The incidence and pattern of angina prior to acute myocardial infarction: A study of 577 cases

BackgroundElectronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.ObjectiveTo evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.DesignEpidemiological cohort, health informatics, health economics and ethnographic approaches were used.Setting230 NHS hospitals and 226 general practices in England and Wales.ParticipantsUp to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.Main outcome measuresQuality of care, fatal and non-fatal cardiovascular disease (CVD) events.Data platform and methodsWe created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.ResultsCALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.ConclusionsEmerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.Future workThe vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.Study registrationCALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).

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“…180,181 Our study extends knowledge in several respects. First, we confirmed this association with prospective data.…”

Section: Figure 28supporting

confidence: 70%

Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme

Hemingway

Feder

Denaxas

et al. 2017

Programme Grants Appl Res

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“…In the literature, prevalence of chronic angina prior to infarction ranges from 25% to 50% [14][15][16] . These differences may be attributed to diverse definitions of chronic angina and different populations studied.…”

Section: Discussionmentioning

confidence: 99%

“…In-hospital mortality was similar in both groups, but in the 3 years following hospital discharge, it was higher in patients with previous angina (16% versus 7%). Another cohort study 15 , carried out with 587 patients, reported a 52% incidence of angina prior to infarction (in the preceding month). The study divided the patients into 4 groups as follows: no angina prior to acute myocardial infarction, chronic unstable angina, chronic stable angina, and angina of recent onset.…”

Section: Discussionmentioning

confidence: 99%

Acute Myocardial Infarction: The First Manifestation of Ischemic Heart Disease and Relation to Risk Factors

Manfroi

Peukert²,

Berti³

et al. 2002

Arq. Bras. Cardiol.

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Objective -To assess the association between cardiovascular risk factors and acute myocardial infarction as the first manifestation of ischemic heart disease, correlating them with coronary angiographic findings. Methods - (RR=0.19; P=0.04) and left ventricular hypertrophy (RR=0.27; 95% CI=0, P=0.03). The remaining risk factors were not statistically significant. Conclusion -Prevalence of acute myocardial infarction as the first manifestation of ischemic

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“…Unstable angina was classified as new-onset angina, which was defined as the new development of ischemic chest pain within the month before the final CAG, and chronic unstable (worsening) angina, which was defined as an increase in the severity of symptoms in patients with chronic stable angina. 9 …”

Section: Patient and Lesion Characteristicsmentioning

confidence: 99%

Process of Progression of Coronary Artery Lesions From Mild or Moderate Stenosis to Moderate or Severe Stenosis

et al. 1999

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Background-The process of progression in coronary artery disease is unknown. Methods and Results-The subjects were 36 patients with 36 objective vessels with clinically significant progression of coronary artery disease (Ն15% per year) in whom 4 serial coronary arteriograms (CAGs) were performed at intervals of Ϸ4 months in a 1-year period. The degree of progression of percent stenosis between each of 2 serial CAGs was classified as marked (M: Ն15%), slight (S: 5% to 14%), and no progression (N: Ͻ5%). From the pattern of progression, the 36 vessels were classified as 14 type 1 vessels with marked progression (N3 N3 M in 13 vessels and S3 S3 M in 1 vessel) and 22 type 2 vessels without marked progression (S3 S3 S in 18 vessels, N3 S3 S in 4). Percent stenosis at the first, second, third, and final CAGs was 44Ϯ14%, 46Ϯ13%, 46Ϯ13%, and 88Ϯ10% (PϽ0.05 versus first CAG) in type 1 vessels and 44Ϯ11%, 50Ϯ9%, 59Ϯ9%, and 67Ϯ9% in type 2 vessels (PϽ0.05 for second, third, and final CAGs versus first CAG). Type 1 vessels featured the sudden appearance of severe stenosis due to marked progression, angina pectoris, or myocardial infarction (71%) and Ambrose type II eccentric lesions indicating plaque rupture or thrombi (57%). Type 2 vessels featured continuous slight progression of stenosis with smooth vessel walls; angina pectoris (14%) occurred when the percent stenosis reached a severe level. An increase in serum C-reactive protein was observed only in the type 2 vessel group, which suggests a relation between continuous slight progression and inflammatory change. Conclusions-Two types of stenosis progression provide a new insight into the mechanism of coronary artery disease.(Circulation. 1999;100:903-909.)

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The incidence and pattern of angina prior to acute myocardial infarction: A study of 577 cases

Cited by 104 publications

References 16 publications

Acute Myocardial Infarction: The First Manifestation of Ischemic Heart Disease and Relation to Risk Factors

Process of Progression of Coronary Artery Lesions From Mild or Moderate Stenosis to Moderate or Severe Stenosis

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