Trends in cardiovascular disease biomarkers and their socioeconomic patterning among adults in the Scottish population 1995 to 2009: cross-sectional surveys

Objectives To examine secular and socioeconomic changes in biological cardiovascular disease risk factor and biomarker prevalences in the Scottish population. This could contribute to an understanding of why the decline in coronary heart disease mortality in Scotland has recently stalled along with persistence of associated socioeconomic inequalities. Design Cross-sectional surveys. Setting Scotland. Participants Scottish Health Surveys: 1995, 1998, 2003, 2008 and 2009 (6190, 6656, 5497, 4202 and 4964 respondents, respectively, aged 25–64 years). Primary outcome measures Gender-stratified, age-standardised prevalences of obesity, hypertension, hypercholesterolaemia and low high-density lipoprotein cholesterol blood concentration as well as elevated fibrinogen and C reactive protein concentrations according to education and social class groupings. Inequalities were assessed using the slope index of inequality, and time trends were assessed using linear regression. Results The prevalence of obesity, including central obesity, increased between 1995 and 2009 among men and women, irrespective of socioeconomic position. In 2009, the prevalence of obesity (defined by body mass index) was 29.8% (95% CI 27.9% to 31.7%) for men and 28.2% (26.3% to 30.2%) for women. The proportion of individuals with hypertension remained relatively unchanged between 1995 and 2008/2009, while the prevalence of hypercholesterolaemia declined in men from 79.6% (78.1% to 81.1%) to 63.8% (59.9% to 67.8%) and in women from 74.1% (72.6% to 75.7%) to 66.3% (62.6% to 70.0%). Socioeconomic inequalities persisted over time among men and women for most of the biomarkers and were particularly striking for the anthropometric measures when stratified by education. Conclusions If there are to be further declines in coronary heart disease mortality and reduction in associated inequalities, then there needs to be a favourable step change in the prevalence of cardiovascular disease risk factors. This may require radical population-wide interventions

Adiposity has differing associations with incident coronary heart disease and mortality in the Scottish population: cross-sectional surveys with follow-up

Objective: Investigation of the association of excess adiposity with three different outcomes: all-cause mortality, coronary heart disease (CHD) mortality and incident CHD. Design: Cross-sectional surveys linked to hospital admissions and death records. Subjects: 19 329 adults (aged 18–86 years) from a representative sample of the Scottish population. Measurements: Gender-stratified Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause mortality, CHD mortality and incident CHD. Separate models incorporating the anthropometric measurements body mass index (BMI), waist circumference (WC) or waist–hip ratio (WHR) were created adjusted for age, year of survey, smoking status and alcohol consumption. Results: For both genders, BMI-defined obesity (greater than or equal to30 kg m−2) was not associated with either an increased risk of all-cause mortality or CHD mortality. However, there was an increased risk of incident CHD among the obese men (hazard ratio (HR)=1.78; 95% confidence interval=1.37–2.31) and obese women (HR=1.93; 95% confidence interval=1.44–2.59). There was a similar pattern for WC with regard to the three outcomes; for incident CHD, the HR=1.70 (1.35–2.14) for men and 1.71 (1.28–2.29) for women in the highest WC category (men greater than or equal to102 cm, women greater than or equal to88 cm), synonymous with abdominal obesity. For men, the highest category of WHR (greater than or equal to1.0) was associated with an increased risk of all-cause mortality (1.29; 1.04–1.60) and incident CHD (1.55; 1.19–2.01). Among women with a high WHR (greater than or equal to0.85) there was an increased risk of all outcomes: all-cause mortality (1.56; 1.26–1.94), CHD mortality (2.49; 1.36–4.56) and incident CHD (1.76; 1.31–2.38). Conclusions: In this study excess adiposity was associated with an increased risk of incident CHD but not necessarily death. One possibility is that modern medical intervention has contributed to improved survival of first CHD events. The future health burden of increased obesity levels may manifest as an increase in the prevalence of individuals living with CHD and its consequences

Equine asthma: managing the environment

Equine asthma is an umbrella term defined by nonseptic lower airway inflammation. Currently there are two broad categories, namely mild to moderate equine asthma (formerly known as inflammatory airway disease) and severe equine asthma (formerly known as recurrent airway obstruction or heaves). Environmental challenge is involved in the aetiopathogenesis of both these subcategories. Much of this challenge, and the part that we can control, is provided by the organic dust associated with the stabling of horses. This article reviews the available evidence relating to the environmental management of equine asthma and tries to relate this to practical options for providing a low-dust environment

Equine asthma: managing the environment

Equine asthma is an umbrella term defined by nonseptic lower airway inflammation. Currently there are two broad categories, namely mild to moderate equine asthma (formerly known as inflammatory airway disease) and severe equine asthma (formerly known as recurrent airway obstruction or heaves). Environmental challenge is involved in the aetiopathogenesis of both these subcategories. Much of this challenge, and the part that we can control, is provided by the organic dust associated with the stabling of horses. This article reviews the available evidence relating to the environmental management of equine asthma and tries to relate this to practical options for providing a low-dust environment

Ticagrelor in patients with diabetes and stable coronary artery disease with a history of previous percutaneous coronary intervention (THEMIS-PCI) : a phase 3, placebo-controlled, randomised trial

Background: Patients with stable coronary artery disease and diabetes with previous percutaneous coronary intervention (PCI), particularly those with previous stenting, are at high risk of ischaemic events. These patients are generally treated with aspirin. In this trial, we aimed to investigate if these patients would benefit from treatment with aspirin plus ticagrelor. Methods: The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) was a phase 3 randomised, double-blinded, placebo-controlled trial, done in 1315 sites in 42 countries. Patients were eligible if 50 years or older, with type 2 diabetes, receiving anti-hyperglycaemic drugs for at least 6 months, with stable coronary artery disease, and one of three other mutually non-exclusive criteria: a history of previous PCI or of coronary artery bypass grafting, or documentation of angiographic stenosis of 50% or more in at least one coronary artery. Eligible patients were randomly assigned (1:1) to either ticagrelor or placebo, by use of an interactive voice-response or web-response system. The THEMIS-PCI trial comprised a prespecified subgroup of patients with previous PCI. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke (measured in the intention-to-treat population). Findings: Between Feb 17, 2014, and May 24, 2016, 11 154 patients (58% of the overall THEMIS trial) with a history of previous PCI were enrolled in the THEMIS-PCI trial. Median follow-up was 3·3 years (IQR 2·8–3·8). In the previous PCI group, fewer patients receiving ticagrelor had a primary efficacy outcome event than in the placebo group (404 [7·3%] of 5558 vs 480 [8·6%] of 5596; HR 0·85 [95% CI 0·74–0·97], p=0·013). The same effect was not observed in patients without PCI (p=0·76, p interaction=0·16). The proportion of patients with cardiovascular death was similar in both treatment groups (174 [3·1%] with ticagrelor vs 183 (3·3%) with placebo; HR 0·96 [95% CI 0·78–1·18], p=0·68), as well as all-cause death (282 [5·1%] vs 323 [5·8%]; 0·88 [0·75–1·03], p=0·11). TIMI major bleeding occurred in 111 (2·0%) of 5536 patients receiving ticagrelor and 62 (1·1%) of 5564 patients receiving placebo (HR 2·03 [95% CI 1·48–2·76], p<0·0001), and fatal bleeding in 6 (0·1%) of 5536 patients with ticagrelor and 6 (0·1%) of 5564 with placebo (1·13 [0·36–3·50], p=0·83). Intracranial haemorrhage occurred in 33 (0·6%) and 31 (0·6%) patients (1·21 [0·74–1·97], p=0·45). Ticagrelor improved net clinical benefit: 519/5558 (9·3%) versus 617/5596 (11·0%), HR=0·85, 95% CI 0·75–0·95, p=0·005, in contrast to patients without PCI where it did not, p interaction=0·012. Benefit was present irrespective of time from most recent PCI. Interpretation: In patients with diabetes, stable coronary artery disease, and previous PCI, ticagrelor added to aspirin reduced cardiovascular death, myocardial infarction, and stroke, although with increased major bleeding. In that large, easily identified population, ticagrelor provided a favourable net clinical benefit (more than in patients without history of PCI). This effect shows that long-term therapy with ticagrelor in addition to aspirin should be considered in patients with diabetes and a history of PCI who have tolerated antiplatelet therapy, have high ischaemic risk, and low bleeding risk