Skip to main content
PMC home page
Journal of Epidemiology and Community Health logoLink to Journal of Epidemiology and Community Health
. 2005 Dec;59(12):1041–1046. doi: 10.1136/jech.2005.035717

Population impact of stricter adherence to recommendations for pharmacological and lifestyle interventions over one year in patients with coronary heart disease

I Gemmell 1, R Heller 1, P McElduff 1, K Payne 1, G Butler 1, R Edwards 1, M Roland 1, P Durrington 1
PMCID: PMC1732977  PMID: 16286491

Abstract

Design: Modelling study.

Setting: Primary care.

Data sources: Published data on prevalence of acute myocardial infarction and heart failure, baseline risk of mortality, the relative risk reduction associated with different interventions and the proportion treated, eligible for treatment and adhering to each intervention.

Main results: Adopting the NSF recommendations for pharmacological interventions would prevent an extra 1027 (95% CI 418 to 1994) deaths in post-acute myocardial infarction (AMI) patients and an extra 37 899 (95% CI 25 690 to 52 503) deaths in heart failure patients in the first year after diagnosis. Lifestyle based interventions would prevent an extra 848 (95% CI 71 to 1 614) deaths in post-AMI patients and an extra 7249 (95% CI 995 to 16 696) deaths in heart failure patients.

Conclusions: Moving from current to "best" practice as recommended in the NSF will have a much greater impact on one year mortality rates among heart failure patients compared with post-AMI patients. Meeting pharmacological based recommendations for heart failure patients will prevent more deaths than meeting lifestyle based recommendations. Population impact numbers can help communicate the impact on a population of the implementation of guidelines and, when created using local data, could help policy makers assess the local impact of implementing a range of health care targets.

Full Text

The Full Text of this article is available as a PDF (170.3 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Almela P., Benages A., Peiró S., Minguez M., Peña A., Pascual I., Mora F. Outpatient management of upper digestive hemorrhage not associated with portal hypertension: a large prospective cohort. Am J Gastroenterol. 2001 Aug;96(8):2341–2348. doi: 10.1111/j.1572-0241.2001.04087.x. [DOI] [PubMed] [Google Scholar]
  2. Antithrombotic Trialists' Collaboration Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002 Jan 12;324(7329):71–86. doi: 10.1136/bmj.324.7329.71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Belardinelli R., Georgiou D., Cianci G., Purcaro A. Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation. 1999 Mar 9;99(9):1173–1182. doi: 10.1161/01.cir.99.9.1173. [DOI] [PubMed] [Google Scholar]
  4. Brotons Carlos, Permanyer Gaietà, Pacheco Valeria, Moral Irene, Ribera Aida, Cascant Purificación, Pinar Josep, PREMISE study group Prophylactic treatment after myocardial infarction in primary care: how far can we go? Fam Pract. 2003 Feb;20(1):32–35. doi: 10.1093/fampra/20.1.32. [DOI] [PubMed] [Google Scholar]
  5. Bucher Heiner C., Hengstler Peter, Schindler Christian, Meier Gabriela. N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials. Am J Med. 2002 Mar;112(4):298–304. doi: 10.1016/s0002-9343(01)01114-7. [DOI] [PubMed] [Google Scholar]
  6. Campbell N. C., Thain J., Deans H. G., Ritchie L. D., Rawles J. M. Secondary prevention in coronary heart disease: baseline survey of provision in general practice. BMJ. 1998 May 9;316(7142):1430–1434. doi: 10.1136/bmj.316.7142.1430. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Capewell S., Livingston B. M., MacIntyre K., Chalmers J. W., Boyd J., Finlayson A., Redpath A., Pell J. P., Evans C. J., McMurray J. J. Trends in case-fatality in 117 718 patients admitted with acute myocardial infarction in Scotland. Eur Heart J. 2000 Nov;21(22):1833–1840. doi: 10.1053/euhj.2000.2318. [DOI] [PubMed] [Google Scholar]
  8. Carroll Kevin, Majeed Azeem, Firth Caroline, Gray Jeremy. Prevalence and management of coronary heart disease in primary care: population-based cross-sectional study using a disease register. J Public Health Med. 2003 Mar;25(1):29–35. doi: 10.1093/pubmed/fdg007. [DOI] [PubMed] [Google Scholar]
  9. Corrigan Mairead, Cupples Margaret E., Stevenson Mike. Quitting and restarting smoking: cohort study of patients with angina in primary care. BMJ. 2002 Apr 27;324(7344):1016–1017. doi: 10.1136/bmj.324.7344.1016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Cotter Gad, Shemesh Eyal, Zehavi Miriam, Dinur Irit, Rudnick Abraham, Milo Olga, Vered Zvi, Krakover Rikardo, Kaluski Edo, Kornberg Abraham. Lack of aspirin effect: aspirin resistance or resistance to taking aspirin? Am Heart J. 2004 Feb;147(2):293–300. doi: 10.1016/j.ahj.2003.07.011. [DOI] [PubMed] [Google Scholar]
  11. Cowie M. R., Wood D. A., Coats A. J., Thompson S. G., Poole-Wilson P. A., Suresh V., Sutton G. C. Incidence and aetiology of heart failure; a population-based study. Eur Heart J. 1999 Mar;20(6):421–428. doi: 10.1053/euhj.1998.1280. [DOI] [PubMed] [Google Scholar]
  12. Critchley Julia A., Capewell Simon. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA. 2003 Jul 2;290(1):86–97. doi: 10.1001/jama.290.1.86. [DOI] [PubMed] [Google Scholar]
  13. Cupples M. E., McKnight A. Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk. BMJ. 1994 Oct 15;309(6960):993–996. doi: 10.1136/bmj.309.6960.993. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Davies M., Hobbs F., Davis R., Kenkre J., Roalfe A. K., Hare R., Wosornu D., Lancashire R. J. Prevalence of left-ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England Screening study: a population based study. Lancet. 2001 Aug 11;358(9280):439–444. doi: 10.1016/s0140-6736(01)05620-3. [DOI] [PubMed] [Google Scholar]
  15. Domanski M. J., Exner D. V., Borkowf C. B., Geller N. L., Rosenberg Y., Pfeffer M. A. Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials. J Am Coll Cardiol. 1999 Mar;33(3):598–604. doi: 10.1016/s0735-1097(98)00609-3. [DOI] [PubMed] [Google Scholar]
  16. Dudley Nigel J., Bowling Ann, Bond Matthew, McKee Dorothy, McClay Scott Marie, Banning Adrian, Elder Andrew T., Martin A. Tony, Blackman Iva. Age- and sex-related bias in the management of heart disease in a district general hospital. Age Ageing. 2002 Jan;31(1):37–42. doi: 10.1093/ageing/31.1.37. [DOI] [PubMed] [Google Scholar]
  17. EUROASPIRE II Study Group Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries; principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J. 2001 Apr;22(7):554–572. doi: 10.1053/euhj.2001.2610. [DOI] [PubMed] [Google Scholar]
  18. Eagle Kim A., Kline-Rogers Eva, Goodman Shaun G., Gurfinkel Enrique P., Avezum Alvaro, Flather Marcus D., Granger Christopher B., Erickson Steve, White Kami, Steg Philippe Gabriel. Adherence to evidence-based therapies after discharge for acute coronary syndromes: an ongoing prospective, observational study. Am J Med. 2004 Jul 15;117(2):73–81. doi: 10.1016/j.amjmed.2003.12.041. [DOI] [PubMed] [Google Scholar]
  19. Feder G., Griffiths C., Eldridge S., Spence M. Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial. BMJ. 1999 Jun 5;318(7197):1522–1526. doi: 10.1136/bmj.318.7197.1522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Flanagan D. E., Cox P., Paine D., Davies J., Armitage M. Secondary prevention of coronary heart disease in primary care: a healthy heart initiative. QJM. 1999 May;92(5):245–250. doi: 10.1093/qjmed/92.5.245. [DOI] [PubMed] [Google Scholar]
  21. Flather M. D., Yusuf S., Køber L., Pfeffer M., Hall A., Murray G., Torp-Pedersen C., Ball S., Pogue J., Moyé L. Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet. 2000 May 6;355(9215):1575–1581. doi: 10.1016/s0140-6736(00)02212-1. [DOI] [PubMed] [Google Scholar]
  22. Fox Kevin F., Wood David A., Wright Melissa, Bond Sharon, Nuttall Michaela, Arora Barbara, Dawson Ellen, Devane Patricia, Sutcliffe Steven J., Brown Ken. Evaluation of a cardiac prevention and rehabilitation programme for all patients at first presentation with coronary artery disease. J Cardiovasc Risk. 2002 Dec;9(6):355–359. doi: 10.1097/01.hjr.0000049245.21319.69. [DOI] [PubMed] [Google Scholar]
  23. Freemantle N., Cleland J., Young P., Mason J., Harrison J. beta Blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999 Jun 26;318(7200):1730–1737. doi: 10.1136/bmj.318.7200.1730. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Greenland Sander. Interval estimation by simulation as an alternative to and extension of confidence intervals. Int J Epidemiol. 2004 Aug 19;33(6):1389–1397. doi: 10.1093/ije/dyh276. [DOI] [PubMed] [Google Scholar]
  25. Gustafsson Finn, Kragelund Charlotte B., Torp-Pedersen Christian, Seibaek Marie, Burchardt Hans, Akkan Dilek, Thune Jens Jakob, Køber Lars, DIAMOND study group Effect of obesity and being overweight on long-term mortality in congestive heart failure: influence of left ventricular systolic function. Eur Heart J. 2004 Nov 30;26(1):58–64. doi: 10.1093/eurheartj/ehi022. [DOI] [PubMed] [Google Scholar]
  26. Hedman J., Kaprio J., Poussa T., Nieminen M. M. Prevalence of asthma, aspirin intolerance, nasal polyposis and chronic obstructive pulmonary disease in a population-based study. Int J Epidemiol. 1999 Aug;28(4):717–722. doi: 10.1093/ije/28.4.717. [DOI] [PubMed] [Google Scholar]
  27. Heller R. F., Dobson A. J. Disease impact number and population impact number: population perspectives to measures of risk and benefit. BMJ. 2000 Oct 14;321(7266):950–953. doi: 10.1136/bmj.321.7266.950. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Heller R. F., Page J. A population perspective to evidence based medicine: "evidence for population health". J Epidemiol Community Health. 2002 Jan;56(1):45–47. doi: 10.1136/jech.56.1.45. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Heller Richard F., Edwards Richard, McElduff Patrick. Implementing guidelines in primary care: can population impact measures help? BMC Public Health. 2003 Jan 23;3:7–7. doi: 10.1186/1471-2458-3-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Hippisley-Cox J., Pringle M., Crown N., Meal A., Wynn A. Sex inequalities in ischaemic heart disease in general practice: cross sectional survey. BMJ. 2001 Apr 7;322(7290):832–832. doi: 10.1136/bmj.322.7290.832. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Horwich T. B., Fonarow G. C., Hamilton M. A., MacLellan W. R., Woo M. A., Tillisch J. H. The relationship between obesity and mortality in patients with heart failure. J Am Coll Cardiol. 2001 Sep;38(3):789–795. doi: 10.1016/s0735-1097(01)01448-6. [DOI] [PubMed] [Google Scholar]
  32. Insull W. The problem of compliance to cholesterol altering therapy. J Intern Med. 1997 Apr;241(4):317–325. doi: 10.1046/j.1365-2796.1997.112133000.x. [DOI] [PubMed] [Google Scholar]
  33. Jolly K., Bradley F., Sharp S., Smith H., Thompson S., Kinmonth A. L., Mant D. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group. BMJ. 1999 Mar 13;318(7185):706–711. doi: 10.1136/bmj.318.7185.706. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. LaRosa J. H., LaRosa J. C. Enhancing drug compliance in lipid-lowering treatment. Arch Fam Med. 2000 Nov-Dec;9(10):1169–1175. doi: 10.1001/archfami.9.10.1169. [DOI] [PubMed] [Google Scholar]
  35. Latini R., Tognoni G., Maggioni A. P., Baigent C., Braunwald E., Chen Z. M., Collins R., Flather M., Franzosi M. G., Kjekshus J. Clinical effects of early angiotensin-converting enzyme inhibitor treatment for acute myocardial infarction are similar in the presence and absence of aspirin: systematic overview of individual data from 96,712 randomized patients. Angiotensin-converting Enzyme Inhibitor Myocardial Infarction Collaborative Group. J Am Coll Cardiol. 2000 Jun;35(7):1801–1807. doi: 10.1016/s0735-1097(00)00638-0. [DOI] [PubMed] [Google Scholar]
  36. Lyratzopoulos Georgios, Cook Gary A., McElduff Patrick, Havely Daniel, Edwards Richard, Heller Richard F. Assessing the impact of heart failure specialist services on patient populations. BMC Health Serv Res. 2004 May 24;4(1):10–10. doi: 10.1186/1472-6963-4-10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. MacIntyre K., Capewell S., Stewart S., Chalmers J. W., Boyd J., Finlayson A., Redpath A., Pell J. P., McMurray J. J. Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995. Circulation. 2000 Sep 5;102(10):1126–1131. doi: 10.1161/01.cir.102.10.1126. [DOI] [PubMed] [Google Scholar]
  38. Mant J., Hicks N. Detecting differences in quality of care: the sensitivity of measures of process and outcome in treating acute myocardial infarction. BMJ. 1995 Sep 23;311(7008):793–796. doi: 10.1136/bmj.311.7008.793. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Marshall Tom, Rouse Andrew. Resource implications and health benefits of primary prevention strategies for cardiovascular disease in people aged 30 to 74: mathematical modelling study. BMJ. 2002 Jul 27;325(7357):197–197. doi: 10.1136/bmj.325.7357.197. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Michalsen A., König G., Thimme W. Preventable causative factors leading to hospital admission with decompensated heart failure. Heart. 1998 Nov;80(5):437–441. doi: 10.1136/hrt.80.5.437. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Newby L. Kristin, Bhapkar Manjushri V., White Harvey D., Moliterno David J., LaPointe Nancy M. Allen, Kandzari David E., Verheugt Freek W. A., Kramer Judith M., Armstrong Paul W., Califf Robert M. Aspirin use post-acute coronary syndromes: intolerance, bleeding and discontinuation. J Thromb Thrombolysis. 2003 Dec;16(3):119–128. doi: 10.1023/B:THRO.0000024050.78728.35. [DOI] [PubMed] [Google Scholar]
  42. Nockels R., Oakeshott P. Awareness among young women of sexually transmitted chlamydia infection. Fam Pract. 1999 Feb;16(1):94–94. doi: 10.1093/fampra/16.1.94. [DOI] [PubMed] [Google Scholar]
  43. Pitt B., Zannad F., Remme W. J., Cody R., Castaigne A., Perez A., Palensky J., Wittes J. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999 Sep 2;341(10):709–717. doi: 10.1056/NEJM199909023411001. [DOI] [PubMed] [Google Scholar]
  44. Roe C. M., Motheral B. R., Teitelbaum F., Rich M. W. Angiotensin-converting enzyme inhibitor compliance and dosing among patients with heart failure. Am Heart J. 1999 Nov;138(5 Pt 1):818–825. doi: 10.1016/s0002-8703(99)70005-0. [DOI] [PubMed] [Google Scholar]
  45. Rutten Frans H., Grobbee Diederick E., Hoes Arno W. Differences between general practitioners and cardiologists in diagnosis and management of heart failure: a survey in every-day practice. Eur J Heart Fail. 2003 Jun;5(3):337–344. doi: 10.1016/s1388-9842(03)00050-3. [DOI] [PubMed] [Google Scholar]
  46. Sarasin F. P., Maschiangelo M. L., Schaller M. D., Héliot C., Mischler S., Gaspoz J. M. Successful implementation of guidelines for encouraging the use of beta blockers in patients after acute myocardial infarction. Am J Med. 1999 May;106(5):499–505. doi: 10.1016/s0002-9343(99)00065-0. [DOI] [PubMed] [Google Scholar]
  47. Shibata M. C., Flather M. D., Wang D. Systematic review of the impact of beta blockers on mortality and hospital admissions in heart failure. Eur J Heart Fail. 2001 Jun;3(3):351–357. doi: 10.1016/s1388-9842(01)00144-1. [DOI] [PubMed] [Google Scholar]
  48. Simpson Ewurabena, Beck Christine, Richard Hugues, Eisenberg Mark J., Pilote Louise. Drug prescriptions after acute myocardial infarction: dosage, compliance, and persistence. Am Heart J. 2003 Mar;145(3):438–444. doi: 10.1067/mhj.2003.143. [DOI] [PubMed] [Google Scholar]
  49. Suskin N., Sheth T., Negassa A., Yusuf S. Relationship of current and past smoking to mortality and morbidity in patients with left ventricular dysfunction. J Am Coll Cardiol. 2001 May;37(6):1677–1682. doi: 10.1016/s0735-1097(01)01195-0. [DOI] [PubMed] [Google Scholar]
  50. Unal B., Critchley J. A., Capewell S. Missing, mediocre, or merely obsolete? An evaluation of UK data sources for coronary heart disease. J Epidemiol Community Health. 2003 Jul;57(7):530–535. doi: 10.1136/jech.57.7.530. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

[Web-only Appendix]
jepicomh_59_12_1041__index.html (1.3KB, html)
jepicomh_59_12_1041__1.pdf (47KB, pdf)

Articles from Journal of Epidemiology and Community Health are provided here courtesy of BMJ Publishing Group

RESOURCES