Almanac 2013-stable coronary artery disease

Abstract

ALMANAC series 219Coronary heart disease in decline Epidemiological data from Europe, the USA and elsewhere in the developed world show a steep decline in coronary heart disease (CHD) mortality during the last 40 years (1). Concern about levelling of mortality rates in younger adults (2) has been somewhat alleviated by data from The Netherlands showing that in men aged <55 years, rates of decline have again accelerated, increasing from only 16% in 1993-1999 to 46% in 1999-2007 (3). A similar pattern was observed in young women with rates of decline of 5% and 38% during the same time periods. This is encouraging, particularly in the context of data from Denmark and the UK showing declining mortality and also a sharp fall in standardised incidence rates for acute myocardial infarction indicating that coronary prevention, as well as acute treatments, has contributed to recent mortality trends (4, 5). Meanwhile an Australian study reminds us that myocardial infarction is but one of several manifestations of cardiovascular disease by reporting that decreasing incidence and recurrence rates for hospitalised CHD from 2000 to 2007 have also been seen for cerebrovascular and peripheral arterial disease (6).However, the epidemiological news is not all good, and data from the UK show that the pernicious relationship between socioeconomic status (SES) and CHD has shown no tendency to go away in recent years, the gradients between top and bottom SES quintile groups for hospital admissions remaining essentially unchanged across the age range (7). Whether this has contributed to the almost 3-fold risk of myocardial infarction associated with stillbirth and 9-fold risk associated with recurrent miscarriage in a recent German study is unclear because the investigators made no adjustment for SES (8). Nor is it clear if SES has contributed to the persistent ethnic differences in both US and UK studies of CHD mortality although other factors appear also to be important. Thus, African-American men have greater exposure to CHD risk factors than Caucasians and, when adjustment is made for this, their susceptibility to CHD is no greater, although mortality rates are twice as high (9). For African-American women, incidence and mortality rates are higher than their Caucasian counter-parts. These findings suggesting that exposure to risk factors contributes to ethnic differences in the incidence of CHD are to some extent reflected in a recent report from the Health Survey for England in which 13 293 Caucasian and 2120 S Asians consented to mortality followup (10). Physical inactivity increased susceptibility to disease and not by increased case-fatality rates (11). Diagnosis of stable coronary artery diseaseThe recent AHA/ACC guideline update (12) emphasised the importance of individualising the diagnostic workup based on the estimated probability of coronary artery disease. In this respect, it mirrored an earlier National Institute of Clinical Excellence (NICE) guideline on chest pain diagnosis (13), but there were important differences ...