Effect of socioeconomic deprivation on waiting time for cardiac surgery: retrospective cohort study

OBJECTIVE: To determine whether the priority given to patients referred for cardiac surgery is associated with socioeconomic status. DESIGN: Retrospective study with multivariate logistic regression analysis of the association between deprivation and classification of urgency with allowance for age, sex, and type of operation. Multivariate linear regression analysis was used to determine association between deprivation and waiting time within each category of urgency, with allowance for age, sex, and type of operation. SETTING: NHS waiting lists in Scotland. PARTICIPANTS: 26 642 patients waiting for cardiac surgery, 1 January 1986 to 31 December 1997. MAIN OUTCOME MEASURES: Deprivation as measured by Carstairs deprivation category. Time spent on NHS waiting list. RESULTS: Patients who were most deprived tended to be younger and were more likely to be female. Patients in deprivation categories 6 and 7 (most deprived) waited about three weeks longer for surgery than those in category 1 (mean difference 24 days, 95% confidence interval 15 to 32). Deprived patients had an odds ratio of 0.5 (0.46 to 0.61) for having their operations classified as urgent compared with the least deprived, after allowance for age, sex, and type of operation. When urgent and routine cases were considered separately, there was no significant difference in waiting times between the most and least deprived categories. CONCLUSIONS: Socioeconomically deprived patients are thought to be more likely to develop coronary heart disease but are less likely to be investigated and offered surgery once it has developed. Such patients may be further disadvantaged by having to wait longer for surgery because of being given lower priority

Percutaneous coronary intervention in the elderly: changes in case-mix and periprocedural outcomes in 31758 patients treated between 2000 and 2007

<p>Background: The elderly account for an increasing proportion of the population and have a high prevalence of coronary heart disease. Percutaneous coronary intervention (PCI) is the most common method of revascularization in the elderly. We examined whether the risk of periprocedural complications after PCI was higher among elderly (age ≥75 years) patients and whether it has changed over time.</p> <p>Methods and Results: The Scottish Coronary Revascularization Register was used to undertake a retrospective cohort study on all 31 758 patients undergoing nonemergency PCI in Scotland between April 2000 and March 2007, inclusive. There was an increase in the number and percentage of PCIs undertaken in elderly patients, from 196 (8.7%) in 2000 to 752 (13.9%) in 2007. Compared with younger patients, the elderly were more likely to have multivessel disease, multiple comorbidity, and a history of myocardial infarction or coronary artery bypass grafting (χ2 tests, all P<0.001). The elderly had a higher risk of major adverse cardiovascular events within 30 days of PCI (4.5% versus 2.7%, χ2 test P<0.001). Over the 7 years, there was a significant increase in the proportion of elderly patients who had multiple comorbidity (χ2 test for trend, P<0.001). Despite this, the underlying risk of complications did not change significantly over time either among the elderly (χ2 test for trend, P=0.142) or overall (χ2 test for trend, P=0.083).</p> <p>Conclusions: Elderly patients have a higher risk of periprocedural complications and account for an increasing proportion of PCIs. Despite this, the risk of complications after PCI has not increased over time.</p&gt

Comparison of mass and targeted screening strategies for cardiovascular risk: simulation of the effectiveness, cost-effectiveness and coverage using a cross-sectional survey of 3921 people

Background: Cardiovascular primary prevention should be targeted at those with the highest global risk. However, it is unclear how best to identify such individuals from the general population. The aim of this study was to compare mass and targeted screening strategies in terms of effectiveness, cost effectiveness and coverage.\ud \ud Methods: The Scottish Health Survey provided cross-sectional data on 3921 asymptomatic members of the general population aged 40–74 years. We undertook simulation models of five screening strategies: mass screening, targeted screening of deprived communities, targeted screening of family members and combinations of the latter two.\ud \ud Results: To identify one individual at high risk of premature cardiovascular disease using mass screening required 16.0 people to be screened at a cost of £370. Screening deprived communities targeted 17% of the general population but identified 45% of those at high risk, and identified one high-risk individual for every 6.1 people screened at a cost of £141. Screening family members targeted 28% of the general population but identified 61% of those at high risk, and identified one high-risk individual for every 7.4 people screened at a cost of £170. Combining both approaches enabled 84% of high risk individuals to be identified by screening only 41% of the population. Extending targeted to mass screening identified only one additional high-risk person for every 58.8 screened at a cost of £1358.\ud \ud Conclusions: Targeted screening strategies are less costly than mass screening, and can identify up to 84% of high-risk individuals. The additional resources required for mass screening may not be justified

Obesity paradox in a cohort of 4880 consecutive patients undergoing percutaneous coronary intervention

<b>Aims</b>: We sought to investigate the impact of body mass index (BMI) on long-term all-cause mortality in patients following first-time elective percutaneous coronary intervention (PCI). <b>Methods and results</b>: We used the Scottish Coronary Revascularisation Register to undertake a cohort study of all patients undergoing elective PCI in Scotland between April 1997 and March 2006 inclusive. We excluded patients who had previously undergone revascularization. There were 219 deaths within 5 years of 4880 procedures. Compared with normal weight individuals, those with a BMI ≥27.5 and <30 were at reduced risk of dying (HR 0.59, 95% CI 0.39–0.90, 95%, P = 0.014). There was no attenuation of the association after adjustment for potential confounders, including age, hypertension, diabetes, and left ventricular function (adjusted HR 0.59, 95% CI 0.39–0.90, P = 0.015), and there were no statistically significant interactions. The results were unaltered by restricting the analysis to events beyond 30 days of follow-up. <b>Conclusion</b>: Among patients undergoing percutaneous intervention for coronary artery disease, increased BMI was associated with improved 5 year survival. Among those with established coronary disease, the adverse effects of excess adipose tissue may be offset by beneficial vasoactive properties

Drug-eluting stents versus bare-metal stents for off-label indications: a propensity score-matched outcome study

Background-The US Food and Drug Administration recently concluded that data on off-label drug-eluting stent (DES) safety are limited. However, in actual clinical practice, DES are often used for off-label indications, and observational studies demonstrate that complications are higher when compared with on-label use. We aimed to determine whether clinical outcomes differ after DES and bare-metal stent implantation in a patient cohort defined by DES off-label indications. Methods and Results-We used the national revascularization registry in Scotland to identify patients who underwent coronary stenting for an off-label indication between January 2003 and September 2005. Individual-level linkage to comprehensive national admission and death databases was used to ascertain the end points of death, myocardial infarction, and target-vessel revascularization. We calculated propensity scores on the basis of clinical, demographic, and angiographic variables and matched DES to bare-metal stents on a 1:1 basis. The final study population consisted of 1642 patients, well matched for important covariables at baseline. Event-free survival was calculated over 24 months with the Kaplan-Meier method. All-cause death was more common after bare-metal stent implantation during follow-up (7.7% versus 6.6%; hazard ratio 0.63; 95% confidence interval, 0.40 to 0.99; P=0.04). No difference in the rates of myocardial infarction were noted (7.3% versus 7.5%; hazard ratio 1.02; 95% confidence interval, 0.69 to 1.54; P=0.92). Target-vessel revascularization was reduced in patients treated with DES (13.9% versus 10.7%; hazard ratio 0.67; 95% confidence interval, 0.49 to 0.93; P=0.02). Conclusions-At 24 months, patients treated with DES for off-label indications had lower rates of death and target-vessel revascularization and similar rates of myocardial infarction, as compared with patients treated with bare-metal stents. (Circ Cardiovasc Intervent. 2008;1:45-52.

Smoke-free legislation and hospitalizations for acute coronary syndrome

Background Previous studies have suggested a reduction in the total number of hospital admissions for acute coronary syndrome after the enactment of legislation banning smoking in public places. However, it is unknown whether the reduction in admissions involved nonsmokers, smokers, or both. Methods Since the end of March 2006, smoking has been prohibited by law in all enclosed public places throughout Scotland. We collected information prospectively on smoking status and exposure to secondhand smoke based on questionnaires and biochemical findings from all patients admitted with acute coronary syndrome to nine Scottish hospitals during the 10-month period preceding the passage of the legislation and during the same period the next year. These hospitals accounted for 64% of admissions for acute coronary syndrome in Scotland, which has a population of 5.1 million. Results Overall, the number of admissions for acute coronary syndrome decreased from 3235 to 2684 -- a 17% reduction (95% confidence interval, 16 to 18) -- as compared with a 4% reduction in England (which has no such legislation) during the same period and a mean annual decrease of 3% (maximum decrease, 9%) in Scotland during the decade preceding the study. The reduction in the number of admissions was not due to an increase in the number of deaths of patients with acute coronary syndrome who were not admitted to the hospital; this latter number decreased by 6%. There was a 14% reduction in the number of admissions for acute coronary syndrome among smokers, a 19% reduction among former smokers, and a 21% reduction among persons who had never smoked. Persons who had never smoked reported a decrease in the weekly duration of exposure to secondhand smoke (P<0.001 by the chi-square test for trend) that was confirmed by a decrease in their geometric mean concentration of serum cotinine from 0.68 to 0.56 ng per milliliter (P<0.001 by the t-test). Conclusions The number of admissions for acute coronary syndrome decreased after the implementation of smoke-free legislation. A total of 67% of the decrease involved nonsmokers. However, fewer admissions among smokers also contributed to the overall reduction