cohorts (n = 1,000) of secondary prevention patients with previous CHD or stroke. Systematic reviews, Portuguese registries, mortality tables and official reports were searched to identify effectiveness, epidemiological, costs and utility data. Outcomes were costs (€, 2020) per life year (LY) and Quality Adjusted LY (QALY) gained. One-way (OWA) and probabilistic (PSA) sensitivity analyses tested consistency. Assumptions were validated by experts. Results In the CHD cohort, the incremental cost-effectiveness ratio for the polypill strategy (ICER) is 2,402 €/LY and the incremental cost-utility ratio (ICUR) is 2,328 €/QALY. Incremental cost reaches 278,927 € (polypill, 13,198,506 €; monocomponents: 12,919,579 €) with less subsequent CV events (552.31 vs 641.88) and CV deaths (102.4 vs 118.68). Assuming a willingness-to-pay (WTP) threshold of 30.000 €/QALY gained, the PSA shows a 81.4% probability for the polypill to be cost-effective and 39.1% chances to be costs saving compared to usual care. In the stroke cohort, the ICER is 386 €/LY and the ICUR is 553 €/QALY. Incremental costs are 34,178 € (polypill, 10,138,807 €; monocomponents: 10,104,629 €) with less subsequent CV events (481.99 vs 564.50) and CV deaths (101.00 vs. 117.23) with the polypill. There is a 75.9% probability for the polypill to be cost-effective and 49.5% chances to be costs saving. Conclusion The CV polypill is a cost-effective secondary prevention strategy compared to usual care with monocomponents. Its ICER is well below acceptable thresholds in both CV and cerebrovascular disease patients. It reduces the number of recurrent events at a moderately higher cost compared to monocomponents.

Cholesterol goal achievement and lipid-lowering therapy in patients with stable or acute coronary heart disease in Singapore: results from the Dyslipidemia International Study II

Dyslipidaemia is a major risk factor for coronary heart disease (CHD). There is a lack of data on the extent of lipid abnormalities and lipid-lowering therapy (LLT) in Singapore. The Dyslipidemia International Study (DYSIS) II was a multinational observational study of patients with stable CHD and hospitalised patients with an acute coronary syndrome (ACS). A full lipid profile and use of LLT were documented at baseline, and for the ACS cohort, at four months post-hospitalisation. 325 patients were recruited from four sites in Singapore; 199 had stable CHD and 126 were hospitalised with an ACS. At baseline, 96.5% of the CHD cohort and 66.4% of the ACS cohort were being treated with LLT. In both cohorts, low-density lipoprotein cholesterol (LDL-C) levels were lower for the treated than the non-treated patients; accordingly, a higher proportion of patients met the LDL-C goal of < 70 mg/dL (CHD: 28.1% vs. 0%, p = 0.10; ACS: 20.2% vs. 0%, p < 0.01). By the four-month follow-up, a higher proportion of the ACS patients that were originally not treated with LLT had met the LDL-C goal (from 0% to 54.5%), correlating with the increased use of medication. However, there was negligible improvement in the patients who were treated prior to the ACS. Dyslipidaemia is a significant concern in Singapore, with few patients with stable or acute CHD meeting the recommended European Society of Cardiology/European Atherosclerosis Society goal. LLT was widely used but not optimised, indicating considerable scope for improved management of these very-high-risk patients.

Low-density Lipoprotein Cholesterol Target Attainment in Patients with Stable or Acute Coronary Heart Disease in the Philippines: Results from the Dyslipidemia International Study II

Objective. To quantify the extent of hyperlipidemia and its treatment in patients with stable coronary heart disease (CHD) or an acute coronary syndrome (ACS) in the Philippines.&#x0D; Methods. The Dyslipidemia International Study (DYSIS) II was an observational, multinational study conducted in patients aged ≥18 years with stable CHD or being hospitalized with an ACS. A full lipid profile was evaluated at baseline, and for the ACS cohort, at 4 months after discharge from hospital. Achievement of low-density lipoprotein cholesterol (LDL-C) targets and the use of lipid-lowering therapy (LLT) were assessed.&#x0D; Results. A total of 232 patients were enrolled from 10 centers in the Philippines, 184 with stable CHD and 48 being hospitalized with an ACS. The mean LDL-C level for the CHD patients was 88.0±40.1 mg/dL, with 33.3% achieving the target of &lt;70 mg/dL recommended for very high-risk patients. For the ACS cohort, the mean LDL-C level was 109.0±48.5 mg/dL, with target attainment of 25.0%. The majority of the CHD cohort was being treated with LLT (97.3%), while 55.3% of the ACS patients were receiving LLT prior to hospitalization, rising to 100.0% at follow-up. There was little use of non-statins.&#x0D; Conclusions. For these very high-risk patients from the Philippines, LDL-C target attainment was poor. Opportunities for better monitoring and treatment of these subjects are being missed.

Low-density lipoprotein cholesterol target attainment in patients with stable or acute coronary heart disease in the Asia-Pacific region: results from the Dyslipidemia International Study II.

As mortality due to cardiovascular disease increases throughout the world, accurate data on risk factors such as hyperlipidemia are required. This is lacking in the Asia-Pacific region. The observational Dyslipidemia International Study (DYSIS) II was established to quantify the extent of hyperlipidemia in adults with acute and stable coronary heart disease globally. Patients with stable coronary heart disease or hospitalised with an acute coronary syndrome were enrolled across nine Asia-Pacific countries from July 2013 to October 2014. Lipid-lowering therapy and low-density lipoprotein cholesterol target attainment (<70 mg/dL) were assessed. The acute coronary syndrome cohort was followed up 4 months post-discharge. Of the 4592 patients enrolled, 2794 had stable coronary heart disease and 1798 were admitted with an acute coronary syndrome. In the coronary heart disease cohort, the mean low-density lipoprotein cholesterol level was 86.9 mg/dL, with 91.7% using lipid-lowering therapy and 31% achieving low-density lipoprotein cholesterol of less than 70 mg/dL. In the acute coronary syndrome cohort at admission, the corresponding values were 103.2 mg/dL, 63.4% and 23.0%, respectively. Target attainment was significantly higher in lipid-lowering therapy-treated than non-treated patients in each cohort (32.6% vs. 12.9% and 31.1% vs. 9.0%, respectively). Mean atorvastatin-equivalent dosages were low (20 ± 15 and 22 ± 18 mg/day, respectively), with little use of non-statin adjuvants (13.0% and 6.8%, respectively). Low-density lipoprotein cholesterol target attainment had improved by follow-up for the acute coronary syndrome patients, but remained low (41.7%). Many patients in Asia at very high risk of recurrent cardiovascular events had a low-density lipoprotein cholesterol level above the recommended target. Although lipid-lowering therapy was common, it was not used to its full potential.

Attainment of cholesterol target values in Greece: results from the Dyslipidemia International Study II.

IntroductionCurrent European guidelines recommend treatment with lipid-lowering therapy (LLT) to a low-density lipoprotein cholesterol (LDL-C) target of < 70 mg/dl for patients at very high risk. LDL-C target attainment and use of LLTs in these patients in Greece is not known.Material and methodsThe Dyslipidemia International Study (DYSIS) II was a multicenter observational study. The coronary heart disease (CHD) cohort was divided into two groups based on treatment status (on LLT for ≥ 3 months or not on LLT). The acute coronary syndrome (ACS) cohort was evaluated at the time of admission and again 120 ±15 days after admission.ResultsIn the CHD cohort (n = 499), 457 (91.6%) patients were on LLT. The LDL-C target value was attained by 26.5% of LLT users. Statin monotherapy was used by 77.5% of treated patients, with a mean ± SD atorvastatin dose equivalent of 24 ±16 mg/day. In the ACS cohort (n = 200), 159 (79.5%) patients were on LLT at admission. Mean ± SD LDL-C levels were 108 ±40 mg/dl at admission and 86 ±25 mg/dl at follow-up. LDL-C target value attainment rates were 16.2% at admission and 25.0% at follow-up. At admission, statin monotherapy was used by 86.8% of treated patients. The mean ± SD atorvastatin dose equivalent increased from 20 ±14 mg/day at admission to 29 ±15 mg/day at follow-up. The statin dose was associated with higher odds of LDL-C target value attainment (OR = 1.05, 95% CI: 1.02–1.08).ConclusionsThe LDL-C target attainment by very high risk patients in Greece is suboptimal. Increasing the statin dose or combining it with non-statins may improve target value attainment.

Design and outcomes of the Patient Centered Outcomes Research Institute coronary heart disease cohort study.

BackgroundThe Patient Centered Outcomes Research Institute (PCORI) established Clinical Data Research Networks (CDRNs) to support pragmatic research. The objective was to electronically identify, recruit, and survey coronary heart disease (CHD) patients and describe their characteristics, health status, and willingness to participate in future research.MethodsWe developed a computable phenotype and assembled CHD patients 30 years or older and had visits or hospitalizations between 2009 and 2015. A sample of patients was surveyed between August 2014 and September 2015. Survey administration included the following methods: face-to-face, telephone, paper or web portal. Survey items covered broad domains including: health literacy and numeracy, and socio-demographics, physical and mental health, health behaviors, access to medical care, and willingness to participate in future research.ResultsOf 5517 approached patients, 2605 completed the survey. Participants were mostly white (∼88%), male (68%) and had a median age of 69 years (interquartile range [IQR] 61–76 years). Most respondents' health literacy and numeracy were adequate (83.2% and 84.3%, respectively). Only 4% of respondents reported that their overall health or physical health was excellent. The majority (∼58%) reported that their health was good or very good, while 40% reported that their general and physical health were fair or poor. The majority reported that their quality of life was good to excellent (81%). Limitations in physical health and function were common, including often/always having fatigue (25%), pain (38.7%), or sleep difficulty (19.7%). A patient sample (n = 1936) was provided with a trial summary which would randomize their aspirin dose; and 63% reported that they would consider participating.ConclusionMany patients with CHD had limitations in physical health. However, the majority reported a good or excellent quality of life.

Relation of Perceived Health Competence to Physical Activity in Patients With Coronary Heart Disease

Physical inactivity is highly associated with mortality, especially in patients with coronary heart disease. We evaluated the effect of perceived health competence, a patient's belief in his or her ability to achieve health-related goals, on cumulative physical activity levels in the Mid-South Coronary Heart Disease Cohort Study. The Mid-South Coronary Heart Disease Cohort Study consists of 2,587 outpatients (32% were female) with coronary heart disease at an academic medical center network in the United States. Cumulative physical activity was quantified in metabolic equivalent (MET)-minutes per week with the International Physical Activity Questionnaire. We investigated associations between the 2-item Perceived Health Competence Scale (PHCS-2) and MET-minutes/week after adjusting for co-morbidities and psychosocial factors with linear regression. Nearly half of participants (47%) exhibited low physical activity levels (<600 MET-minutes/week). Perceived health competence was highly associated with physical activity after multivariable adjustment. A nonlinear relation was observed, with the strongest effect on physical activity occurring at lower levels of perceived health competence. There was effect modification by gender (p = 0.03 for interaction). The relation between perceived health competence and physical activity was stronger in women compared with men; an increase in the PHCS-2 from 3 to 4 was associated with a 73% increase in MET-minutes/week in women (95% confidence interval 43% to 109%, p <0.0001) compared with a 53% increase in men (95% confidence interval 27% to 84%, p <0.0001). In conclusion, low perceived health competence was strongly associated with less physical activity in patients with coronary heart disease and may represent a potential target for behavioral interventions.

Cholesterol target value attainment and lipid-lowering therapy in patients with stable or acute coronary heart disease: Results from the Dyslipidemia International Study II

Background and aimsLow-density lipoprotein cholesterol (LDL-C) is a major contributor to cardiovascular disease. In the Dyslipidemia International Study II (DYSIS II), we determined LDL-C target value attainment, use of lipid-lowering therapy (LLT), and cardiovascular outcomes in patients with stable coronary heart disease (CHD) and those suffering from an acute coronary syndrome (ACS). MethodsDYSIS II included patients from 18 countries. Patients with either stable CHD or an ACS were enrolled if they were ≥18 years old and had a full lipid profile available. Data were collected at a physician visit (CHD cohort) or at hospital admission and 120 days later (ACS cohort). ResultsA total of 10,661 patients were enrolled, 6794 with stable CHD and 3867 with an ACS. Mean LDL-C levels were low at 88 mg/dl and 108 mg/dl for the CHD and ACS cohorts respectively, with only 29.4% and 18.9% displaying a level below 70 mg/dl. LLT was utilized by 93.8% of the CHD cohort, with a mean daily statin dosage of 25 ± 18 mg. The proportion of the ACS cohort treated with LLT rose from 65.2% at admission to 95.6% at follow-up. LLT-treated patients, who were female, obese, or current smokers, were less likely to achieve an LDL-C level of <70 mg/dl, while those with type 2 diabetes, chronic kidney disease, or those taking a higher statin dosage were more likely. ConclusionsFew of these very high-risk patients achieved the LDL-C target, indicating huge potential for improving cardiovascular outcome by use of more intensive LLT.

Associations between serum calcium, phosphorus and mortality among patients with coronary heart disease.

Serum calcium and phosphorus abnormalities are associated with cardiovascular disorders in general population, but evidence among patients with established coronary heart disease (CHD) is limited and controversial. This study aimed to investigate the associations of baseline serum calcium and phosphorus levels with long-term mortality risk among patients with CHD. We conducted a prospective cohort study among 3187 patients with CHD from October 2008 and December 2011 in China. Cox proportional hazards model was used to assess the associations of serum calcium and phosphorus at baseline with the risk of death. During follow-up (mean, 4.9years), 295 patients died, 193 of which resulted from cardiovascular causes. Multivariable-adjusted hazard ratios (HR) for each 1mmol/L increase in serum calcium at baseline were 0.27 (95% confidence interval (CI) 0.14-0.51) for all-cause mortality and 0.26 (95% CI 0.12-0.54) for cardiovascular mortality. Patients in the highest compared to the lowest quartile of serum calcium were at lower risk of all-cause mortality (HR, 95% CI 0.57, 0.40-0.82) and cardiovascular mortality (0.50, 0.32-0.79) (both P trend<0.001). This inverse association between serum calcium and the risk of mortality did not change when participants were stratified by sex, age groups, level of overweight, types of CHD, and history of diabetes. We also observed a graded positive association between baseline serum phosphorus and the risks of mortality. The present study is the first to report that lower serum calcium at baseline is associated with an increased risk of all-cause and cardiovascular mortality in a Chinese coronary heart disease cohort. Further studies are required to investigate the causal relationship and actual mechanisms.

The effect of progressive resistance training on aerobic fitness and strength in adults with coronary heart disease: A systematic review and meta-analysis of randomised controlled trials.

Design We aimed to evaluate the effect of progressive resistance training on cardiorespiratory fitness and muscular strength in coronary heart disease, when compared to control or aerobic training, and when combined with aerobic training. Secondary aims were to evaluate the safety and efficacy of progressive resistance training on other physiological and clinical outcomes. Methods and results Electronic databases were searched from inception until July 2016. Designs included progressive resistance training vs control, progressive resistance training vs aerobic training, and combined training vs aerobic training. From 268,778 titles, 34 studies were included (1940 participants; 71.9% male; age 60 ± 7 years). Progressive resistance training was more effective than control for lower (standardized mean difference 0.57, 95% confidence interval (0.17-0.96)) and upper (1.43 (0.73-2.13)) body strength. Aerobic fitness improved similarly after progressive resistance training (16.9%) or aerobic training (21.0%); (standardized mean difference -0.13, 95% confidence interval (-0.35-0.08)). Combined training was more effective than aerobic training for aerobic fitness (0.21 (0.09-0.34), lower (0.62 (0.32-0.92)) and upper (0.51 (0.27-0.74)) body strength. Twenty studies reported adverse event information, with five reporting 64 cardiovascular complications, 63 during aerobic training. Conclusion Isolated progressive resistance training resulted in an increase in lower and upper body strength, and improved aerobic fitness to a similar degree as aerobic training in coronary heart disease cohorts. Importantly, when progressive resistance training was added to aerobic training, effects on both fitness and strength were enhanced compared to aerobic training alone. Reporting of adverse events was poor, and clinical gaps were identified for women, older adults, high intensity progressive resistance training and long-term outcomes, warranting future trials to confirm safety and effectiveness.

FREQUENCY AND PREDICTORS OF CHOLESTEROL GOAL ATTAINMENT IN PATIENTS WITH CORONARY HEART DISEASE: RESULTS FROM THE DYSLIPIDEMIA INTERNATIONAL STUDY II

Background: The objective of the second Dyslipidemia International Study (DYSIS II) was to document LDL-C goal attainment among patients with documented coronary heart disease (CHD) or acute coronary syndrome (ACS). Methods: The CHD cohort of DYSIS II included patients from 17 countries of Asia,

The impact of inflammation on the obesity paradox in coronary heart disease

Despite the well-known adverse effects of obesity on almost all aspects of coronary heart disease, many studies of coronary heart disease cohorts have demonstrated an inverse relationship between obesity, as defined by body mass index (BMI), and subsequent prognosis: the 'obesity paradox'. The etiology of this and the potential role of inflammation in this process remain unknown. We studied 519 patients with coronary heart disease before and after cardiac rehabilitation, dividing them into groups based on C-reactive protein ((CRP)⩾3 mg l-1 and CRP<3 mg l-1 after cardiac rehabilitation). BMI was calculated and body fat was measured using the skin-fold method. Lean mass index (LMI) was calculated as (1-%body fat) × BMI. The population was divided according to age- and gender-adjusted categories based on LMI and body fat and analyzed by total mortality over >3-year follow-up by National Death Index in both CRP groups. During >3-year follow-up, all-cause mortality was higher in the high inflammation and in the low BMI group. In proportional hazard analysis, even after adjusting for ejection fraction and peak O2 consumption, higher BMI was associated with lower mortality in the entire population (hazard ratio (HR) 0.38; confidence interval 0.15-0.97) and a trend to lower mortality in both subgroups (HR 0.45 in low CRP, P=0.24 vs HR 0.32, P=0.06 in high CRP). High body fat, however, was associated with significantly lower mortality in the high CRP group (HR 0.22; P=0.03) but not in the low CRP group (HR 0.73; P=0.64). Conversely, high LMI was associated with markedly lower mortality in the low CRP group (HR 0.04; P=0.04). The obesity paradox has multiple underlying etiologies. Body composition has a different role in different populations with an obesity paradox by BMI. Especially in the subpopulation with persistently high CRP levels, body fat seems protective.

UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

BackgroundDepression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.ObjectivesOur aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.DesignThe UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.SettingThirty-three GP surgeries in south London.ParticipantsAdult patients on GP CHD registers.InterventionsFrom the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.Main outcome measuresThe main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.ResultsPersonalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.ConclusionsChest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.Trial registrationCurrent Controlled Trials ISRCTN21615909.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.

Abstract 11771: Health Self-efficacy is Associated With Increased Physical Activity in Patients With Coronary Heart Disease

Introduction: Physical inactivity is strongly associated with morbidity and mortality, especially in patients with coronary heart disease (CHD). Low levels of health self-efficacy, or a patient’s belief in his ability to engage in behaviors to improve his health, may serve as a barrier to regular physical activity in CHD patients. We evaluated the association of health self-efficacy with physical activity in the Mid-South Coronary Heart Disease Cohort Study (MCHDCS). Methods: The MCHDCS is a prospective cohort of outpatients with CHD. Participants complete a set of validated demographic, psychological, social, behavioral, and functional measures. Health self-efficacy is assayed using two items from the Perceived Health Competence Scale (PHCS-2) that comprise a ten point scale with higher scores indicating better self-efficacy. Physical activity is evaluated with the International Physical Activity Questionnaire, which measures activity in metabolic equivalent (MET)-minutes/week. Less than 600 MET-minutes/week is considered to be a low physical activity level. We used negative binomial and ordinal logistic regression to evaluate the association of self-efficacy with physical activity. Results: A total of 1612 MCHDCS participants (31% female, 9% minority, mean age 67.5 + 10.6 years) were included in the analysis. The majority of participants had low physical activity levels, with a median of 540 (interquartile range 100 to 1600) MET-minutes/week. Each one point increase on the PHCS-2 scale was associated with an 8.7% increase (95% confidence interval 2.9%-14.9%, p=0.003) in MET-minutes/week after adjustment for socioeconomic status as well as depression, health literacy, social support and other factors (Table). Conclusions: Health self-efficacy is associated with physical activity in patients with CHD. Further study is needed to determine whether interventions to increase self-efficacy will raise levels of physical activity in this population.

Carotid Intima-Media Thickness and Long-Term Exposure to Traffic-Related Air Pollution in Middle-Aged Residents of Taiwan: A Cross-Sectional Study.

BackgroundAssociations between long-term exposure to air pollution and carotid intima-media thickness (CIMT) have inconsistent findings.ObjectivesIn this study we aimed to evaluate association between 1-year average exposure to traffic-related air pollution and CIMT in middle-aged adults in Asia.MethodsCIMT was measured in Taipei, Taiwan, between 2009 and 2011 in 689 volunteers 35–65 years of age who were recruited as the control subjects of an acute coronary heart disease cohort study. We applied land-use regression models developed by the European Study of Cohorts for Air Pollution Effects (ESCAPE) to estimate each subject’s 1-year average exposure to traffic-related air pollutants with particulate matter diameters ≤ 10 μm (PM10) and ≤ 2.5 μm (PM2.5) and the absorbance levels of PM2.5 (PM2.5abs), nitrogen dioxide (NO2), and nitrogen oxides (NOx) in the urban environment.ResultsOne-year average air pollution exposures were 44.21 ± 4.19 μg/m3 for PM10, 27.34 ± 5.12 μg/m3 for PM2.5, and (1.97 ± 0.36) × 10–5/m for PM2.5abs. Multivariate regression analyses showed average percentage increases in maximum left CIMT of 4.23% (95% CI: 0.32, 8.13) per 1.0 × 10–5/m increase in PM2.5abs; 3.72% (95% CI: 0.32, 7.11) per 10-μg/m3 increase in PM10; 2.81% (95% CI: 0.32, 5.31) per 20-μg/m3 increase in NO2; and 0.74% (95% CI: 0.08, 1.41) per 10-μg/m3 increase in NOx. The associations were not evident for right CIMT, and PM2.5 mass concentration was not associated with the outcomes.ConclusionsLong-term exposures to traffic-related air pollution of PM2.5abs, PM10, NO2, and NOx were positively associated with subclinical atherosclerosis in middle-aged adults.CitationSu TC, Hwang JJ, Shen YC, Chan CC. 2015. Carotid intima–media thickness and long-term exposure to traffic-related air pollution in middle-aged residents of Taiwan: a cross-sectional study. Environ Health Perspect 123:773–778; http://dx.doi.org/10.1289/ehp.1408553

Amyloid-Beta (1-40) and the Risk of Death From Cardiovascular Causes in Patients With Coronary Heart Disease

BackgroundThe amyloid beta peptide is the major protein constituent of neuritic plaques in Alzheimer disease and appears to play a central role in vascular inflammation pathophysiology. ObjectivesThis study sought to determine the clinical value of amyloid-beta 1-40 (Abeta40) measurement in predicting cardiovascular (CV) mortality in patients with coronary heart disease (CHD) and arterial stiffness progression in young healthy subjects. MethodsAbeta40 was retrospectively measured in blood samples collected from 3 independent prospective cohorts and 2 case-control cohorts (total N = 1,464). Major adverse cardiac events (MACE) were assessed in the 2 prospective cohorts (n = 877) followed for a median of 4.4 years. To look at effects on subclinical disease, arterial stiffness was evaluated at baseline and after 5-year follow-up (n = 107) in young healthy subjects. The primary endpoint was the predictive value of Abeta40 for CV mortality and outcomes in patients with CHD. ResultsIn Cox proportional hazards models adjusted for age, sex, estimated glomerular filtration rate, left ventricular ejection fraction, high-sensitivity C-reactive protein, and high-sensitivity troponin T, Abeta40 independently predicted CV death and MACE in patients with CHD (p < 0.05 for all). After multivariate adjustment, Abeta40 levels conferred a substantial enhancement of net reclassification index and integrated discrimination improvement of individuals at risk in the total combined CHD cohort over the best predictive model. Further cohort-based analysis revealed that Abeta40 levels were significantly and independently associated with arterial stiffness progression, incident subclinical atherosclerosis, and incident CHD. ConclusionsMeasuring blood levels of Abeta40 identified patients at high risk for CV death.

Abstract 17312: Amyloid-β (1-40) and the Risk of Death from Cardiovascular Causes in Patients with Coronary Heart Disease

Introduction: Investigation of the clinical value of biologic pathways that are involved in pathogenesis of atherosclerotic disease is essential for identification of novel therapeutic targets and improvement of cardiovascular risk stratification. Hypothesis: To determine the clinical value of amyloid-β 1-40 (Aβ40) measurement in predicting cardiovascular (CV) mortality in patients with coronary heart disease (CHD) and arterial stiffness progression in young healthy subjects. Methods: Aβ40 was retrospectively measured in blood samples collected from three independent prospective cohorts and two case-control cohorts (total n=1464). Major adverse CV events (MACE) were assessed in the two prospective cohorts (n=877) followed for a median of 4.4 years. Arterial stiffness was evaluated at baseline and after a 5-year follow-up period (n=107) in young healthy subjects. The primary endpoint was the predictive value of Aβ40 for CV mortality and outcomes in patients with CHD. Further, the associations of Aβ40 levels with arterial stiffness progression, incident subclinical atherosclerosis and incident CHD were addressed. Results: In Cox proportional-hazards models adjusted for age, gender, glomerular filtration rate, left ventricular ejection fraction, high-sensitivity C-reactive protein and high-sensitivity troponin-T, Aβ40 was an independent predictor of CV death and MACE in patients with CHD (P&lt;0.05 for all). After multivariate adjustment, Aβ40 levels conferred a substantial enhancement of net reclassification index (continuous NRI value and 95% confidence interval: 36.7%, 12.5-60.7, P=0.001) and integrated discrimination improvement (IDI value±SE: 1.92±0.62, P&lt;0.001) of individuals at risk in the total combined CHD cohort over the best predictive model. Further cohort-based analysis revealed that Aβ40 levels were significantly and independently associated with arterial stiffness progression, incident subclinical atherosclerosis and incident CHD. Conclusions: Measuring blood levels of Aβ40 identifies patients at high risk for cardiovascular death.

Abstract 102: Major Adverse Cardiovascular Events in U.S. Coronary Heart Disease and Acute Coronary Syndrome Patients

Background: Healthcare resource utilization and costs associated with cardiovascular events among patients with coronary heart disease (CHD) and acute coronary syndrome (ACS) are needed to assess the value of treatments. Methods: A retrospective analysis of a large US administrative claims database (1/1/2006-12/31/2011) was conducted to describe episodes of major adverse cardiovascular events (MACE: hospitalization for stroke, myocardial infarction (MI), or cardiac arrest) in adults with CHD and ACS, respectively. The CHD cohort (n=245,185) had either a diagnosis of MI, a percutaneous coronary intervention (PCI) procedure or coronary artery bypass graft (CABG), or both, a CHD diagnosis and a multiple vessel coronary procedure, at a minimum. The ACS cohort (N= 75,231, not mutually exclusive with CHD) had ≥1 ACS-related hospitalization. The index date was the first observed cohort-specific disease claim and the 30-day period following the service date of the index episode or discharge date (for hospitalizations). Patients were required to have continuous health plan enrollment for 12 months +/- the index episode. HF, MI, and cardiac arrest diagnoses did not specify whether they were fatal or not. Results: Mean age in both cohorts was ~65 years and ~66% were male. The overall MI rate during the 12-month follow-up period was 15.6 and 26.4 per 1,000 person years for CHD and ACS patient, respectively. Among patients with at least one MACE, 286 CHD patients (4.8% of those with an event) and 137 ACS patients (5.5% of those with an event) experienced a second event during the 12-month follow-up period. Mean (SD) total episode-related costs per patient were $19,230 ($34,983) for CHD patients and $23,490 ($36,749) for ACS patients. Inpatient hospitalization represented the highest proportion of costs at 86.9% of CHD and 95.0% of ACS episode-related costs, while CVD-related pharmacotherapy mean costs (SD) were only $226 ($293) and $228 ($294) per patient for CHD and ACS, respectively. Conclusions: CHD and ACS are resource intensive diseases in the first year after index episode, with most costs related to hospitalizations. Outpatient cardiovascular drug costs make up a small proportion of the total costs.

The Impact of Premorbid and Postmorbid Depression Onset on Mortality and Cardiac Morbidity Among Patients With Coronary Heart Disease

Depression is associated with increased cardiac morbidity and mortality in the general population and in patients with coronary heart disease (CHD). Recent evidence suggests that patients with new-onset depression post-CHD diagnosis have worse outcomes than do those who had previous or recurrent depression. This meta-analysis investigated the timing of depression onset in established CHD and CHD-free cohorts to determine what time frame is associated with greater mortality and cardiac morbidity. The MEDLINE, EMBASE, and PsycINFO databases were searched systematically to identify articles examining a depression time frame that specified an end point of all-cause mortality, cardiac mortality, rehospitalization, or major adverse cardiac events. A meta-analysis was conducted to estimate effect sizes by time frame of depression. Twenty-two prospective cohort studies were identified. Nine studies investigated premorbid depression in CHD-free cohorts in relation to cardiac death. Thirteen studies in patient samples with CHD examined new-onset depression in comparison with previous or recurrent depression. The pooled effect size (risk ratio) was 0.76 (95% confidence interval (CI) = 0.48-1.19) for history of depression only, 1.79 (95% CI = 1.45-2.21) for premorbid depression onset, 2.11 (95% CI = 1.66-2.68) for postmorbid or new depression onset, and 1.59 (95% CI = 1.08-2.34) for recurrent depression. Both premorbid and postmorbid depression onsets are potentially hazardous, and the question of timing may be irrelevant with respect to adverse cardiac outcomes. However, the combination of premorbid depression with the absence of depression at the time of a cardiac event (i.e., historical depression only) is not associated with such outcomes and deserves further investigation.