Secondary prevention in 24 431 patients with coronary heart disease: survey in primary care
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7300.1463 (Published 16 June 2001) Cite this as: BMJ 2001;322:1463
All rapid responses
Sir,
the article by Brady et al focused on secondary prevention in
patients with coronary heart disease (CHD) in primary care(1). Since it
has been demonstrated that prescribing behaviour of general practitioners
is greatly influenced by the medication given at discharge after a
hospitalisation(2,3), we analysed data from the Italian Group of
Pharmacosurveillance in the Elderly (GIFA), which surveyed 32203 patients
admitted to about 40 clinical centers throughout Italy during two 2-month
periods between 1988 and 1998(4). Limiting the analysis to 1997 and 1998
surveys to allow a meaningful comparison, we found that nearly 20% of
patients (n=1775) had a discharge diagnosis of CHD. Mean age was 74±12
years, men represented 58% and were significantly younger than women (mean
age 71±12 vs. 79±9 years, respectively; p<_0.001. p="p"/> Relative to those in primary care, a higher proportion of
hospitalized patients appeared to attain optimal blood pressure control
(>160/90 mmHg in 5% of men and 9% of women) and cholesterol levels
(>5 nmol in 9% of both men and women). Instead, at discharge a lower
proportion of patients was taking either an aspirin (men=41%, women=29%),
a ß-blocker (10%, and 6%), or a statin (7%, and 4%).
Despite the different settings, the intrinsic heterogeneity of the
samples, and/or the cultural differences, we hypothesize that patient age
is a factor which deeply influences the way preventive measures are
undertaken in CHD patients. In fact, while one could attribute the worse
treatment figures for women observed by Brady to gender per se, we think
they might be due to the age difference (72 vs. 67 years). Data reported
in table support our hypothesis.
Age groups (years) <70 (n=544) 70-80 (n=593) >80 (n=638) p* Risk factors Continued smoking 107 (20) 60 (10) 21 (3) <_0.001 diabetes="diabetes" mellitus="mellitus" _150="_150" _28="_28" _169="_169" _112="_112" _17="_17" _0.001="_0.001" hypertension="hypertension" _="_"/>160/90 mmHg) 22 (4) 40 (7) 52 (8) 0.015 Total cholesterol >5 nmol 72 (13) 50 (8) 35 (5) <_0.001 preventive="preventive" drug="drug" treatment="treatment" aspirin="aspirin" _273="_273" _50="_50" _194="_194" _33="_33" _174="_174" _27="_27" _0.001="_0.001" ß-blockers="ß-blockers" _94="_94" _17="_17" _39="_39" _7="_7" _11="_11" _2="_2" angiotensin="angiotensin" converting="converting" enzyme="enzyme" inhibitors="inhibitors" _32="_32" _173="_173" _29="_29" _129="_129" _20="_20" statins="statins" _66="_66" _12="_12" _5="_5" _1="_1" _="_" pearson="pearson" number="number" in="in" parentheses="parentheses" represent="represent" percentages="percentages" pre="pre"/>
The lower prevalence of hypercholesterolemia and diabetes mellitus
among older patients likely reflect selective survival, rather than a
better clinical practice. Instead, these patients attained suboptimal BP
control in higher proportion and they received fewer medications. At a
logistic regression analysis, the likelihood of not receiving preventive
treatments was strongly associated with age (Table 2).
Likelihood of not receiving* Aspirin ß-blockers ACE inhibitors Statins OR (95% CI)† OR (95% CI) OR (95% CI) OR (95% CI) Age (years) <_70 _1.0="_1.0" _70-80="_70-80" _1.9="_1.9" _1.5-2.5="_1.5-2.5" _3.0="_3.0" _2.0-4.5="_2.0-4.5" _1.1="_1.1" _0.9-1.5="_0.9-1.5" _1.8-4.8="_1.8-4.8"/>80 2.4 (1.8-3.1) 12.0 (6.3-23.2) 1.8 (1.4-2.4) 13.0 (5.8- 29.3) * adjusted for gender; † OR (95% CI) = Odds Ratio (95% Confidence Interval)
A substantial body of evidence has been accumulated demonstrating the
efficacy of preventive measures both in younger and older CHD patients.
Although it is true that elderly people often suffer from multiple
diseases and that clinical judgement should always prevail when deciding
whether to treat or not to treat, it appears unwarranted not to carry out
preventive measures solely on the basis of age(5).
In conclusion, Brady et al. fail to identify age as an important
determinant of inadequate compliance to the implementation of preventive
measures in CHD patients. Optimal treatment seems still biased by an
unjustified prejudice toward aged persons, both in primary and secondary
care.
1. Brady AJB, Oliver MA, and Pittard JB. Secondary prevention in 24
431 patients with coronary heart disease: survey in primary care. BMJ
2001;322:1463
2. Khan M, Mukkamala A, Taylor DK, Espinosa A, Duff J. Use of lipid
drugs with acute myocardial infarction patients: an examination of
physician prescribing behaviors. J Cardiovasc Pharmacol Ther 1998;3:217-22
3. Sarasin FP, Maschiangelo ML, Schaller MD, Heliot C, Mischler S,
Gaspoz JM. Successful implementation of guidelines for encouraging the use
of beta blockers in patients after acute myocardial infarction. Am J Med
1999;106:499-505
4. Carbonin P, Pahor M, Bernabei R, Sgadari A for the Gruppo Italiano
di Farmacovigilanza nell'Anziano (G.I.F.A.). Is age an independent risk
factor of adverse drug reactions in hospitalized medical patients? J Am
Geriatr Soc 1991;39:1093-9
5. Sgadari A, Antonelli Incalzi R, Onder G, Pedone C, Gambassi G.
Lipid-lowering therapy in patients with coronary artery disease: sex or
age bias? Arch Intern Med 2000;160:2684
Antonio Sgadari, assistant professor,
Centro di Medicina dell’Invecchiamento
Università Cattolica del Sacro Cuore
L.go F. Vito, 1
00168 Rome, Italy
E-mail: antonio_sgadari@rm.unicatt.it
Giovanni Gambassi, associate professor
Centro di Medicina dell’Invecchiamento
Università Cattolica del Sacro Cuore
Rome, Italy
Matteo Cesari, assistant professor
Centro di Medicina dell’Invecchiamento
Università Cattolica del Sacro Cuore
Rome, Italy
Roberto Bernabei, associate professor
Centro di Medicina dell’Invecchiamento
Università Cattolica del Sacro Cuore
Rome, Italy
Competing interests: Age groups (years) <70(n=544) 70-80(n=593) >80(n=638) p*Risk factors Continued smoking 107 (20) 60 (10) 21 (3)
EDITOR - Brady et al in their survey of secondary
prevention in primary care report that lipids are poorly
managed1. Cholesterol had been measured in 58%; 56% had a
cholesterol <=5mmol/l (24% of those in whom cholesterol was
measured). Indeed they suggest that the picture may be even
worse than they report.
In 1998 an evidence based lipid lowering drug strategy,
First Affordable Treatment Strategy (FATS), was developed
across our district. A steering group was chaired by a
Consultant in Public Health Medicine with representatives
from Primary Care and a variety of hospital specialties. We
focussed on a practical strategy targeting high risk groups
(First…..), and on implementation and dissemination. FATS
was introduced at identical workshops with different
speakers presenting the same slides. During the workshops
practices collected folders containing A5 laminated
summaries, additional notes explaining how the decision to
include each component had been reached, and information for
practice nurses and receptionists. Similar information was
distributed to appropriate consultants. We facilitated FATS
by a Community Cardiology/Healthy Hearts team, working at
practice level. At this stage we chose an initial target
cholesterol for secondary prevention of 5.5mmol/l.
A year later an audit of cholesterol management in secondary
prevention was undertaken. The prevalence of coronary heart
disease (CHD) from previous primary care audits is
approximately 5.4%. Data was collected from random samples
in 58 (81%) practices in the district. Cholesterol had been
measured in 5271 (66%) patients with coronary disease and of
these 3,035 (58%) had a cholesterol <=5.5mmol/l (our target),
and 1,759 (33%) a cholesterol <5mmol/l. In patients aged 35
to 74 years cholesterol had been measured in 4113 (81%), of
whom 2,434 (59%) had a cholesterol <=5.5mmol/l, and 1,424
(35%) <5mmol/l.
Many more patients in our district had had a cholesterol
measured and were below target than that reported by Brady
et al (58% vs 24%). This difference is unlikely to have come
about by chance, suggesting that our strategy was effective.
We have now moved to the revised target of <5mmol/l in
FATS2. The NSF for CHD emphasises the requirement for
protocols to offer structured care to patients with CHD.
These results suggest having a protocol is not sufficient.
The process of involving all stakeholders in protocol
development, active dissemination and support for
implementation, plus feedback of audit data have facilitated
the very good results we have obtained.
Yours faithfully
Jane S Skinner, Consultant Community Cardiologist, Royal
Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne
NE1 4LP
Philip C Adams, Consultant Cardiologist, Royal Victoria
Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP
Sue Roberts, Consultant Physician, and Clinical Co ordinator
for Healthy Hearts Team, Northumbria Healthcare Trust
Steve Blades, General Practitioner, The Grove Medical Group,
1 The Grove, Gosforth, Newcastle upon Tyne NE3 1NU
Ian Spencer, Director of Primary Care, Newcastle and North
Tyneside Health Authority, Newcastle General Hospital,
Newcastle upon Tyne NE4 6BE
for the FATS steering group
Competing interests: PCA has received honoraria from various
drug companies
for lecturing and chairing meetings. JSS has received
honoraria for lecturing and educational grants to attend
meetings from various drug companies
Reference
1. Brady AJB, Oliver MA, Pittard JB. Secondary prevention in
24 431 patients with coronary heart disease: survey in
primary care. BMJ 2001;322:1463
Corresponding author: Dr JS Skinner, Consultant Community
Cardiologist, Royal Victoria Infirmary, Queen Victoria Road,
Newca
Competing interests: No competing interests
Dear Sir,
We read with interest the article by Brady et al on secondary
prevention in patients with coronary heart disease in primary care(1). We
have also recently completed a similar survey in the Rhondda Cynon Taff
Local Health Group for the period between January and June 2000. This
group provides primary care for 94,421 people in the Rhondda valley, an
area with substantial coronary artery disease in South Wales. Our results
(Table 1) compare favourably with Brady et al’s results and also with the
EUROASPIRE(2) and GISSI-Prevenzione(3) trials, thus showing that treatment
in primary care can attain the standards of prescribing in large multi-
centre secondary prevention trials. Furthermore, although there is still
room for improvement if we are to meet the targets prescribed in the
National Service Framework(4), our more recent results demonstrate the
improvements that have been made in preventive drug treatment in primary
care since Brady et al’s study.
Justin SW Taylor
Research Fellow in Cardiology, Royal Glamorgan Hospital
E-mail: jswt@totalise.co.uk
Anne Hinchliffe
Lead Primary Care Pharmacist, Rhondda Cynon Taff Local Health Group
Neeraj Prasad
Consultant in Cardiology, Birmingham City Hospital
Table 1 Modifiable risk factors and prescription of secondary preventive drug treatment in 1,446 patients with a diagnosis of coronary disease in the Taff Ely Partnership. Values are numbers (percentages) of patients Total (n=1446) Risk Factor Cholesterol never recorded 387 (27%) Total cholesterol >5 mmol/l 883 (61%) Preventive drug treatment Aspirin 1190 (82%) Beta blockers 689 (48%) Previous myocardial infarction 298/599 (50%) Statins 632 (44%)
References
(1) Brady AJB, Oliver MA, Pittard JB. Secondary prevention in 24 431
patients with coronary heart disease: survey in primary care. BMJ
2001;322:1463.
(2) The EUROASPIRE Study Group. A European Society of Cardiology survey of
secondary prevention of coronary heart disease: Principal results.
European Heart Journal 1997;18:1569-1582.
(3) The GISSI-Prevenzione Investigators. Dietary supplementation with n-3
polyunsaturated fatty acids and vitamin E after myocardial infarction:
results of the GISSI-Prevenzione trial. Lancet 1999;354:447-453.
(4) National Service Framework for Coronary Heart Disease. London:
Department of Health, 2000.
Competing interests: Table 1Modifiable risk factors and prescription of secondary preventive drugtreatment in 1,446 patients with a diagnosis of coronary disease in the Taff Ely Partnership. Values are numbers (percentages) of patientsTotal (n=1446)Risk Factor Cholesterol never recorded 387 (27%) Total cholesterol >5 mmol/l 883 (61%) Preventive drug treatment Aspirin 1190 (82%) Beta blockers 689 (48%) Previous myocardial infarction 298/599 (50%) Statins 632 (44%)
The Brady et al paper highlights a number of important issues
including information managment, setting targets in primary care and
resource implications.
Firstly, why is there such a discrepancy between primary care data on
heart disease presented in this paper and "national figures"? Was such a
large sample unrepresentative? or does it highlight the inadequacy of data
recording and transfer, between agencies within our National Health
Service.
Secondly, why does treatment with drugs for secondary prevention with
such a strong evidence base appear so poor? Most studies are done in
hospital settings with a highly select population following acute events
where high initiation rates of drugs can be achieved. In comparison, the
majority of events in primary care have occured in the past when the use
of such drugs were often not so comprehensive or may not have existed.
Therefore these patients need to be identifiable and then treated in
retrospect if deemed appropriate. Similarly adherance and concordance
with medication taken over many years becomes more difficult to achieve.
Such factors should be taken into account when "targets" on the treatment
of populations are proposed.
We are currently undertaking a similar audit within central Fife
across 18 practices and a population of 97,000. These are mixture of
practices from "paperless" to "computer not plugged in yet". We then
compare our recorded data to local SMR figures. Our comprehensive figures
demonstrate to date high levels of heart disease, comparably high usage of
secondary prevention drugs but also much higher smoking rates than shown
in this paper.
Our own experience would suggest that resources should be targeted at
information management with a simple universal standardised computerised
data set to help identify patients and clinical resources (for example
specialist nurses) made available to treat these patients appropriately to
well defined standards.
Reference
Secondary prevention in 24 431 patients with coronary heart disease:
survey in primary care.
A J B Brady, M A Oliver, and J B Pittard.
BMJ 2001; 322: 1463
Competing interests: No competing interests
Editor
We were interested in the report of Brady et al (1) on secondary
prevention in patients with coronary heart disease. We carried out a very
similar survey using data from primary care in November 2000. We thought
your readers might be interested in our findings. The Surrey Primary Care
Research Group (SPCRG) consists of 28 practices (population 263,000)
across the UK that are interested in research and supply good quality
computerised data for individual studies. We identified 7325 patients
aged over 40 with a history of coronary heart disease using a MIQUEST
query (2). This equates to 5.9% of all patients aged over 40 and 2.8% of
the study population. The mean ages of the men and women were 69 and 72
respectively. The comparative results with the study of Brady et al are
presented in Table 1.
Our study identified a similar proportion of patients with a
diagnosis of coronary heart disease to that reported by Brady et al.
Moreover, the mean ages of the patients and the proportion with diabetes
are also similar. We found a lower prevalence of current smoking and
elevated blood pressure in patients with coronary heart disease. The
proportion of patients with a BP > 160/90mmHg was almost half that
reported by Brady et al. This may be due to the greater use of beta-
blockers and ACE inhibitors in the SPCRG practices. The use of lipid
lowering therapy was double that of the earlier study (43.9% compared to
18% in men and 29.5% compared to 13% in women). Interestingly, the
proportion who did not have a cholesterol concentration recorded on the
computer system was similar to the study by Brady et al and the percentage
of women with raised cholesterol (>5 mmol/L) was higher. It is possible
that the differences between the two studies are due to different
underlying populations although the characteristics of the patients are
similar in many respects. The differences may also be indicative of the
considerable efforts that have gone on locally to encourage secondary
prescribing to lipid lowering therapy. Thus our study, two years after
that by Brady et al, has demonstrated a substantial increase in the use of
lipid lowering therapy, but the proportion of patients achieving the
target of a total cholesterol concentration below 5 mmol/L is unchanged.
This raises the issue as to whether simply auditing prescribing rather
than a biological outcome is the appropriate strategy.
Table 1
Men Women
n = 4271) (n = 3054)
Current smoker 16.6% 13.2%
Diabetes mellitus 13.0% 11.0%
Hypertension >160/90 17.3% 20.5%
Cholesterol never recorded 37.5% 55.3%
Total cholesterol >5mmol/L 40.0% 57.0%
Treatment:
Beta-blockers 36.2% 33.6%
Previous AMI and beta-blockers 37.4% 37.3%
ACE inhibitor 29.9% 26.3%
Lipid lowering therapy 43.9% 29.5%
Ross Lawrenson
Professor of Primary Health Care
John Williams
Visiting Senior Fellow
References.
1) Brady AJB, Oliver MA, Pittard JB. Secondary prevention in 24,431
patients with coronary heart disease: survey in primary care. BMJ 2001;
322: 1463
2) Lawrenson RA, Williams T, Farmer RD. Clinical information for research;
the use of general practice databases. Journal of Public Health 1999;
21(3): 299-304
Competing interests: Table 1 Men Women n = 4271) (n = 3054)Current smoker 16.6% 13.2%Diabetes mellitus 13.0% 11.0%Hypertension >160/90 17.3% 20.5%Cholesterol never recorded 37.5% 55.3%Total cholesterol >5mmol/L 40.0% 57.0%Treatment:Beta-blockers 36.2% 33.6%Previous AMI and beta-blockers 37.4% 37.3%ACE inhibitor 29.9% 26.3%Lipid lowering therapy 43.9% 29.5%
Some of the findings of Brady et al’s survey of secondary prevention
of coronary heart disease in primary care1 are certainly worrying, but so
is their failure to put them in perspective. Shouldn’t comment on
performance use the standards at the time of measurement rather than those
of a few years later?
Recommendations for the secondary prevention of coronary heart
disease are continually developing. The survey data collection started in
March 1997, but in this area it was only after the distribution of Health
Authority guidelines in April 1997 that many practices started a concerted
effort to measure cholesterol in patients with coronary heart disease and
treat with statins as appropriate. There was also considerable uncertainty
about whether beta-blockers should be continued for longer than two years
after myocardial infarction, and I don’t think it was known then that the
management of blood pressure is at least as important as good control of
blood glucose in diabetes. To my mind, their most worrying finding is
therefore that only about half the patients were taking aspirin.
The survey’s publication as such a short report causes other
difficulties in its interpretation. How many practices were excluded
because they had recently undergone an audit of coronary heart disease?
Such practices might be ones with better than average performance. Primary
care is probably now doing considerably better than this survey suggests.
If we are given adequate resources we will do much more.
John Temple,
general practitioner and part-time lecturer in general
practice
Division of General Practice, University of Nottingham, Nottingham NG7 2UH
1. Brady A, Oliver M & Pittard J. Secondary prevention in 24 431
patients with coronary heart disease: survey in primary care. BMJ 2001;
322:1463.
Competing interests: No competing interests
EDITOR - Brady et al’s survey of secondary prevention for patients
with coronary heart disease in general practice gives very disappointing
results.1 Over the last two years several primary care trusts including my
own are funding nurse led clinics in primary care.2 This has enabled all
13 practices within Carrick Primary Care Trust in Cornwall to set up a
coronary heart disease register and provide a call and recall system as
recommended in the national service framework for coronary heart disease.3
In a recent survey of all practices covering a population of 100 000
I found the prevalence of coronary disease in patients aged <_75 years="years" to="to" be="be" _2.4.="_2.4." for="for" _118="_118" acute="acute" myocardial="myocardial" infarction="infarction" survivors="survivors" aged="aged" _75="_75" in="in" _1999="_1999" _2000="_2000" i="i" found="found" the="the" following="following" figures="figures" brady="brady" et="et" als="als" brackets.="brackets." br="br"/>1. On antiplatelet therapy: 96% (50%)
2. On statin: 70% (16%).
3. On beta-blockers: 69% (21%).
4. On angiotensin converting enzyme inhibitors: 53% (13%).
5. Current smokers: 11% (23%).
6. Blood pressure of 7. Most recent total cholesterol <_5 xmlns:l="urn:x-prefix:l" mmol="mmol" l:_="l:_" _57="_57" _57.="_57." p="p"/> The two sets of patients are not exactly comparable but the enormous
difference in the figures does indicate the success of our strategy in
Cornwall, not only in recording information but also in reducing risk
factors.
Moher et al 4 have confirmed that structured follow-up of coronary
patients , either by GP or by practice nurse can improve the recording of
relevant information but surprisingly these measures did not increase the
prescription of relevant drugs or improve risk factors.
Hugh Bethell (personal communication) and I believe that the missing
factors that will improve the outcomes for coronary patients are adequate
funding of the secondary prevention initiative backed up by meticulous
training and support of the practice nurses.
H M Dalal
Coronary Heart Disease Lead for Carrick Primary Care Trust
18 Lemon Street,
Truro
TR1 2 LZ
1. Brady AJB, Oliver MA, Pittard JB. Secondary prevention in 24 431
patients with coronary heart disease: survey in primary care. BMJ
2001;322(7300):1463-.
2. Dalal HM, Bethell H. Reducing risk of recurrent coronary heart disease
in Cornwall [letter; comment]. Bmj 1999;319(7213):853.
3. Great Britain Department of H, Executive NHS. National service
framework for coronary heart disease : modern standards & service
models. London: Department of Health, 2000.
4. Moher M, Yudkin P, Wright L, Turner R, Fuller A, Schofield T, et al.
Cluster randomised controlled trial to compare three methods of promoting
secondary prevention of coronary heart disease in primary. BMJ
2001;322(7298):1338-.
Competing interests: No competing interests
Dear Editor,
The survey published by Brady et al covering 1.7% of the population of England,Scotland and Wales seems to give an aura of validity and generalisability. However, the truth is that there is a marked variation in the computer documentation of CHD in neighbouring practices, leave alone the rest of the country. the great usefulness of the survey is to remind all primary care clinicians to audit/ review their CHD populations. Unfortunately, few practices have the resources to implement the NSF on CHD. Hardly any resources either financial or human trickle into teh grass root practices.
We were able to look at 199 documented CHD patients (between the ages of 35 and 75, in accordance with the NSF on CHD and most interventional evidence)out of a population of 8,000 in a City practice.
The prevalence of M:F was 2:1. In our review, we collected data on patients with a BMI >30; SBP>150; DBP>85; proprtion on Beta blockers, ACE Inhibitors and other factors given below. We analysed males and females separately.
61% of our male CHD patients, and 20% of our female CHD patients are smokers according to computer documentation.
Only 63% of females and 67% of males were documented as taking aspirin.
However, the validity of these figures are questionable due to the gaps between manual and computer records. Some of those not taking aspirin were intolerant or allergic to aspirin and some were buying it over the counter. As for statins, only 49% of the females and 54% of the males were on statins and 62% of females and 37% of males were having a TC of >5mmols implying inadequate control.
The great usefulness of the review, is that it is a powerful educational tool, and motivates us to do better in a planned way, and reaudit after a time period.
Competing interests: No competing interests
We were interested to read the paper by Brady, Oliver and Pittard. In
our area we have been operating a Primary Care Clinical Effectiveness
Project since April 1998 and our results appear to be somewhat better than
those reported in the paper. Our results for 1999/2000 were based on a
patient population of about 360,000 (although the work now covers 543,000)
For example our practices identified 10,606 patients with ischaemic
heart disease of which 85% are taking antiplatelet therapy with a further
6% contraindicated. Of those in this group aged 75 years or less 74% had
had cholesterol reduced to 5 mmol/l or less, or by 20%.
The practices identified 29,205 patients with Hypertension and 89% of
these had recorded blood pressure of 160/90 or better.
For Atrial Fibrillation 3,340 patients were identified with 40%
taking Warfarin and 53% taking aspirin and 6% contraindicated.
In 8,286 patients with diabetes 91% had blood pressure of 160/90 or
better recorded and of those at risk 65% had cholesterol of 5 mmol/l or
less or reduced by 20%.
We are currebtly collating the results reported for 2000/2001 which
we expect to show at least as good if not better results.
We do not underestimate the efforts of practice in our area in
achiveing these results but it is clear that with the right support and
incentives primary care can manage these and many other chronic conditions
to very high standards.
Further information about our work can be obtained from our website
at
www.ekent-ha.sthames.nhs.uk
Derek Mitchell
Competing interests: No competing interests
District wide audit confirms unmet need
Editor
Brady and colleagues report poor recording and uptake of secondary
prevention for coronary heart disease in primary care.1 They note possible
bias because the study represented larger computerised practices. However,
we found a similar picture in Portsmouth and South East Hampshire, in a
study that covered all 78 practices in the Health Authority area.
The Heart LEAP (Linking Evidence And Practice) project surveyed the
recording and management of secondary prevention measures in patients with
a diagnosis of coronary heart disease. The table shows the results from
the first 32 practices analysed, covering a population of 212,000. The
prevalence of coronary heart disease was 2.9%.
Much of the relevant information was not recorded. 38% had no record
of a cholesterol level; 28% of patients had not had their blood pressure
recorded in the previous year; and 10% had no recording of smoking status.
The other point of interest is to see the rule of halves (actually closer
to two thirds!) operate with regard to lipid lowering. Of the 62% that had
had their cholesterol ever recorded, it was greater than 5 mmol/l in 65%.
Of those with a level greater than 5 mmol/l, 60% were not prescribed lipid
lowering therapy. Of those that were prescribed lipid lowering therapy,
the cholesterol level was still greater than 5 mmol/l in 54%.
These results are broadly in line with those of Brady et al, and also
previous studies.2-4 They demonstrate substantial unmet need in this
priority area. However, we are encouraged by the universal uptake of the
LEAP project across the district. As part of the study, disease registers
were updated in every practice, and work to obtain district wide agreement
on relevant diagnostic codes has commenced. The results are being fed back
at both individual practice and Primary Care Group level, with
recommendations for prioritising further actions. Re-audit to assess
improvements in recording and uptake will demonstrate the success or
otherwise of this process.
1. Brady AJB, Oliver MA, Pittard JB. Secondary prevention in 24431
patients with coronary heart disease: survey in primary care. BMJ
2001;322:1463
2. Flanagan DEH, Cox P, Paine D, Armitage M. Secondary prevention of
coronary heart disease in primary care: a healthy heart initiative. Q J
Med 1999;92:245-50
3. Bowker TJ, Clayton TC, McLennan NR, Hobson HL, Pyke SD, Schofield B, et
al. A British Cardiac Society survey of the potential for secondary
prevention of coronary disease: ASPIRE. Heart 1996;75:334-42
4. Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM. Secondary
prevention in coronary heart disease: baseline survey of provision in
general practice. BMJ 1998;316:1430-4
Yours faithfully
Dr Mike Sadler
Medical Director, NHS Direct Hampshire and the Isle of Wight,
Highcroft,
Romsey Road,
Winchester SO22 5DH
e-mail: mike.sadler@hants-iow.nhsdirect.nhs.uk
Mrs Nicky Heyworth
Clinical Effectiveness Manager
Isle of Wight, Portsmouth and South East Hampshire Health Authority,
Finchdean House,
Milton Road,
Portsmouth PO3 6DP
Competing interests: Risk factor PercentageContinued smoking 16Diabetes mellitus 14Hypertension (>150/90 mm Hg) 30Cholesterol never recorded 38Total cholesterol >5 mmol/l 65BMI>30 22Preventive drug treatment PercentageAspirin or warfarin 49Beta blockers if previous myocardial infarction (MI) 36Angiotensin converting enzyme inhibitors if previous MI 32Lipid lowering therapy 30