Does stroke health promotion increase awareness of appropriate behavioural response? Impact of the face, arm, speech and time (FAST) campaign on population knowledge of stroke risk factors, warning signs and emergency response.

INTRODUCTION: Inability to identify stroke warning signs accurately is an important cause of delay in seeking medical attention, leading to potential ineligibility for acute intervention. We report on post-campaign findings (wave 2) of national surveys to estimate changes in population knowledge following a media-based Face, Arm, Speech, Time stroke awareness campaign, comparing findings to those of a pre-campaign population survey (wave 1).Participants and methods: One thousand and ten randomly selected adults (18+) completed the Stroke Awareness Questionnaire on knowledge of warning signs, risk factors and response to stroke at wave 2 and findings were compared to wave 1 survey results. Logistic regression was used to examine the association between demographic characteristics and self-reported risk factors with knowledge of stroke and emergency response. RESULTS: No significant differences existed in the ability of respondents to define stroke or to identify two or more stroke risk factors between waves 1 and 2 surveys (71% and 70%, respectively). Respondents to the wave 2 survey were five times more likely (odds ratio 4.9, p < .001) than those responding at wave 1 to know at least two warning signs of stroke (67% vs. 31%, respectively), specifically those targeted by the Face, Arm, Speech, Time campaign. While significant improvement in intention to call an ambulance was noted (odds ratio 1.5, p < .001, 57% at wave 2 compared to 47% at wave 1), for almost half of respondents (43%) this would not have been their first response to stroke. Less than 5% of respondents to both surveys identified thrombolysis as an emergency treatment for stroke (3.9% at wave 2 compared to 1.8% at wave 1). DISCUSSION: Although significant improvements were made in several areas of stroke knowledge and intended response, awareness of acute stroke interventions was poor and intended behavioural response was suboptimal. CONCLUSION: Findings from this study indicate need for targeted campaigns to improve population understanding of the reasons underlying the importance of rapid emergency response to stroke.

Interarm blood pressure difference in a post-stroke population.

An increased interarm systolic blood pressure (SBP) difference of ≥10 mm Hg is associated with increased cardiovascular risk and a difference of ≥15 mm Hg with increased cerebrovascular risk. The stroke population presents a high-risk group for future cardiovascular and cerebrovascular events and therefore estimation of interarm SBP difference as a predictive tool may assist with further secondary stroke prevention. The aim of the study was to determine the prevalence of interarm SBP and diastolic blood pressure difference in a post-stroke population. A comprehensive assessment of secondary risk factors along with blood pressure measurements were taken 6-months' post-ischemic stroke from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke cohort. Descriptive and logistic regression analyses were performed. Odds ratios and 95% confidence intervals are presented. Two hundred thirty-eight (M: F,139:99; mean age, 68.4 years) of 256 patients followed up at 6 months post-stroke had suitable blood pressure readings from both arms. Ninety-six patients (40.3%) had an interarm SBP difference of ≥10 mm Hg and 49 (20.6%) had a difference of ≥15 mm Hg. A history of hypertension, diabetes, smoking, and obesity was not significantly associated with an increased risk of interarm SBP difference. After multivariate logistic analysis, a history of alcohol excess was associated with an increased IASBP ≥15 mm Hg (odds ratio 2.32, 95% confidence interval 1.03-5.22). We have demonstrated that interarm SBP difference is commonly seen in a post stroke population.

Public knowledge and understanding of dementia-evidence from a national survey in Ireland.

Background: there is growing consensus around the importance of population level approaches which seek to improve public knowledge and awareness of dementia. Aim: to assess knowledge of the relationship between dementia and ageing, and of the risk and protective factors associated with it, among the general public in Ireland. Design: cross-sectional survey. Participants selected using quota sampling based on Census data. Methods: the final sample of 1,217 respondents provided estimates of dementia knowledge in the Irish population. Logistic regression was used to assess the impact of potential predictor variables on knowledge of dementia. Results: a majority (52%) reported that they knew someone living with dementia. Just 39% were confident that they could tell the difference between the early signs of dementia and normal ageing. Less than half (46%) believed that there were things they could do to reduce their risk of developing dementia, and knowledge of risk and protective factors for dementia was very poor. Although significant differences were seen according to area of residence, social class and experience of dementia, even those groups with 'better' understanding demonstrated substantial knowledge deficits regarding risk and protective factors. Conclusions: the general public in Ireland are confused about the relationship between dementia and ageing, and knowledge of risk and protective factors for dementia is very poor. While not dissimilar to those reported internationally, the findings present a challenge to those tasked with promoting behaviour change and interventions to delay or prevent the onset of dementia.

A comparison of service organisation and guideline compliance between two adjacent European health services.

INTRODUCTION: Outcomes in stroke patients are improved by a co-ordinated organisation of stroke services and provision of evidence-based care. We studied the organisation of care and application of guidelines in two neighbouring health care systems with similar characteristics. METHODS: Organisational elements of the 2015 National Stroke Audit (NSA) from the Republic of Ireland (ROI) were compared with the Sentinel Stroke National Audit Programme (SSNAP) in Northern Ireland (NI) and the United Kingdom (UK). Compliance was compared with UK and European guidelines. RESULTS: Twenty-one of 28 ROI hospitals (78%) reported having a stroke unit (SU) compared with all 10 in NI. Average SU size was smaller in ROI (6 beds vs. 15 beds) and bed availability per head of population was lower (1:30,633 vs. 1:12,037 p < 0.0001 Chi Sq). Fifty-four percent of ROI patients were admitted to SU care compared with 96% of UK patients (p < 0.0001). Twenty-four-hour physiological monitoring was available in 54% of ROI SUs compared to 91% of UK units (p < 0.0001). There was no significant difference between ROI and NI in access to senior specialist physicians or nurses or in SU nurse staffing (3.9/10 beds weekday mornings) but there was a higher proportion of trained nurses in ROI units (2.9/10 beds vs. 2.3/10 beds (p = 0.02 Chi Sq). CONCLUSION: Whilst the majority of hospitals in both jurisdictions met key criteria for organised stroke care the small size and underdevelopment of the ROI units meant a substantial proportion of patients were unable to access this specialised care.

Access to Rehabilitation at Six Months Post Stroke: A Profile from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) Study.

BACKGROUND AND PURPOSE: Stroke is the third leading cause of death and disability. Few studies have assessed the profile and adequacy of access to rehabilitation services after ischaemic stroke both in the inpatient and community setting. The objectives of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) study were to assess the disability and rehabilitation profile, adherence with rehabilitation recommendations and needs of patients 6 months following hospital admission for stroke. METHODS: A rehabilitation prescription was completed before hospital discharge for each participant, and adherence to this prescription was assessed at 6 months to determine whether patients received their recommended rehabilitation needs. RESULTS: Two hundred and fifty six patients were recruited to ASPIRE-S. The average age was 69 (SD 12.8). A majority (n = 221, 86%) were referred to the hospital multidisciplinary team, 59% (n = 132) were referred to all services (physiotherapy (PT), occupational therapy (OT), speech and language therapy (SLT)). Fifty-four percent (n = 119) of patients (seen by the multidisciplinary team) were referred for further rehabilitation in the community on discharge. Of these 119 patients, 112 (95%) recalled receiving community rehabilitation services. However, while most (68%) patients were referred for several disciplines (PT, OT, SLT), the most commonly recalled therapy (55%) was from a single discipline. The most commonly recommended frequency of therapy required was on a weekly basis. Sixty-one patients (51%) reported a delay in services, with some still awaiting services at 6 months. CONCLUSION: Results from this prospective study revealed that a significant number of patients (57%) did not receive the therapy recommended on discharge. Future initiatives should include the development of policies, which support more effective, equitable multidisciplinary rehabilitation for stroke patients in the community.

Secondary prevention after ischaemic stroke: the ASPIRE-S study.

BACKGROUND: Survivors of ischaemic stroke (IS) are at high-risk for future vascular events. Comprehensive information on the adequacy of secondary prevention after IS is lacking despite the knowledge that appropriate secondary prevention improves long-term patient outcomes. ASPIRE-S (Action on Secondary Prevention Interventions and Rehabilitation in Stroke) aimed to prospectively assess secondary prevention in patients 6 months following IS. METHODS: Consenting patients admitted with IS to three Dublin hospitals were recruited over 1 year, from October 2011. At 6 months post IS a comprehensive assessment was completed, modelled on the EUROASPIRE protocol for evaluation of the adequacy of secondary prevention in post-discharge cardiac patients. This assessment included measurements of blood pressure, body mass index and fasting lipid and glucose profiles. Secondary preventive medications and smoking status were also documented. RESULTS: Three hundred two patients (58 % male) participated, of whom 256 (85 %) were followed-up at 6 months. Mean age was 69 years (range 22-95). At follow-up, 68 % of patients had a BMI >25 kg/m(2) and 16.4 % were still smoking. Almost two-thirds (63.4 %) had a blood pressure >140/90 and 23 % had low-density-lipoprotein >2.5 mmol/L. 28 % of diabetic patients had HbA1c ≥ 7 %. Ninety seven percent of patients were on anti-platelet and/or anticoagulant therapy. Of those with atrial fibrillation, 82 % were anti-coagulated (mean INR of 2.4). Ninety-five percent were on lipid-lowering therapy and three-quarters were on anti-hypertensive therapy. CONCLUSION: This prospective multi-centre survey of IS patients demonstrated a high prevalence of remaining modifiable risk factors at 6 months post stroke, despite the widespread prescription of secondary preventive medications. There is scope to improve preventive measures after IS (in particular blood pressure) by incorporating evidence-based guidelines into quality assurance cycles in stroke care.

Statin use in adults at high risk of cardiovascular disease mortality: cross-sectional analysis of baseline data from The Irish Longitudinal Study on Ageing (TILDA).

OBJECTIVES: This study aims to examine the extent to which statins are used by adults at high risk of cardiovascular disease (CVD) compared to European clinical guidelines. The high-risk groups examined are those with (1) known CVD, (2) known diabetes and (3) a high or very high risk (≥5%) of CVD mortality based on Systematic COronary Risk Evaluation (SCORE). DESIGN: This study is cross-sectional in design using data from the first wave (2009-2011) of The Irish Longitudinal Study on Ageing (TILDA). SETTING AND PARTICIPANTS: The sample (n=3372) is representative of community living adults aged 50-64 years in Ireland. RESULTS: Statins were used by 68.6% (95% CI 61.5% to 75.8%) of those with known CVD, 57.4% (95% CI 49.1% to 65.7%) of those with known diabetes and by 19.7% (95% CI 13.0% to 26.3%) of adults with a SCORE risk ≥5%. Over a third (38.5%, 95% CI 31.0% to 46.0%) of those with known CVD, 46.8% (95% CI 38.4% to 55.1%) of those with known diabetes and 85.2% (95% CI 79.3% to 91.1%) of those with a SCORE risk ≥5% were at or above the low-density lipoprotein cholesterol (LDL-C) target of 2.5 mmol/L specified in the 2007 European guidelines. CONCLUSIONS: Despite strong evidence and clinical guidelines recommending the use of statins for secondary prevention, a gap exists between guidelines and practice in this cohort. It is also of concern that a low proportion of adults with a SCORE risk ≥5% were taking statins. A policy response that strengthens secondary prevention, and improves risk assessment and shared decision-making in the primary prevention of CVD is required.

The future cost of stroke in Ireland: an analysis of the potential impact of demographic change and implementation of evidence-based therapies.

BACKGROUND AND PURPOSE: this paper examines the impact of demographic change from 2007 to 2021 on the total cost of stroke in Ireland and analyses potential impacts of expanded access to stroke unit care and thrombolytic therapy on stroke outcomes and costs. METHODS: total costs of stroke are estimated for the projected number of stroke cases in 2021 in Ireland. Analysis also estimates the potential number of deaths or institutionalised cases averted among incident stroke cases in Ireland in 2007 at different rates of access to stroke unit care and thrombolytic therapy. Drawing on these results, total stroke costs in Ireland in 2007 are recalculated on the basis of the revised numbers of incident stroke patients estimated to survive stroke, and of the numbers estimated to reside at home rather than in a nursing home in the context of expanded access to stroke units or thrombolytic therapy. RESULTS: future costs of stroke in Ireland are estimated to increase by 52-57% between 2007 and 2021 on the basis of demographic change. The projected increase in aggregate stroke costs for all incident cases in 1 year in Ireland due to the delivery of stroke unit care and thrombolytic therapy can be offset to some extent by reductions in nursing home and other post-acute costs.

Trends in hospitalisation for acute myocardial infarction in Ireland, 1997-2008.

OBJECTIVE: To study the temporal and gender trends in age-standardised hospitalisation rates, in-hospital mortality rates and indicators of health service use for acute myocardial infarction (AMI), and the sub-categories, ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI), in Ireland, 1997-2008. DESIGN, SETTING, PATIENTS: Anonymised data from the hospital inpatient enquiry were studied for the ICD codes covering STEMI and NSTEMI in all 39 acute hospitals in Ireland over a 12-year period. Age standardisation (direct method) was used to study hospitalisation and in-hospital mortality rates. Joinpoint regression analysis was undertaken to identify significant inflection points in hospitalisation trends. MAIN OUTCOME MEASURES: Age-standardised hospitalisation rates, in-hospital mortality and indicators of health service use (length of stay, bed days) for AMI, STEMI and NSTEMI patients. RESULTS: From 1997 to 2008, hospitalisation rates for AMI decreased by 27%, and by 68% for STEMI patients (test for trend p<0.001), and increased by 122% for NSTEMI, (test for trend p<0.001). The mean age of male STEMI patients decreased (p<0.01), while those for the remaining groupings of AMI and subcategories increased. The proportion of males increased significantly for STEMI and NSTEMI (p<0.001). In-hospital mortality decreased steadily (p=0.01 STEMI, p=0.02 NSTEMI), as did median length of stay. CONCLUSIONS: The authors found a steady decrease in hospitalisation rates with AMI, and a shift away from STEMI towards rising rates of NSTEMI patients who are increasingly older. In an ageing population, and with increasing survival rates, surveillance of acute coronary syndrome and allied conditions is necessary to inform clinicians and policy makers.

The cost of stroke and transient ischaemic attack in Ireland: a prevalence-based estimate.

BACKGROUND: stroke is a leading cause of death and disability globally. The economic costs of stroke are high but not often fully quantified. This paper estimates the economic burden of stroke and transient ischaemic attack (TIA) in Ireland in 2007. METHODS: a prevalence-based approach using a societal perspective is adopted. Both direct and indirect costs are estimated. RESULTS: total stroke costs are estimated to have been €489-€805 million in 2007, comprising €345-€557 million in direct costs and €143-€248 million in indirect costs. Nursing home care and indirect costs together account for the largest proportion of total stroke costs (74-82%). The total cost of TIA was approximately €11.1 million in 2007, with acute hospital care accounting for 90% of the total. CONCLUSIONS: the chronic phase of the disease accounts for the largest proportion of the total annual economic burden of stroke. This highlights the need to maximise functional outcomes to lessen the longer term economic and personal impacts of stroke.

Knowledge of stroke risk factors and warning signs in Ireland: development and application of the Stroke Awareness Questionnaire (SAQ).

BACKGROUND: Inability to recognize stroke warning signs and delay in seeking medical attention for recognized symptoms contribute to treatment delay, thus limiting the potential for intervention and impacting negatively on potential stroke outcome. AIM: To examine knowledge of stroke risk factors and warning signs in the adult population in Ireland. METHODS: In 2009, 1000 members of the general public were interviewed by telephone using quota-based population sampling of adults (≥18 years). Information was gathered using the Stroke Awareness Questionnaire (SAQ). RESULTS: 71% of participants could correctly list two or more risk factors for stroke, typically generic lifestyle risk factors. Two-thirds could not identify two warning signs for stroke. While 31% could identify two or more stroke warning signs, there was no consistency in warning signs identified. Less than 50% stated they would call an ambulance if having a stroke. Overall, there were significant gaps in knowledge, with poorest levels evident in those aged ≥65 years. CONCLUSIONS: Survey findings provide first evidence on levels of knowledge of stroke risk factors and warning signs in the Irish adult population. Awareness of stroke warning signs was poor, as was awareness of the need to call emergency services and the potential for acute stroke intervention. These factors contribute to delay in seeking medical attention following stroke, with resulting implications for stroke outcome.

From prevention to nursing home care: a comprehensive national audit of stroke care.

BACKGROUND: Many countries are developing national audits of stroke care. However, these typically focus on stroke care from acute event to hospital discharge rather than the full spectrum from prevention to long-term care. We report on a comprehensive national audit of stroke care in the community and hospitals in the Republic of Ireland. The findings provide insights into the wider needs of people with stroke and their families, a basis for developing stroke-appropriate health strategies, and a global model for the evaluation of stroke services. METHODS: Six national surveys were completed: general practitioners (prevention and primary care), hospital organisational and clinical audit of 2,570 consecutive stroke admissions (acute and hospital care), allied health professionals and public health nurses (discharge to community care), nursing homes (needs of patients discharged to long-term care), and patient and carers (post-hospital phase of rehabilitation and ongoing care). RESULTS: The audit identified substantial deficits in a number of areas including primary prevention, emergency assessment/investigation and treatment in hospital, discharge planning, rehabilitation and ongoing secondary prevention, and communication with patients and families. There was a lack of coordination and communication between the acute and community services, with a dearth of therapy services in both home and nursing home settings. CONCLUSION: This multi-faceted national stroke audit facilitated multiple perspectives on the continuum of stroke prevention and care. An overall synthesis of surveys supports the development of a multidisciplinary perspective in planning the development of comprehensive stroke services at the national level, and may assist in regional and global development of stroke strategies.

The clustering of health behaviours in Ireland and their relationship with mental health, self-rated health and quality of life.

BACKGROUND: Health behaviours do not occur in isolation. Rather they cluster together. It is important to examine patterns of health behaviours to inform a more holistic approach to health in both health promotion and illness prevention strategies. Examination of patterns is also important because of the increased risk of mortality, morbidity and synergistic effects of health behaviours. This study examines the clustering of health behaviours in a nationally representative sample of Irish adults and explores the association of these clusters with mental health, self-rated health and quality of life. METHODS: TwoStep Cluster analysis using SPSS was carried out on the SLÁN 2007 data (national Survey of Lifestyle, Attitudes and Nutrition, n = 10,364; response rate =62%; food frequency n = 9,223; cluster analysis n = 7,350). Patterns of smoking, drinking alcohol, physical activity and diet were considered. Associations with positive and negative mental health, quality of life and self-rated health were assessed. RESULTS: Six health behaviour clusters were identified: Former Smokers, 21.3% (n = 1,564), Temperate, 14.6% (n = 1,075), Physically Inactive, 17.8% (n = 1,310), Healthy Lifestyle, 9.3% (n = 681), Multiple Risk Factor, 17% (n = 1248), and Mixed Lifestyle, 20% (n = 1,472). Cluster profiles varied with men aged 18-29 years, in the lower social classes most likely to adopt unhealthy behaviour patterns. In contrast, women from the higher social classes and aged 65 years and over were most likely to be in the Healthy Lifestyle cluster. Having healthier patterns of behaviour was associated with positive lower levels of psychological distress and higher levels of energy vitality. CONCLUSION: The current study identifies discernible patterns of lifestyle behaviours in the Irish population which are similar to those of our European counterparts. Healthier clusters (Former Smokers, Temperate and Healthy Lifestyle) reported higher levels of energy vitality, lower levels of psychological distress, better self-rated health and better quality of life. In contrast, those in the Multiple Risk Factor cluster had the lowest levels of energy and vitality and the highest levels of psychological distress. Identification of these discernible patterns because of their relationship with mortality, morbidity and longevity is important for identifying national and international health behaviour patterns.

Living longer and feeling better: healthy lifestyle, self-rated health, obesity and depression in Ireland.

BACKGROUND: The combination of four protective lifestyle behaviours (being physically active, a non-smoker, a moderate alcohol consumer and having adequate fruit and vegetable intake) has been estimated to increase life expectancy by 14 years. However, the effect of adopting these lifestyle behaviours on general health, obesity and mental health is less defined. We examined the combined effect of these behaviours on self-rated health, overweight/obesity and depression. METHODS: Using data from the Survey of Lifestyle Attitudes and Nutrition (SLAN) 2007 (), a protective lifestyle behaviour (PLB) score was constructed for 10,364 men and women (>18 years), and representative of the Republic of Ireland adult population (response rate 62%). Respondents scored a maximum of four points, one point each for being physically active, consuming five or more fruit and vegetable servings daily, a non-smoker and a moderate drinker. RESULTS: One-fifth of respondents (20%) adopted four PLBs, 35% adopted three, 29% two, 13% one and 2% adopted none. Compared to those with zero PLBs, those with four were seven times more likely to rate their general health as excellent/very good [OR 6.8 95% CI (3.64-12.82)] and four times more likely to have better mental health [OR 4.4 95% CI (2.34-8.22)]. CONCLUSIONS: Adoption of core protective lifestyle factors known to increase life expectancy is associated with positive self-rated health, healthier weight and better mental health. These lifestyles have the potential to add quality and quantity to life.

Stroke awareness in the general population: knowledge of stroke risk factors and warning signs in older adults.

BACKGROUND: Stroke is a leading cause of death and functional impairment. While older people are particularly vulnerable to stroke, research suggests that they have the poorest awareness of stroke warning signs and risk factors. This study examined knowledge of stroke warning signs and risk factors among community-dwelling older adults. METHODS: Randomly selected community-dwelling older people (aged 65+) in Ireland (n = 2,033; 68% response rate). Participants completed home interviews. Questions assessed knowledge of stroke warning signs and risk factors, and personal risk factors for stroke. RESULTS: Of the overall sample, 6% had previously experienced a stroke or transient ischaemic attack. When asked to identify stroke risk factors from a provided list, less than half of the overall sample identified established risk factors (e.g., smoking, hypercholesterolaemia), hypertension being the only exception (identified by 74%). Similarly, less than half identified established warning signs (e.g., weakness, headache), with slurred speech (54%) as the exception. Overall, there were considerable gaps in awareness with poorest levels evident in those with primary level education only and in those living in Northern Ireland (compared with Republic of Ireland). CONCLUSION: Knowledge deficits in this study suggest that most of the common early symptoms or signs of stroke were recognized as such by less than half of the older adults surveyed. As such, many older adults may not recognise early symptoms of stroke in themselves or others. Thus, they may lose vital time in presenting for medical attention. Lack of public awareness about stroke warning signs and risk factors must be addressed as one important contribution to reducing mortality and morbidity from stroke.

Cost-effectiveness of treatments reducing coronary heart disease mortality in Ireland, 2000 to 2010.

OBJECTIVE: Coronary heart disease (CHD) is associated with a large burden of disease in Ireland and is responsible for more than 6000 deaths annually. This study examined the cost-effectiveness of specific CHD treatments in Ireland. METHODS: Irish epidemiological data on patient numbers and median survival in specific groups, plus the uptake, effectiveness, and costs of specific interventions, all stratified by age and sex, were incorporated into a previously validated CHD mortality model, the IMPACT model. This model calculates the number of life-years gained (LYGs) by specific cardiology interventions to generate incremental cost-effectiveness ratios (ICERs) per LYG for each intervention. RESULTS: In 2000, medical and surgical treatments together prevented or postponed approximately 1885 CHD deaths in patients aged 25 to 84 years, and thus generated approximately 14,505 extra life-years (minimum 7270, maximum 22,475). In general, all the cardiac interventions investigated were highly cost-effective in the Irish setting. Aspirin, beta-blockers, ACE inhibitors, spironolactone, and warfarin for specific conditions were the most cost-effective interventions (< euro 3000/LYG), followed by the statins for secondary prevention (< euro 6500/LYG). Revascularization for chronic angina and primary angioplasty for myocardial infarction, although still cost-effective, had the highest ICER (between euro 12,000 and euro 20,000/LYG). CONCLUSIONS: Using a comprehensive standardized methodology, cost-effectiveness ratios in this study clearly favored simple medical treatments for myocardial infarction, secondary prevention, angina, and heart failure.

Heartwatch: a secondary prevention programme in primary care in Ireland.

BACKGROUND: Heartwatch, a secondary prevention programme in primary care was initiated in 2003, based on the second European Joint Task Force recommendations for secondary prevention of coronary heart disease (CHD). The aim was to examine the effect of the first 2 years of the Heartwatch programme on cardiovascular risk factors and treatments. DESIGN: Prospective cohort study of patients with established CHD enrolled into the Heartwatch programme. METHODS: Four hundred and seventy (20%) general practitioners nationwide participated in the programme, recruiting 11,542 patients with established CHD (earlier myocardial infarction, coronary intervention or coronary artery bypass surgery). Clinical data were electronically transferred by each general practitioner to a central database. Comparison of changes in risk factors and treatments at 1-year and 2-year follow-up from baseline were made using paired t-test for continuous and McNemar's test for categorical data. RESULTS: Statistically significant changes in systolic blood pressure, diastolic blood pressure, total and low-density lipoprotien cholesterol and smoking status at 1 and 2 years (P <0.0001) were observed. Little or no improvements were shown for exercise, BMI or waist circumference. Increases in the prescribing of statins, angiotensin-converting enzyme inhibitors and beta-blockers over the course of the study were observed. CONCLUSION: The Heartwatch programme has demonstrated significant improvements in the main risk factors and treatments for CHD. More effective interventions are required to reduce BMI, waist circumference and physical inactivity in this population. The increases in treatment uptake are approaching the optimal levels in this population.

Quality of life assessment in heart failure interventions: a 10-year (1996-2005) review.

The increasing prevalence and poor prognosis associated with heart failure have prompted research to focus on improving quality of life (QoL) for heart failure patients. Research from 1996-2005 was systematically reviewed to identify randomized controlled trials that assessed QoL in heart failure. In 120 studies, 44 were medication trials; 19 surgical/procedural interventions; and 57 patient care/service delivery interventions. Studies were summarized in terms of aim, population, QoL measures used and QoL findings. Studies used 47 different measures of QoL-generic, health-related, condition-specific, domain-specific and utility measures. Most used a single QoL measure. In 87%, a condition specific QoL measure was used, with the Minnesota Living with Heart Failure Questionnaire being the favoured assessment tool. The range of QoL measures in use poses challenges for development of cumulative knowledge. Although comparability across studies is important, this must be informed by the responsiveness of the instrument selected. As carried out in other cardiac groups, comparative evaluations of instrument responsiveness are needed in heart failure.

Comparing primary prevention with secondary prevention to explain decreasing coronary heart disease death rates in Ireland, 1985-2000.

BACKGROUND: To investigate whether primary prevention might be more favourable than secondary prevention (risk factor reduction in patients with coronary heart disease(CHD)). METHODS: The cell-based IMPACT CHD mortality model was used to integrate data for Ireland describing CHD patient numbers, uptake of specific treatments, trends in major cardiovascular risk factors, and the mortality benefits of these specific risk factor changes in CHD patients and in healthy people without recognised CHD. RESULTS: Between 1985 and 2000, approximately 2,530 fewer deaths were attributable to reductions in the three major risk factors in Ireland. Overall smoking prevalence declined by 14% between 1985 and 2000, resulting in about 685 fewer deaths (minimum estimate 330, maximum estimate 1,285) attributable to smoking cessation: about 275 in healthy people and 410 in known CHD patients. Population total cholesterol concentrations fell by 4.6%, resulting in approximately 1,300 (minimum estimate 1,115, maximum estimate 1,660) fewer deaths attributable to dietary changes(1,185 in healthy people and 115 in CHD patients) plus 305 fewer deaths attributable to statin treatment (45 in people without CHD and 260 in CHD patients). Mean population diastolic blood pressure fell by 7.2%, resulting in approximately 170 (minimum estimate 105, maximum estimate 300) fewer deaths attributable to secular falls in blood pressure (140 in healthy people and 30 in CHD patients), plus approximately 70 fewer deaths attributable to antihypertensive treatments in people without CHD. Of all the deaths attributable to risk factor falls, some 1,715 (68%) occurred in people without recognized CHD and 815(32%) in CHD patients. CONCLUSION: Compared with secondary prevention, primary prevention achieved a two-fold larger reduction in CHD deaths. Future national CHD policies should therefore prioritize nationwide interventions to promote healthy diets and reduce smoking.