International Journal of Cardiology 171 (2014) e81–e83
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Geographic variations in prevalent cardiovascular disease subtypes: UK Understanding Society cohort, 2009–2010 Ivy Shiue a,b,⁎, Krasimira Hristova c a b c
School of the Built Environment, Heriot-Watt University, UK Owens Institute for Behavioral Research, University of Georgia, USA Department of Noninvasive Functional Diagnostic and Imaging, University National Heart Hospital, Bulgaria
a r t i c l e
i n f o
Article history: Received 4 September 2013 Accepted 30 November 2013 Available online 6 December 2013
Table 1 Demographic and social characteristics of the study cohort. n (%) or mean ± SD
Keywords: Cardiovascular disease Epidemiology Prevention Population health Social determinants
Regional variations of cardiovascular disease (CVD) subtypes have been investigated over the last decades. Mostly, researchers focused on incidence and mortality. However, knowing the regional variations in prevalent CVD could further help medical professionals and policy makers prepare medical and social resources such as ambulance response, diagnostic acumen, and so on to be efficiently (re)allocated in the next years since rehabilitation facility will also play an important role in helping patients and family at both regional and national levels. Therefore, we aimed to provide recent evidence on regional variance in prevalent CVD subtypes including heart failure, coronary heart disease (CHD), angina, myocardial infarction (MI), and stroke in a national and population-based setting in the UK. Data were extracted and analysed in the UK Longitudinal Household Survey (Understanding Society, access available via: http://www. understandingsociety.org.uk/) Wave 1, 2009–2010, which has been a national, population-based, multi-year study among people above 16 years old residing in England, Scotland, Wales, and Northern Ireland. Study design and sampling method were described and published in detail in the working paper series [1]. Information on demographics, living and work conditions, and self-reported CVD (Has as doctor or health professional ever told you that you have any of the condition listed? What age were you when you were first told you had?) was obtained by household interview. Self-reported CVD events included heart failure, CHD, angina, MI, and stroke. ⁎ Corresponding author at: School of the Built Environment, Heriot-Watt University, Riccarton, EH14 4AS, Edinburgh, Scotland, UK. Tel.: +44 7577444812. E-mail address: [email protected] (I. Shiue). 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.098
Sex Male Female Age (mean ± SD), years 16–39 40–59 60–79 ≥80 Birthplace Born in England Born in Scotland Born in Wales Born in North Ireland Not born in the UK Body mass index b18.5 18.5–25 25–30 ≥30 Education ≥High school bHigh school Marital status Single/In civil partnership Married/Registered (including same sex couples) Separated but married Divorced/Widowed Salary b£20,000 £20,000 to £49,999 £50,000 to £99,999 ≥£100,000 Neighbourhood satisfaction Agree Neither agree nor disagree Disagree Ever high blood pressure Ever cardiovascular disease Heart failure Coronary heart disease Angina Myocardial infarction Stroke
23,202 (45.5%) 27,792 (54.5%) 45.6 ± 18.2 20,858 (40.9%) 17,396 (34.1%) 10,849 (21.3%) 1891 (3.7%) 33,480 (65.7%) 3567 (7.0%) 2154 (4.2%) 2033 (4.0%) 9744 (19.1%) 26.0 ± 5.1 1064 (2.4%) 19,735 (38.7%) 15,535 (34.9%) 8147 (18.3%) 20,044 (39.4%) 30,831 (60.6%) 14,964 (31.4%) 24,180 (50.7%) 1289 (2.7%) 7266 (15.2%) 16,803 (86.6%) 2112 (10.9%) 415 (2.1%) 72 (0.4%) 25,913 (66.1%) 7390 (18.9%) 5896 (15.0%) 8706 (18.3%) 276 (0.6%) 854 (1.8%) 1353 (4.8%) 1060 (2.2%) 867 (1.8%)
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Table 2 Regional variations of prevalent cardiovascular disease events in adults aged 16 years and above. a) Heart failure
Regions London Northwest Yorkshire and Humber East midlands West midlands East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
Yes (n = 276, 0.6%)
No (n = 47,329, 99.4%)
27 (0.4%) 35 (0.7%) 21 (0.5%) 18 (0.5%) 25 (0.6%) 18 (0.4%) 11 (0.6%) 28 (0.5%) 24 (0.7%) 20 (0.9%) 28 (0.8%) 21 (1.1%)
7579 (99.6%) 5045 (99.3%) 3927 (99.5%) 3522 (99.5%) 4307 (99.4%) 4144 (99.6%) 1902 (99.4%) 5737 (99.5%) 3588 (99.3%) 2238 (99.1%) 3370 (99.2%) 1970 (98.9%)
Yes (n = 854, 1.8%)
No (n = 46,751, 98.2%)
P value
Crude OR
Adjusted OR
P value⁎
1.00 1.95 (1.18–3.22) 1.50 (0.85–2.66) 1.43 (0.79–2.61) 1.63 (0.94–2.81) 1.22 (0.67–2.22) 1.62 (0.80–3.28) 1.37 (0.81–2.33) 1.88 (1.08–3.26) 2.51 (1.40–4.48) 2.33 (1.37–3.96) 2.99 (1.69–5.30)
1.00 n/a n/a) n/a 1.28 (0.16–10.11) 1.02 (0.13–8.05) n/a 0.39 (0.03–4.71) 2.03 (0.29–13.92) n/a 3.75 (0.40–35.35) n/a
n/a n/a n/a 0.82 0.98 n/a 0.46 0.47 n/a 0.25 n/a
Crude OR
Adjusted OR
P value⁎
1.00 1.87 (1.39–2.53) 1.95 (1.42–2.66) 1.89 (1.37–2.62) 1.66 (1.20–2.28) 2.20 (1.63–2.98) 1.67 (1.11–2.52) 1.72 (1.28–2.31) 1.53 (1.08–2.15) 1.85 (1.27–2.69) 2.06 (0.49–2.85) 2.66 (1.87–3.77)
1.00 0.67 (0.19–2.39) 1.37 (0.41–4.55) 1.79 (0.59–5.44) 1.32 (0.42–4.13) 2.79 (1.07–7.32) n/a 1.99 (0.76–5.19) 2.02 (0.68–5.95) 0.38 (0.03–4.51) 1.67 (0.44–6.31) 1.85 (0.24–14.44)
0.53 0.61 0.30 0.63 0.04 n/a 0.16 0.20 0.44 0.45 0.56
Crude OR
Adjusted OR
P value⁎
1.00 2.37 (1.87–3.01) 2.38 (1.85–3.06) 2.23 (1.71–2.89) 1.71 (1.31–2.23) 1.78 (1.37–2.32) 2.50 (1.85–3.38) 1.56 (1.22–2.01) 1.76 (1.33–2.31) 2.32 (1.73–3.11) 2.70 (2.09–3.48) 2.72 (2.03–3.63)
1.00 1.33 (0.55–3.24) 1.61 (0.63–4.16) 1.30 (0.49–3.46) 1.78 (0.74–4.30) 1.94 (0.83–4.55) 1.31 (0.39–4.36) 1.23 (0.52–2.91) 1.45 (0.56–3.74) 0.32 (0.05–2.05) 0.86 (0.27–2.70) 1.17 (0.14–9.52)
0.52 0.32 0.59 0.20 0.13 0.66 0.65 0.45 0.23 0.79 0.88
Crude OR
Adjusted OR
P value⁎
1.00 1.87 (1.41–2.48) 2.69 (2.04–3.55) 2.00 (1.48–2.71) 1.93 (1.45–2.59) 2.06 (1.54–2.75) 2.13 (1.49–3.04) 1.98 (1.51–2.60) 2.08 (1.55–2.81) 2.15 (1.53–3.01) 2.14 (1.58–2.89) 2.40 (1.71–3.37)
1.00 0.79 (0.29–2.17) 1.62 (0.62–4.20) 1.58 (0.62–4.06) 0.77 (0.26–2.25) 2.06 (0.87–4.86) 0.57 (0.12–2.74) 0.83 (0.32–2.13) 0.86 (0.29–2.55) 0.42 (0.08–2.28) 1.14 (0.35–3.70) 0.53 (0.02–12.14)
0.65 0.32 0.34 0.63 0.10 0.48 0.69 0.79 0.32 0.83 0.69
Crude OR
Adjusted OR
P value⁎
1.00 2.17 (1.62–2.92) 1.76 (1.27–2.45) 2.32 (1.69–3.18) 2.01 (1.47–2.74)
1.00 1.42 (0.42–4.84) 0.79 (0.17–3.64) 0.73 (0.16–3.39) 1.16 (0.30–4.51)
0.58 0.76 0.69 0.83
0.006
b) Coronary heart disease
Regions London Northwest Yorkshire and Humber East midlands West midlands East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
P value b0.001
79 (1.0%) 98 (1.9%) 79 (2.0%) 69 (2.0%) 74 (1.7%) 94 (2.3%) 33 (1.7%) 102 (1.8%) 57 (1.6%) 43 (1.9%) 72 (2.1%) 54 (2.7%)
7527 (99.0%) 4982 (98.1%) 3869 (98.0%) 3471 (98.0%) 4258 (98.3%) 4068 (97.7%) 1880 (98.3%) 5663 (98.2%) 3555 (98.4%) 2215 (98.1%) 3326 (97.9%) 1937 (97.3%)
Yes (n = 1353, 2.8%)
No (n = 46,252, 97.2%)
114 (1.5%) 177 (3.5%) 138 (3.5%) 116 (3.3%) 110 (2.5%) 110 (2.6%) 70 (3.7%) 134 (2.3%) 94 (2.6%) 77 (3.4%) 134 (3.9%) 79 (4.0%)
7492 (98.5%) 4903 (96.5%) 3810 (96.5%) 3424 (96.7%) 4222 (97.5%) 4052 (97.4%) 1843 (96.3%) 5631 (97.7%) 3518 (97.4%) 2181 (96.6%) 3264 (96.1%) 1912 (96.0%)
Yes (n = 1060, 3.2%)
No (n = 46,545, 96.8%)
c) Angina
Regions London Northwest Yorkshire and Humber East midlands West midlands East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
P value b0.001
d) Myocardial infarction
Regions London Northwest Yorkshire and Humber East midlands West midlands East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
P value b0.001
89 (1.2%) 110 (2.2%) 122 (3.1%) 82 (2.3%) 97 (2.2%) 99 (2.4%) 47 (2.5%) 132 (2.3%) 87 (2.4%) 56 (2.5%) 84 (2.5%) 55 (2.8%)
7517 (98.8%) 4970 (97.8%) 3826 (96.9%) 3458 (97.7%) 4235 (97.8%) 4063 (97.6%) 1866 (97.5%) 5633 (97.7%) 3525 (97.6%) 2202 (97.5%) 3314 (97.5%) 1936 (97.2%)
Yes (n = 867, 1.8%)
No (n = 46,738, 98.2%)
76 (1.0%) 109 (2.2%) 69 (1.8%) 81 (2.3%) 86 (2.0%)
7530 (99.0%) 4971 (97.8%) 3879 (98.2%) 3459 (97.7%) 4246 (98.0%)
e) Stroke
Regions London Northwest Yorkshire and Humber East midlands West midlands
P value b0.001
I. Shiue, K. Hristova / International Journal of Cardiology 171 (2014) e81–e83
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Table 2 (continued) e) Stroke
East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
Yes (n = 867, 1.8%)
No (n = 46,738, 98.2%)
69 (1.7%) 45 (2.4%) 103 (1.8%) 64 (1.8%) 39 (1.7%) 85 (2.5%) 41 (2.1%)
4093 (98.3%) 1868 (97.6%) 5662 (98.2%) 3548 (98.2%) 2219 (98.3%) 3313 (97.5%) 1950 (97.9%)
P value
Crude OR
Adjusted OR
P value⁎
1.67 (1.20–2.32) 2.39 (1.65–2.46) 1.80 (1.34–2.43) 1.79 (1.28–2.50) 1.74 (1.18–2.57) 2.54 (1.86–3.47) 2.08 (1.42–3.06)
1.26 (0.34–4.63) 1.47 (0.32–6.86) 1.48 (0.45–4.90) 1.37 (0.37–5.09) 2.43 (0.46–12.89) 1.95 (0.35–10.75) 11.43 (2.04–64.05)
0.73 0.62 0.52 0.64 0.30 0.45 0.01
⁎ P values denote those of adjusted ORs.
Study covariates including age, sex, birthplace, body mass index, education, marital status, salary (proxy of occupation), ever high blood pressure, age of onset (binary: 0 = ex-cardiovascular disease, 1 = new onset CVD) [2] and willingness to stay in the current neighbourhood (proxy of perception on neighbourhood satisfaction) were adjusted. Likert scale was used (very agree and agree into “agree”, “neither agree nor disagree”, disagree and very disagree into “disagree”) for assessing perception on neighbourhood satisfaction. Analysis involved chi-square test, t-test, and logistic regression modelling. Effects were estimated by using odds ratios (OR) and 95% confidence intervals (CI), with P value b 0.05 considered statistically significant. Statistical software STATA version 12.0 (STATA, College Station, Texas, USA) was used to perform all the analyses. Since it is only a secondary data analysis in the present study, no further ethics approval is required. Of 50,994 people included in the study cohort, 276 (0.6%) had heart failure, 854 (1.8%) had CHD, 1353 (4.8%) had angina, 1060 (2.2%) had heart attack or MI, and 867 (1.8%) had stroke. Very few people had their CVD event (incident cardiovascular event) at the age when they were interviewed (10, 0.02% for heart failure; 33, 0.06% for CHD; 45, 0.09% for angina; 0, 0% heart attack or MI; 0, 0% for stroke). Table 1 shows the demographic and social characteristics of the study cohort. In general, about half of the population were overweight (53.2% had BMI over 25) and 18.3% had ever high blood pressure (n = 8706). There was little regional variance in the CVD prevalence (Table 2) observed. Specifically, stroke prevalence peaked in Northern Ireland (OR 11.43, 95%CI 2.04–64.05, P = 0.01) and CHD prevalence peaked in East of England (OR 2.79, 95%CI 1.07–7.32, P = 0.04). For other CVD subtypes (heart failure, angina, and MI), however, no geographic difference was detected after the full adjustment. Although in 2000 it was observed lower incidence of MI in England than Scotland, Wales, and Northern Ireland, case-fatality was found in the opposite direction among these regions [3]. This could explain why we did not find much geographic variance in prevalent MI even after further classifying sub-regions within England, statistically. Similar observations were also made for CHD and stroke. Previously, researchers claimed that higher rates in Scotland and/or Wales than in England could be explained by establish risk factors such as hypertension and smoking [4,5]. A systematic review later concluded that geographic variation in stroke across the UK between 1985 and 2008 was narrowed [6]. In our study, we have observed higher prevalence of stroke in Northern Ireland and that of CHD in East of England only, compared to the London region. These are consistent with other later observations on no regional differences in CVD among women [7]. On one hand, improved treatments and success in reducing CV risk factors have decreased the
burden in the UK. On the other hand, the different rates in CV risk factors reduction would need to be further studied since in the crude modelling, large geographic variance was noted for each CVD subtype. In other words, how efficient and cost-effective public health programs could benefit the general public's CV health across different regions will be key in the following years and even decades. This study has several strengths. First, it is in a national, populationbased setting using a representative sampling method in the very recent years. Moreover, the whole data contain all adults aged 16 years and above which could give a better national overview of the burden of the disease distribution. However, some limitation still cannot be ignored. Data on incident CVD subtypes were not enough for statistical analysis and can only be adjusted as a covariate in the present study. Moreover, due to limited number of CVD subtypes events in the elderly, we were unable to examine the regional variation of CVD subtypes in the very old. As there is not much literature focusing on geographic variance in prevalence or incidence of heart failure and angina in the UK, we were unable to compare. In summary, we have found limited regional variations in the prevalence of CHD and stroke but not MI, heart failure, and angina, based on the data in 2009 and 2010. The two British regions that will require further attention are Northern Ireland and East of England. We suggest that continuing implementing efficient and cost-effective public health programs in the next years, particularly in those two regions mentioned earlier, would help keep closing the gaps in burden of prevalent CVD and sustain the human capital in the UK. References [1] Buck N, McFall S. Understanding society. Design overview. Longit Life Course Stud 2012;3:5–17 [free access via: http://www.llcsjournal.org/index.php/llcs/article/ view/159/168]. [2] Shiue I. Associated social factors of prevalent asthma in adults and the very old in the UK. Allergy 2013;68:392–6. [3] Dunn NR, Arscott A, Thorogood M, et al. Regional variation in incidence and case fatality of myocardial infarction among young women in England, Scotland and Wales. J Epidemiol Community Health 2000;54:293–8. [4] Morris RW, Whincup PH, Lampe FC, Walker M, Wannamethee SG, Shaper AG. Geographic variation in incidence of coronary heart disease in Britain: the contribution of established risk factors. Heart 2001;86:277–83. [5] Morris RW, Whincup PH, Emberson JR, Lampe FC, Walker M, Shaper AG. North–south gradients in Britain for stroke and CHD: are they explained by the same factors? Stroke 2003;34:2604–9. [6] Bhatnagar P, Scarborough P, Smeeton NC, Allender S. The incidence of all stroke and stroke subtype in the United Kingdom, 1985 to 2008: a systematic review. BMC Public Health 2010;10:539. [7] Kim LG, Carson C, Lawlor DA, Ebrahim S. Geographical variation in cardiovascular incidence: results from the British Women's Heart and Health Study. BMC Public Health 2010;10:696.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Geographic variations in prevalent cardiovascular disease subtypes: UK Understanding Society cohort, 2009–2010 Ivy Shiue a,b,⁎, Krasimira Hristova c a b c
School of the Built Environment, Heriot-Watt University, UK Owens Institute for Behavioral Research, University of Georgia, USA Department of Noninvasive Functional Diagnostic and Imaging, University National Heart Hospital, Bulgaria
a r t i c l e
i n f o
Article history: Received 4 September 2013 Accepted 30 November 2013 Available online 6 December 2013
Table 1 Demographic and social characteristics of the study cohort. n (%) or mean ± SD
Keywords: Cardiovascular disease Epidemiology Prevention Population health Social determinants
Regional variations of cardiovascular disease (CVD) subtypes have been investigated over the last decades. Mostly, researchers focused on incidence and mortality. However, knowing the regional variations in prevalent CVD could further help medical professionals and policy makers prepare medical and social resources such as ambulance response, diagnostic acumen, and so on to be efficiently (re)allocated in the next years since rehabilitation facility will also play an important role in helping patients and family at both regional and national levels. Therefore, we aimed to provide recent evidence on regional variance in prevalent CVD subtypes including heart failure, coronary heart disease (CHD), angina, myocardial infarction (MI), and stroke in a national and population-based setting in the UK. Data were extracted and analysed in the UK Longitudinal Household Survey (Understanding Society, access available via: http://www. understandingsociety.org.uk/) Wave 1, 2009–2010, which has been a national, population-based, multi-year study among people above 16 years old residing in England, Scotland, Wales, and Northern Ireland. Study design and sampling method were described and published in detail in the working paper series [1]. Information on demographics, living and work conditions, and self-reported CVD (Has as doctor or health professional ever told you that you have any of the condition listed? What age were you when you were first told you had?) was obtained by household interview. Self-reported CVD events included heart failure, CHD, angina, MI, and stroke. ⁎ Corresponding author at: School of the Built Environment, Heriot-Watt University, Riccarton, EH14 4AS, Edinburgh, Scotland, UK. Tel.: +44 7577444812. E-mail address: [email protected] (I. Shiue). 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.098
Sex Male Female Age (mean ± SD), years 16–39 40–59 60–79 ≥80 Birthplace Born in England Born in Scotland Born in Wales Born in North Ireland Not born in the UK Body mass index b18.5 18.5–25 25–30 ≥30 Education ≥High school bHigh school Marital status Single/In civil partnership Married/Registered (including same sex couples) Separated but married Divorced/Widowed Salary b£20,000 £20,000 to £49,999 £50,000 to £99,999 ≥£100,000 Neighbourhood satisfaction Agree Neither agree nor disagree Disagree Ever high blood pressure Ever cardiovascular disease Heart failure Coronary heart disease Angina Myocardial infarction Stroke
23,202 (45.5%) 27,792 (54.5%) 45.6 ± 18.2 20,858 (40.9%) 17,396 (34.1%) 10,849 (21.3%) 1891 (3.7%) 33,480 (65.7%) 3567 (7.0%) 2154 (4.2%) 2033 (4.0%) 9744 (19.1%) 26.0 ± 5.1 1064 (2.4%) 19,735 (38.7%) 15,535 (34.9%) 8147 (18.3%) 20,044 (39.4%) 30,831 (60.6%) 14,964 (31.4%) 24,180 (50.7%) 1289 (2.7%) 7266 (15.2%) 16,803 (86.6%) 2112 (10.9%) 415 (2.1%) 72 (0.4%) 25,913 (66.1%) 7390 (18.9%) 5896 (15.0%) 8706 (18.3%) 276 (0.6%) 854 (1.8%) 1353 (4.8%) 1060 (2.2%) 867 (1.8%)
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Table 2 Regional variations of prevalent cardiovascular disease events in adults aged 16 years and above. a) Heart failure
Regions London Northwest Yorkshire and Humber East midlands West midlands East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
Yes (n = 276, 0.6%)
No (n = 47,329, 99.4%)
27 (0.4%) 35 (0.7%) 21 (0.5%) 18 (0.5%) 25 (0.6%) 18 (0.4%) 11 (0.6%) 28 (0.5%) 24 (0.7%) 20 (0.9%) 28 (0.8%) 21 (1.1%)
7579 (99.6%) 5045 (99.3%) 3927 (99.5%) 3522 (99.5%) 4307 (99.4%) 4144 (99.6%) 1902 (99.4%) 5737 (99.5%) 3588 (99.3%) 2238 (99.1%) 3370 (99.2%) 1970 (98.9%)
Yes (n = 854, 1.8%)
No (n = 46,751, 98.2%)
P value
Crude OR
Adjusted OR
P value⁎
1.00 1.95 (1.18–3.22) 1.50 (0.85–2.66) 1.43 (0.79–2.61) 1.63 (0.94–2.81) 1.22 (0.67–2.22) 1.62 (0.80–3.28) 1.37 (0.81–2.33) 1.88 (1.08–3.26) 2.51 (1.40–4.48) 2.33 (1.37–3.96) 2.99 (1.69–5.30)
1.00 n/a n/a) n/a 1.28 (0.16–10.11) 1.02 (0.13–8.05) n/a 0.39 (0.03–4.71) 2.03 (0.29–13.92) n/a 3.75 (0.40–35.35) n/a
n/a n/a n/a 0.82 0.98 n/a 0.46 0.47 n/a 0.25 n/a
Crude OR
Adjusted OR
P value⁎
1.00 1.87 (1.39–2.53) 1.95 (1.42–2.66) 1.89 (1.37–2.62) 1.66 (1.20–2.28) 2.20 (1.63–2.98) 1.67 (1.11–2.52) 1.72 (1.28–2.31) 1.53 (1.08–2.15) 1.85 (1.27–2.69) 2.06 (0.49–2.85) 2.66 (1.87–3.77)
1.00 0.67 (0.19–2.39) 1.37 (0.41–4.55) 1.79 (0.59–5.44) 1.32 (0.42–4.13) 2.79 (1.07–7.32) n/a 1.99 (0.76–5.19) 2.02 (0.68–5.95) 0.38 (0.03–4.51) 1.67 (0.44–6.31) 1.85 (0.24–14.44)
0.53 0.61 0.30 0.63 0.04 n/a 0.16 0.20 0.44 0.45 0.56
Crude OR
Adjusted OR
P value⁎
1.00 2.37 (1.87–3.01) 2.38 (1.85–3.06) 2.23 (1.71–2.89) 1.71 (1.31–2.23) 1.78 (1.37–2.32) 2.50 (1.85–3.38) 1.56 (1.22–2.01) 1.76 (1.33–2.31) 2.32 (1.73–3.11) 2.70 (2.09–3.48) 2.72 (2.03–3.63)
1.00 1.33 (0.55–3.24) 1.61 (0.63–4.16) 1.30 (0.49–3.46) 1.78 (0.74–4.30) 1.94 (0.83–4.55) 1.31 (0.39–4.36) 1.23 (0.52–2.91) 1.45 (0.56–3.74) 0.32 (0.05–2.05) 0.86 (0.27–2.70) 1.17 (0.14–9.52)
0.52 0.32 0.59 0.20 0.13 0.66 0.65 0.45 0.23 0.79 0.88
Crude OR
Adjusted OR
P value⁎
1.00 1.87 (1.41–2.48) 2.69 (2.04–3.55) 2.00 (1.48–2.71) 1.93 (1.45–2.59) 2.06 (1.54–2.75) 2.13 (1.49–3.04) 1.98 (1.51–2.60) 2.08 (1.55–2.81) 2.15 (1.53–3.01) 2.14 (1.58–2.89) 2.40 (1.71–3.37)
1.00 0.79 (0.29–2.17) 1.62 (0.62–4.20) 1.58 (0.62–4.06) 0.77 (0.26–2.25) 2.06 (0.87–4.86) 0.57 (0.12–2.74) 0.83 (0.32–2.13) 0.86 (0.29–2.55) 0.42 (0.08–2.28) 1.14 (0.35–3.70) 0.53 (0.02–12.14)
0.65 0.32 0.34 0.63 0.10 0.48 0.69 0.79 0.32 0.83 0.69
Crude OR
Adjusted OR
P value⁎
1.00 2.17 (1.62–2.92) 1.76 (1.27–2.45) 2.32 (1.69–3.18) 2.01 (1.47–2.74)
1.00 1.42 (0.42–4.84) 0.79 (0.17–3.64) 0.73 (0.16–3.39) 1.16 (0.30–4.51)
0.58 0.76 0.69 0.83
0.006
b) Coronary heart disease
Regions London Northwest Yorkshire and Humber East midlands West midlands East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
P value b0.001
79 (1.0%) 98 (1.9%) 79 (2.0%) 69 (2.0%) 74 (1.7%) 94 (2.3%) 33 (1.7%) 102 (1.8%) 57 (1.6%) 43 (1.9%) 72 (2.1%) 54 (2.7%)
7527 (99.0%) 4982 (98.1%) 3869 (98.0%) 3471 (98.0%) 4258 (98.3%) 4068 (97.7%) 1880 (98.3%) 5663 (98.2%) 3555 (98.4%) 2215 (98.1%) 3326 (97.9%) 1937 (97.3%)
Yes (n = 1353, 2.8%)
No (n = 46,252, 97.2%)
114 (1.5%) 177 (3.5%) 138 (3.5%) 116 (3.3%) 110 (2.5%) 110 (2.6%) 70 (3.7%) 134 (2.3%) 94 (2.6%) 77 (3.4%) 134 (3.9%) 79 (4.0%)
7492 (98.5%) 4903 (96.5%) 3810 (96.5%) 3424 (96.7%) 4222 (97.5%) 4052 (97.4%) 1843 (96.3%) 5631 (97.7%) 3518 (97.4%) 2181 (96.6%) 3264 (96.1%) 1912 (96.0%)
Yes (n = 1060, 3.2%)
No (n = 46,545, 96.8%)
c) Angina
Regions London Northwest Yorkshire and Humber East midlands West midlands East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
P value b0.001
d) Myocardial infarction
Regions London Northwest Yorkshire and Humber East midlands West midlands East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
P value b0.001
89 (1.2%) 110 (2.2%) 122 (3.1%) 82 (2.3%) 97 (2.2%) 99 (2.4%) 47 (2.5%) 132 (2.3%) 87 (2.4%) 56 (2.5%) 84 (2.5%) 55 (2.8%)
7517 (98.8%) 4970 (97.8%) 3826 (96.9%) 3458 (97.7%) 4235 (97.8%) 4063 (97.6%) 1866 (97.5%) 5633 (97.7%) 3525 (97.6%) 2202 (97.5%) 3314 (97.5%) 1936 (97.2%)
Yes (n = 867, 1.8%)
No (n = 46,738, 98.2%)
76 (1.0%) 109 (2.2%) 69 (1.8%) 81 (2.3%) 86 (2.0%)
7530 (99.0%) 4971 (97.8%) 3879 (98.2%) 3459 (97.7%) 4246 (98.0%)
e) Stroke
Regions London Northwest Yorkshire and Humber East midlands West midlands
P value b0.001
I. Shiue, K. Hristova / International Journal of Cardiology 171 (2014) e81–e83
e83
Table 2 (continued) e) Stroke
East of England Northeast Southeast Southwest Wales Scotland Northern Ireland
Yes (n = 867, 1.8%)
No (n = 46,738, 98.2%)
69 (1.7%) 45 (2.4%) 103 (1.8%) 64 (1.8%) 39 (1.7%) 85 (2.5%) 41 (2.1%)
4093 (98.3%) 1868 (97.6%) 5662 (98.2%) 3548 (98.2%) 2219 (98.3%) 3313 (97.5%) 1950 (97.9%)
P value
Crude OR
Adjusted OR
P value⁎
1.67 (1.20–2.32) 2.39 (1.65–2.46) 1.80 (1.34–2.43) 1.79 (1.28–2.50) 1.74 (1.18–2.57) 2.54 (1.86–3.47) 2.08 (1.42–3.06)
1.26 (0.34–4.63) 1.47 (0.32–6.86) 1.48 (0.45–4.90) 1.37 (0.37–5.09) 2.43 (0.46–12.89) 1.95 (0.35–10.75) 11.43 (2.04–64.05)
0.73 0.62 0.52 0.64 0.30 0.45 0.01
⁎ P values denote those of adjusted ORs.
Study covariates including age, sex, birthplace, body mass index, education, marital status, salary (proxy of occupation), ever high blood pressure, age of onset (binary: 0 = ex-cardiovascular disease, 1 = new onset CVD) [2] and willingness to stay in the current neighbourhood (proxy of perception on neighbourhood satisfaction) were adjusted. Likert scale was used (very agree and agree into “agree”, “neither agree nor disagree”, disagree and very disagree into “disagree”) for assessing perception on neighbourhood satisfaction. Analysis involved chi-square test, t-test, and logistic regression modelling. Effects were estimated by using odds ratios (OR) and 95% confidence intervals (CI), with P value b 0.05 considered statistically significant. Statistical software STATA version 12.0 (STATA, College Station, Texas, USA) was used to perform all the analyses. Since it is only a secondary data analysis in the present study, no further ethics approval is required. Of 50,994 people included in the study cohort, 276 (0.6%) had heart failure, 854 (1.8%) had CHD, 1353 (4.8%) had angina, 1060 (2.2%) had heart attack or MI, and 867 (1.8%) had stroke. Very few people had their CVD event (incident cardiovascular event) at the age when they were interviewed (10, 0.02% for heart failure; 33, 0.06% for CHD; 45, 0.09% for angina; 0, 0% heart attack or MI; 0, 0% for stroke). Table 1 shows the demographic and social characteristics of the study cohort. In general, about half of the population were overweight (53.2% had BMI over 25) and 18.3% had ever high blood pressure (n = 8706). There was little regional variance in the CVD prevalence (Table 2) observed. Specifically, stroke prevalence peaked in Northern Ireland (OR 11.43, 95%CI 2.04–64.05, P = 0.01) and CHD prevalence peaked in East of England (OR 2.79, 95%CI 1.07–7.32, P = 0.04). For other CVD subtypes (heart failure, angina, and MI), however, no geographic difference was detected after the full adjustment. Although in 2000 it was observed lower incidence of MI in England than Scotland, Wales, and Northern Ireland, case-fatality was found in the opposite direction among these regions [3]. This could explain why we did not find much geographic variance in prevalent MI even after further classifying sub-regions within England, statistically. Similar observations were also made for CHD and stroke. Previously, researchers claimed that higher rates in Scotland and/or Wales than in England could be explained by establish risk factors such as hypertension and smoking [4,5]. A systematic review later concluded that geographic variation in stroke across the UK between 1985 and 2008 was narrowed [6]. In our study, we have observed higher prevalence of stroke in Northern Ireland and that of CHD in East of England only, compared to the London region. These are consistent with other later observations on no regional differences in CVD among women [7]. On one hand, improved treatments and success in reducing CV risk factors have decreased the
burden in the UK. On the other hand, the different rates in CV risk factors reduction would need to be further studied since in the crude modelling, large geographic variance was noted for each CVD subtype. In other words, how efficient and cost-effective public health programs could benefit the general public's CV health across different regions will be key in the following years and even decades. This study has several strengths. First, it is in a national, populationbased setting using a representative sampling method in the very recent years. Moreover, the whole data contain all adults aged 16 years and above which could give a better national overview of the burden of the disease distribution. However, some limitation still cannot be ignored. Data on incident CVD subtypes were not enough for statistical analysis and can only be adjusted as a covariate in the present study. Moreover, due to limited number of CVD subtypes events in the elderly, we were unable to examine the regional variation of CVD subtypes in the very old. As there is not much literature focusing on geographic variance in prevalence or incidence of heart failure and angina in the UK, we were unable to compare. In summary, we have found limited regional variations in the prevalence of CHD and stroke but not MI, heart failure, and angina, based on the data in 2009 and 2010. The two British regions that will require further attention are Northern Ireland and East of England. We suggest that continuing implementing efficient and cost-effective public health programs in the next years, particularly in those two regions mentioned earlier, would help keep closing the gaps in burden of prevalent CVD and sustain the human capital in the UK. References [1] Buck N, McFall S. Understanding society. Design overview. Longit Life Course Stud 2012;3:5–17 [free access via: http://www.llcsjournal.org/index.php/llcs/article/ view/159/168]. [2] Shiue I. Associated social factors of prevalent asthma in adults and the very old in the UK. Allergy 2013;68:392–6. [3] Dunn NR, Arscott A, Thorogood M, et al. Regional variation in incidence and case fatality of myocardial infarction among young women in England, Scotland and Wales. J Epidemiol Community Health 2000;54:293–8. [4] Morris RW, Whincup PH, Lampe FC, Walker M, Wannamethee SG, Shaper AG. Geographic variation in incidence of coronary heart disease in Britain: the contribution of established risk factors. Heart 2001;86:277–83. [5] Morris RW, Whincup PH, Emberson JR, Lampe FC, Walker M, Shaper AG. North–south gradients in Britain for stroke and CHD: are they explained by the same factors? Stroke 2003;34:2604–9. [6] Bhatnagar P, Scarborough P, Smeeton NC, Allender S. The incidence of all stroke and stroke subtype in the United Kingdom, 1985 to 2008: a systematic review. BMC Public Health 2010;10:539. [7] Kim LG, Carson C, Lawlor DA, Ebrahim S. Geographical variation in cardiovascular incidence: results from the British Women's Heart and Health Study. BMC Public Health 2010;10:696.
