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Objective: To assess the evidence for a reduced risk of acute coronary events following comprehensive smoke-free legislation., Methods: Two independent systematic reviews were undertaken using PubMed, Embase and Science Direct with no date restrictions imposed. Meta-analysis was undertaken using a random effects model to obtain a pooled estimate of the relative risk. Linear regression was used to examine possible bias and meta-regression was used to investigate possible causes of heterogeneity., Main Outcome Measure: Acute coronary events., Results: The 17 eligible studies (10 from North America, 6 from Europe and 1 from Australasia) provided 35 estimates of effect size. Apart from five subgroup analyses, all of the published results suggested a reduction in the incidence of acute coronary events following the introduction of smoke-free legislation. Meta-analysis produced a pooled estimate of the relative risk of 0.90 (95% CI 0.86 to 0.94). There was significant heterogeneity (overall I(2)=95.1%, p<0.001) but there was no evidence of small study bias (p=0.714). On univariate random effects meta-regression analysis, studies with longer data collection following legislation produced greater estimates of risk reduction and remained significant after adjustment for other study characteristics (adjusted coefficient -0.005, 95% CI -0.007 to -0.002, multiplicity adjusted p=0.006)., Conclusions: There is now a large body of evidence supporting a reduction in acute coronary events following the implementation of comprehensive smoke-free legislation, with the effect increasing over time from implementation. Countries that have not yet adopted smoke-free legislation should be encouraged to do so.

Aim: To assess the effect of changing clinical practice on the costs and outcomes of percutaneous coronary intervention (PCI) between 1998 and 2002., Setting: Two tertiary interventional centres., Patients: Consecutive patients undergoing PCI over a 12-month period between 1998 and 2002., Design: Comparative observational study of costs and 12-month clinical outcomes of consecutive PCI procedures in 1998 (n = 1047) and 2002 (n = 1346). Clinical data were recorded in the Scottish PCI register. Repeat PCI, coronary artery bypass graft and mortality were obtained by record linkage. Costs of equipment were calculated using a computerised bar-code system and standard National Health Service reference costs., Results: Between 1998 and 2002, the use of bare metal stents increased from 44% to 81%, and the use of glycoprotein IIB/IIIA inhibitors increased from 0% to 14% of cases. During this time, a significant reduction was observed in repeat target-vessel PCI (from 8.4% to 5.1%, p = 0.001), any repeat PCI (from 11.7% to 9.2%, p = 0.05) and any repeat revascularisation (from 15.1% to 11.3%, p = 0.009) within 12 months. Significantly higher cost per case in 2002 compared with 1998 (mean (standard deviation) 2311 pounds (1158) v 1785 pounds (907), p<0.001) was mainly due to increased contribution from bed-day costs in 2002 (45.0% (16.3%) v 26.2% (12.6%), p = 0.01) associated with non-elective cases spending significantly longer in hospital (6.22 (4.3) v 4.6 (4.3) days, p = 0.01)., Conclusions: Greater use of stents and glycoprotein IIb/IIIa inhibitors between 1998 and 2002 has been accompanied by a marked reduction in the need for repeat revascularisation. Longer duration of hospital stay for non-elective cases is mainly responsible for increasing costs. Strategies to reduce the length of stay could considerably reduce the costs of PCI.

Objectives: To determine whether socioeconomic status (SES) influences clinical outcomes and quality of life after percutaneous coronary intervention (PCI)., Design: Prospective observational study., Setting: Two interventional cardiac centres., Participants: 1346 consecutive patients undergoing PCI over a 12-month period., Outcomes: Self reported health-related quality of life (HRQoL; EuroQol-5 Dimensions (EQ-5D); EuroQol Visual Analogue Scale (EQ-VAS)), repeat angiography, revascularisation, hospital admission, myocardial infarction and death within 12 months, by SES derived using postal address code., Main Results: No significant differences were found between patients with high and low SES in the occurrence of repeat angiography (p = 0.55), repeat revascularisation (PCI, p = 0.81, CAEG, p = 0.27), total cardiac hospitalisation (p = 0.10), myocardial infarction (p = 0.97) or death 12 months after PCI (p = 0.88). Non-procedure-related readmissions were higher in patients with low SES (18.6% v 13.7%; p = 0.025). After adjustment for confounding factors, patients with low SES had lower HRQoL scores at baseline (95% CI for difference 0.01 to 0.14; p = 0.003) and at 12 months (95% CI 0.07 to 0.17; p<0.001) compared with those with high SES., Conclusions: Clinical outcomes were similar for patients in different SES groups. Patients with low SES had considerably more non-procedure-related readmissions and lower quality-of-life scores. Future studies on HRQoL after coronary revascularisation should take account of these important differences related to SES.

Objective: To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix., Design: Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period., Methods: All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models., Results: Of the 17,417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events., Conclusion: Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery.

Aim: To determine whether mortality following percutaneous coronary intervention vs. coronary bypass grafting varies according to whether or not patients have diabetes., Methods: We used the Scottish Coronary Revascularization Register to identify all patients undergoing revascularization in Scottish NHS hospitals since 1997. We excluded single-vessel disease, left main stem stenosis, and bypass grafting performed at the same time as other operations. We used death certificate data from the Registrar General to identify all subsequent deaths., Results: Of the 6320 eligible procedures, 5042 (80%) were bypass grafts and 1278 (20%) angioplasties. Overall 831 (13%) patients had diabetes with no significant difference by procedure (13% vs. 12%). A total of 382 deaths occurred over a mean follow-up of 2.3 years. Diabetic patients had a poorer prognosis following both surgery (adjusted hazards ratio (HR) 1.43, 95% confidence interval (CI) 1.08, 1.89) and percutaneous intervention (adjusted HR 2.58, 95% CI 1.43, 4.63). Among non-diabetic patients, no significant differences in mortality were detected between the two procedures. Among diabetic patients, no significant difference was detected in those with two-vessel disease. In those with impaired left ventricular function and triple-vessel disease, angioplasty was associated with a significantly higher risk of death (adjusted HR 3.58, 95% CI 1.40, 9.19)., Conclusions: This is the first study to demonstrate statistically significant results that support the BARI trial findings. Our study demonstrated a significant difference for triple-vessel disease but not two-vessel disease. The former may be due to incomplete revascularization using percutaneous intervention. Our results require corroboration from randomized trials.

This study compares 12 month clinical outcomes and procedural costs at two interventional centres with significant differences in crude mortality and revascularization outcomes between 1997 and 1998. Percutaneous coronary intervention (PCI) registry data on 1046 consecutive patients treated contemporaneously at two university centres were linked to hospital discharge and death data to provide 12 month follow-up information on survival and repeat revascularization. Costs were determined by detailed analysis of equipment use, length of stay and staff from 100 contemporary cases at each centre to derive a procedural cost model. This model was then applied retrospectively to estimate cost per procedure. Stents were used more frequently at one centre (56 versus 26 per cent, chi(2) test, p < 0.001) resulting in greater procedural cost [mean (SE), pounds sterling 1970 (34) versus pounds sterling 1521 (39), t-test, p < 0.001). One year repeat target vessel PCI was significantly greater at the centre using more stents (10.3 versus 5.6 per cent, chi(2) test, p = 0.005) and the need for any repeat revascularization (PCI or coronary artery by-pass surgery) was also significantly greater at this centre (18.4 versus 10.8 per cent, chi(2) test, p < 0.001). Cox regression revealed that after correction for case-mix the difference in the need for repeat target vessel PCI between the two centres was no longer significant (p = 0.15). In the two centres studied, crude differences in cost per case, mortality and the need for revascularization were largely accounted for by significant differences in case-mix. Comparison of outcomes and costs between centres should not be published without careful adjustment for differences in case-mix.

Coronary revascularisation continues to be underused despite evidence that this results in poorer outcomes

Objective: To determine current outcomes of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG)., Design: The Scottish coronary revascularisation register provided prospectively collected data on case mix and in-hospital complications for all revascularisation procedures between April 1997 and March 1999 (4775 PTCA; 5115 CABG). Linkage to routine hospital discharge and death data provided follow up information on survival and repeat revascularisation., Results: Stents were used in 51% of PTCA procedures. CABG patients were older, had more severe coronary disease, and had greater comorbidity. PTCA was more likely to be undertaken as an urgent or emergency procedure. Perioperative death and urgent surgery followed 0.3% and 0.6% of PTCA procedures, respectively. Case fatality rates were higher following CABG, with 6.7% dead within two years compared with 3.4% following PTCA. PTCA was more often followed by readmission for ischaemic heart disease, repeat angiography, or revascularisation: 22.8% of patients had repeat revascularisation within two years, compared with 1.8% following CABG., Conclusions: The severity of coronary heart disease was greater than in previously published registry studies and randomised trials. Despite this, overall survival figures were comparable and repeat revascularisation rates lower, particularly following PTCA. Perioperative death and urgent surgery following PTCA were also lower. These favourable outcomes may be attributable, in part, to increased use of bail out and elective stenting.

Coronary heart disease exhibits a winter peak and summer trough in incidence and mortality, in countries both north and south of the equator. In England and Wales, the winter peak accounts for an additional 20,000 deaths per annum. It is likely that this reflects seasonal variations in risk factors. Seasonal variations have been demonstrated in a number of lifestyle risk factors such a physical activity and diet. However, a number of studies have also suggested a direct effect of environmental temperature on physiological and rheological factors. We review the available evidence on seasonal variations in coronary heart disease and possible explanations for them.

Aims: To determine the extent to which increases in the uptake of effective treatments could further reduce coronary heart disease mortality in Scotland., Methods and Results: A cohort-based mortality model combining effectiveness data from published meta-analyses with available information on uptake of all coronary heart disease treatments in all patient categories in Scotland (population 5.1 million). In 1994, medical and surgical coronary disease treatments prevented or postponed an estimated 2722 deaths (minimum estimate 1373, maximum estimate 5986). Increasing treatment uptake to 100% of all eligible patients was considered unrealistic. Increasing uptake to 80% would have prevented or postponed a further 4078 deaths (39% from increases in secondary prevention therapies, 29%, 13%, 10% and 9% from the treatments of heart failure, acute myocardial infarction, hypertension and angina respectively)., Conclusions: Many eligible patients are currently not receiving treatment that is effective in reducing coronary heart disease mortality. Increasing treatment uptake could prevent or postpone a further 4080 deaths each year in Scotland, approximately, more than doubling the present benefit from treatment. By implication, about 30 000 additional deaths could be prevented, annually, in the U.K. Comparable symptom and morbidity benefits might also be expected. Future clinical audit activities should focus particularly on secondary prevention and heart failure treatments.

Objective: To determine whether age, sex, level of deprivation, and area of residence affect the likelihood of investigation and treatment of patients with coronary heart disease., Design, Patients, and Interventions: Routine discharge data were used to identify patients admitted with acute myocardial infarction (AMI) between 1991 and 1993 inclusive. Record linkage provided the proportion undergoing angiography, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG) over the following two years. Multiple logistic regression analysis was used to determine whether age, sex, deprivation, and area of residence were independently associated with progression to investigation and revascularisation., Setting: Mainland Scotland 1991 to 1995 inclusive., Main Outcome Measures: Two year incidence of angiography, PTCA, and CABG. Results-36 838 patients were admitted with AMI. 4831 (13%) underwent angiography, 587 (2%) PTCA, and 1825 (5%) CABG. Women were significantly less likely to undergo angiography (p < 0.001) and CABG (p < 0.001) but more likely to undergo PTCA (p < 0.05). Older patients were less likely to undergo all three procedures (p < 0.001). Socioeconomic deprivation was associated with a reduced likelihood of both angiography and CABG (p < 0.001). There were significant geographic variations in all three modalities (p < 0.001)., Conclusion: Variations in investigation and management were demonstrated by age, sex, geography, and socioeconomic deprivation. These are unlikely to be accounted for by differences in need; differences in clinical practice are, therefore, likely.

Presents a population based analysis of hospital discharge rates for suspected acute coronary syndromes between 1990 and 2000. Trends in population discharge rates for myocardial infarction, angina and chest pain; Participants, methods and results; Report that the decline in myocardial infarction was greater in men than in women in young and older age groups; Increase in angina in men; Implications for resources, finances and services.

This article focuses on a study that explores recent population trends in the incidence of and survival from cardiogenic shock complicating acute myocardial infarction (AMI). Historically, cardiogenic shock as a result of an AMI has a poor prognosis. Its management and the management of AMI have changed in recent years. Contemporary population studies examining incidence and outcome are lacking. The adjusted incidence of cardiogenic shock has increased in recent years and there has been no improvement in survival. While the risk of developing cardiogenic shock is greater in women than in men there is no difference in survival between men and women.