Artykuły w czasopismach na temat „Coronary heart disease – Western Australia – Epidemiology”

Background Temporal trends in incidence and mortality of cardiovascular disease (CVD) have been well described, with recent data suggesting declining improvements in those aged under 55 years. However, little is known about the combined impact of incidence and mortality trends on disease prevalence, an important indicator of disease burden and cost. We analysed changes in age-specific and age-standardised temporal trends in prevalence and incidence of CVD subtypes. Methods Annual prevalence and incidence rates of coronary heart disease, cerebrovascular disease and peripheral arterial disease for the Western Australian population for 1995–2010 were calculated using data from the Western Australian Data Linkage System. Joinpoint regression analyses were used to identify joinpoints in trends in age-specific and age-standardised annual prevalence and incidence rates for each CVD subtype. Results Between 1995 and 2010, age- and sex-specific incidence and prevalence of the CVD subtypes generally decreased among middle-aged and older adults, but were stable or increased among younger adults. In < 55 year olds, increases in incidence tended to occur from 2003, while increases in prevalence were from 2007/2008. Declines in age-standardised incidence were greater than those in crude incidence, with changes in population structure having a greater impact among men than women. Conclusions The majority of CVDs occurs in older adults. Our findings of generally worsening trends in prevalence in younger adults across most CVD subtypes were in contrast to generally declining trends in older age groups. These data highlight the importance of monitoring prevalence and incidence, particularly in younger adults.

AbstractWithin Europe large differences exist in mortality from coronary heart disease and stroke. These diseases show a clear West-East gradient with high rates in Eastern Europe. In spite the decreasing trend in age-adjusted cardiovascular disease mortality in Western European countries an increase in the number of cardiovascular patients is expected because of the ageing of the population. Consequently the health care cost for these diseases will increase.Total and HDL cholesterol are major determinants of coronary heart disease. Saturated and trans fatty acids have a total and LDL cholesterol elevating effect and unsaturated fatty acids a lowering effect. N-3 polyunsaturated fatty acids seem to have a protective effect on coronary heart disease occurrence independent of their effect on cholesterol.Dietary antioxidants could be of importance because they may prevent oxidation of the atherogenic cholesterol rich LDL lipoproteins. There is however no convincing evidence that either vitamin E, carotenoids or vitamin C protect against coronary heart disease. Observational research has shown that flavonols, polyphenols with strong antioxidant properties present in plant foods, may protect against coronary heart disease.Blood pressure is a major determinant of coronary heart disease and stroke. Historically salt is viewed as the most important dietary determinant of blood pressure. Recent research shows that also a low-fat diet rich in potassium, calcium and magnesium lowers blood pressure substantially. This suggests a multifactorial influence of different nutrients on blood pressure.It can be concluded that a diet low in saturated and trans fatty acids and rich in plant foods in combination with regular fish consumption is associated with a low risk of cardiovascular mortality.

BackgroundPopulation-based coronary heart disease (CHD) studies have focused on myocardial infarction (MI) with limited data on trends across the spectrum of CHD. We investigated trends in hospitalisation rates for acute and chronic CHD subgroups in England and Australia from 1996 to 2013.MethodsCHD hospitalisations for individuals aged 35–84 years were identified from electronic hospital data from 1996 to 2013 for England and Australia and from the Oxford Region and Western Australia. CHD subgroups identified were acute coronary syndromes (ACS) (MI and unstable angina) and chronic CHD (stable angina and ‘other CHD’). We calculated age-standardised and age-specific rates and estimated annual changes (95% CI) from age-adjusted Poisson regression.ResultsFrom 1996 to 2013, there were 4.9 million CHD hospitalisations in England and 2.6 million in Australia (67% men). From 1996 to 2003, there was between-country variation in the direction of trends in ACS and chronic CHD hospitalisation rates (p<0.001). During 2004–2013, reductions in ACS hospitalisation rates were greater than for chronic CHD hospitalisation rates in both countries, with the largest subgroup declines in unstable angina (England: men: −7.1 %/year, 95% CI −7.2 to –7.0; women: −7.5 %/year, 95% CI −7.7 to –7.3; Australia: men: −8.5 %/year, 95% CI −8.6 to –8.4; women: −8.6 %/year, 95% CI −8.8 to –8.4). Other CHD rates increased in individuals aged 75–84 years in both countries. Chronic CHD comprised half of all CHD admissions, with the majority involving angiography or percutaneous coronary intervention.ConclusionsSince 2004, rates of all CHD subgroups have fallen, with greater declines in acute than chronic presentations. The slower declines and high proportion of chronic CHD admissions undergoing coronary procedures requires greater focus.

Objectives The aim of the present study was to determine cardiovascular disease (CVD) risk factors and compare presentation and severity of ischaemic heart disease (IHD) among South Asians (SAs) and Anglo Australians (AAs). Methods A retrospective clinical case audit was conducted at a public tertiary hospital. The study population included SA and AA patients hospitalised for IHD. Baseline characteristics, evidence of diabetes and other CVD risk factors were recorded. Angiography data were also included to determine severity, and these were assessed using a modified Gensini score. Results SAs had lower mean (± s.d.) age of IHD presentation that AAs (52 ± 9 vs 55 ± 9 years, respectively; P = 0.02), as well as a lower average body mass index (BMI; 26 ± 4 vs 29 ± 6 kg/m2, respectively; P = 0.005), but a higher prevalence of type 2 diabetes (57% vs 31%, respectively; P = 0.001). No significant differences were found in coronary angiography parameters. There were no significant differences in the median (interquartile range) Gensini score between SAs and AAs (43.5 (27–75) vs 44 (26.5–68.5), respectively), median vessel score (1 (1–2) vs 2 (1–3), respectively) or multivessel score (37% (33/89) vs 54% (22/41), respectively). Conclusions The findings show that in those with established IHD, cardiovascular risk factors, such as age at onset and BMI, differ between SAs and AAs and these differences should be considered in the prevention and management of IHD. What is known about the topic? There is much evidence on CVD and SAs, it being a leading cause of mortality and morbidity for this population both in their home countries and in countries they have migrated to. Studies conducted in Western nations other than Australia have suggested a difference in the risk profiles and presentations of CVD among SA migrants compared with the host populations in developed countries. Although this pattern of cardiovascular risk factors among SAs has been well documented, there is insufficient knowledge about this population, currently the largest population of incoming migrants, and CVD in the Australian setting. What does this paper add? This paper confirms that a similar pattern of CVD exists in Australia among SAs as does in other Western nations they have migrated to. The CVD pattern found in this population is that of an earlier age of onset at lower BMI compared with the host AA population, as well as a differing cardiovascular risk profile, with higher rates of type 2 diabetes and lower smoking rates. In addition, this study finds similar angiographic results for both the SAs and AAs; however, the SAs exhibit these similar angiographic patterns at younger ages. What are the implications for practitioners? SAs in Australia represent a high cardiovascular risk group and should be targeted for more aggressive screening at younger ages. Appropriate preventative strategies should also be considered bearing in mind the differing risk factors for this population, namely low BMI and high rates of type 2 diabetes. More intensive treatment strategies should also be regarded by practitioners. Importantly, both policy makers and health professionals must consider that all these strategies should be culturally targeted and tailored to this population and not assume a ‘one-size fits all’ approach.

Abstract Background Although high-density lipoprotein (HDL) and non-HDL cholesterol have opposite associations with coronary heart disease, multi-country reports of lipid trends only use total cholesterol (TC). Our aim was to compare trends in total, HDL and non-HDL cholesterol and the total-to-HDL cholesterol ratio in Asian and Western countries. Methods We pooled 458 population-based studies with 82.1 million participants in 23 Asian and Western countries. We estimated changes in mean total, HDL and non-HDL cholesterol and mean total-to-HDL cholesterol ratio by country, sex and age group. Results Since ∼1980, mean TC increased in Asian countries. In Japan and South Korea, the TC rise was due to rising HDL cholesterol, which increased by up to 0.17 mmol/L per decade in Japanese women; in China, it was due to rising non-HDL cholesterol. TC declined in Western countries, except in Polish men. The decline was largest in Finland and Norway, at ∼0.4 mmol/L per decade. The decline in TC in most Western countries was the net effect of an increase in HDL cholesterol and a decline in non-HDL cholesterol, with the HDL cholesterol increase largest in New Zealand and Switzerland. Mean total-to-HDL cholesterol ratio declined in Japan, South Korea and most Western countries, by as much as ∼0.7 per decade in Swiss men (equivalent to ∼26% decline in coronary heart disease risk per decade). The ratio increased in China. Conclusions HDL cholesterol has risen and the total-to-HDL cholesterol ratio has declined in many Western countries, Japan and South Korea, with only a weak correlation with changes in TC or non-HDL cholesterol.

Peripheral arterial disease (PAD) is not an uncommon but a commonly neglected condition by many medical practitioners. It is a disease that threatens not only the limb but also life itself! Atherosclerosis is the commonest cause of PAD in the western nations. The cardinal symptom is intermittent claudication (IC) but majority of the patients are asymptomatic. Ankle-brachial pressure index (ABI) is an effective screening tool for PAD. A diminished ABI (< 0.9) is a definite sign of PAD. Its prevalence steadily increases with age. In Germany almost a fifth of the patients aged over 65 years suffer from it. With increasing life expectancy the prevalence of PAD is on the increase. PAD is a manifestation of diffuse and severe atherosclerosis. It is a strong marker of cardiovascular disease; a very strong association exists between PAD and other atherosclerotic disorders such as coronary artery disease (CAD) and cerebrovascular disease (CVD). PAD is an independent predictor of high mortality in patients with CAD. Smoking, diabetes mellitus and advancing age are the cardinal risk factors. A relatively small number of PAD patients lose limbs by amputation. Most patients with PAD die of either heart attacks or strokes and they die of the former conditions far earlier than controls. PAD still remains an esoteric disease and there is a significant lack of awareness of this condition by many physicians, and therefore under-diagnosed and underestimated. Measures to promote awareness of PAD among physicians and the society in general are needed. Since most patients are asymptomatic and carry potentially significant morbidity and mortality risks, screening for PAD should be made a routine practice at primary care level.

Background Due to the progressive deconditioning, comorbidities and higher complication rates, elderly patients are in particular need of cardiac rehabilitation. We compared elderly patients (65+ years old) participating in cardiac rehabilitation, focusing on baseline characteristics, risk factor control and functional assessment. Methods The EU-CaRE study is a prospective study comparing cardiac rehabilitation in eight centres across Western Europe. Consecutive patients with acute coronary syndrome, stable coronary artery disease and heart valve replacement undergoing cardiac rehabilitation were included. Results Of 1633 patients (median age 72 years) participating, 54% had acute coronary syndrome, 33% had stable coronary artery disease and 13% followed valve replacement. Fifty-five per cent had undergone percutaneous coronary intervention and 29% coronary artery bypass grafting. Characteristics varied across centres: 23% (17–27%) were women, 4% (0–12%) were of non-European origin and 16% (4–32%) were living alone. Median time from index event to start of cardiac rehabilitation varied from 11 to 49 days ( p < 0.001). Mean VO2peak was relatively low (16 mL/kg per min) and varied significantly between the participating centres, largely unaffected by multivariable adjustment. Overall patients received guideline recommended treatment: 93% (87–97%) were on a statin and 70% (55–85%) an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. However, risk factor control was inadequate: 58% had three or more risk factors not controlled. Conclusion EU-CaRE provides a snapshot of the elderly population with heart disease participating in cardiac rehabilitation across countries in Western Europe. Risk factors and exercise capacity indicate the continued need for cardiac rehabilitation in these patients. Of concern, the lag-time to start of cardiac rehabilitation needs improvement in many centres.

Background Over the past few decades decreases in coronary heart disease morbidity and mortality rates have been observed throughout the western world. We sought to determine whether the acute coronary event rates had decreased between 2006 and 2014 among French adults, and whether there were sex and age-specific differences. Methods We examined the French MONICA population-based registries monitoring the Lille urban area in northern France, the Bas-Rhin county in north-eastern France and the Haute Garonne county in south-western France. All acute coronary events among men and women aged 35–74 were collected. Results Over the study period, the age-standardised attack rates decreased in both men (annual percentage change −1.5%, P = 0.0006) and women (annual percentage change −2.1%, P = 0.002). Also, the age-standardised incidence rates decreased in both men (annual percentage change −0.9%, P = 0.03) and women (annual percentage change −1.8%, P = 0.002) due to decreases in the 65–74 year age group. In men, age-standardised mortality rates decreased by 3.5% per year ( P = 0.0004), especially in the 55–64 and 65–74 year age groups. In women, these rates decreased by 4.3% per year ( P = 0.0009), particularly in the 35–44 and 65–74 year age groups. We also observed significant decreases in case fatality among both men (annual percentage change −1.7%, P < 0.0001) and women (annual percentage change −1.9%, P = 0.009). Conclusions Downward trends in acute coronary event attack, incidence and mortality rates were observed between 2006 and 2014 in men and women. This effect was age dependent and was primarily due to decreases in the 65–74 year age group. There were no substantial declines in the younger age groups except for mortality in young women. Prevention measures still need to be strengthened, particularly in young adults.

Sudden cardiac death (SCD) is a serious medical problem worldwide. Multiple landmark studies have demonstrated the benefit of implantable cardioverter–defibrillator (ICD) therapy in preventing SCD in at-risk patients. Although the data available in Asia are limited, the disease pattern seems to be different from that in the western world. The Asian population seems to have a lower incidence of SCD. Coronary heart disease, which is the major underlying cause of SCD in the west, may play a less important role in Asian countries. In addition, non-structural heart disease seems to be a more prevalent cause of SCD in Asia. It is thus questionable whether the results of ICD trials can be applied directly to Asian countries, as most of these trials seldom recruited Asian patients. This article will review SCD in Asia, focusing on the epidemiology and risk factors for SCD in Asia and highlighting some unique features that may be different from those seen in the western world.

Objective. This study of equity and access characterises admissions for coronary, cerebrovascular and peripheral arterial disease by hospital type (rural, tertiary and non-tertiary metropolitan) in a representative Australian population. Methods. We conducted a descriptive analysis using data linkage of all residents aged 35–84 years hospitalised in Western Australia with a primary diagnosis for an atherothrombotic event in 2007. We compared sociodemographic and clinical features by atherothrombotic territory and hospital type. Results. There were 11670 index admissions for atherothrombotic disease in 2007 of which 46% were in tertiary hospitals, 41% were in non-tertiary metropolitan hospitals and 13% were in rural hospitals. Coronary heart disease comprised 72% of admissions, followed by cerebrovascular disease (19%) and peripheral arterial disease (9%). Comparisons of socioeconomic disadvantage reveal that for those admitted to rural hospitals, more than one-third were in the most disadvantaged quintile, compared with one-fifth to any metropolitan hospital. Conclusions. Significant differences in demographic characteristics were evident between Western Australian tertiary and non-tertiary hospitals for patients hospitalised for atherothrombotic disease. Notably, the differences among tertiary, non-tertiary metropolitan and rural hospitals were related to socioeconomic disadvantage. This has implications for atherothrombotic healthcare provision and the generalisation of research findings from studies conducted exclusively in the tertiary metropolitan hospitals. What is known about the topic? Equity and access to hospital care for atherothrombotic disease in a geographically diverse population is poorly characterised. National data show that both fatal and non-fatal coronary heart disease and non-fatal stroke hospitalisations increase with remoteness. Fatal in-hospital stroke is greatest in major cities, whereas peripheral arterial disease hospitalisations are greatest in the inner and outer regional areas. What does this paper add? This study demonstrates that around 13% of atherothrombotic events were treated in rural hospitals with in-hospital case fatality higher than in tertiary and non-tertiary metropolitan hospitals. A greater proportion of atherothrombotic disease cases treated in rural hospitals were in the most disadvantaged Socioeconomic Indices For Area group. What are the implications for practitioners? It is important to consider differences in disadvantage when generalising results of studies generated from tertiary hospital data to non-tertiary metropolitan and rural patients.

ObjectivesTo develop a method for categorising coronary heart disease (CHD) subtype in linked data accounting for different CHD diagnoses across records, and to compare hospital admission numbers and ratios of unlinked versus linked data for each CHD subtype over time, and across age groups and sex.DesignCohort study.Data sourcePerson-linked hospital administrative data covering all admissions for CHD in Western Australia from 1988 to 2013.Main outcomeRatios of (1) unlinked admission counts to contiguous admission (CA) counts (accounting for transfers), and (2) 28-day episode counts (accounting for transfers and readmissions) to CA counts stratified by CHD subtype, sex and age group.ResultsIn all CHD subtypes, the ratios changed in a linear or quadratic fashion over time and the coefficients of the trend term differed across CHD subtypes. Furthermore, for many CHD subtypes the ratios also differed by age group and sex. For example, in women aged 35–54 years, the ratio of unlinked to CA counts for non-ST elevation myocardial infarction admissions in 2000 was 1.10, and this increased in a linear fashion to 1.30 in 2013, representing an annual increase of 0.0148.ConclusionThe use of unlinked counts in epidemiological estimates of CHD hospitalisations overestimates CHD counts. The CA and 28-day episode counts are more aligned with epidemiological studies of CHD. The degree of overestimation of counts using only unlinked counts varies in a complex manner with CHD subtype, time, sex and age group, and it is not possible to apply a simple correction factor to counts obtained from unlinked data.

Introduction: Atrial fibrillation (AF) is the commonest cardiac arrhythmia encountered in clinical practice. The hall mark sign of atrial fibrillation is an irregular rhythm in ECG with no obvious P wave. In Western countries, Coronary Artery Disease (CAD) is the commonest cause of AF. Plenty of data and studies are available regarding the epidemiology and etiology of AF in the Western Population but similar studies and data in Nepal are scarce. This study was therefore conducted with an objective to establish the etiological profile of atrial fibrillation patients in mid western Nepal.Materials and Methods: This was a hospital based study, carried out in the Department of Internal Medicine, Nepalgunj Medical College Teaching Hospital, Nepalgunj, for a duration of 1 year from th th 14 September 2013 to 13 September 2014. A total of 74 consecutive cases diagnosed as AF were included in the study on the basis of inclusion and exclusion criteria.Results: A total of 74 consecutive patients were included in the study. The mean age of the subjects was 39.2 years. The majority of the subjects were below 50 years of age (70.27%). There were only 2 subjects below 19 and 3 patients above 70 years of age. Out of the 74 patients 52(70.2%) were from the age group of below 50 years of age. In western countries the incidence is higher in the elder population. Rheumatic heart disease was the most common etiology in this study with a total of 29 (39.2%) cases. CAD in our study was seen in 12 patients (16.2%). Overall structural heart disease was seen in 64(86.5%) cases and in the rest of the cases echocardiography was normal.Conclusion: This study has shown that the etiological profile of AF is different in patients attending our hospital situated in mid-western Nepal from western countries. Unlike the western countries AF is more common in the younger age group and the most common etiology in Nepal is RHD, whereas in western countries it is CAD.JNGMC, Vol. 14 No. 2 December 2016, Page: 23-25

Aims The European Cardiac Rehabilitation in the Elderly (EU-CaRE) HORIZON 2020 project compares the sustainable effects of cardiac rehabilitation (CR) in elderly patients. Methods and results A total of 1633 patients with coronary artery disease (CAD) or heart valve replacement (HVR), with or without revascularization, aged 65 or above, who participated in CR were included. Peak oxygen uptake (VO2peak), smoking, body mass index, diet, physical activity, serum lipids, psychological distress and medication were assessed before and after CR (T0 and T1) and after 12 months (T2). Patients undergoing coronary artery bypass surgery or surgical HVR had lower VO2peak at T0 and a greater increase to T1 and T2 (2.8 and 4.4 ml/kg/min, respectively) than CAD patients undergoing percutaneous or no revascularization (1.6 and 1.4 ml/kg/min, respectively). After multivariable adjustment, earlier CR uptake was associated with greater improvements in VO2peak. The proportion of CAD patients with three or more uncontrolled risk factors declined from 58.4% at T0 to 40.1% at T2 ( p < 0.0001). Psychological distress scores all improved and adherence to medication was overall good at all sites. There were significant differences in risk factor burden across sites, but no CR program was superior to others. Conclusions The outcomes of VO2peak in CR programs across Europe seemed mainly determined by timing of uptake and were maintained or even further improved at 1-year follow-up. Despite significant improvements, 40.1% of CAD patients still had three or more risk factors not at target after 1 year. Differences across sites could not be ascribed to characteristics of the CR programs offered.

PurposeLimited published data exist on the clinical epidemiology of atrial fibrillation (AF) in South Asia including India. Most of the published data are from the Western countries and the Far East. The Kerala AF registry was initiated to collect systematic, prospective data on clinical characteristics, risk factors, treatment pattern and outcomes of consecutive AF patients who consulted cardiologists across the state of Kerala, India.ParticipantsAll newly diagnosed and previously reported patients aged ≥18 years with documented evidence of AF on ECG were included. Patients with transient AF due to infection, acute myocardial infarction, alcohol intoxication, metabolic abnormalities and AF seen in postoperative cases and critically ill patients with life expectancy less than 30 days were excluded.Findings to dateA total of 3421 patients were recruited from 53 hospitals across Kerala from April 2016 to April 2017. There were 51% (n=1744) women. The median age of the cohort was 65 (IQR 56–74) years. Hypertension, diabetes mellitus and dyslipidaemia were present in 53.8%, 34.5% and 42.2% patients, respectively. Chronic kidney disease was observed in 46.6%, coronary artery disease in 34.8% and heart failure (HF) in 26.5% of patients. Mean CHA2DS2-VASc score of the cohort was 2.9, and HAS-BLED score was 1.7. Detailed information of antithrombotic and antiarrhythmic drugs was collected at baseline and on follow-up. During 1-year follow-up, 443 deaths (12.9%) occurred of which 332 (9.7%) were cardiac death and 63 (1.8%) were due to stroke. There were 578 (16.8%) hospitalisations mainly due to acute coronary syndrome, arrythmias and HF.Future plansCurrently, this is the largest prospective study on AF patients from India, and the cohort will be followed for 5 years to observe the treatment patterns and clinical outcomes. The investigators encourage collaborations with national and international AF researchers.Trial registration numberCTRI/2017/10/010097.

Background Studies on associations between urban green space and mental health have yielded mixed results. This study examines associations of green space exposures with subjective health and depressed affect of middle-aged and older adults in four European cohorts. Methods Data came from four Western-European and Central-European ageing cohorts harmonised as part of the Mindmap project, comprising 16 189 adults with an average age of 50–71 years. Green space exposure was based on the distance to the nearest green space and the amount of green space within 800 m buffers around residential addresses. Cohort-specific and one-step individual participant data (IPD) meta-analyses were used to examine associations of green space exposures with subjective health and depressed affect. Results The amount of green spaces within 800 m buffers was lowest for Residential Environment and CORonary heart Disease (Paris, 15.0 hectares) and highest for Health, Alcohol and Psychosocial factors In Eastern Europe (Czech Republic, 35.9 hectares). IPD analyses indicated no evidence of an association between the distance to the nearest green space and depressed affect (OR 0.98, 95% CI 0.96 to 1.00) or good self-rated health (OR 1.01, 95% CI 0.99 to 1.02). Likewise, the amount of green space within 800 m buffers did not predict depressed affect (OR 0.98, 95% CI 0.96 to 1.00) or good self-rated health (OR 1.01, 95% CI 0.99 to 1.02). Findings were consistent across all cohorts. Conclusions Data from four European ageing cohorts provide no support for the hypothesis that green space exposure is associated with subjective health or depressed affect. While longitudinal evidence is required, these findings suggest that green space may be less important for older urban residents.

ObjectiveThis study assessed the effect of the frequency of general practitioner (GP) visitation in the 12 months before a 21% consumer copayment increase in the Pharmaceutical Benefits Scheme (PBS; January 2005) on the reduction or discontinuation of statin dispensing for tertiary prevention. MethodsThe study used routinely collected, whole-population linked PBS, Medicare, mortality and hospital data from Western Australia. From 2004 to 2005, individuals were classified as having discontinued, reduced or continued their use of statins in the first six months of 2005 following the 21% consumer copayment increase on 1 January 2005. The frequency of GP visits was calculated in 2004 from Medicare data. Multivariate logistic regression models were used to determine the association between GP visits and statin use following the copayment increase. ResultsIn December 2004, there were 22495 stable statin users for tertiary prevention of prior coronary heart disease, prior stroke or prior coronary artery revascularisation procedure. Following the copayment increase, patients either discontinued (3%), reduced (12%) or continued (85%) their statins. Individuals who visited a GP three or more times in 2004 were 47% less likely to discontinue their statins in 2005 than people attending only once. Subgroup analysis showed the effect was apparent in men, and long-term or new statin users. The frequency of GP visits did not affect the proportion of patients reducing their statin therapy. ConclusionsPatients who visited their GP at least three times per year had a lower risk of ceasing their statins in the year following the copayment increase. GPs can help patients maintain treatment following rises in medicines costs. What is known about the topic?Following the 21% increase in medication copayment in 2005, individuals discontinued or reduced their statin usage, including for tertiary prevention. What does this paper add?Patients who visited their GP at least three times per year were less likely to discontinue their statin therapy for tertiary prevention following a large copayment increase. What are the implications for practitioners?This paper identifies the important role that GPs have in maintaining the continued use of important medications following rises in medicines costs.

A few days ago, in August 2013, a Cochrane Database Systemic Review reported that the existing limited evidence to date on the effect of Mediterranean diet (MD) on primary prevention of cardiovascular disease (CVD), suggests some favorable effects on risk factors; however, the reduction of CVD event rates was not mentioned [1]. The review included 11 trials (15 papers, 52,044 participants); 7 trials described the intervention as a MD. Clinical events were reported in only one trial [Women's Health Initiative (WHI) 48,835 postmenopausal women with an intervention not described as a MD but increased fruit and vegetable and cereal intake], where no statistically significant effects of the intervention were seen on fatal and non-fatal endpoints during the 8 years of its duration [1]. Since the WHI study was huge and had a great weight in the analysis, it eliminated any other beneficial effect on CVD incidence from other studies. Moreover, in this study the diet used as an intervention was not MD. On April 2013 the results of the Prevención con Dieta Mediterránea (PREDIMED), a multicenter trial from Spain, were published in New England Journal of Medicine [2]. The study included a total of 7,447 persons (aged 55-80 years) with no CVD at baseline. These were randomized to 1 of 3 diets: a MD supplemented with extra-virgin olive oil, a MD supplemented with mixed nuts or a control diet (advice to reduce dietary fat) [2]. An interim analysis terminated the trial prematurely at 4.8 years. The primary endpoint was the rate of major CVD (myocardial infarction, stroke, or CVD death). The multivariable-adjusted hazard ratios were 0.70 (95% confidence interval [CI], 0.54 to 0.92) and 0.72 (95% CI, 0.54 to 0.96) for the group assigned to a MD with extravirgin olive oil and the group assigned to a MD with nuts, respectively, vs. the control group [2]. No diet-related adverse effects were reported [2]. Moreover, a post hoc analysis of PREDIMED that will be published in September 2013, in the American Journal of Clinical Nutrition, suggests that one of the mechanisms by which MD, particularly if supplemented with virgin olive oil, can exert health benefits is through changes in the transcriptomic response of genes related to CVD risk [3]. These results of the PREDIMED trial confirm that changes in diet can have beneficial effects on CVD risk. However, the study was criticized for mainly 3 reasons. One is that in MD the dietary pattern as an entity is rather more important than the inclusion or avoidance of specific nutrients [4]. Second there were low (in absolute terms) primary composite CVD outcome rates (3.8% and 3.4% in the intervention groups vs. 4.4% in the control group) and a minor absolute risk difference (range 0.6 to 1%), thus limiting the importance of the study findings [5]. Furthermore there were statistically significant differences in baseline characteristics between the groups: men (+5.7%), obese persons (+4.7%), diuretic use (+3.5%), and oral hypoglycaemic use (+3.2%) in the control group than in the intervention group [5]. And third there was a complete lack of policy implications [6]. The PREDIMED trial was neither a pure test of a Mediterranean-style diet nor a pure test of extra- virgin olive oil or nuts. All the above make the interpretation of the PREDIMED trial similarly difficult to that of the Lyon Diet Heart Study [7], which tested provision of a margarine rich in alpha-linolenic acid on top of brief advice to consume a MD in high CVD risk patients with astonishing results [7]. Policymakers [8] and Great Scientific Organizations, like Mayo Clinic [9], already recommend consumption of a Mediterranean-style diet on the basis of a body of evidence from observational and interventional studies, in antithesis to the findings of the Cochrane Database Systemic Review [1]. On the other hand, the policy implications of the PREDIMED trial related primarily to the supplemental foods [2] and not MD itself, thus, we probably have to go both back and elsewhere to find evidence base for the benefits of MD and if these are related in any degree to blood pressure (BP) reduction. The Seven Countries Study showed that the risk and rates of heart attack and stroke both at the population and at the individual level were directly and independently related to the level of serum total cholesterol (TC). It demonstrated that the association between TC level and coronary heart disease (CHD) risk from 5 to 40 years follow-up is found consistently across different cultures [10,11]. The Seven Countries Study started in 1958 in former Yugoslavia. In total, 12,763 men, 40–59 years of age, were enrolled as 16 cohorts, in 7 countries, in 4 regions of the world (United States, Northern Europe, Southern Europe, Japan); 1 cohort is in the United States, 2 cohorts in Finland, 1 in the Netherlands, 3 in Italy, 5 in the former Yugoslavia (two in Croatia, and three in Serbia), 2 in Greece (1 in Crete and 1 in Corfu), and 2 in Japan [10]. The Seven Countries Study has continued, with high levels of participation, for more than 50 years.􀀁The initial and objective data on CVD health in relation to the MD originated from the Seven Countries Study [10]. CHD deaths in the United States and Northern Europe greatly exceeded those in Southern Europe, even when controlled for age, TC and BP levels, smoking, physical activity, and weight [12]. After further investigation, the importance of the eating pattern characterized as the MD became clear [12,13]. What exactly is meant by "Mediterranean diet" today, and its benefits, is detailed by other researches during the last 20 years [14,15]. During the 90's, for the first time, the concept of a food pyramid and the need for an adherence to MD score were born [14-16]. As a result of the Seven Countries Study, the MD has been popularized as a "healthy" diet. Nevertheless, it has not replaced the "prudent" diet commonly prescribed to coronary patients [17]. The Crete cohort of the Seven Countries Study had the lowest rates of deaths from CVD [10]; even the 25 year mortality was lower than others (for example vs. the Italian cohort) [18]. This was attributed to the entire lifestyle of Cretans including a variation of MD, the Cretan-type MD. Many investigators during the last 20 years would rather refer to the Cretan-type MD rather than plain MD, which is a rather abstract definition [19-22]. The 40 years’ CVD mortality in the Corfu cohort showed that participants also benefited from the long-term adoption of a nutritional pattern (close to the Cretan-type) of MD, the presence of physical activity, optimism, and a positive psychological profile [23]. During the last 15 years, and before the economic crisis, Greeks adopted a more western way of life. Nevertheless, several aspects of the traditional Greek way of life and diet, suggest that a relatively high consumption of vegetables and fruits or olive oil and bread, remained well-established among large segments of the Greek population, and may explain why a population with a few healthy habits still enjoys one of the longer life expectancies among the 16 cohorts of the Seven Country Study 40 years after its initiation [23]. The Working Group on Epidemiology and Prevention of the European Society of Cardiology (ESC) coordinated in 2003 information from 12 European cohort studies, including 205,000 persons, and assessed the 10-year CVD mortality rates. This gave birth to the SCORE (Systematic Coronary Risk Estimation) project [24]. The European Society of Cardiology encouraged the creation of local SCORES for each country, based on the original SCORE and local data. Indeed the HellenicSCORE (equations and charts) present the calibration of the risk by age group and sex, based on mortality data, as reported by the National Statistical Services of Greece and prevalence data regarding smoking, TC and BP levels, as reported by the ATTICA study [25]. This was very successfully tested in the ATTEMPT Study [26]. The predicated rates of CVD were verified in a survival study with a nearly 4-year follow-up in patients with metabolic syndrome and randomization to intensive versus moderate risk factor treatment [27]. In the meantime the MD score (MedDietScore) was developed, according to the adherence to MD [28].􀀁The weekly consumption of the following 9 food groups: non-refined cereals(whole grain bread and pasta, brown rice, etc.), fruits, vegetables, legumes, potatoes, fish, meat and meat products, poultry, full fat dairy products (like cheese, yoghurt, milk), as well asolibe oil and alcohol intake, were included [28]. The inclusion of dietary evaluation (MedDietScore), as well as other sociodemographic and anthropometric characteristics, increases the accuracy and reduces estimating bias of CVD risk prediction models [29]. Thus, we have a country adjusted integrated system that can predict CVD risk. It was clear, during the use of HellenicSCORE and MedDietScore, that a better adherence to MD was related to a lower CVD risk. On the contrary, aging, central fat, hypertension (HTN), diabetes, inflammation, low social status and abstinence from a MD seem to predict CVD events within a 5-year period; actual data from the ATTICA study [30]. All these put the adoption of MD at a high position among CVD risk factors, for good and for bad, according to the degree of adoption (MedDietScore). However, does MD affect the level of BP? Is HTN one of the factors to increase CVD risk if the adherence to MD (MedDietScore) is low? There is some evidence on this issue. It has been suggested by a review on the dietary influences on BP that there is more than enough evidence from observational and clinical studies that diets low in saturated fats and sodium and rich in fruits, vegetables, and fiber, with adequate amounts of potassium, calcium, and magnesium, are effective in the prevention and treatment of HTN alone or as an adjunct to pharmacologic therapy [31]. Such dietary combinations are provided by the MD [31]. The association of adherence to the MD with the incidence of HTN was evaluated among 9,408 men and women enrolled in a dynamic Spanish prospective cohort (SUN) study during 1999- 2005 [32]. The adherence to MD was associated with reduced mean values of systolic BP [moderate adherence, -2.4 mm Hg (95% CI: -4.0, -0.8); high adherence, -3.1 mm Hg (95% CI: -5.4, -0.8)] and diastolic BP [moderate adherence, - 1.3 mm Hg (95% CI: -2.5, -0.1); high adherence, -1.9 mm Hg (95% CI: -3.6, -0.1)] after 6 years of follow-up [32]. These results suggest that adhering to a Mediterranean-type diet could contribute to the prevention of age-related increase in BP [32]. In the ATTICA Study the mean value of the MedDiet Score was 25.5 (±3) for men and 27 (±3) for women (p<0.001). The prevalence of HTN was 36.6% in men and 23.7% in women (p<0.001) [33]. Diet score was 23.5±6.4 in hypertensive and 26.8±6.6 in normotensive individuals (p<0.001). The sensitivity of defining people with HTN was higher than for any other CVD risk factor, suggesting that the adoption of MD reduces the risk for HTN [33]. In an elderly population of Cyprus, another Mediterranean Country, 60% of men and 58% of women have HTN, along with other classical CVD risk factors [34]. A 10-unit increase in the MedDietScore was associated with 21% lower odds of having one additional risk factor, including HTN, in women (p< 0.001) and with 14% lower odds in men (p=0.05) [34]. The results of the CARDIO2000 study [35] point out that the adoption of MD by physically active subjects seems to significantly reduce the coronary heart disease (CHD) events and prevent, just about, the one-third of acute CHD syndromes, in controlled subjects with HTN [35]. This supports the idea that MD combined with physical activity provides substantial protection from acute coronary events in patients with HTN [35]. Other data from the SUN Study also [36] suggest that there is an inverse relationship between fruit and vegetable consumption and the prevalence of nonpreviously diagnosed HTN in a Mediterranean population with a very high intake of both fat (paradoxically) and plantderived foods [36]. There was a 77 % reduction in the prevalence of HTN for those with the higher consumption of both fruit and vegetables compared with those at the lower quintiles of both food groups [36]. This inverse relationship was also evident when considering BP as a continuous variable, with a mean systolic BP and diastolic BP of 2.2 mmHg lower for those with the highest consumption of fruit and vegetables compared with those with the lowest intake [36]. The study concludes that in a Mediterranean population, with an elevated fat consumption, a high fruit and vegetable intake is inversely associated with BP levels [36]. From the same (SUN) study it was reported that there is an inverse association between fiber or fruit/vegetable consumption and weight gain, thus emphasizing the importance of replacing some dietary compounds by such foods and fiber-rich products, which may help to avoid weight gain [37]. This brinks about the issue of MD and obesity, mainly central, which is the key clinical manifestation of metabolic syndrome (MetS); this includes HTN. Data suggest that the prevalence of MetS has dramatically increased during the recent years, especially in Western Countries and South East Asia [38]. More than one third (35 %) of adults in the U.S. could be characterized as having the MetS, which translates to nearly 84 million U.S. adults affected by MetS [38]. Unfortunately the prevalence of MetS in Mediterranean Countries is high (one forth of the adult population), although definitely lower than that in U.S. [39,40]. It has been shown by prospective cohort studies, cross-sectional studies and clinical trials that adherence to the MD was associated with reduced risk of the MetS and its individual components also, in particular waist circumference, triglycerides levels, low density lipoprotein cholesterol (HDL-C), BP levels and glucose metabolism [38,41]. These effects of MD increase life expectancy in patients with MetS [42]. On the other hand, Mediterranean countries, such as Greece, have experienced a rapid social-economic change in the last 15 years and recently an economic crisis; both having negative impacts on healthy eating. These community changes affect nutritional habits and there is a tendency to abandon the traditional healthy MD [43]. However, if we continue to try at the elementary school level, things might be better than they look. A study aiming to examine the long-term effects of the "Cretan Health and Nutrition Education Program" on BP, examined several parameters: BP, dietary, anthropometrical and physical activity data nearly 10 years after the original study (at baseline year 1992-1993, and follow-up examination at year 2001-2002) [44]. The findings of the study revealed that the increase over the 10- year period in systolic BP and diastolic BP was higher in the control group than in the MD intervention group (P=0.003 and P<0.001 respectively). These facts are encouraging, indicating favorable changes in BP, micronutrients intake, body mass index (BMI) and physical activity over a 10-year period and 4 years after program's cessation [44]. We just have to keep trying to establish MD at an early age. In brief, MD reduces CVD risk and this action could be at least in part attributed to the reduction of BP and MetS. Given that the complete adoption of MD is practically impossible, a high degree of adherence is desirable. This could substantially reduce adverse CVD events as well as the incidence of acute coronary syndromes, by one third, If combined with a high level of physical activity. A high adherence to MD also reduces the prevalence of MetS, a part of which is HTN, and diminishes its clinical consequences, improving life expectancy. It is more effective if MD is adopted early in life.

Background Cardiovascular disease is already the leading cause of death in many Asian populations. Relationships between vascular risk factors and cardiovascular disease may differ in Asian and western populations. Previously, a lack of prospective data has prevented the reliable quantification of such differences, which, if they were shown to exist, would suggest that novel cardiovascular prevention and treatment strategies are required for Asia. Design An individual participant data meta-analysis of 32 studies from the Asia-Pacific region involving 331 100 subjects (75% from Asia; 25% from the predominantly Caucasian populations of Australia and New Zealand). Methods Outcomes were death from coronary heart disease, ischaemic and haemorrhagic stroke. Hazard ratios were estimated from Cox models for systolic blood pressure (SBP), total cholesterol, triglycerides, body mass index, diabetes and current cigarette smoking, stratified by study and sex and adjusted for age, the other risk factors and regression dilution. Results After an average period of follow-up of 4 years there were 2082 deaths from coronary heart disease, 600 from haemorrhagic stroke and 420 from ischaemic stroke. The direction and strength of the associations between risk factors and cardiovascular outcomes were similar in the two regions, although in two cases there were significant differences. Triglycerides were more strongly associated with coronary heart disease in Australia and New Zealand ( P = 0.03), whereas SBP showed a stronger relationship with haemorrhagic stroke in Asia ( P = 0.04). Conclusions Classical vascular risk factors act similarly in Asian and Caucasian populations; prevention and treatment strategies should thus be similar. Blood pressure reduction should be particularly effective in Asia.

Abstract Background Burden of disease describes the impact of living with and dying prematurely from different diseases or injuries. The Australian Burden of Disease Study (ABDS) 2018 estimated the health impact of 219 diseases and injuries on the Australian population. Methods Burden of disease measures years of healthy life lost from living with (non-fatal) and dying prematurely from (fatal) disease and injury. Fatal and non-fatal burden combined provides the total burden, measured in disability-adjusted life years (DALY). One DALY equals 1 year of healthy life lost. Disease burden was estimated for the years 2018, 2015, 2011 and 2003 for Australia. Results In 2018, 5.0 million years of healthy life were lost from disease and injury. Living with illness or injury caused more total disease burden than dying prematurely (52% vs 48%). Between 2003 and 2018, total burden decreased by 13%, driven by less premature deaths. Disease groups with the biggest absolute reductions in burden (DALY rate) were cardiovascular diseases and cancers. The five leading causes of burden were coronary heart disease, back pain, dementia, chronic obstructive pulmonary disease and lung cancer. Males experienced more burden than females for most age groups. Conclusions Overall burden of disease declined between 2003 and 2018, due to a large reduction in burden from dying prematurely. Living with the impact of chronic diseases contributed substantial burden in Australia in 2018. Key messages Living with illness or injury accounts for most of the disease burden in Australia. There have been improvements in fatal burden since 2003.

Abstract Funding Acknowledgements Type of funding sources: None. Background Factors influencing return to remunerated work following an acute cardiac illness are poorly defined. We wished to compare the factors in our cohorts following first presentation of acute coronary syndrome(ACS) and decompensated heart failure(HF). Methods Prospectively identified subjects, aged 18-65years, from a rehabilitation population for ACS and HF during 2018-2019 underwent a survey. Results Of 133cases meeting inclusion criteria, 84 completed the survey(41 HF, 80% male, mean age 55years; 43 ACS, 86% male, mean age 57years). Socio-economic indexes for Areas(SIEFA) index were similar for HF(900) & ACS(909) groups, which represents 11th and 14th percentile for Australia respectively. Cardiovascular risk factors were similar except hypercholesterolemia(37% v 60%; p = 0.029) was more common in ACS. Many subjects did not continue beyond Yr12, (54% HF v 30% ACS; p = 0.029). A majority of ACS cases returned to work as compared with HF(70% v 44%; p = 0.017)(Figure). On multivariate analysis, male gender[p = 0.031;OR 13.71 (1.28-147.36)]; access to financial benefits[p &lt; 0.001;OR 22.75 (4.31-119.99)] and a desire to return to work [p = 0.014;OR 12.1 (1.67-87.82)] were associated with successful return to work (Table). Limitations Our study has small numbers so will be difficult to generalise to a wider population. We do show a signal towards the complex interplay of the social and individual factors in determining return to work. Further larger studies are required to tease out the differences between the individual factors to help predict return to work in the Australian context. Conclusion Successful return to work for patients with first presentation of ACS or HF could not be reliably predicted. Patients with ACS returned to work more often than HF. In HF patients who do n to return to work, recurrent symptoms, individual motivation, social support and access to financial benefits have a complex interplay. Predictors of return to work Predictor P value OR (95% CI) Diagnosis (heart failure) 0.095 0.29 (0.07, 1.24) Gender (male) 0.031 13.71 (1.28, 147.36) Access to benefit (none) &lt;0.001 22.75 (4.31, 119.99) Desire to RTW (yes) 0.014 12.1 (1.67, 87.82) Abstract Figure. Rates of return to work in the 2 groups