Optimal strategies for identifying patients with myocardial infarction in general practice

Background. In order to provide evidence-based secondary prevention of coronary heart disease (CHD) in general practice, eligible patients need to be identified. The optimal strategy is one in which all appropriate patients are identified with the least effort. Objective. The purpose of the study was to determine the optimal strategy to identify subjects with a myocardial infarction (MI) from general practice records using different search criteria. Methods. The study was a cross-sectional survey of 10 general practices in Tayside, Scotland. A random sample of all subjects aged over 35 (n = 5061) and registered with the general practices was obtained. The main outcome measures were sensitivity, specificity, positive predictive value (PPV) and yield (the number of records that need to be examined to detect a 'true case'). Results. Of the sample of 5061, 207 (4.1%) were defined to have had a 'gold standard' MI. A Read code for ischaemic heart disease (IHD) had the highest sensitivity (95%) but with a poor PPV (52%). All searches had high specificities. The addition of a record of hospitalization for MI to the Read code for MI gave 100% sensitivity and high yield (1 in 1.11). In situations where the Read coding is of poor quality, the alternative search strategy of a hospital record of MI or receiving aspirin or nitrates was optimum. Conclusions. Patients who had experienced an MI can be easily identified from a combination of a Read code for MI and a record of hospitalization for an MI giving 100% sensitivity and specificity with a yield of 1 in 1.11.</p

The HEARTS collaboration - Delivering improved secondary prevention of CHD for patients with heart disease

Full implementation of the available evidence on secondary prevention should ensure that all patients after myocardial infarction should be offered both effective treatment and be maintained on treatment. This article describes the Heart disease Evidence-based Audit and Research in Tayside Scotland (HEARTS) collaboration which has been set up to try and achieve this. HEARTS can collect electronic data from many sources; prioritise data from multiple sources, such as hospital and general practice; process and link patient records; and, allow manual validation of electronic data. It can also facilitate clinical governance issues in general practice and hospital plus disseminate information to patients. It is hoped that, in addition to secondary prevention, it will be able to extend its focus to other aspects of cardiovascular disease in the future as well as being used for epidemiological and qualitative projects. The system maintains the security and rights of patients at all times.</p

CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label,parallel-group, multicentre trial

Background The benefi t of CT coronary angiography (CTCA) in patients presenting with stable chest pain has not been systematically studied. We aimed to assess the eff ect of CTCA on the diagnosis, management, and outcome of patients referred to the cardiology clinic with suspected angina due to coronary heart disease. Methods In this prospective open-label, parallel-group, multicentre trial, we recruited patients aged 18–75 years referred for the assessment of suspected angina due to coronary heart disease from 12 cardiology chest pain clinics across Scotland. We randomly assigned (1:1) participants to standard care plus CTCA or standard care alone. Randomisation was done with a web-based service to ensure allocation concealment. The primary endpoint was certainty of the diagnosis of angina secondary to coronary heart disease at 6 weeks. All analyses were intention to treat, and patients were analysed in the group they were allocated to, irrespective of compliance with scanning. This study is registered with ClinicalTrials.gov, number NCT01149590. Findings Between Nov 18, 2010, and Sept 24, 2014, we randomly assigned 4146 (42%) of 9849 patients who had been referred for assessment of suspected angina due to coronary heart disease. 47% of participants had a baseline clinic diagnosis of coronary heart disease and 36% had angina due to coronary heart disease. At 6 weeks, CTCA reclassifi ed the diagnosis of coronary heart disease in 558 (27%) patients and the diagnosis of angina due to coronary heart disease in 481 (23%) patients (standard care 22 [1%] and 23 [1%]; p<0·0001). Although both the certainty (relative risk [RR] 2·56, 95% CI 2·33–2·79; p<0·0001) and frequency of coronary heart disease increased (1·09, 1·02–1·17; p=0·0172), the certainty increased (1·79, 1·62–1·96; p<0·0001) and frequency seemed to decrease (0·93, 0·85–1·02; p=0·1289) for the diagnosis of angina due to coronary heart disease. This changed planned investigations (15% vs 1%; p<0·0001) and treatments (23% vs 5%; p<0·0001) but did not aff ect 6-week symptom severity or subsequent admittances to hospital for chest pain. After 1·7 years, CTCA was associated with a 38% reduction in fatal and nonfatal myocardial infarction (26 vs 42, HR 0·62, 95% CI 0·38–1·01; p=0·0527), but this was not signifi cant. Interpretation In patients with suspected angina due to coronary heart disease, CTCA clarifi es the diagnosis, enables targeting of interventions, and might reduce the future risk of myocardial infarction. Funding The Chief Scientist Offi ce of the Scottish Government Health and Social Care Directorates funded the trial with supplementary awards from Edinburgh and Lothian’s Health Foundation Trust and the Heart Diseases Research Fund