Letters to the Editor
573
Trends of cardiovascular disease amongst psychiatric patients between 2001 and 2012 in Greater Manchester, UK Paul Carter a, Gurjit Rai a, Amir Aziz b, Jake Mann c, Suresh Chandran d, Hardeep Uppal e, Rahul Potluri e,⁎ a
The Medical School, University of Birmingham, Birmingham, UK Department of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK Department of Medicine and Health, University of Leeds, Leeds, UK d Department of Acute Medicine, North Western Deanery, Manchester, UK e ACALM Study Unit in collaboration with Aston Medical School, Aston University, Birmingham, UK b c
a r t i c l e
i n f o
Article history: Received 2 February 2014 Accepted 14 March 2014 Available online 21 March 2014 Keywords: Cardiovascular disease Trends Psychiatric disease UK
Dear Editor, Cardiovascular disease (CVD) is an important cause of mortality and morbidity in patients with psychiatric disease. CVD is increased in neuropsychiatric conditions including depression [1,2] bipolar [2], schizophrenia [3–5], Alzheimer's disease [6], Parkinson's disease [7] and emotional stress [8,9]. Awareness of psychiatric disease as a novel CV risk factor is increasing, and aspects relating to its epidemiology and the potential causes have been reviewed [10]. Despite the expanding literature on CV risk in psychiatric disease, there is scanty evidence that this has translated into clinical knowledge and improvement [11,12],. Our group previously analysed the secular trends of cardiovascular co-morbidities in 12,383 psychiatric patients presenting to a hospital in Birmingham, UK, between 2000 and 2007 [12]. We demonstrated a significant burden of CV disease in these patients, with at least 1 in 4 suffering from a cardiovascular co-morbidity. More importantly, , there was an overall increase of risk factors of CVD (hyperlipidaemia, hypertension and type 2 diabetes) and ischaemic heart disease over this time period.. Given our work and other significant studies in this field, it is important to re-evaluate secular trends again in 2013 and analyse the effect of increased awareness on CVD amongst psychiatric patients [3,5–7,12]. Therefore, we studied the prevalence and secular trends of cardiovascular risk factors and co-morbidities amongst a large population of patients with psychiatric disease presenting to multiple hospitals in the Greater Manchester region of the, UK, between 2001 and 2012. This complements our previous study allowing a comparison of secular trends over a much longer time period in a different region of the UK. We compiled a database of all adult (age 18 or over) psychiatric patients admitted across several multi-ethnic general hospitals throughout the Greater Manchester region using ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol between 1st January 2001 and 31st December 2012. The ACALM study uses ICD-10 diagnosis and OPCS-4 procedure codes to trace patients from raw local health authority computerized hospital activity analysis register. The presence of a cardiovascular co-morbidites were also traced by using the ACALM protocol as defined by the presence of defined by the presence of hypertension, type 2 diabetes, ⁎ Corresponding author at: Honorary Clinical Lecturer in Cardiology, Aston University, UK. E-mail address: [email protected] (R. Potluri).
type 1 diabetes, hyperlipidaemia, atrial fibrillation, peripheral vascular disease, chronic kidney disease, carotid artery disease, haemorrhagic stroke, ischaemic stroke, cardiomyopathy, heart failure, myocardial infarction and ischaemic heart disease. We analysed the prevalence of cardiovascular co-morbidities in psychiatric patients over the entire 12-year study period and in four 3year periods namely 2001–2003; 2004–2006; 2007–2009 and 2010– 2012. Data analysis was performed using SPSS Version 20.0. Completely anonymous patient data was used and processed in accordance with the local ethical research and development policy. The methodology has been previously used by our group and others [3,5–7,12–15]. There were a total of 74,734 adult patients with psychiatric conditions admitted to hospital between 2001 and 2012 with a mean age of 53.3 years ± 22.1 SD and of which 49.6% were male. This represents 8.9% of the total 841,399 adult patients admitted to hospital(s) during this time period. The study group was predominantly Caucasian (84%), with lower proportions of South Asian (3.7%), AfroCaribbean (1.6%) and oriental (0.2%) patients. The prevalence of the main diagnoses over the 12-years were; hypertension (20.2%), ischaemic heart disease (9.63%), type 2 diabetes mellitus (8.49%), atrial fibrillation (6.63%), hyperlipidaemia (5.25%), heart failure (4.60%), ischaemic stroke (3.88%), chronic kidney disease (3.34%), myocardial infarction (2.38%) and peripheral vascular disease (1.42%) (Table 1). Overall, there were a total of 53,972 cardiovascular diagnoses found amongst the psychiatric patients over the entire 12-year study period. When analysed in four 3-year periods, the number of cardiovascular diagnoses showed an initial increase in the number of diagnoses from 7413 between 2001 and 2003 to a peak of 21,090 diagnoses between 2004 and 2006. This was followed by a steady decrease to 15,917 between 2007 and 2009 and 9546 between 2010 and 2012. This unimodal trend was represented in many of the most prevalent comorbidities (hypertension, ischaemic heart disease, type 1 and 2 diabetes mellitus, atrial fibrillation, chronic kidney disease and peripheral vascular disease). However, a constant decrease in the prevalence of MI, ischaemic and haemorrhagic stroke and heart failure was seen over the study period, with a constant increase in the prevalence of hyperlipidaemia and cardiomyopathy. Our main findings were 1) a high prevalence of cardiovascular comorbidities in psychiatric patients attending general hospitals in Greater Manchester, UK between 2001 and 2012, with a particularly high prevalence of cardiovascular risk factors (hypertension, diabetes mellitus and hyperlipidaemia) 2) a unimodal trend in the prevalence of cardiovascular co-morbidities over this time period which was demonstrated by most of the co-morbidities studied and 3) a steady declining trend in many of the serious cardiovascular sequelae analysed (MI, stroke and heart failure) between 2001 and 2012. The high prevalence of cardiovascular co-morbidities we have found amongst psychiatric patients is in accordance with the literature, as well as our previous Birmingham study [12]. Notably, a high proportion of psychiatric patients suffered from cardiovascular risk factors, in particular hypertension, which was found in 10% and 20% of patients in Birmingham and Manchester, respectively. Hypertension and other cardiovascular risk factors could be raised in psychiatric patients for a number of reasons including side effects of medication [10,16], low
574
Letters to the Editor
Table 1 Shows the trends of cardiovascular co-morbidites in patients with psychiatric conditions over the time period 2001–2012. Prevalence of comorbidity during time period (% of psychiatric patients with each cardiovascular comorbidity)
Hypertension Peripheral vascular disease Chronic kidney disease Atrial fibrillation Carotid artery disease Type 1 diabetes mellitus Type 2 diabetes mellitus Myocardial infarction Ischaemic stroke Haemorrhagic stroke Cardiomyopathy Heart failure Hyperlipidaemia Ischaemic heart disease
2001–2003
2004–2006
2007–2009
2010–2012
2000–2012
16.16 1.58 2.77 6.74 0.20 1.31 8.41 3.14 5.03 0.46 0.28 5.73 3.32 10.09
21.80 1.63 4.18 7.96 0.17 1.42 9.85 2.82 4.39 0.36 0.29 5.25 4.97 11.54
24.85 1.45 3.83 7.11 0.23 1.10 8.89 1.95 3.38 0.32 0.28 4.30 6.38 10.01
20.09 0.96 2.61 4.80 0.27 0.96 7.36 1.55 2.43 0.29 0.37 2.94 6.67 7.15
20.24 1.42 3.34 6.63 0.20 1.21 8.49 2.38 3.88 0.35 0.30 4.60 5.25 9.63
Overall prevalence in the period 2001 to 2012 is shown in bold.
compliance to cardiovascular medications such as antihypertensives [10,17], negative lifestyle behaviours or an underlying pathophysiological cause such as overactivity of the hypothalamo-pituitary axis or sympathetic nervous system [10,18]. Further comparison demonstrates a considerably higher prevalence of co-morbidities in Manchester. We demonstrated, at least a 50% greater prevalence of MI, ischaemic heart disease, ischaemic stroke, hypertension and heart failure in the Manchester cohort, with hyperlipidaemia five-fold greater amongst patients from this region. This could represent differing clinical practice between the two cities, with a higher rate of detection, especially of risk factors or it could also be due to a true increased cardiovascular risk in this area [13–15]. The main aim of this study was to analyse the secular trends in cardiovascular co-morbidities beyond 2007 as our previous study had showed a worrying increasing trend between 2000 and 2007. Consistent with this, we demonstrated increasing trends in cardiovascular co-morbidities over a similar time period (2001–2006) and in the same co-morbidities. Importantly though, the prevalence of all of these aforementioned co-morbidities, as well as cardiovascular diagnoses overall, decreased after this time, between 2007 and 2012. There may therefore have been a recent improvement in prevention of CV disease in psychiatric patients. This may be translating into clinical benefit as the prevalence of serious CV sequelae decreased throughout the study period from 2001 to 2012, which again is consistent with the Birmingham cohort. These secular trends provide optimistic evidence with regard to management of CV risk in psychiatric patients. Our study has provided support to previous evidence that although the burden of CV disease amongst psychiatric patients was increasing, in more recent years it could now be declining. However, the burden, in particular risk factors, still remains high, and could be particularly prevalent in Manchester. Therefore, clinicians should continue to actively assess and manage risk factors in these patients, and further studies should ascertain the mechanisms for the enhanced CV risk amongst psychiatric patients. http://dx.doi.org/10.1016/j.ijcard.2014.03.116 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
References [1] Rugulies R. Depression as a predictor for coronary heart disease. A review and metaanalysis. Am J Prev Med 2002;23:51–61. [2] Osby U, Brandt L, Correia N, Ekbom A, Sparen P. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry 2001;58(9):844–50. [3] Schoepf D, Potluri R, Uppal H, Natalwala A, Narendran P, Heun R. Type-2 diabetes mellitus in schizophrenia: increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up. Eur Psychiatry 2012;27(1):33–42. [4] Jeste DV, Gladsjo JA, Lindamer LA, Lacro JP. Medical comorbidity in schizophrenia. Schizophr Bull 1996;22(3):413–30. [5] Schoepf D, Uppal H, Potluri R, Heun R. Physical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions. Eur Arch Psychiatry Clin Neurosci 2014;264(1):3–28. [6] Heun R, Schoepf D, Potluri R, Natalwala A. Alzheimer's disease and co-morbidity: increased prevalence and possible risk factors of excess mortality in a naturalistic 7year follow-up. Eur Psychiatry 2013;28(1):40–8. [7] Potluri R, Natalwala A, Nakajima M, et al. Prevalence of mental health disorders among patients with Parkinson's disease in the United Kingdom. J Clin Neurosci 2011;18(12):1746–7. [8] Rosengren A, Hawken S, Ounpuu S, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case–control study. Lancet 2004;364(9438):953–62. [9] Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet 2007;370(9592):1089–100. [10] Smith Patrick J, Blumenthal James A. Behavioural aspects of cardiovascular disease: epidemiology, mechanisms, and treatment. Rev Esp Cardiol 2011;64:924–33. [11] Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. JAMA 2007;298(15):1794–6. [12] Carter P, Mann J, Sangha J, et al. The burden of cardiovascular disease amongst psychiatric patients. Int J Cardiol 2013;169(4):65–6. [13] Khouw N, Wasim M, Aziz A, Uppal H, Chandran S, Potluri R. Length of hospital stay is shorter in South Asian patients with myocardial infarction. Int J Cardiol Feb 1 2014;171(2):e54–5. [14] Ciputra R, Sembiring Y, Prawato O, et al. Length of stay in hospital is longer in ethnic minority patients after coronary artery bypass surgery. Int J Cardiol Jan 8 2014:2234–46. [15] Smith S, Gollop N, Uppal H, Chandran S, Potluri R. Length of hospital stay is shorter in South Asian patients with acute pulmonary embolism. Heart Asia 2014;6(1):1–2. [16] Citrome L, Blonde L, Damatarca C. Metabolic issues in patients with severe mental illness. South Med J 2005;98(7):714–20. [17] Wang PS, Bohn RL, Knight E, Glynn RJ, Mogun H, Avorn J. Noncompliance with antihypertensive medications. J Gen Intern Med 2002;17(7):504–11. [18] Pariante C, Miller A. Glucocorticoid receptors in major depression: relevance to pathophysiology an treatment. Biol Psychiatry 2001;49:391–404.
573
Trends of cardiovascular disease amongst psychiatric patients between 2001 and 2012 in Greater Manchester, UK Paul Carter a, Gurjit Rai a, Amir Aziz b, Jake Mann c, Suresh Chandran d, Hardeep Uppal e, Rahul Potluri e,⁎ a
The Medical School, University of Birmingham, Birmingham, UK Department of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK Department of Medicine and Health, University of Leeds, Leeds, UK d Department of Acute Medicine, North Western Deanery, Manchester, UK e ACALM Study Unit in collaboration with Aston Medical School, Aston University, Birmingham, UK b c
a r t i c l e
i n f o
Article history: Received 2 February 2014 Accepted 14 March 2014 Available online 21 March 2014 Keywords: Cardiovascular disease Trends Psychiatric disease UK
Dear Editor, Cardiovascular disease (CVD) is an important cause of mortality and morbidity in patients with psychiatric disease. CVD is increased in neuropsychiatric conditions including depression [1,2] bipolar [2], schizophrenia [3–5], Alzheimer's disease [6], Parkinson's disease [7] and emotional stress [8,9]. Awareness of psychiatric disease as a novel CV risk factor is increasing, and aspects relating to its epidemiology and the potential causes have been reviewed [10]. Despite the expanding literature on CV risk in psychiatric disease, there is scanty evidence that this has translated into clinical knowledge and improvement [11,12],. Our group previously analysed the secular trends of cardiovascular co-morbidities in 12,383 psychiatric patients presenting to a hospital in Birmingham, UK, between 2000 and 2007 [12]. We demonstrated a significant burden of CV disease in these patients, with at least 1 in 4 suffering from a cardiovascular co-morbidity. More importantly, , there was an overall increase of risk factors of CVD (hyperlipidaemia, hypertension and type 2 diabetes) and ischaemic heart disease over this time period.. Given our work and other significant studies in this field, it is important to re-evaluate secular trends again in 2013 and analyse the effect of increased awareness on CVD amongst psychiatric patients [3,5–7,12]. Therefore, we studied the prevalence and secular trends of cardiovascular risk factors and co-morbidities amongst a large population of patients with psychiatric disease presenting to multiple hospitals in the Greater Manchester region of the, UK, between 2001 and 2012. This complements our previous study allowing a comparison of secular trends over a much longer time period in a different region of the UK. We compiled a database of all adult (age 18 or over) psychiatric patients admitted across several multi-ethnic general hospitals throughout the Greater Manchester region using ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol between 1st January 2001 and 31st December 2012. The ACALM study uses ICD-10 diagnosis and OPCS-4 procedure codes to trace patients from raw local health authority computerized hospital activity analysis register. The presence of a cardiovascular co-morbidites were also traced by using the ACALM protocol as defined by the presence of defined by the presence of hypertension, type 2 diabetes, ⁎ Corresponding author at: Honorary Clinical Lecturer in Cardiology, Aston University, UK. E-mail address: [email protected] (R. Potluri).
type 1 diabetes, hyperlipidaemia, atrial fibrillation, peripheral vascular disease, chronic kidney disease, carotid artery disease, haemorrhagic stroke, ischaemic stroke, cardiomyopathy, heart failure, myocardial infarction and ischaemic heart disease. We analysed the prevalence of cardiovascular co-morbidities in psychiatric patients over the entire 12-year study period and in four 3year periods namely 2001–2003; 2004–2006; 2007–2009 and 2010– 2012. Data analysis was performed using SPSS Version 20.0. Completely anonymous patient data was used and processed in accordance with the local ethical research and development policy. The methodology has been previously used by our group and others [3,5–7,12–15]. There were a total of 74,734 adult patients with psychiatric conditions admitted to hospital between 2001 and 2012 with a mean age of 53.3 years ± 22.1 SD and of which 49.6% were male. This represents 8.9% of the total 841,399 adult patients admitted to hospital(s) during this time period. The study group was predominantly Caucasian (84%), with lower proportions of South Asian (3.7%), AfroCaribbean (1.6%) and oriental (0.2%) patients. The prevalence of the main diagnoses over the 12-years were; hypertension (20.2%), ischaemic heart disease (9.63%), type 2 diabetes mellitus (8.49%), atrial fibrillation (6.63%), hyperlipidaemia (5.25%), heart failure (4.60%), ischaemic stroke (3.88%), chronic kidney disease (3.34%), myocardial infarction (2.38%) and peripheral vascular disease (1.42%) (Table 1). Overall, there were a total of 53,972 cardiovascular diagnoses found amongst the psychiatric patients over the entire 12-year study period. When analysed in four 3-year periods, the number of cardiovascular diagnoses showed an initial increase in the number of diagnoses from 7413 between 2001 and 2003 to a peak of 21,090 diagnoses between 2004 and 2006. This was followed by a steady decrease to 15,917 between 2007 and 2009 and 9546 between 2010 and 2012. This unimodal trend was represented in many of the most prevalent comorbidities (hypertension, ischaemic heart disease, type 1 and 2 diabetes mellitus, atrial fibrillation, chronic kidney disease and peripheral vascular disease). However, a constant decrease in the prevalence of MI, ischaemic and haemorrhagic stroke and heart failure was seen over the study period, with a constant increase in the prevalence of hyperlipidaemia and cardiomyopathy. Our main findings were 1) a high prevalence of cardiovascular comorbidities in psychiatric patients attending general hospitals in Greater Manchester, UK between 2001 and 2012, with a particularly high prevalence of cardiovascular risk factors (hypertension, diabetes mellitus and hyperlipidaemia) 2) a unimodal trend in the prevalence of cardiovascular co-morbidities over this time period which was demonstrated by most of the co-morbidities studied and 3) a steady declining trend in many of the serious cardiovascular sequelae analysed (MI, stroke and heart failure) between 2001 and 2012. The high prevalence of cardiovascular co-morbidities we have found amongst psychiatric patients is in accordance with the literature, as well as our previous Birmingham study [12]. Notably, a high proportion of psychiatric patients suffered from cardiovascular risk factors, in particular hypertension, which was found in 10% and 20% of patients in Birmingham and Manchester, respectively. Hypertension and other cardiovascular risk factors could be raised in psychiatric patients for a number of reasons including side effects of medication [10,16], low
574
Letters to the Editor
Table 1 Shows the trends of cardiovascular co-morbidites in patients with psychiatric conditions over the time period 2001–2012. Prevalence of comorbidity during time period (% of psychiatric patients with each cardiovascular comorbidity)
Hypertension Peripheral vascular disease Chronic kidney disease Atrial fibrillation Carotid artery disease Type 1 diabetes mellitus Type 2 diabetes mellitus Myocardial infarction Ischaemic stroke Haemorrhagic stroke Cardiomyopathy Heart failure Hyperlipidaemia Ischaemic heart disease
2001–2003
2004–2006
2007–2009
2010–2012
2000–2012
16.16 1.58 2.77 6.74 0.20 1.31 8.41 3.14 5.03 0.46 0.28 5.73 3.32 10.09
21.80 1.63 4.18 7.96 0.17 1.42 9.85 2.82 4.39 0.36 0.29 5.25 4.97 11.54
24.85 1.45 3.83 7.11 0.23 1.10 8.89 1.95 3.38 0.32 0.28 4.30 6.38 10.01
20.09 0.96 2.61 4.80 0.27 0.96 7.36 1.55 2.43 0.29 0.37 2.94 6.67 7.15
20.24 1.42 3.34 6.63 0.20 1.21 8.49 2.38 3.88 0.35 0.30 4.60 5.25 9.63
Overall prevalence in the period 2001 to 2012 is shown in bold.
compliance to cardiovascular medications such as antihypertensives [10,17], negative lifestyle behaviours or an underlying pathophysiological cause such as overactivity of the hypothalamo-pituitary axis or sympathetic nervous system [10,18]. Further comparison demonstrates a considerably higher prevalence of co-morbidities in Manchester. We demonstrated, at least a 50% greater prevalence of MI, ischaemic heart disease, ischaemic stroke, hypertension and heart failure in the Manchester cohort, with hyperlipidaemia five-fold greater amongst patients from this region. This could represent differing clinical practice between the two cities, with a higher rate of detection, especially of risk factors or it could also be due to a true increased cardiovascular risk in this area [13–15]. The main aim of this study was to analyse the secular trends in cardiovascular co-morbidities beyond 2007 as our previous study had showed a worrying increasing trend between 2000 and 2007. Consistent with this, we demonstrated increasing trends in cardiovascular co-morbidities over a similar time period (2001–2006) and in the same co-morbidities. Importantly though, the prevalence of all of these aforementioned co-morbidities, as well as cardiovascular diagnoses overall, decreased after this time, between 2007 and 2012. There may therefore have been a recent improvement in prevention of CV disease in psychiatric patients. This may be translating into clinical benefit as the prevalence of serious CV sequelae decreased throughout the study period from 2001 to 2012, which again is consistent with the Birmingham cohort. These secular trends provide optimistic evidence with regard to management of CV risk in psychiatric patients. Our study has provided support to previous evidence that although the burden of CV disease amongst psychiatric patients was increasing, in more recent years it could now be declining. However, the burden, in particular risk factors, still remains high, and could be particularly prevalent in Manchester. Therefore, clinicians should continue to actively assess and manage risk factors in these patients, and further studies should ascertain the mechanisms for the enhanced CV risk amongst psychiatric patients. http://dx.doi.org/10.1016/j.ijcard.2014.03.116 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
References [1] Rugulies R. Depression as a predictor for coronary heart disease. A review and metaanalysis. Am J Prev Med 2002;23:51–61. [2] Osby U, Brandt L, Correia N, Ekbom A, Sparen P. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry 2001;58(9):844–50. [3] Schoepf D, Potluri R, Uppal H, Natalwala A, Narendran P, Heun R. Type-2 diabetes mellitus in schizophrenia: increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up. Eur Psychiatry 2012;27(1):33–42. [4] Jeste DV, Gladsjo JA, Lindamer LA, Lacro JP. Medical comorbidity in schizophrenia. Schizophr Bull 1996;22(3):413–30. [5] Schoepf D, Uppal H, Potluri R, Heun R. Physical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions. Eur Arch Psychiatry Clin Neurosci 2014;264(1):3–28. [6] Heun R, Schoepf D, Potluri R, Natalwala A. Alzheimer's disease and co-morbidity: increased prevalence and possible risk factors of excess mortality in a naturalistic 7year follow-up. Eur Psychiatry 2013;28(1):40–8. [7] Potluri R, Natalwala A, Nakajima M, et al. Prevalence of mental health disorders among patients with Parkinson's disease in the United Kingdom. J Clin Neurosci 2011;18(12):1746–7. [8] Rosengren A, Hawken S, Ounpuu S, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case–control study. Lancet 2004;364(9438):953–62. [9] Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet 2007;370(9592):1089–100. [10] Smith Patrick J, Blumenthal James A. Behavioural aspects of cardiovascular disease: epidemiology, mechanisms, and treatment. Rev Esp Cardiol 2011;64:924–33. [11] Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. JAMA 2007;298(15):1794–6. [12] Carter P, Mann J, Sangha J, et al. The burden of cardiovascular disease amongst psychiatric patients. Int J Cardiol 2013;169(4):65–6. [13] Khouw N, Wasim M, Aziz A, Uppal H, Chandran S, Potluri R. Length of hospital stay is shorter in South Asian patients with myocardial infarction. Int J Cardiol Feb 1 2014;171(2):e54–5. [14] Ciputra R, Sembiring Y, Prawato O, et al. Length of stay in hospital is longer in ethnic minority patients after coronary artery bypass surgery. Int J Cardiol Jan 8 2014:2234–46. [15] Smith S, Gollop N, Uppal H, Chandran S, Potluri R. Length of hospital stay is shorter in South Asian patients with acute pulmonary embolism. Heart Asia 2014;6(1):1–2. [16] Citrome L, Blonde L, Damatarca C. Metabolic issues in patients with severe mental illness. South Med J 2005;98(7):714–20. [17] Wang PS, Bohn RL, Knight E, Glynn RJ, Mogun H, Avorn J. Noncompliance with antihypertensive medications. J Gen Intern Med 2002;17(7):504–11. [18] Pariante C, Miller A. Glucocorticoid receptors in major depression: relevance to pathophysiology an treatment. Biol Psychiatry 2001;49:391–404.
