In the study, Louis Levene and colleagues, from the Department of Health Sciences at the University of Leicester (Leicester, UK), set out to identify factors that explain variations in CHD between Primary Care Trusts (PCTs) in England. The investigators used a hierarchical regression model to compare age-standardised rates of death from each of the 152 primary care trusts in England with their population and service characteristics. Additional data, for the study which was undertaken for the years 2006, 2007 and 2008, was acquired from general practice registers for diabetes and hypertension.
Results showed that the mean age standardised CHD mortality rates per 100,000 European Standard Population were 97.9 in 2006, 93.5 in 2007 and 88.4 in 2008. Across all three years index of multiple deprivations, smoking, white ethnicity, and registers of individuals with diabetes were positively associated with CHD mortality; while the levels of detected hypertension were negatively associated with CHD. The association of mortality with white ethnicity, explained the authors, was misleading since it arose because hypertension detection was higher in PCTs with higher proportions of white individuals.
Commenting on the study, ESC spokesperson Aldo Maggioni, said, “The study showed clearly that a preventive strategy directed at identifying hypertension in the general population offers a more efficient approach to reducing CHD death than providing intensive treatment to the relatively small number of patients already identified with hypertension.”
Maggioni, director of the Italian Association of Hospital Cardiologists (Florence, Italy), added that this does not, however, mean that hypertension is not an important risk factor to treat on an individual patient basis.
New strategies, he said, are needed to increase population wide rates of detection of hypertension, with GPs and specialists in community medicine providing the key health care professionals. “The real issue is that hypertension is asymptomatic, making it unlikely those patients will visit their family doctors complaining of the problem. What’s therefore needed is to introduce incentive schemes that encourage GPs to invite their patients into the practice for screening,” he said.
John Martin, an ESC spokesperson from University College London (UK), commented: “The study demonstrates the importance that social differences play in the cause of heart disease. Although we have had great success in understanding the biological causes of heart disease we’re not going to really manage to reduce the incidence until we start to tackle the underlying social differences. Clearly, governments need to play a far greater role in getting to grips with these issues and controlling the tobacco industry.”
While the study was performed in England, Maggioni stressed that there was no reason to suppose that the conclusions are not applicable to other European countries where there was universal access to primary health care. “However, in the US and some Eastern European, where there’s no national health service, it’s likely that variations in the primary care services available to patients would have the biggest impact on CHD mortality,” he said.
Welcoming the decrease in CHD mortality identified in the study, Maggioni commented that he had recently undertaken a similar study in Italy that demonstrated an 11% reduction in hospital admissions for acute coronary syndromes (ACS). The fact that both England and Italy are showing similar decreases suggests that reduction is widespread across European countries with good access to primary health care,” he said, adding that in Italy there is no national death registry, making it impossible to produce similar statistics on CHD mortality.
One weakness of the JAMA study, he added, was that the data used in the study had been collected at different times.
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