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Leng G C (Wolfson Unit for Prevention of Peripheral Vascular Diseases, Department of Public Health Sciences, The Medical School, Teviot Place, University of Edinburgh, EH8 9AG, UK), Lee A J, Fowkes F G R, Whiteman M, Dunbar J, Housley E and Ruckley C V. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. International Journal of Epidemiology 1996; 25: 1172–1181.Background Intermittent claudication is associated with a poor prognosis, but less is known of the risks associated with asymptomatic peripheral arterial disease. The aims of this study were to determine the incidence and natural history of claudication, and the incidence of cardiovascular events in symptomatic and asymptomatic peripheral arterial disease. Methods In 1988, 1592 subjects aged 55–74 years were selected randomly from the age-sex registers of 10 general practices in Edinburgh, Scotland. The presence of peripheral arterial disease was determined by the World Health Organization questionnaire on Intermittent claudication, the ankle brachial pressure Index and a reactive hyperaemia test. This cohort was followed prospectively over 5 years for subsequent cardiovascular events and death. Results One hundred and sixteen new cases of claudication were identified (incidence density 15.5 per 1000 person-years). Of those with claudication at baseline, 28.8% still had pain after 5 years, 8.2% underwent vascular surgery or amputation, and 1.4% developed leg ulceration. Claudicants had a significantly increased risk of developing angina compared with normals (RR: 2.31, 95% Cl: 1.04–5.10), and asymptomatic subjects had a slightly Increased risk of myo-cardial infarction and stroke. Deaths from cardiovascular disease were more likely in both claudicants (RR: 2.67, 95% Cl: 1.34–5.29) and subjects with major (RR: 2.08, 95% CI: 1.13–3.83) or minor asymptomatic disease (RR: 1.74, 95% Cl: 1.09–2.76). Subjects with major asymptomatic disease also had an increased risk of non-cardiovascular death (RR: 2.19, 95% Cl: 1.33–3.59), and therefore had the highest overall risk of death (RR: 2.44, 95% Cl: 1.59–3.74). Conclusions Subjects with asymptomatic peripheral arterial disease appear to have the same increased risk of cardiovascular events and death found In claudicants. [ABSTRACT FROM PUBLISHER]

Objectives: The principal aim was to determine whether the emergency readmission rate varies between medical specialties, and to identify whether differences in emergency readmission rates between hospital trusts can be reduced by standardising for specialty. Possible factors influencing emergency readmission were also investigated, including frequency of previous admission and cause of readmission., Design: Emergency readmission rates were obtained from the Scottish Morbidity Record scheme (SMR1) using record linkage, standardised for age and sex. Rates throughout Scotland were analysed by specialty, and rates for general medicine compared among teaching hospital trusts. Cause of emergency readmission was determined from hospital records in a random sample (177 patients)., Setting: Medical specialties throughout Scotland., Subjects: All patients readmitted as an emergency within 28 days of discharge (October 1990 to September 1994)., Results: Emergency readmissions varied markedly between medical specialties, with highest rates in nephrology (24.2%, 95% CI 23.5 to 24.8) and haematology (20.4%, 95% CI 19.9 to 20.9), and the lowest in homeopathy (2.2%, 95% CI 1.6 to 2.7) and metabolic diseases (3.5%, 95% CI 2.4 to 4.5). The largest number of emergency readmissions was in general medicine, accounting for 63% of the total. Restricting emergency readmission rates to general medicine significantly altered previous rates. In the year preceding the emergency readmission, 59% of all patients had been admitted to hospital at least once, and most emergency readmissions (73.3%) resulted from a chronic underlying condition., Conclusions: Significant variations in emergency readmission rates occurred between medical specialties, suggesting that differences between hospital trusts are influenced by differences in specialties and thus case mix. The majority of emergency readmissions occurred in patients with an underlying chronic condition, and many had a history of multiple previous hospital admissions. The emergency readmission rate is therefore unlikely to be a valid outcome indicator reflecting quality of care until routine data are available for standardisation by case mix.

Aims: The role of cardiovascular risk factors and atherosclerosis in the aetiology of abdominal aortic aneurysms is not well understood. The aim of this study was to determine the association between atherosclerosis and aortic aneurysm in the general population and the extent to which cardiovascular risk factors might increase the risk of aneurysm independently of an effect on atherosclerotic disease., Methods and Results: In the Edinburgh Artery Study, 1592 men and women aged 55-74 years were followed prospectively over a period of 5 years. Forty subjects were identified as having an abdominal aortic aneurysm and, for each, five controls were randomly selected. Case showed a higher prevalence of cardiovascular disease (P < or = 0.001) and had a lower ankle brachial pressure index (P < or = 0.01). Current and recent ex-cigarette smokers had an increased risk of aortic aneurysm compared with long time ex-smokers and never smokers (odds ratio 3.08, 95% CI 1.53 to 6.21). Adjustment for concurrent atherosclerotic disease reduced the odds ratio to 2.63 (95% CI 1.26 to 5.45). The risk of aortic aneurysm was not related to elevation in diastolic blood pressure or in serum cholesterol., Conclusions: These findings indicate that atherosclerotic disease is associated with risk of aortic aneurysm in the general population. In addition, cigarette smoking appears to have a direct effect on the risk of aortic aneurysm which is independent of atherosclerosis.

Objective: To determine whether a low ankle brachial pressure index is associated with an increased risk of cardiovascular events and death, and whether the prediction of such events could be improved by including this index., Design: Cohort study., Setting: 11 practices in Edinburgh, Scotland., Subjects: 1592 men and women aged 55-74 years selected at random from the age-sex registers of 11 general practices and followed up for 5 years., Main Outcome Measures: Incidence of fatal and non-fatal cardiovascular events and all cause mortality., Results: At baseline 90 (5.7%) of subjects had an ankle brachial pressure index < or = 0.7, 288 (18.2%) had an index < or = 0.9, and 566 (35.6%) < or = 1.0. After five years subjects with an index < or = 0.9 at baseline had an increased risk of non-fatal myocardial infarction (relative risk 1.38, 95% confidence interval 0.88 to 2.16), stroke (1.98, 1.05 to 3.77), cardiovascular death (1.85, 1.15 to 2.97), and all cause mortality (1.58, 1.14 to 2.18) after adjustment for age, sex, coronary disease, and diabetes at baseline. The ability to predict subsequent events was greatly increased by combining the index with other risk factors--for example, hypertensive smokers with normal cholesterol concentrations had a positive predictive value of 25.0%, increasing to 43.8% in subjects with a low index and decreasing to 15.6% in those with a normal index., Conclusion: The ankle brachial pressure index is a good predictor of subsequent cardiovascular events, and improves on predictions by conventional risk factors alone. It is simple and accurate and could be included in routine screening of cardiovascular status.

A higher than expected number of violent deaths and suicides in coronary prevention trials has provoked interest in the possibility that low serum cholesterol concentrations are associated in the general population with personality characteristics predisposing to aggressive and suicidal behaviour. We have investigated this possibility in the Edinburgh Artery Study. We measured serum lipid concentrations in blood samples taken from fasting subjects and assessed personality characteristics on the Bedford Foulds Personality Deviance Scales in a random sample of 1592 men and women aged 55-74 years, selected from age-sex registers of ten general practices in Edinburgh. Serum cholesterol concentration was not significantly associated with aggression in men, but it was associated in multivariate analysis (though not univariate analysis) with denigratory attitudes towards others among women. However, serum triglyceride concentration was related, especially in men, to hostile acts (r = 0.13, p < 0.001) and domineering attitude (r = 0.12, p < 0.001) independently of age, total and HDL cholesterol, cigarette smoking, and alcohol consumption. Subjects taking part in prevention trials have higher triglyceride concentrations than the general population and the relation between serum triglyceride concentration and aggression merits further investigation.