Coronary heart disease statistics: morbidity supplement .../media/files/research/...Coronary heart disease statistics: morbidity supplement 1 Coronary heart disease statistics: morbidity

Coronary heartdisease statistics:

morbiditysupplement

1

Coronaryheart diseasestatistics:morbiditysupplement

2001 edition

Mike Rayner1, Sophie Petersen1, Michael Moher 2, Lucy Wright2 and Fiona Lampe3

1 British Heart Foundation Health Promotion Research Group, Department of

Public Health, University of Oxford

2 Department of Primary Health Care, University of Oxford

3 Cardiovascular Research Unit, Department of Primary Care and Population

Sciences, Royal Free and University College Medical School, London


morbiditysupplement

2


morbiditysupplement

3

ContentsPage

Foreword 5Summary 6Introduction 71. Myocardial infarction (heart attack) 9

Table 1.1 Incidence of myocardial infarction, adults aged between30 and 69, latest available year, UK studies compared 12

Table 1.1a Incidence of myocardial infarction, adults aged less than 80,by sex and age, 1994/95, Oxfordshire 12

Table 1.1b Coronary event rates, coronary case fatality, annual change incoronary event rates and annual change in coronary casefatality, adults aged 35-64, by sex, latest available data,MONICA Project populations 13

Fig 1.1b (1) Age-standardised coronary event rates, men aged 35-64,latest available data, MONICA Project populations 14

Fig 1.1b (2) Age-standardised coronary event rates, women aged 35-64,latest available data, MONICA Project populations 14

Table 1.1c Change in incidence of myocardial infarction, adults agedbetween 30 and 75, between 1966 and 1996, UK studies compared 15

Table 1.2 Prevalence of myocardial infarction, adults aged between55 and 74, latest available year, UK studies compared 16

Table 1.2a Percentage who report experience of myocardial infarction(ever and recently), by sex and age, 1998, England 17

Table 1.2b Prevalence of myocardial infarction by sex and age,1981/82 and 1991/92, England and Wales 17

Table 1.2c Prevalence of self-reported longstanding heart attack, adults aged16 years and above by sex and age, 1988-1998, Great Britain 18

Fig 1.2c Prevalence of self-reported longstanding heart attack by sex,for all ages and for under 75 years, 1988-1998, Great Britain 18

Table 1.3 28-day case fatality for myocardial infarction, adults,latest available year, UK studies compared 19

Table 1.3a Survival after a mycardial infraction, adults aged less than 80,1994/95, Oxfordshire 19

Table 1.3b 28-day case fatality for myocardial infarction,adults aged 35-79, by sex and age, 1994/95, Oxfordshire 19

Fig 1.3c Change in 28-day case fatality for myocardial infarction,adults aged between 30 and 69, between 1966 and 1995,UK studies compared 20

2. Angina 21Table 2.1 Incidence of angina in adults, latest available year,

UK studies compared 23

Table 2.2 Prevalence of angina, adults aged between 55 and 74,latest available year, UK studies compared 24

Table 2.2a Percentage who report experience of angina (ever and recently),by sex and age, 1998, England 25


morbiditysupplement

4

Table 2.2b Prevalence of angina by sex and age, 1981/82 and 1991/92,England and Wales 25

Table 2.2c Change in prevalence of angina, men aged 40-75,between 1978 and 1996, Great Britain 25

3. All coronary heart disease 26Table 3 Prevalence of all CHD, adults aged between 55 and 74,

latest available year, UK studies compared 28

Table 3a Prevalence of treated CHD by sex,age and deprivation category, 1994/98, England and Wales 29

Fig 3a Prevalence of treated CHD by sex anddeprivation category, 1994/98, England and Wales 29

Table 3b Prevalence of chest pain and diagnosed heart disease inadults aged 40 and above, by sex and ethnic group, 1993/94,England and Wales 30

Table 3c Prevalence of treated coronary heart disease by sex,age and region, 1994/98, England and Wales 30

Fig 3c(1) Age-standardised prevalence of treated CHD for men,by region, 1994/98, England and Wales 31

Fig 3c(2) Age-standardised prevalence of treated CHD for women,by region, 1994/98, England and Wales 32

Table 3d Change in prevalence of diagnosed CHD, men aged between40 and 64, between 1978 and 1996, Great Britain 33

Table 3e Percentage reporting longstanding illness by age, sex andcondition group, 1998, Great Britain 33

Fig 3e Percentage of all longstanding illness by condition group,adults, 1998, Great Britain 34

4. Heart failure 35Table 4.1 Incidence of heart failure, by sex and age, 1995/96, Hillingdon 37

Table 4.2 Prevalence of heart failure, adults aged between 45 and 84,latest available year, UK studies compared 38

Table 4.2a Prevalence of treated heart failure, by sex and age, 1998,England and Wales 39

Table 4.2b Prevalence of left ventricular dysfunction, adults,latest available year, UK studies compared 40

Table 4.3 Survival after initial diagnosis of heart failure, adults,1995/96, Hillingdon 40

Appendix 1. 41Appendix 2. 42Appendix 3. 44


morbiditysupplement

5

ForewordThere is a common belief that a heart attack is a "good way to go". However, this is often far

from the truth. Coronary heart disease (CHD) is not only the single most common cause of

death in the UK but also one of the most important causes of suffering and disability.

This supplement to our main compendium Coronary heart disease statistics brings together all of

the evidence describing how many people develop, or have to live with the consequences of,

coronary heart disease. It also looks at how long people survive after a heart attack or diagnosis

of angina or heart failure. This comprehensive set of estimates shows, for the first time in our

statistical publications, that the amount of prolonged and serious illness caused by CHD is

enormous.

While our main statistics show that mortality from CHD is falling in the UK, the information on

morbidity trends is not so clear. However, morbidity does seem to be increasing substantially in

those over 75 years old. This may be related to the introduction of more effective forms of

treatment for CHD. Consequently, there are many more people who are surviving but suffering

from the disease.

Morbidity data are much less comprehensive and reliable than mortality data so patterns and

trends (and the reasons for those patterns and trends) are much harder to discern. We need

further research into the problem of morbidity from CHD in the UK.

In the meantime we do know from the data reproduced here that morbidity, like mortality, is

higher in Scotland, Northern Ireland and the North of England than in the South of England.

Also, like mortality, it is higher in lower socio-economic groups and in the South Asian

communities. We also know a considerable amount about what forms of prevention, treatment

and rehabilitation would be most likely to reduce the burden of morbidity from CHD and the

unequal distribution of that burden. While awaiting the results of further research we need to

put what we do know into more effective action.

Dr. Vivienne Press

Assistant Medical Director


morbiditysupplement

6

SummaryHeart attack■ In the UK1 there are about 274,000 heart attacks each year, of which around 149,000 are in

men and 125,000 are in women.

● In those aged under 65, there are about 86,000 heart attacks each year (around 66,000 in

men and 20,000 in women).

● In those aged under 75, there are about 104,000 heart attacks each year (around 73,000

in men and 31,000 in women).

■ Currently in the UK1 there are about 1.3 million people who have had a heart attack, of

which around 850,000 are men and 450,000 are women.

● In those aged under 65, there are about 106,000 people who have had a heart attack

(around 79,000 men and 27,000 women).

● In those aged under 75, there are about 400,000 people who have had a heart attack

(around 300,000 men and around 100,000 women).

Angina■ In the UK1 there are about 330,000 new cases of angina each year, of which around 174,000

are in men and 158,000 are in women.

● In those aged under 75, there are about 180,000 new cases of angina each year (around

93,000 in men and 85,000 in women).

■ Currently in the UK1 there are about 2.1 million people who have or have had angina, of

which around 1.1 million are men and 1 million are women.

● In those aged under 75, there are about 700,000 people who have or have had angina

(around 450,000 men and 250,000 women).

Heart failure■ In the UK1 there are about 63,000 new cases of heart failure each year, of which around

33,000 are in men and 30,000 are in women.

■ Currently in the UK1 there are about 760,000 people who have heart failure, of which around

350,000 are men and 410,000 are women.

1 These estimates are derived from applying age-specific rates from selected studies to the UK population estimates for 1999. Forselection criteria see Introduction. See Appendix 3 for UK population estimates.


morbiditysupplement

7

IntroductionAimsThe aim of this supplement is to provide more detailed information on morbidity from coronary

heart disease (CHD) and associated conditions than can be provided in the main compendium -

Coronary heart disease statistics. It is divided into three main sections: myocardial infarction

(heart attack), angina and heart failure. It has one further section called ‘All coronary heart

disease’ because some sources of data on morbidity from CHD do not provide separate data on

myocardial infarction and angina.1

In each main section we have aimed to report upon incidence and prevalence of each disease or

condition by sex, age, socio-economic group and ethnic origin in the UK. We have also aimed to

report upon geographical variations within the UK, international differences and changes over

time. In some few instances we have been able to make comparisons in incidence and prevalence

with other diseases and health-related conditions.

Morbidity has various effects on the individual: in particular it leads to an increased risk of

mortality. Each section provides some data on this direct effect of morbidity.

Morbidity also leads to an increased risk of further diseases and ill health and also to a reduced

quality of life – both physical and mental. We had intended to provide data on these direct effects

of morbidity but have not found enough data from which we could draw general conclusions.

Morbidity also has a variety of indirect effects e.g. in relation to subsequent consultations with a

doctor, admissions to hospital, treatment and rehabilitation. These - particularly hospital

admissions and doctor consultations - are often taken as indicators of incidence and prevalence.

We have included some data on doctor consultations, but only where more direct measures of

incidence and prevalence are not available.

Finally the supplement gives a list of currently agreed performance indicators for morbidity from

CHD and associated conditions (see Appendix 1). The Department of Health is presently consulting

on how such performance indicators might be monitored.

SourcesVarious sources of information relating to morbidity from CHD and associated conditions have

been used in compiling this supplement. The sources used are listed in Appendix 2.

The sources of morbidity data can be divided into: routinely collected national data, national

studies and local studies. Each source has pros and cons. Most sources only provide data on one

or two aspects of morbidity from CHD and related conditions. Not all sources supply data for all

1 National Health Service Information Authority (2000) The Healthcare Frameworks Implementation Pack: Healthcare Frameworkfor Coronary Heart Disease. NHS Information Authority: Winchester, lists the following cardiovascular conditions related to CHD:angina, (controlled, symptomatic and unstable), myocardial infarction (simple and complex), heart block, supraventricular arrhythmia,ventricular arrythmia, acute cardiac breathlessness/pulmonary oedema, heart failure and post-angioplasty/surgical complications.


morbiditysupplement

8

ages or even both sexes. Data are collected in different ways with different degrees of validity

and reliability. Sample sizes of studies vary considerably as do sampling methods.

In compiling this supplement we have aimed to investigate and cite all possible sources of recent

data relating to morbidity from CHD and heart failure in the UK but have presented data, and

calculated UK estimates, only from studies which give the widest coverage in terms of age, sex,

geographical location, etc. and which used valid and reliable methods of data collection.

We have not included data from studies carried out outside of the UK (except when making

international comparisons). There are however various non-UK sources of data which might

provide useful indicators to the likely situation in the UK, for example studies in Framingham

(US), Gothenburg (Sweden), Reyjkavik (Iceland), etc. We have not included data from studies

carried out prior to 1985 (except for time-trend data).

Data from trials of drugs or surgery, have not been included either, because the subjects of such

trials are generally only a selected proportion of the population. We have included baseline data

from one trial of different implementation strategies for promoting secondary prevention of

CHD in general practice - the ASSIST trial – because this study did not involve selection of

particular patients.


morbiditysupplement

9

1. Myocardialinfarction(heart attack)

1.1 IncidenceTable 1.1 shows the results of four surveys of the incidence of myocardial infarction (MI) or

heart attack. It shows that the incidence of heart attack varies around the UK, but that on average

the incidence rate for men aged between 30 and 69 is about 600 per 100,000 and for women it

is about 200 per 100,000.

From these incidence rates we estimate that there are about 66,000 heart attacks per year in men

aged under 65 living in the UK and 20,000 in women giving a total of 86,000.

Table 1.1 also shows that the incidence rate is between 2 and 2.5 times the mortality rate. This

provides a rough way of calculating the number of heart attacks for people aged under 75 and

for people of all ages living in the UK.

Given that about 36,500 men and 15,500 women under the age of 75 die each year from a heart

attack1 we estimate that there are about 73,000 heart attacks in men aged under 75 and 31,000

in women giving a total of 104,000. Given that in total about 74,500 men and 62,500 women of

all ages die each year from a heart attack we estimate that there are about 149,000 heart attacks

in men of all ages and about 125,000 in women giving a total of about 274,000.2

Table 1.1a, with further data from the OXMIS Study, shows that the incidence rate of heart

attack is higher in men than in women and that incidence increases with age.

It is highly likely that incidence rates – like mortality rates - are higher in Scotland, Northern

Ireland and the North of England than in the South of England. Table 1.1 suggests such a trend.

Table 1.1b with the latest data from the MONICA Project suggests that international differences

in the incidence of heart attack parallel international differences in mortality rates. Incidence of

heart attack is higher in MONICA populations in Northern, Central and Eastern Europe than it

is in populations in Southern and Western Europe. The two MONICA populations in the UK –

Belfast and Glasgow - have the two highest incidence rates for women and the second and fourth

highest incidence rates for men (out of a total of 35 MONICA populations). (See also Fig 1.1b(1)

and 1.1b(2).)


morbiditysupplement

10

Table 1.1c shows that most studies indicate that the incidence of heart attack is falling in the UK

– on average by about 2% per year in men and women under the age of 70. Table 1.1c also

shows that the decline in incidence accounts for about half of the decline in mortality.

1.2 PrevalenceTable 1.2 shows that different studies give different estimates for the prevalence of a previous

heart attack. The Health Survey for England and the British Regional Heart Study give higher

prevalence rates than the ASSIST trial or Morbidity Statistics from General Practice. This is

likely to be because of different ways of collecting the data - the Health Survey for England and

the British Regional Heart Study involved asking people whether they recalled having a heart

attack as diagnosed by a doctor whilst the ASSIST trial and Morbidity Statistics from General

Practice data were drawn from GP notes.3 Morbidity Statistics from General Practice gives much

lower estimates of prevalence than all the other studies probably because this study only counts

a case as prevalent if the person attended their GP during the survey year.

The ASSIST trial involved searching through individual patient notes in 18 general practices in

Warwickshire. Assuming the ASSIST trial practice populations were representative of the UK the

ASSIST trial suggests that about 5% men and 1% of women aged 55-65 have had a heart attack.

From these prevalence rates we estimate that there are about 79,000 men aged under 65 living in the

UK who have had a heart attack and about 27,000 women giving a total of about 106,000.

The ASSIST trial also suggests that about 7% men and 2% of women aged 55-75 have had a

heart attack. From these prevalence rates we estimate that there are about 300,000 men aged

under 75 living in the UK who have had a heart attack and about 100,000 women giving a total

of about 400,000.

Table 1.2a, with further data from the Health Survey for England, suggests that about 4% of all

men and 2% of women have had a heart attack. From these prevalence rates we estimate that

there are about 850,000 men living in the UK who have had a heart attack and about 450,000

women giving a total of about 1.3 million.4

Table 1.2a also indicates that prevalence is higher in men than in women and increases with age.

There are only a few studies that have examined the change in the prevalence of heart attack over

time and these studies do not present a clear or complete picture.

It is often stated that prevalence of a previous heart attack must be increasing because case

fatality is falling (see Section 1.3), i.e. with declining case fatality there must be an increasing

number of people who have had a heart attack in the past. However since incidence of heart

attack is also falling, it remains possible that the effect of the decline in incidence outweighs the

effect of the decline in case fatality and that prevalence is falling too.

Table 1.2b, with data from Morbidity Statistics from General Practice, suggests that prevalence

of heart attack – as recorded by GPs - is falling and the decline is greatest in younger age groups.

But as noted above Morbidity Statistics from General Practice only counts a case as prevalent if

the person attended their GP during the survey year.

Table 1.2c, with data from the General Household Survey, suggest that there has been no marked


morbiditysupplement

11

change in rates of self-reported prevalence of ‘longstanding’ heart attack in adults under 75 but

that in adults aged 75 and over this has increased by 35% in men and 30% in women over the

last 10 years. (See also Fig 1.2c.) The difference between the findings of Morbidity Statistics

from General Practice and the General Household Survey is probably because of different ways

of collecting the data.

1.3 PrognosisTable 1.3 shows that all studies indicate that less than half of people who have a heart attack die

within 28 days.

Table 1.3a, with further data from the OXMIS Study, shows that of those who die within 28

days of having a heart attack, three quarters die within the first 24 hours.

British Regional Heart Study data indicate that after 28 days, chances of survival improve but

are still not as good as men who have not had a heart attack. The study found that of 198 men

aged 42-64 who had a heart attack between 1978 and 1985, and who survived for 28 days, 77%

were alive 5 years after their heart attack, and 63% were alive at 10 years. Of men of the same

age without any evidence of CHD, 96% and 91% survived for 5 and 10 years respectively.5,6

Table 1.3b and Table 1.3 show that 28-day case fatality does not routinely vary with sex in the

UK. Table 1.3b, with further data from the OXMIS Study, also shows that 28-day case fatality

increases with age.

Table 1.3 shows that 28-day case fatality varies around the UK but this variation is small.7 In

general it is found that differences between populations in case-fatality are much smaller than

differences in incidence and mortality.8

Table 1.1b, with the latest data from the MONICA Project, shows that case fatality from heart

attack is higher in many populations in Central and Eastern Europe than in most populations in

Northern, Southern and Western Europe. The two UK MONICA populations – Belfast and

Glasgow – have lower case fatality rates than average for MONICA populations.

Table 1.3c shows that 28-day case fatality for heart attack is falling on average by about 1.5%

per year in men and women under about the age of 70 in the UK.

1 Petersen S, Rayner M, Press V (2000) Coronary heart disease statistics. British Heart Foundation: London.

2 Given that case-fatality rises with age (see Section 1.3) it is likely that the incidence: mortality rate ratio is nearer 2 than 2.5. Similarestimates of the numbers of heart attacks can also be calculated from the case-fatality: mortality rate ratio.

3 The British Regional Heart Study team has carried out a study comparing GP notes with patient self-reports and has shown thatabout 33% of patients who recall a doctor-diagnosis of a heart attack will not have a heart attack recorded in their notes. Only 6%of patients will not recall having had a heart attack if a heart attack is recorded in their notes. (Walker MK, Whincup PH, ShaperAG, Lennon LT, Thompson AG (1998) Validation of patient recall of doctor-diagnosed heart attack and stroke: a postal questionnaireand record review comparison. American Journal of Epidemiology 148; 355-361.)

4 We have derived these estimates from the Health Survey for England rather than the ASSIST trial because the former, unlike thelatter, includes people of all ages.

5 Lampe FC, Whincup PH, Wannamathee SG, Shaper AG, Walker M, Ebrahim S (2000) The natural history of prevalent ischaemicheart disease in middle-aged men. European Heart Journal 21; 1052-1062.

6 Lampe FC, on behalf of the British Regional Heart Study team, personal communication.

7 This is also shown by the United Kingdom Heart Attack Study (Norris RM (1998) Fatality outside hospital from acute coronaryevents in three British health districts, 1994-5. British Medical Journal 316; 1065-70).

8 Volmink JA, Newton JN, Hicks NR, Sleight P, Fowler GH, Neil HAW (1998) Coronary event and case fatality rates in an Englishpopulation: results of the Oxford myocardial infarction incidence study. Heart 80; 40-44.


morbiditysupplement

12

Table 1.1 Incidence of myocardial infarction, adults agedbetween 30 and 69, latest available year, UK studiescompared

Source Study Year Place Sex Age group Incidence/ Mortality/ Incidence/100,000 100,000 mortality

Volmink et al, 1998 OXMIS 1994/95 Oxfordshire Men 35-64 273Women 35-64 66

Volmink et al, 1998 OXMIS 1994/95 Oxfordshire Men 30-69 292 120 2.43Women 30-69 94 44 2.14

Tunstall-Pedoe et al, 1999 MONICA 1985/94 Glasgow Men 35-64 777 365 2.13Women 35-64 265 123 2.15

Tunstall-Pedoe et al, 1999 MONICA 1983/93 Belfast Men 35-64 695 279 2.49Women 35-64 188 79 2.38

Lampe et al, 2000 BRHS 1983/95 Great Britain Men 45-59* 950 426 2.23

* at start of follow up (1983/85)

Some rates were age-standardised. See sources for methods of age-standardisation and definitions of MI.

Sources: Volmink JA, Newton JN, Hicks NR, Sleight P, Fowler GH, Neil HAW, on behalf of the Oxford Myocardial Infarction Incidence StudyGroup (1998) Coronary event and case fatality rates in an English population: results of the Oxford myocardial infarction incidencestudy. Heart 80; 40-44;

Tunstall-Pedoe H, Kuulasmaa K, Mahonen M, Tolonen H, Ruokokoski E, Amouyel P, for the WHO MONICA Project (1999).Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10 year results from 37WHO MONICA Project populations. Lancet 353; 1547-1557;

Lame FC, Whincup PH, Wannamathee SG, Shaper AG, Walker M, Ebrahim S (2000) Tha natural history of prevalent ischaemic heartdisease in middle-aged men. European Heart Journal 21; 1052-1062.

Table 1.1a Incidence of myocardial infarction, adults aged lessthan 80, by sex and age, 1994/95, Oxfordshire

Age group Population Number of Incidence /events 100,000

MEN

<35 155283 5 3.235-49 62321 58 93.150-64 43378 226 521.065-79 27230 388 1424.9

WOMEN

<35 143283 0 0.035-49 60339 8 13.350-64 43599 61 140.065-79 33218 249 749.6

Non-fatal and fatal definite MI, fatal possible MI and unclassifiable coronary deaths (MONICA definition 1).

Source: Volmink JA, Newton JN, Hicks NR, Sleight P, Fowler GH, Neil HAW, on behalf of the Oxford Myocardial Infarction Incidence StudyGroup (1998) Coronary event and case fatality rates in an English population: results of the Oxford myocardial infarction incidencestudy. Heart 80; 40-44.


morbiditysupplement

13

Tabl

e 1.

1bC

oron

ary

even

t ra

tes,

cor

onar

y ca

se f

atal

ity,

annu

al c

hang

e in

cor

onar

y ev

ent

rate

s an

d an

nual

cha

nge

inco

rona

ry c

ase

fata

lity,

adu

lts a

ged

35-6

4, b

y se

x, la

test

ava

ilabl

e da

ta, M

ON

ICA

Pro

ject

pop

ulat

ions

MEN

WO

MEN

Cor

onar

y ev

ent

Cor

onar

y ca

sex

Ann

ual c

hang

e in

Ann

ual c

hang

e in

Cor

onar

y ev

ent

Cor

onar

y ca

seA

nnua

l cha

nge

inA

nnua

l cha

nge

inra

tera

teco

rona

ry e

vent

coro

nary

cas

e r

ate

fata

lity

coro

nary

eve

ntco

rona

ry c

ase

Even

ts%

of f

atal

ities

rat

e fa

talit

yEv

ents

% o

f fat

aliti

es r

ate

fata

lity

per

100,

000

with

in 2

8 da

ys%

%pe

r 10

0,00

0w

ithin

28

days

%%

MO

NIC

A p

opul

atio

nM

ON

ICA

Surv

ey y

ears

popu

latio

n co

de

Aus

tral

ia-N

ewca

stle

AU

S-N

EW19

85/9

347

940

.6-5

.1-2

.215

340

.9-5

.6-3

.0A

ustr

alia

-Per

thA

US-

PER

1984

/93

389

36.8

-3.1

-1.5

9241

.7-2

.2-2

.3Be

lgiu

m-C

harl

eroi

BEL-

CH

A19

83/9

248

750

.10.

3-1

.811

859

.31.

1-1

.8Be

lgiu

m-G

hent

BEL-

GH

E19

83/9

234

647

.4-3

.2-1

.677

58.0

-3.0

-1.8

Can

ada-

Hal

ifax

Cou

nty

CA

N-H

AL

1984

/93

523

37.5

-4.7

-1.5

139

33.6

0.5

-4.6

Chi

na-B

eijin

gC

HN

-BEI

1984

/93

8158

.82.

31.

135

73.6

-0.5

1.3

Cze

ch R

epub

licC

ZE-

CZ

E19

84/9

351

552

.8-0

.40.

710

153

.92.

1-1

.2D

enm

ark-

Glo

stru

pD

EN-G

LO19

82/9

151

752

.5-4

.21.

514

058

.0-2

.52.

5Fi

nlan

d-K

uopi

o Pr

ovin

ceFI

N-K

UO

1983

/92

718

45.7

-6.0

1.0

124

38.7

-4.5

1.0

Finl

and-

Nor

th K

arel

iaFI

N-N

KA

1983

/92

835

48.1

-6.5

-0.5

145

41.3

-5.1

-0.2

Finl

and-

Turk

u/Lo

imaa

FIN

-TU

L19

83/9

254

948

.5-4

.2-0

.294

48.9

-4.5

-1.9

Fran

ce-L

ille

FRA

-LIL

1985

/94

298

58.7

-1.1

-0.3

6469

.5-1

.60.

8Fr

ance

-Str

asbo

urg

FRA

-ST

R19

85/9

329

249

.0-3

.9-1

.764

57.1

-6.6

-2.3

Fran

ce-T

oulo

use

FRA

-TO

U19

85/9

323

340

.0-2

.1-3

.836

59.8

-1.7

-3.6

Ger

man

y-A

ugsb

urg

GER

-AU

G19

85/9

428

655

.1-3

.21.

363

64.6

0.9

-0.4

Ger

man

y-Br

emen

GER

-BR

E19

85/9

236

149

.6-3

.4-0

.981

52.0

0.7

-2.9

Ger

man

y-Ea

st G

erm

any

GER

-EG

E19

85/9

337

050

.0-0

.51.

778

62.8

2.5

-2.2

Icel

and

ICE-

ICE

1981

/94

486

36.9

-4.7

-2.1

9934

.1-3

.7-1

.0It

aly-

Are

a Br

ianz

aIT

A-B

RI

1985

/94

279

40.7

-2.3

-0.8

4252

.5-3

.5-4

.8It

aly-

Friu

liIT

A-F

RI

1984

/93

253

45.1

-0.9

-2.0

4749

.9-0

.8-2

.0Li

thua

nia-

Kau

nas

LTU

-KA

U19

83/9

249

854

.81.

21.

080

53.7

2.7

-1.2

New

Zea

land

-Auc

klan

dN

EZ-A

UC

1983

/91

434

49.5

-5.1

-0.6

115

51.4

-3.5

0.6

Pola

nd-T

arno

brze

g Vo

void

ship

POL-

TAR

1984

/93

461

82.7

1.1

1.2

110

88.4

-0.1

-0.7

Pola

nd-W

arsa

wPO

L-W

AR

1984

/94

586

59.9

-0.8

-0.4

153

59.2

1.0

-2.1

Rus

sia-

Mos

cow

(con

trol

)R

US-

MO

C19

85/9

347

760

.7-1

.03.

092

60.2

-6.7

1.5

Rus

sia-

Nov

osib

irsk

(con

trol

)R

US-

NO

C19

84/9

246

459

.90.

9-0

.111

166

.52.

30.

3Sp

ain-

Cat

alon

iaSP

A-C

AT19

85/9

421

036

.71.

8-1

.735

45.5

2.0

1.5

Swed

en-G

othe

nbur

gSW

E-G

OT

1984

/94

363

43.6

-4.2

0.3

8445

.4-3

.71.

2Sw

eden

-Nor

ther

n Sw

eden

SWE-

NSW

1985

/95

509

36.1

-5.1

-2.9

119

34.4

-2.4

0.4

Switz

erla

nd-T

icin

oSW

I-T

IC19

85/9

329

033

.5-2

.6-4

.2Sw

itzer

land

-Vau

d/Fr

ibou

rgSW

I-VA

F19

85/9

323

138

.4-3

.6-3

.0U

nite

d K

ingd

om-B

elfa

stU

NK

-BEL

1983

/93

695

41.0

-4.6

-1.5

188

41.5

-2.4

-1.7

Uni

ted

Kin

gdom

-Gla

sgow

UN

K-G

LA19

85/9

477

748

.2-1

.4-1

.326

546

.40.

2-2

.1U

nite

d St

ates

-Sta

nfor

dU

SA-S

TA19

80/9

243

147

.9-4

.2-1

.613

453

.7-2

.4-0

.4Yu

gosl

avia

-Nov

i Sad

YU

G-N

OS

1984

/95

422

51.9

0.4

-0.4

101

49.9

2.8

0.5

Rat

es a

re fo

r M

ON

ICA

eve

nt d

efin

ition

1 w

hich

incl

udes

fata

l def

inite

MI,

fata

l pos

sibl

e M

I, u

ncla

ssifi

able

dea

th a

nd n

onfa

tal d

efin

ite M

I. A

ge-s

tand

ardi

sed

rate

s: s

ee s

ourc

e fo

r de

tails

and

how

tren

ds w

ere

calc

ulat

ed.

Sour

ce:

Tuns

tall-

Pedo

e H

, Kuu

lasm

aa K

, Mah

onen

M, T

olon

en H

, Ruo

koko

ski E

, Am

ouye

l P, f

or th

e W

HO

MO

NIC

A P

r oje

ct (1

999)

. Con

trib

utio

n of

tren

ds in

sur

viva

l and

cor

onar

y-ev

ent r

ates

to c

hang

es in

cor

onar

y he

art d

isea

se m

orta

lity:

10

year

res

ults

from

37

WH

O M

ON

ICA

Pro

ject

pop

ulat

ions

. Lan

cet 3

53; 1

547-

1557

.


morbiditysupplement

14

Fig 1.1b (2) Age-standardised coronary event rates, womenaged 34-65, latest available data, MONICAProject populations

Fig 1.1b(1) Age-standardised coronary event rates, menaged 35-64, latest available data, MONICAProject populations

0

100

200

300

400

500

600

700

800

900

Fin

lan

d-N

ort

h K

arel

ia

Un

ited

Kin

gd

om

-Gla

sgo

w

Fin

lan

d-K

uo

pio

Pro

vin

ce

Un

ited

Kin

gd

om

-Bel

fast

Pola

nd

-War

saw

Fin

lan

d-T

urk

u/L

oim

aa

Can

ada

Den

mar

k-G

lost

rup

Cze

ch R

epu

blic

Swed

en-N

ort

her

n S

wed

en

Lith

uan

ia-K

aun

as

Bel

giu

m-C

har

lero

i

Icel

and

Au

stra

lia-N

ewca

stle

Russ

ia-M

osc

ow

(co

ntr

ol)

Russ

ia-N

ovo

sib

irsk

(co

ntr

ol)

Pola

nd

-Tar

no

brz

eg V

ovo

idsh

ip

New

Zea

lan

d-A

uck

lan

d

Un

ited

Sta

tes-

Stan

ford

Yu

go

slav

ia-N

ovi

Sad

Au

stra

lia-P

erth

Ger

man

y-Ea

st G

erm

any

Swed

en-G

oth

enb

urg

Ger

man

y-B

rem

en

Bel

giu

m-G

hen

t

Fran

ce-L

ille

Fran

ce-S

tras

bo

urg

Swit

zerl

and

-Tic

ino

Ger

man

y-A

ug

sbu

rg

Ital

y-A

rea

Bri

anza

Ital

y-Fr

iuli

Fran

ce-T

ou

lou

se

Swit

zerl

and

-Vau

d/F

rib

ou

rg

Spai

n-C

atal

on

ia

Ch

ina-

Bei

jing

MONICA population

Co

ron

ary

even

t ra

te p

er 1

00

,00

0 p

op

ula

tio

n

0

50

100

150

200

250

300

Un

ited

Kin

gd

om

-Gla

sgo

w

Un

ited

Kin

gd

om

-Bel

fast

Au

stra

lia-N

ewca

stle

Pola

nd

-War

saw

Fin

lan

d-N

ort

h K

arel

ia

Den

mar

k-G

lost

rup

Can

ada

Un

ited

Sta

tes-

Stan

ford

Fin

lan

d-K

uo

pio

Pro

vin

ce

Swed

en-N

ort

her

n S

wed

en

Bel

giu

m-C

har

lero

i

New

Zea

lan

d-A

uck

lan

d

Russ

ia-N

ovo

sib

irsk

(co

ntr

ol)

Pola

nd

-Tar

no

brz

eg V

ovo

idsh

ip

Cze

ch R

epu

blic

Yu

go

slav

ia-N

ovi

Sad

Icel

and

Fin

lan

d-T

urk

u/L

oim

aa

Au

stra

lia-P

erth

Russ

ia-M

osc

ow

(co

ntr

ol)

Swed

en-G

oth

enb

urg

Ger

man

y-B

rem

en

Lith

uan

ia-K

aun

as

Ger

man

y-Ea

st G

erm

any

Bel

giu

m-G

hen

t

Fran

ce-L

ille

Fran

ce-S

tras

bo

urg

Ger

man

y-A

ug

sbu

rg

Ital

y-Fr

iuli

Ital

y-A

rea

Bri

anza

Fran

ce-T

ou

lou

se

Ch

ina-

Bei

jing

Spai

n-C

atal

on

ia

Co

ron

ary

even

t ra

te p

er 1

00

,00

0 p

op

ula

tio

n

MONICA population


morbiditysupplement

15

Tabl

e 1.

1cC

hang

e in

inc

iden

ce o

f m

yoca

rdia

l in

farc

tion,

adu

lts a

ged

betw

een

30 a

nd 7

5,be

twee

n 19

66 a

nd 1

996,

UK

stu

dies

com

pare

d

Sour

ceSt

udy

Year

sPl

ace

Sex

Age

gro

up%

cha

nge

in in

cide

nt%

cha

nge

in m

orta

lity

% c

hang

e in

inci

dent

rat

e/ra

te p

er y

ear

rat

e pe

r ye

ar%

cha

nge

in m

orta

lity

rate

Volm

ink

et a

l, 19

98O

XM

IS19

66/6

7 - 1

994/

95O

xfor

dshi

reM

en30

-69

-1.2

-1.8

0.66

Wom

en30

-69

-0.3

-1.3

0.22

Tuns

tall-

Pedo

e et

al,

1999

MO

NIC

A19

85 -

1994

Gla

sgow

Men

35-6

4-1

.4-2

.60.

54W

omen

35-6

40.

2-2

.0-0

.10

Tuns

tall-

Pedo

e et

al,

1999

MO

NIC

A19

83 -

1993

Belfa

stM

en35

-64

-4.6

-6.0

0.77

Wom

en35

-64

-2.4

-3.9

0.62

Lam

pe e

t al,

2000

BRH

S19

78 -

1996

Gre

at B

rita

inM

en40

-75

-2.5

-4.2

0.60

Sour

ces:

Vol

min

k JA

, New

ton

JN, H

icks

NR

, Sle

ight

P, F

owle

r G

H, N

eil H

AW, o

n be

half

of th

e O

xfor

d M

yoca

rdia

l Inf

arct

ion

Inci

denc

e St

udy

Gro

up (1

998)

Cor

onar

y ev

ent a

nd c

ase

fata

lity

rate

s in

an

Eng

lish

popu

latio

n: r

esul

ts o

f the

Oxf

ord

myo

card

ial i

nfar

ctio

n in

cide

nce

stud

y. H

eart

80;

40-

44;

Tuns

tall-

Pedo

e H

, Kuu

lasm

aa K

, Mah

onen

M, T

olon

en H

, Ruo

koko

ski E

, Am

ouye

l P, f

or th

e W

HO

MO

NIC

A P

roje

ct (1

999)

. Con

trib

utio

n of

tren

ds in

sur

viva

l and

cor

onar

y-ev

ent r

ates

to c

hang

es in

coro

nary

hea

rt d

isea

se m

orta

lity:

10

year

res

ults

from

37

WH

O M

ON

ICA

Pro

ject

pop

ulat

ions

. Lan

cet 3

53; 1

547-

1557

;

Lam

pe F

C, M

orri

s RW

, Whi

ncup

PH

, Wal

ker

M, E

brah

im S

, Sha

per

AG

(200

0) I

s th

e pr

eval

ence

of c

oron

ary

hear

t dis

ease

falli

ng in

Bri

tish

men

? T

he B

ritis

h R

egio

nal H

eart

Stu

dy, 1

978

to 1

996.

Pos

ter

at C

ardi

ovas

cula

r D

isea

se P

reve

ntio

n V

con

fere

nce,

4th

-7th

Apr

il, K

ensi

ngto

n T o

wn

Hal

l, L

ondo

n.


morbiditysupplement

16

Tabl

e 1.

2Pr

eval

ence

of

myo

card

ial

infa

rctio

n, a

dults

age

d be

twee

n 55

and

74*

, la

test

avai

labl

e ye

ar, U

K s

tudi

es c

ompa

red

MEN

WO

MEN

Sour

ceSt

udy

Year

Plac

e55

-64

65-7

455

-64

65-7

4%

%%

%

Join

t Hea

lth S

urve

ys U

nit,

1999

HSE

1998

Engl

and

8.4

11.6

2.4

5.5

Pers

onal

com

mun

icat

ion

ASS

IST

1997

/98

War

wic

kshi

re4.

77.

80.

92.

7

Roy

al C

olle

ge o

f Gen

eral

Pra

ctiti

oner

s et

al,

1995

Mor

bidi

ty S

tatis

tics

from

Gen

eral

Pra

ctic

e19

91/9

2En

glan

d an

d W

ales

0.7*

*1.

60.

2**

0.7

Pers

onal

com

mun

icat

ion

BRH

S19

92G

reat

Bri

tain

8.0

13.1

*D

ata

from

the

4th

Nat

iona

l Stu

dy o

f Mor

bidi

ty S

tatis

tics

from

Gen

eral

Pra

ctic

e is

for

adul

ts a

ged

betw

een

45 a

nd 7

4.**

for

thos

e ag

ed 4

5-64

.

Sour

ces:

Join

t Hea

lth S

urve

ys U

nit (

1999

) Hea

lth S

urve

y fo

r E

ngla

nd 1

998.

The

Sta

tione

ry O

ffic

e: L

ondo

n;

M M

oher

on

beha

lf of

the

ASS

IST

tria

l tea

m, D

epar

tmen

t of P

rim

ary

Hea

lth C

are,

Uni

vers

ity o

f Oxf

ord,

per

sona

l com

mun

icat

ion;

Roy

al C

olle

ge o

f G

ener

al P

ract

ition

ers,

the

Off

ice

of P

opul

atio

n C

ensu

ses

and

Surv

eys

and

the

Dep

artm

ent

of H

ealth

(19

95)

Mor

bidi

ty S

tatis

tics

from

Gen

eral

Pra

ctic

e,Fo

urth

Nat

iona

l Stu

dy 1

991-

1992

. HM

SO: L

ondo

n;

F L

ampe

on

beha

lf of

the B

RH

S te

am, D

epar

tmen

t of P

rim

ary

Car

e and

Pop

ulat

ion

Scie

nces

, Roy

al F

ree a

nd U

nive

rsity

Col

lege

Med

ical

Sch

ool,

Lon

don,

per

sona

l com

mun

icat

ion.

Oth

er s

ourc

e of

pre

vale

nce

data

:Sm

ith W

C, K

enic

er M

B, T

unst

all-P

edoe

H, C

lark

EC

, Cro

mbi

e IK

(199

0) P

reva

lenc

e of

cor

onar

y he

art d

isea

se in

Sco

tland

: Sco

ttis

h H

eart

Hea

lth S

tudy

. Bri

tish

Hea

rt Jo

urna

l64

; 295

-298

.


morbiditysupplement

17

Table 1.2a Percentage who report experience of myocardialinfarction (ever and recently), by sex and age, 1998,England

All ages 16-24 25-34 35-44 45-54 55-64 65-74 75 & over% % % % % % % %

MEN

Ever experienced 4.2 0.1 0.2 0.5 2.7 8.4 11.6 13.5Recently experienced 0.6 0.1 0.0 0.2 0.5 0.8 1.8 1.2(in last 12 months)

Base 7193 875 1338 1305 1289 987 837 562

WOMEN

Ever experienced 1.8 0.0 0.1 0.3 0.8 2.4 5.5 6.5Recently experienced 0.3 0.0 0.0 0.0 0.1 0.7 1.0 0.8(in last 12 months)

Base 8715 1006 1630 1573 1484 1148 967 907

Source: Joint Health Surveys Unit (1999) Health Survey for England 1998. The Stationery Office: London.

Table 1.2b Prevalence of myocardial infarction by sex and age,1981/82 and 1991/92, England and Wales

All ages 15-24 25-44 45-64 65-74 75 & over% % % % % %

MEN 1981 / 82 0.55 0.00 0.16 1.17 1.99 2.241991 / 92 0.38 0.00 0.06 0.73 1.58 1.86

Change -31% - -63% -38% -21% -17%

WOMEN 1981 / 82 0.29 0.00 0.03 0.38 1.11 1.281991 / 92 0.20 0.00 0.01 0.20 0.71 1.18

Change -31% - -67% -47% -34% -8%

ICD (9th Revision) code 410.

Source: Royal College of General Practitioners, the Office of Population Censuses and Surveys, and the Department of Health (1995) Morbidity Statisticsfrom General Practice, Fourth National Study, 1991-1992. HMSO: London.


morbiditysupplement

18

Table 1.2c Prevalence of self-reported longstanding heartattack, adults aged 16 years and above by sexand age, 1988-1998, Great Britain

All ages 16-44 45-64 65-74 75 & over% % % % %

MEN 1988 2.2 0.2 4.7 7.5 8.21989 2.3 0.2 4.6 10.0 7.91994 2.3 0.1 3.1 6.6 8.11995 2.5 0.1 3.4 9.2 5.41996 2.3 0.1 3.0 6.6 7.51998 3.2 0.3 4.0 8.9 11.1

WOMEN 1988 1.7 0.1 2.0 6.7 6.61989 1.7 0.1 2.4 6.4 6.51994 2.1 0.1 2.0 5.9 7.31995 1.8 0.1 1.7 4.5 7.31996 2.4 0.1 2.8 6.5 8.31998 2.2 0.0 1.8 6.5 8.6

Source: Office for National Statistics (2000) Living in Britain. Results from the 1998 General Household Survey. The StationeryOffice: London and previous editions.

Fig 1.2c Prevalence of self-reported longstanding heartattack by sex, for all ages and for under 75 years,1988-1998, Great Britian

0

2

4

6

8

10

12

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998Year

%

Men: all ages

Men: 75 & over

Women: all ages

Women: 75 & over


morbiditysupplement

19

Table 1.3 28-day case fatality for myocardial infarction, adults,latest available year, UK studies compared

Source Study Year Place Sex Age group % of fatalities within 28 days

Volmink et al, 1998 OXMIS 1994/95 Oxfordshire Men 30-69 41Women 30-69 44

Norris, 1998* UKHAS 1994/95 UK Men <75 44Women <75 47

Tunstall-Pedoe et al, 1999 MONICA 1985/94 Glasgow Men 35-64 48Women 35-64 46

Tunstall Pedoe et al, 1999 MONICA 1983/93 Belfast Men 35-64 41Women 35-64 42

Lampe et al, 2000 BRHS 1978/95 Great Britain Men 40-59** 41

* 30 days rather than 28 days;** in 1978-80.

Sources: Volmink JA, Newton JN, Hicks NR, Sleight P, Fowler GH, Neil HAW, on behalf of the Oxford Myocardial Infarction Incidence Study Group (1998)Coronary event and case fatality rates in an English population: results of the Oxford myocardial infarction incidence study. Heart 80; 40-44;

Norris RM on behalf of the United Kingdom Heart Attack Study Collaborative Group (1998) Fatality outside hospital from acute coronary eventsin three British health districts, 1994-5. British Medical Journal 31; 1065-1070;

Tunstall-Pedoe H, Kuulasmaa K, Mahonen M, Tolonen H, Ruokokoski E, Amouyel P, for the WHO MONICA Project (1999). Contribution oftrends in survival and coronary-event rates to changes in coronary heart diseasemortality: 10 year results from 37 WHO MONICA Projectpopulations. Lancet 353; 1547-1557;

Lampe FC, Morris RW, Whincup PH, Walker M, Ebrahim S, Shaper AG (2000) Is the prevalence of coronary heart disease falling in British men?The British Regional Heart Study, 1978 to 1996. Poster at Cardiovascular Disease Prevention V conference, 4th-7th April, Kensington TownHall, London.

Table 1.3a Survival after a myocardial infarction, adults aged lessthan 80, 1994/95, Oxfordshire

Number Percentage

All with initial heart attack 995 100%

Survive for longer than 24 hours 603 61%

Survive for longer than 28 days 476 48%

Source: Volmink JA (1996) The Oxford Myocardial Infarction Incidence Study. DPhil Thesis. University of Oxford.

Table 1.3b 28-day case fatality for myocardial infraction, adults aged35-79, by sex and age, 1994/95, Oxfordshire

Age group Population Number of events % of fatalities within 28 days

MEN

35-49 62321 20 34.550-64 43378 90 39.865-79 27230 225 58.0

35-79 132929 335 49.5

WOMEN

35-49 60339 2 25.050-64 43599 23 37.765-79 33218 159 63.9

35-79 137156 184 57.9

Non-fatal and fatal definite MI, fatal possible MI and unclassifiable coronary deaths (MONICA definition 1).

Source: Volmink JA (1996) The Oxford Myocardial Infarction Incidence Study. DPhil Thesis. University of Oxford.


morbiditysupplement

20

Tabl

e 1.

3cC

hang

e in

28-

day

case

fat

ality

for

myo

card

ial i

nfar

ctio

n, a

dults

age

d be

twee

n30

and

69,

bet

wee

n 19

66 a

nd 1

995,

UK

stu

dies

com

pare

d

Sour

ceSt

udy

Year

sPl

ace

Sex

Age

gro

up%

cha

nge

in 2

8-da

y ca

sefa

talit

y ra

te p

er y

ear

Volm

ink

et a

l, 19

98O

XM

IS19

66/6

7 - 1

994/

95O

xfor

dshi

reM

en30

-69

-1.0

Wom

en30

-69

-1.1

Tuns

tall-

Pedo

e et

al,

1999

MO

NIC

A19

85 -1

994

Gla

sgow

Men

35-6

4-1

.3W

omen

35-6

4-2

.1

Tuns

tall-

Pedo

e et

al,

1999

MO

NIC

A19

78 -1

9996

Belfa

stM

en35

-64

-1.5

Wom

en35

-64

-1.7

Sour

ces:

Vol

min

k JA

, New

ton

JN, H

icks

NR

, Sle

ight

P, F

owle

r G

H, N

eil H

AW o

n be

half

of t

he O

xfor

d M

yoca

rdia

l Inf

arct

ion

Inci

denc

e St

udy

Gro

up (

1998

) C

oron

ary

even

t an

d ca

se f

atal

ity r

ates

in a

nE

nglis

h po

pula

tion:

res

ults

of t

he O

xfor

d m

yoca

rdia

l inf

arct

ion

inci

denc

e st

udy.

Hea

rt 8

0; 4

0-44

;

Tuns

tall-

Pedo

e H

, Kuu

lasm

aa K

, Mah

onen

M, T

olon

en H

, Ruo

koko

ski E

, Am

ouye

l P, f

or th

e W

HO

MO

NIC

A P

roje

ct (1

999)

Con

trib

utio

n of

tren

ds in

surv

ival

and

cor

onar

y-ev

ent r

ates

to c

hang

esin

cor

onar

y he

art d

isea

se m

orta

lity:

10-

year

res

ults

from

37

MO

NIC

A P

roje

ct p

opul

atio

ns. L

ance

t 353

; 154

7-15

57.


morbiditysupplement

21

2. AnginaThis section, unless otherwise specified, provides statistics in relation to diagnosed angina (either

from studies which asked people whether they recalled a diagnosis of angina or which relied

upon a diagnosis of angina recorded in a doctor’s notes). It is likely that many cases of angina

remain undiagnosed. In the British Regional Heart Study about 4% of men aged 52-75 had

symptoms indicative of angina1 but no recall of a diagnosis of angina and no diagnosis of angina

recorded in their notes indicating that up to a third of angina could be undiagnosed.2 Men who

have symptoms of angina but no diagnosis of angina recorded in their notes – like those with

diagnosed angina – are at increased risk of heart attack and stroke.3

2.1 IncidenceTable 2.1 shows that different studies give different estimates of the incidence of angina. The

Southampton Chest Pain Clinic Study gives much lower figures for the incidence of angina than

the other two studies - Morbidity Statistics from General Practice and a study of the practice

population of one general practice in Oxford.

It is likely that the Southampton Chest Pain Clinic Study definition of angina was more technically

accurate than that of the GPs involved in the Morbidity Statistics from General Practice study or

the Oxford study. (The Southampton Chest Pain Clinic Study involved assessing patients with

chest pain, which in their GP’s opinion could be stable angina, but only 24% were found to have

angina as defined by the study.) On the other hand it is not clear that GPs involved in the

Southampton Chest Pain Clinic Study referred all their patients with angina to the clinic carrying

out the study so the study’s estimates of incidence are probably conservative. The Oxford study,

unlike Morbidity Statistics from General Practice, did not rely on a single diagnosis of angina by

the GPs, but confirmed the diagnosis with a second opinion.

The Oxford study indicates that the incidence rate for men aged 45-74 is about 1043 per 100,000

and for women it is about 903 per 100,000. From these incidence rates we estimate that there

are about 93,000 new cases of angina in men aged under 75 living in the UK and about 85,000

in women giving a total of about 180,000. Equivalent estimates derived from incidence rates

from Morbidity Statistics from General Practice are very similar.

Using data from Morbidity Statistics from General Practice we estimate that there are about

174,0000 new cases of angina in all men living in the UK and about 158,000 in women giving a

total of about 330,000.4

Table 2.1 also shows that incidence of angina is higher in men than in women and increases with age.

Note that the incident rates for angina are similar to the incidence rates for heart attack (Table 1.1).

2.2 PrevalenceTable 2.2 shows the Health Survey for England, the British Regional Heart Study, the Oxford

study and the ASSIST trial all give similar prevalence rates for angina. It seems that differences

between these studies in the methods of data collection have less effect on the estimates of

prevalence of angina than they do with heart attack.5 As with the estimates of prevalence of


morbiditysupplement

22

heart attack, Morbidity Statistics from General Practice give much lower estimates of prevalence

of angina than other studies, probably because this study only counts a case as prevalent if the

person attended their GP during the survey year.

Table 2.2 indicates that the ASSIST trial suggests that about 9% of men and 4% of women aged

55-75 have angina. From these prevalence rates we estimate that there are about 450,000 men

aged under 75 living in the UK who have had angina and about 250,000 women giving a total of

about 700,000.

Table 2.2a, with further data from the Health Survey for England, shows that about 5% of men

and 4% of women have or have had angina. From the prevalence rates in this table we estimate

that there are about 1.1 million men living in the UK who have or have had angina and about 1

million women giving a total of about 2.1 million.6

Table 2.2a also shows that the prevalence of angina is higher in men than in women but that the

difference declines with age so that the prevalence of angina in women aged 75 and over is nearly

the same as that in men (17% and 18% respectively).

As with heart attack there are only a few studies which have examined the change in the prevalence

of angina over time and these studies do not present a clear or complete picture.

Table 2.2b, with data from Morbidity Statistics from General Practice, suggests an increase in the

prevalence of angina in all age groups. This may reflect a real increase in prevalence or it might just

reflect an increase in the number of people with angina who attend their GP on a regular basis.

In contrast to Morbidity Statistics from General Practice, the British Regional Heart Study, shows

a recent fall in the prevalence of angina symptoms (in this case as measured by chest pain

questionnaire) in men aged 50-64 (Table 2.2c). But of course this does not preclude an increase

in the prevalence of angina symptoms in older age groups.

2.3 PrognosisThere have been few studies which have followed-up angina cases arising in the population.

The British Regional Heart Study found that of 157 men aged 42-65 who were diagnosed with

angina between 1978 and 1985, and had no history of heart attack, 89% were alive 5 years after

the diagnosis, and 73% were alive at 10 years. Of men of the same age without any evidence of

CHD, 96% and 91% survived for 5 and 10 years respectively.7,8

1 As measured by the Rose Questionnaire and as defined using standard criteria.

2 Lampe FC, Walker M, Lennon LT, Whincup PH, Ebrahim S (1999) Validity of a self-reported history of doctor-diagnosed angina.Journal of Clinical Epidemiology 52; 73-81.


4 The Oxford study did not include people over 75 so cannot be used to derive estimates of the total number of new cases in the wholepopulation.

5 The British Regional Heart Study has shown that 30% of patients who recall a doctor-diagnosis of angina will not have anginarecorded in their notes and that 20% of patients will not recall having a diagnosis of angina recorded in their notes. (Lampe FC,Walker M, Lennon LT, Whincup PH, Ebrahim S (1999) Validity of a self-reported history of doctor-diagnosed angina. Journal ofClinical Epidemiology 52; 73-81.)

6 These estimates are higher than our previous estimates (e.g. Petersen S, Rayner M, Press V (2000) Coronary heart disease statistics.British Heart Foundation: London) because here we are estimating prevalence from the numbers of people who report ever havinghad angina rather than from the numbers of people who report having angina in the last 12 months. Some people who have hadangina in the past will not have had angina recently because their angina is controlled with drugs.

7 FC Lampe on behalf of the British Regional Heart Study team, personal communication.

8 Other sources of data on prognosis:Gandhi MM, Lampe FC, Wood DA (1995) Incidence, clinical characteristics, and short-term prognosis of angina pectoris. BritishHeart Journal 73; 193-198;Clarke KW, Gray D, Hampton JR (1994) Implication of prescriptions for nitrates: 7 year follow up of patients treated for angina ingeneral practice. Heart 71; 38-40.


morbiditysupplement

23

Table 2.1 Incidence of angina in adults, latest available year, UK studiescompared

Source Study Year Place Sex Age group Incidence/100,000

Ghandi et al, 1995 Southampton Chest Pain Clinic Study 1990/92 Southampton Men 31-40 4041-50 6351-60 14761-70 262

Total 113

Women 31-40 641-50 4751-60 8561-70 91

Total 53

Gill et al, 1999 One general practice in Oxford 1989/91 Oxford Men 45-54 83055-64 135365-74 930

Total 1043

Women 45-54 64355-64 125765-74 827

Total 903

Royal College of General Morbidity Statistics from 1991/92 England and Wales Men <25 0Practitioners et al, 1995 General Practice 25-44 90

45-64 108065-74 225075-84 2730

>85 2020

Total 550

Women <25 025-44 4045-64 66065-74 176075-84 2240

>85 2150

Total 490

Total population for Southampton Chest Pain Clinic Study was 191,677; total number of cases were 110 (70 for men and 40 for women);Total population for Oxford study was 1984; total number of cases was 58 (31 for men, 27 for women).

Sources: Ghandhi MM, Lampe FA, Wood DA (1995) Incidence, clinical characteristics, and short term prognosis of angina pectoris. British Heart Journal; 73; 193-198;

Gill D, Mayou R, Dawes M and Mant D (1999) Presentation, management and course of angina and suspected angina in primary care. Journal of PsychosomaticResearch; 46; 349-358;

Royal College of General Practitioners, the Office of Population Censuses and Surveys and the Department of Health (1995) Morbidity Statistics from GeneralPractice, Fourth National Study 1991-1992. HMSO: London.


morbiditysupplement

24

Tabl

e 2.

2Pr

eval

ence

of a

ngin

a, a

dults

age

d be

twee

n 55

and

74*

, lat

est a

vaila

ble

year

, UK

stud

ies c

ompa

red

MEN

WO

MEN

Sour

ceSt

udy

Year

Plac

e55

-64

65-7

455

-64

65-7

4

Join

t Hea

lth S

urve

ys U

nit,

1999

HSE

1998

Engl

and

10.5

15.6

5.5

9.9

Pers

onal

com

mun

icat

ion

ASS

IST

1997

/98

War

wic

kshi

re6.

511

.52.

56.

2

Roy

al C

olle

ge o

f Gen

eral

Pra

ctiti

oner

s et

al,

1995

Mor

bidi

ty S

tatis

tics

from

Gen

eral

Pra

ctic

e19

91/9

2En

glan

d an

d W

ales

2.6*

*5.

81.

3**

3.6

Gill

et a

l, 19

99O

ne g

ener

al p

ract

ice

in O

xfor

d19

91O

xfor

d10

.413

.66.

17.

4

Pers

onal

com

mun

icat

ion

BRH

S19

92G

reat

Bri

tain

9.2

16.2

*D

ata

from

Mor

bidi

ty S

tatis

tics

from

Gen

eral

Pra

ctic

e is

for

adul

ts a

ged

betw

een

45 a

nd 7

4;**

for

thos

e ag

ed 4

5-64

.

Sour

ces:

Join

t Hea

lth S

urve

ys U

nit (

1999

) Hea

lth S

urve

y fo

r E

ngla

nd 1

998.

The

Sta

tione

ry O

ffic

e: L

ondo

n;

M M

oher

on

beha

lf of

the

ASS

IST

tria

l tea

m, D

epar

tmen

t of P

rim

ary

Hea

lth C

are,

Uni

vers

ity o

f Oxf

ord,

per

sona

l com

mun

icat

ion;

Roy

al C

olle

ge o

f G

ener

al P

ract

ition

ers,

the

Off

ice

of P

opul

atio

n C

ensu

ses

and

Surv

eys

and

the

Dep

artm

ent

of H

ealth

(19

95)

Mor

bidi

ty S

tatis

tics

from

Gen

eral

Pra

ctic

e, F

ourt

h N

atio

nal S

tudy

199

1-19

92.

HM

SO:L

ondo

n;

Gill

D, M

ayou

R, D

awes

M, M

ant D

(199

9) P

rese

ntat

ion,

man

agem

ent a

nd c

ours

e of

ang

ina

and

susp

ecte

d an

gina

in p

rim

ary

care

. Jou

rnal

of P

sych

osom

atic

Res

earc

h; 4

0; 3

49-3

58;

F L

ampe

on

beha

lf of

the

BR

HS

team

, Dep

artm

ent o

f Pri

mar

y C

are

and

Popu

latio

n Sc

ienc

es, R

oyal

Fre

e an

d U

nive

rsity

Col

lege

Med

ical

Sch

ool,

Lon

don,

per

sona

l com

mun

icat

ion.

Oth

er s

ourc

es o

f pre

vale

nce

data

:Sm

ith W

C, K

enic

er M

B, T

unst

all-P

edoe

H, C

lark

EC

, Cro

mbi

e IK

(199

0) P

reva

lenc

e of

cor

onar

y he

art d

isea

se in

Sco

tland

: Sco

ttis

h H

eart

Hea

lth S

tudy

. Bri

tish

Hea

rt J

ourn

al 6

4; 2

95-2

98;

Can

non

PJ, C

onne

ll PA

, Sto

ckle

y IH

, Gar

ner

ST, H

ampt

on J

R (1

988)

Pre

vale

nce

of a

ngin

a as

ass

esse

d by

a s

urve

y of

pre

scri

ptio

ns fo

r ni

trat

es. L

ance

t i; 9

79-9

78.


morbiditysupplement

25

Table 2.2c Change in prevalence of angina, men aged 40-75, between1978 and 1996, Great Britain

Annual % change inAge group Population angina symptoms

50-54 4182 -2.955-59 6089 -1.960-64 4732 -2.5

40-75 7735 -1.8

* all changes signficantly different from 0 (no change), p<0.05, angina assessed by Rose questionnaire, angina defined as current chest pain on exertion.

Source: Lampe FC, Morris RW, Whincup PH, Walker M, Ebrahim S and Shaper AG (2000) Is the prevalence of coronary heart disease falling in Britishmen? The British Regional Heart Study, 1978 to 1996. Poster at Cardiovascular Disease Prevention V conference, 4th-7th April, KensingtonTown Hall, London.

Table 2.2a Percentage who report experience of angina (ever andrecently), by sex and age, 1998, England

All ages 16-24 25-34 35-44 45-54 55-64 65-74 75 & over% % % % % % % %

MEN

Ever experienced 5.3 0.0 0.1 0.7 2.8 10.5 15.6 18.3Recently experienced (in last 12 months) 3.2 0.0 0.1 0.5 1.9 7.1 8.2 11.3

Base 7193 875 1338 1305 1289 987 837 562

WOMEN

Ever experienced 3.9 0.0 0.2 0.4 1.4 5.5 9.9 17.0Recently experienced (in last 12 months) 2.5 0.0 0.0 0.3 1.0 3.7 6.7 10.3

Base 8715 1006 1630 1573 1484 1148 967 907

Source: Joint Health Surveys Unit (1999) Health Survey for England 1998. The Stationery Office: London.

Table 2.2b Prevalence of angina by sex and age, 1981/82 and1991/2, England and Wales

All ages 15-24 25-44 45-64 65-74 75 & over% % % % % %

MEN 1981 / 82 0.81 0.00 0.09 1.72 3.54 3.191991 / 92 1.30 0.00 0.14 2.57 5.80 5.73

Change +60% - +56% +49% +64% +80%

WOMEN 1981 / 82 0.58 0.00 0.07 0.91 2.15 2.281991 / 92 0.98 0.00 0.07 1.33 3.64 4.40

Change +69% - - +46% +69% +93%

ICD (9th Revision) code 413.

Source: Royal College of General Practitioners, the Office of Population Censuses and Surveys, and the Department of Health (1995) Morbidity Statisticsfrom General Practice, Fourth National Study, 1991-1992. HMSO: London.


morbiditysupplement

26

3. All coronaryheart disease

This section looks at the prevalence of all CHD. This is because some studies on the prevalence

of CHD do not give separate data for heart attack and angina but give only prevalence rates for

all CHD.

Table 3 compares two studies that report prevalence of all CHD by sex and age – Morbidity

Statistics from General Practice and Key Health Statistics from General Practice. It also includes

two studies – the British Regional Heart Study and the ASSIST trial - which while reporting

separate prevalence rates for heart attack and angina, also report rates of heart attack or angina.

A prevalence rate for ‘all CHD’ is approximately equivalent to a prevalence rate for heart attack

or angina. Table 3 shows that all four studies give similar prevalence rates for all CHD.

Although people who have had a heart attack are likely to have angina not all will do so. The

ASSIST trial, for example, found that 68% of men and 66% of women aged 55-75 who had

suffered a heart attack had angina (and similarly that 47% of men and 27% of women aged 55-

75 who had angina had experienced a heart attack.1

Table 3a, with further data from Key Health Statistics from General Practice, suggests that

prevalence of CHD – like mortality from CHD - is higher in lower socio-economic groups. The

table shows that prevalence of treated CHD in general practices in deprived areas is higher than

in affluent areas. Deprivation was assessed using information on unemployment, overcrowding,

car availability and home ownership.

Table 3b, with data from a survey of the health of Britain’s ethnic minorities, suggests that

prevalence of CHD – again like mortality from CHD - varies with ethnic group, with Bangladeshi

and Pakistani men and women reporting the highest levels.

Table 3c, with further data from Key Health Statistics from General Practice, suggests that

prevalence of CHD – again like mortality from CHD is higher in the North of England and in

Wales than it is in the South of England. The table shows, for example that prevalence of treated

CHD in the Northern and Yorkshire Region is 44% higher for men and 72% higher for women

that it is in the South Thames Region. This north/south gradient is illustrated in Figs 3c(1) and

(2).

Table 3d, with data from the British Regional Heart Study, suggests that there has been no

change in the prevalence of all diagnosed CHD over the period 1978-1996 in men aged 50-64.

Morbidity Statistics from General Practice, however, suggest an increase in the prevalence of all


morbiditysupplement

27

CHD because the increase in the prevalence of angina (Table 2.2b) is greater than the decrease in

prevalence of heart attack (Table 1.2b).2

There are few studies that allow comparisons to be made between the prevalence of cardiovascular

diseases and conditions with that of other diseases and health-related conditions. Table 3e and

Fig 3e with data from the General Household Survey suggests that 19% of all reported longstanding

illness is cardiovascular.3 Cardiovascular illness was the second most important cause of morbidity

in this survey, after musculo-skeletal problems.

There is a growing body of literature that seeks to compare morbidity from different diseases

and health-related conditions. The most well known study is that of the World Health

Organisation’s Global Burden of Disease Project. This shows that in Established Market

Economies, such as the UK, 6% of years lost in disability are due to cardiovascular diseases

(1.6% are due to CHD and 3.2% are due to stroke). This is more than cancer (4%), similar to

that from musculo-skeletal problems (6%), but less than depression (14%) and road traffic and

other injuries (8%).4

1 M Moher on behalf of the ASSIST trial team, Department of Primary Health Care, University of Oxford, personal communication.

2 Other studies which have examined temporal trends in prevalence of CHD (though over a much shorter period of time than theBritish Regional Heart Study or Morbidity Statistics from General Practice);Office for National Statistics (2000) Key Health Statistics from General Practice. The Stationery Office: London;Joint Health Surveys Unit (1999) Health Survey for England 1998. The Stationery Office: London.

3 Note that in this instance coronary heart disease cannot usefully be separated from all cardiovascular disease.

4 Murray CJL, Lopez AD (1996) The Global Burden of Disease. WHO: Geneva.See also Table 2.2. in British Heart Foundation(2000) European cardiovascular disease statistics. BHF: London.


morbiditysupplement

28

Tabl

e 3

Prev

alen

ce o

f all

CH

D, a

dults

age

d be

twee

n 55

and

74*

, lat

est a

vaila

ble

year

,U

K s

tudi

es c

ompa

red

MEN

WO

MEN

Sour

ceSt

udy

Year

Plac

e55

-64

65-7

455

-64

65-7

4

Pers

onal

com

mun

icat

ion

ASS

IST

1997

/98

War

wic

kshi

re8.

014

.02.

87.

2

Pers

onal

com

mun

icat

ion

BRH

S119

92G

reat

Bri

tain

12.6

22.2

Lam

pe e

t al,

2000

BRH

S119

96G

reat

Bri

tain

11.8

20.1

Off

ice

for

Nat

iona

l Sta

tistic

s, 2

000

Key

Hea

lth S

tatis

tics

from

Gen

eral

Pra

ctic

e219

98En

glan

d an

d W

ales

9.5

18.4

4.9

11.2

Roy

al C

olle

ge o

f Gen

eral

Pra

ctiti

oner

s et

al,

1995

Mor

bidi

ty S

tatis

tics

from

Gen

eral

Pra

ctic

e19

91/9

2En

glan

d an

d W

ales

4.0*

*9.

21.

8**

5.0

*D

ata

from

the

4th

Nat

iona

l Stu

dy o

f Mor

bidi

ty S

tatis

tics

from

Gen

eral

Pra

ctic

e is

for

adul

ts a

ged

bet

wee

n 45

and

74;

**fo

r th

ose

aged

45-

64;

1 Sub

ject

rec

all o

f a d

octo

r-di

agno

sis

of a

ngin

a or

hea

rt a

ttac

k;2 T

reat

ed C

HD

.

Sour

ces:

M M

oher

on

beha

lf of

the

ASS

IST

stu

dy te

am, D

epar

tmen

t of P

rim

ary

Hea

lth C

are,

Uni

vers

ity o

f Oxf

ord,

per

sona

l com

mun

icat

ion;

F L

ampe

on

beha

lf of

the

BR

HS

team

, Dep

artm

ent o

f Pri

mar

y C

are

and

Popu

latio

n Sc

ienc

es, R

oyal

Fre

e an

d U

nive

rsity

Col

lege

Med

ical

Sch

ool,

Lon

don,

per

sona

l com

mun

icat

ion;

Lam

pe F

C, M

orri

s RW

, Whi

ncup

PH

, Wal

ker

M, E

brah

im S

, Sha

per

AG

(200

0) I

s th

e pr

eval

ence

of c

oron

ary

hear

t dis

ease

falli

ng in

Bri

tish

men

? T

he B

ritis

h R

egio

nal H

ear t

Stu

dy, 1

978

to 1

996.

Post

er a

t Car

diov

ascu

lar

Dis

ease

Pr e

vent

ion

V c

onfe

renc

e, 4

th-7

th A

pril,

Ken

sing

ton

Tow

n H

all,

Lon

don;

Off

ice

for

Nat

iona

l Sta

tistic

s (2

000)

Key

Sta

tistic

s fr

om G

ener

al P

ract

ice.

The

Sta

tione

ry O

ffic

e: L

ondo

n;

Roy

al C

olle

ge o

f Gen

eral

Pra

ctiti

oner

s, th

e O

ffic

e of

Pop

ulat

ion

Cen

suse

s and

Sur

veys

and

the

Dep

artm

ent o

f Hea

lth (1

995)

Mor

bidi

ty S

tatis

tics f

rom

Gen

eral

Pra

ctic

e, F

ourt

h N

atio

nal S

tudy

199

1-19

92. H

MSO

: Lon

don.


morbiditysupplement

29

Table 3a Prevalence of treated CHD by sex, age and deprivationcategory, 1994/98, England and Wales

Deprivation Number All ages* 0-34 35-44 45-54 55-64 65-74 75-84 85 & overcategory of cases

% % % % % % % %

MEN Q1: least deprived 12856 3.13 0.01 0.37 2.12 7.40 15.92 22.47 19.06Q2 20739 3.38 0.01 0.48 2.54 8.26 17.04 21.68 21.46Q3 25738 3.56 0.01 0.43 2.80 9.15 17.54 22.03 20.89Q4 25120 3.63 0.01 0.51 3.02 10.01 17.32 21.17 19.93Q5: most deprived 23043 4.09 0.02 0.67 3.91 11.30 19.30 21.28 20.96

All 107777 3.58 0.01 0.50 2.90 9.34 17.51 21.68 20.53

WOMEN Q1: least deprived 9402 1.74 0.01 0.08 0.65 3.18 9.55 15.77 16.78Q2 16145 1.90 0.01 0.15 1.01 4.12 9.78 15.20 16.16Q3 21352 2.13 0.01 0.15 1.18 4.54 11.04 16.87 18.40Q4 21137 2.17 0.01 0.21 1.48 5.09 10.68 15.91 17.03Q5: most deprived 19145 2.60 0.01 0.27 1.90 6.77 12.63 16.95 17.23

All 87289 2.13 0.01 0.18 1.26 4.83 10.81 16.16 17.17

* Age-standardised using the European Standard Population;

Deprivation categories were derived from quintiles of Townsend Material Deprivation Scores for the wards in which the general practices were located.

Source: Office for National Statistics (2000) Key Health Statistics from General Practice: The Stationery Office: London.

Fig 3a Prevalence of treated CHD by sex and deprivationcategory, 1994/98, England and Wales

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Q1: least deprived Q2 Q3 Q4 Q5: most deprived

Deprivation category

%

MenWomen


morbiditysupplement

30

Table 3b Prevalence of chest pain and diagnosed heart disease inadults aged 40 and above, by sex and ethnic group,1993/94, England and Wales

Caribbean Indian African Pakistani Bangladeshi Chinese White% reporting severe chest pain Asianor diagnosed heart disease*

Men 16 13 12 23 28 12 19Women 14 12 11 25 17 5 14

Total 15 13 12 24 24 8 16

Weighted base 586 531 282 260 102 126 1525Unweighted base 494 543 279 392 198 83 1592

* Respondents were asked whether they had ever had angina or ever had a heart attack "including a heart murmur or a rapid heart", or had experienced"severe chest pain which lasting more than half an hour".

Source: Nazroo JY (1997) The Health of Britain's Ethnic Minorities: Findings from a national survey. Policy Studies Institute: London.

Table 3c Prevalence of treated CHD by sex, age and region, 1994/98, England and Wales

Number of cases All ages* 0-34 35-44 45-54 55-64 65-74 75-84 85 & over% % % % % % % %

MEN Northern and Yorkshire 16566 4.2 0.01 0.7 3.6 11.1 20.3 25.0 24.5Trent 12810 3.6 0.01 0.4 3.0 9.9 16.9 21.8 18.5Anglia and Oxford 8678 3.2 0.01 0.5 2.3 7.5 16.1 22.0 19.6North Thames 5544 3.0 0.00 0.3 2.6 7.1 15.4 19.4 17.5South Thames 7190 2.9 0.01 0.4 2.4 7.3 14.6 18.3 16.2South and West 16106 3.3 0.01 0.4 2.3 8.1 16.6 21.8 21.1West Midlands 13447 3.3 0.01 0.5 2.6 8.5 16.5 19.7 19.6North West 20678 4.1 0.02 0.6 3.7 11.5 19.2 22.1 22.2

England 101019 3.6 0.01 0.5 2.9 9.2 17.3 21.6 20.4Wales 6758 4.2 0.01 0.5 3.2 11.7 20.6 23.7 23.4

England and Wales 107777 3.6 0.01 0.5 2.9 9.3 17.5 21.7 20.5

WOMEN Northern and Yorkshire 14998 2.8 0.00 0.2 1.9 6.9 14.0 19.6 21.7Trent 10046 2.2 0.01 0.2 1.4 5.0 11.0 16.4 16.3Anglia and Oxford 6678 1.8 0.01 0.1 1.0 3.8 9.5 15.2 16.5North Thames 4292 1.6 0.00 0.1 0.7 3.3 8.9 13.4 13.5South Thames 5696 1.6 0.00 0.1 1.1 3.1 8.4 13.6 15.9South and West 12036 1.7 0.01 0.1 0.8 3.3 9.3 14.9 15.2West Midlands 10405 1.9 0.01 0.2 1.2 4.3 9.7 14.7 16.2North West 17767 2.6 0.01 0.3 1.7 6.4 12.5 17.9 18.9

England 81918 2.1 0.01 0.2 1.2 4.8 10.8 16.1 17.1Wales 5371 2.4 0.00 0.1 1.6 6.1 11.8 17.6 17.7

England and Wales 87289 2.1 0.01 0.2 1.3 4.8 10.8 16.2 17.2

* Age-standardised using the European Standard Population.

Source: Office for National Statistics (2000) Key Health Statistics from General Practice. The Stationery Office: London.


morbiditysupplement

31

Fig 3c(1) Age-standardised prevalence of treated CHD formen, by region, 1994/98, England and Wales

>3.99

3.75 - 3.99

3.50 - 3.74

3.25 - 3.49

<3.25

Prevalence of treatedCHD (%)

Northern andYorkshire

NorthWest

Wales

Trent

WestMidlands Anglia and

Oxford

NorthThames

SouthThamesSouth and

West


morbiditysupplement

32

Fig 3c(2) Age-standardised prevalence of treated CHD forwomen, by region, 1994/98, England and Wales

>2.59

2.35 - 2.59

2.10 - 2.34

1.85 - 2.09

<1.85

Prevalence of treatedCHD (%)

Northern andYorkshire

NorthWest

Wales

Trent

WestMidlands Anglia and

Oxford

NorthThames

SouthThamesSouth and

West


morbiditysupplement

33

Table 3e Percentage reporting longstanding illness by sex,age and condition group, 1998, Great Britain

All ages 16-44 45-64 65-74 75 & over

Heart and circulatory system (VII) Men 11.3 1.9 15.5 28.1 310Women 9.9 1.3 10.6 26.8 29.9Total 10.6 1.6 13 27.4 30.3

Heart attack Men 3.2 0.3 4.0 8.9 11.1Women 2.2 0.0 1.8 6.5 8.6

Other heart complaints Men 3.0 0.6 4.1 7.3 8.5Women 2.1 0.5 2.1 5.3 6.3

Hypertension Men 3.0 0.6 4.8 6.3 5.9Women 3.8 0.5 5.3 10.3 7.3

Stroke Men 0.8 0.1 0.8 2.6 3.0Women 0.8 0.1 0.5 1.5 4.1

Musculoskeletal system (XIII) Men 15.4 9.4 19.7 22.6 26.0Women 17.3 6.4 21.3 34.0 38.3Total 16.4 7.8 20.5 28.6 33.5

Arthritis and rheumatism Men 6.1 1.6 8.1 14.2 14.5Women 9.7 1.8 12.3 21.8 25.4

Back problems Men 4.7 4.0 6.6 4.0 2.6Women 3.9 3.0 5.5 4.8 2.9

Other bone and joint problems Men 4.6 3.8 4.9 4.4 8.9Women 3.7 1.6 3.5 7.4 10.1

Respiratory system (VIII) Men 7.2 6.6 6.2 10.0 11.5Women 7.6 7.0 7.8 8.3 8.4Total 7.4 6.8 7.0 9.1 9.6

Endocrine and metabolic (III) Men 3.9 1.3 5.3 8.1 8.2Women 5.0 1.8 6.5 11.4 8.6Total 4.5 1.5 5.9 9.9 8.4

Digestive system (IX) Men 3.4 2.0 4.6 5.2 5.9Women 3.9 1.8 4.6 6.4 8.4Total 3.7 1.9 4.6 5.8 7.4

Nervous system (VI) Men 3.1 2.6 3.4 3.8 4.1Women 3.5 3 4.2 3.3 4.2Total 3.3 2.8 3.8 3.5 4.1

Any longstanding illness Men 33.0 24.0 44.0 59.0 68.0Women 34.0 23.0 43.0 59.0 65.0Total 33.0 24.0 44.0 59.0 66.0

Bases Men 7531 3726 2393 873 539Women 8343 4020 2499 989 835

ICD chapters in parentheses.

Source: Office for National Statistics (2000) Living in Britain. Results from the 1998 General Household Survey. The StationeryOffice: London.

Table 3d Change in prevalence of diagnosed CHD, menaged 40-75, between 1978 and 1996, Great Britain

Agegroup Population Annual % change in diagnosed CHD

50-54 4213 -0.455-59 6169 -0.360-64 4839 0.4

40-75 7735 0.1

A diagnosis of either angina or heart attack; no changes signficantly different from 0 (no change), p>0.05.

Source: Lampe FC, Morris RW, Whincup PH, Walker M, Ebrahim S and Shaper AG (2000) Is the prevalence of coronary heartdisease falling in British men? The British Regional Heart Study, 1978 to 1996. Poster at Cardiovascular Disease PreventionV conference, 4th-7th April, Kensington Town Hall, London.


morbiditysupplement

34

Fig 3e Percentage of all reported longstanding illness bycondition group, adults, 1998, Great Britain

Nervous system6%

Digestive6%

Endocrine and metabolic8%Respiratory

13%

Musculo-skeletal29%

Heart and circulatory19%

Other19%


morbiditysupplement

35

4. Heartfailure

4.1 IncidencePopulation-based studies on heart failure are scarce and the studies that have been published are

particularly difficult to compare because of differences in methodology, notably in the diagnosis

of heart failure. The Hillingdon Heart Failure Study however used a combination of clinical

assessment, echocardiography and radiography to diagnose heart failure in the study population

and adhered to European Society of Cardiology guidelines for its definition of heart failure.

Table 4.1 shows that the crude incidence rate for men was 140 per 100,000 and for women it

was 120 per 100,000. From the incidence rates in this table we estimate that there are about

33,000 new cases of heart failure in men in the UK each year and about 30,000 cases in women

giving a total of about 63,000.

Table 4.1 shows that the incidence of heart failure increases steeply in the elderly and is more

common in men than in women.

4.2 PrevalenceThere are a number of different studies of the prevalence of heart failure in the community and

also of left ventricular dysfunction – the main cause of heart failure. Table 4.2 summarises the

results of the four most comparable studies of the prevalence of heart failure – a small scale study

of two general practice populations in Liverpool, a study of the MONICA Project population in

Glasgow, Morbidity Statistics from General Practice and Key Health Statistics from General

Practice. The four studies give similar estimates of prevalence, but it should be noted that only

the study carried out in Glasgow used a particularly systematic approach to the identification of

heart failure (symptomatic left ventricular dysfunction) but this study only looked at the prevalence

of heart failure in a comparatively young age group.

Table 4.2a, with further data from Key Health Statistics from General Practice, suggests that

about 1% of both men and women have heart failure. From these prevalence rates we estimate

that there are about 350,000 men living in the UK who have heart failure and about 410,000

women giving a total of about 760,000.

Table 4.2b shows the results of two studies of the prevalence of left ventricular dysfunction.

These studies are difficult to compare because the studies looked at different age groups.

It is often suggested that the incidence and prevalence of heart failure is increasing. This may well

be the case but there is no direct evidence that it is so.1


morbiditysupplement

36

4.3 PrognosisTable 4.3 with data from the Hillingdon Heart Failure Study shows that about 40% of people

die within one year of an initial diagnosis of heart failure. Comparing Table 4.3 with Table 1.3

indicates that this is only slightly less than the number of people who die within one year of a

heart attack.

1 Office for National Statistics (2000) Key Health Statistics from General Practice. The Stationery Office: London suggests that theprevalence of treated heart failure fell slightly between 1984 and 1988 in both men and women, but this finding may be because ofchanges in the way GPs have diagnosed heart failure over this period.


morbiditysupplement

37

Table 4.1 Incidence of heart failure, by sex and age,1995/96, Hillingdon

Age group Population Number of Incidence/cases 100,000

MEN

25-34 14042 0 035-44 11135 3 2045-54 9405 4 3055-64 7408 21 17065-74 5260 34 39075-84 2506 41 98085 & over 537 15 1680

Total 50293 118 140

WOMEN

25-34 13620 1 435-44 10056 3 2045-54 8827 1 1055-64 7157 8 7065-74 6243 24 23075-84 4254 42 59085 & over 1435 23 960

Total 51592 102 120

Source: Cowie MR, Wood DA, Coats AJS, Thompson SG, Poole-Wilson PA, Suresh V, Sutton GC (1999) Incidence and aetiology ofheart failure. A population-based study. European Heart Journal 20; 421-428.


morbiditysupplement

38

Tabl

e 4.

2Pr

eval

ence

of h

eart

failu

re, a

dults

age

d be

twee

n 45

and

84,

late

st a

vaila

ble

year

,U

K s

tudi

es c

ompa

red

MEN

WO

MEN

Sour

ceSt

udy

Year

Plac

e55

-64

65-7

475

-84

55-6

465

-74

75-8

4

Roy

al C

olle

ge o

f Gen

eral

4th

Nat

iona

l Stu

dy o

f Mor

bidi

tyPr

actit

ione

rs e

t al,

1995

Stat

istic

s fr

om G

ener

al P

ract

ice

1991

/92

Engl

and

and

Wal

es0.

5*3.

28.

00.

4*2.

37.

1

McD

onag

h et

al,

1997

MO

NIC

A19

92G

lasg

ow2.

53.

22.

03.

6

Mai

r et

al,

1996

Two

gene

ral p

ract

ices

in L

iver

pool

1994

Live

rpoo

l2.

75.

310

.4**

1.2

5.1

13.3

**

Off

ice

for

Nat

iona

l Sta

tistic

s, 2

000

Key

Hea

lth S

tatis

tics

from

Gen

eral

Pra

ctic

e19

98En

glan

d an

d W

ales

1.4

4.5

10.9

0.9

3.6

9.9

*fo

r th

ose

aged

45-

64 y

ears

**fo

r th

ose

aged

75

& o

ver

Sour

ces

Roy

al C

olle

ge o

f G

ener

al P

ract

ition

ers,

the

Off

ice

of P

opul

atio

n C

ensu

ses

and

Surv

eys

and

the

Dep

artm

ent

of H

ealth

(19

95)

Mor

bidi

ty S

tatis

tics

from

Gen

eral

Pra

ctic

e,Fo

urth

Nat

iona

l Stu

dy 1

991-

1992

. HM

SO: L

ondo

n;

Mai

r FS

, Cro

wle

y T,

Bun

dred

P (1

996)

Pre

vale

nce,

aet

iolo

gy a

nd m

anag

emen

t of h

eart

failu

re in

gen

eral

pra

ctic

e. B

ritis

h Jo

urna

l of G

ener

al P

ract

ice;

46:

77-

79;

McD

onag

h TA

, Mor

riso

n C

E, L

awre

nce

A, F

ord

I, T

unst

all-P

edoe

H, M

cMur

ray

JJV

(19

97) S

ypto

mat

ic a

nd a

sym

ptom

atic

left

ven

tric

ular

sys

tolic

dys

func

tion

in a

n ur

ban

popu

latio

n. L

ance

t; 35

0: 8

29-8

33;

Off

ice

for

Nat

iona

l Sta

tistic

s (2

000)

Key

Hea

lth S

tatis

tics

from

Gen

eral

Pra

ctic

e. T

he S

tatio

nery

Off

ice:

Lon

don.

Oth

er s

ourc

es o

f pre

vale

nce

data

:Pa

ram

eshw

ar J,

Sha

ckel

l MM

, Ric

hard

son

A, P

oole

-Wils

on P

A, S

utto

n G

C (1

992)

Pre

vale

nce

of h

eart

failu

re in

thre

e ge

nera

l pra

ctic

es in

nor

th w

est L

ondo

n. B

ritis

h Jo

urna

lof

Gen

eral

Pra

ctic

e 42

: 287

-289

.


morbiditysupplement

39

Table 4.2a Prevalence of treated heart failure, by sex andage, 1998, England and Wales

Age group Number of cases %

MEN

0-34 20 0.0135-44 39 0.0445-54 229 0.2755-64 876 1.3965-74 2118 4.4975-84 2798 10.8685+ 1151 19.07

Total* 7231 1.02*

WOMEN

0-34 26 0.0135-44 25 0.0345-54 145 0.1855-64 573 0.9265-74 1907 3.5875-84 3910 9.8685+ 3000 18.88

Total* 9586 0.85*

* Age-standardised using the the European Standard Population.

Source Office for National Statistics (2000) Key Health Statistics from General Practice. The Stationery Office: London.


morbiditysupplement

40

Table 4.3 Survival after initial diagnosis of heart failure,adults, 1995/96, Hillingdon

Number Percentage

All with initial diagnosis of heart failure 220 100%

Survive for longer than 1 month 178 81%

Survive for longer than 3 months 165 75%


Survive until end of first year 136 62%


Source: Cowie M R, Wood D A, Coats A J S, Thompson S G, Suresh V, Poole-Wilson P A, Sutton G C (2000) Survival of patientswith a new diagnosis of heart failure: a population based study. Heart; 83: 505-510.

Table 4.2b Prevalence of left ventricular dysfunction,adults, latest available year, UK studiescompared

Source Study Year Place Sex Age group Prevalence%

McDonagh et al, 1997 MONICA 1992 Glasgow Men 25-34 0.035-44 0.745-54 5.855-64 5.765-74 6.4

Women 25-34 0.035-44 0.045-54 2.455-64 2.065-74 4.9

Morgan et al, 1999 One general practice in 1995/96 Poole Men 70-74 9.4Poole, Dorset 75-79 13.1

80-84 20.5

Total 12.8

Women 70-74 2.275-79 2.480-84 5.4

Total 2.9

Total population for MONICA Project study was 1468;Total population for Poole study was 817; total number of cases was 61 (48 for men, 13 for women).

Sources McDonagh TA, Morrison CE, Lawrence A, Ford I, Tunstall-Pedoe H, McMurray JJV (1997) Symptomatic and asymptomaticleft ventricular systolic dysfunction in an urban population. Lancet 350: 829-833;

Morgan S, Smith H, Simpson G, Liddiard GS, Raphael H, Pickering RM, Mant D (1999) Prevalence and clinical characteristicsof left ventricular dysfunction among elderly patients in general practice setting: cross sectional study. British Medical Journal18: 366-372.

Other sources of prevalence data:Wheeldon NM, MacDonald TM, Flucker CJ, McDermitt DG, Struthers AD (1993) An echocardiographic study of chronicheart failure in the community. Quarterly Journal of Medicine 86; 17-23;

Hobbs FDR, Davis RC, McLeod et al (1998) Prevalence of LVD and valve disease in a typical English region. JournalAmmerican College of Cardiology 31(Suppl 5); 85C.


morbiditysupplement

41

Appendix 1. Performance indicators for morbidity fromCHD and related cardiovascular conditions

Section in Health Indicator CHD National HighSupplement Information National Performance Level

Authority Service Framework FrameworkRef No. Framework

MI 1A Population based heart attack rate for MIs (sic) ✔

MI 1B Annual hospital admission rate for all MIs ✔

MI 1C Annual hospital admission rate for first ever MI ✔

MI 7 Case fatality rates for patients admitted tohospital alive with MI ✔

MI 11A Rate of inpatient admission for MI within 1 yearof a previous hospitalised MI ✔

MI, Angina 11B Rate of inpatient admission for selectedHeart cardiovascular conditions within 1year of aFailure previous hospitalised MI ✔

MI 13 Impact of symptoms on function for patients6 months after first ever MI ✔

MI 20 Proportion of people aged 35-74 with adiagnosis of acute MI who die during theirindex admission to hospital ✔

MI 21 Proportion of people aged 35-74 with adiagnosis of acute MI who die in hospital within30 days of their infarct ✔

MI 27 30-day mortality following MI for people aged50 and over ✔

Heart Age-standardised admission rate for heart failure ✔Failure 29

MI, Angina 41 Rate of cardiovascular events in people with a ✔Heart prior diagnosis of CHD, PVD, TIA orFailure occlusive stroke

MI 42 Proportion of people aged 35-74 with adiagnosis of acute MI who die within 30 days ✔

Source: National Health Service Information Authority (2000) The Healthcare Frameworks Implementation Pack.HealthcareFramework for Coronary Heart Disease. NHS Information Authority: Winchester (Appendix 5.2).

Note that this table extracts from Appendix 5.2 only those performance indicators related to morbidity (incidence, prevalence,case fatality, subsequent disease) and only those performance indicators recognised by the National Service Framework forCoronary heart disease, the National Performance Framework and the High Level Performance Framework.


morbiditysupplement

42

Appendix 2. Sources of data for compiling tables and figures

1. Routinely collected national data:Key Health Statistics from General Practice1

2. National studiesThe General Household Survey2

The Health Survey for England (HSE)3

Morbidity Statistics from General Practice4

The British Regional Heart Study (BRHS)5,6

The Health of Britain’s Ethnic Minorities7

3. Local studiesHeart attackThe Oxford Myocardial Infarction Incidence Study (OXMIS) (568,800; Oxfordshire)8,9

The United Kingdom Heart Attack Study (UKHAS) (282,000; Brighton, 408,000; South

Glamorgan and 264,000; York)10,11

The WHO Monitoring trends and determinants of cardiovascular diseases (MONICA)

Project (158,000; Belfast and 130,000; Glasgow)12

Heart attack and anginaThe Assessment of Implementation Strategy (ASSIST) trial (27,396; Warwickshire)13

AnginaThe Southampton Chest Pain Clinic Study (191,677; Southampton)14

A study in one general practice in Oxford (1984; Oxford)15

Heart failureA study in two general practices in Liverpool (17,405; Liverpool)16

The Hillingdon Heart Failure Study (151,000; Hillingdon)17,18

The WHO Monitoring trends and determinants of cardiovascular diseases (MONICA)

Project (1468; Glasgow)19

A study in one general practice in Poole, Dorset (817, Poole)20

1 Office for National Statistics (2000) Key Health Statistics from General Practice. The Stationery Office: London.

2 Office for National Statistics (2000) Living in Britain. Results from the 1998 General Household Survey. The Stationery Office:London and previous editions.

3 Joint Health Surveys Unit (1999) Health Survey for England 1998. The Stationery Office: London.

4 Royal College of General Practitioners, the Office of Population Censuses and Surveys, and the Department of Health (1995)Morbidity Statistics from General Practice. Fourth National Study 1991-1992, HMSO: London.


morbiditysupplement

43


6 Lampe FC, Morris RW, Whincup PH, Walker M, Ebrahim S, Shaper AG (2000) Is the prevalence of coronary heart disease falling inBritish men? The British Regional Heart Study, 1978 to 1996. Poster at Cardiovascular Disease Prevention V conference, 4th-7thApril, Kensington Town Hall, London.

7 Nazroo JY (1997) The Health of Britain’s Ethnic Minorities: Findings from a national survey. Policy Studies Institute: London.

8 Volmink JA (1996) The Oxford Myocardial Infarctions Incidence Study. Doctorate thesis: University of Oxford.

9 Volmink JA, Newton JN, Hicks NR, Sleight P, Fowler GH, Neil HAW (1998) Coronary event and case fatality rates in an Englishpopulation: results of the Oxford myocardial infarction incidence study. Heart 80; 40-44.

10 The United Kingdom Heart Attack Study (UKHAS) Collaborative Group (1998) The falling mortality from coronary heart disease:a clinicopathological perspective. Heart 80; 121-126.

11 Norris RM on behalf of the United Kingdom Heart Attack Study Collaborative Group (1998) Fatality outside hospital from acutecoronary events in three British health districts, 1994-5. British Medical Journal 316; 1065-1070.

12 Tunstall-Pedoe H, Kuulasmaa K, Mahonen M, Tolonen H, Ruokokoski E, Amouyel P, for the WHO MONICA Project (1999)Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37MONICA Project populations. Lancet 353; 1547-1557.

13 Moher M, Yudkin P, Turner R, Schofield T, Mant D (2000) An assessment of morbidity registers for coronary heart disease inprimary care. British Journal of General Practice 50; 706-709.

14 Gandhi MM, Lampe FC, Wood DA (1995) Incidence, clinical characteristics, and short-term prognosis of angina pectoris. BritishHeart Journal 73; 193-198.

15 Gill D, Mayou R, Dawes M, Mant D (1999) Presentation, management and course of angina and suspected angina in primary care.Journal of Psychosomatic Research; 40; 349-358.

16 Mair FS, Crowley TS, Bundred PE (1996) Prevalence, aetiology and management of heart failure in general practice. British Journalof General Practice 46; 77-79.

17 Cowie MR, Wood DA, Coats AJ, Thompson SG, Poole-Wilson PA, Suresh V, Sutton GC (1999) Incidence and aetiology of heartfailure; a population-based study. European Heart Journal 20(6); 421-428.

18 Cowie MR, Wood DA, Coats AJS, Tompson SG, Suresh V, Poole-Wilson PA, Sutton GC (2000) Survival of patients with a newdiagnosis of heart failure: a population based study. Heart 83; 505-510.

19 McDonagh TA, Morrison CE, Lawrence A, Ford I, Tunstall-Pedoe H, McMurray JJV (1997) Syptomatic and asymptomatic leftventricular systolic dysfunction in an urban population. Lancet 350; 829-833.

20 Morgan S, Smith H, Simpson G, Liddiard GS, Raphael H, Pickering RM, Mant D (1999) Prevalence and clinical characteristics ofleft ventricular dysfunction among elderly patients in general practice setting: cross sectional study. British Medical Journal 18; 366-372.


morbiditysupplement

44

App

endi

x 3

Mid

-199

9 po

pula

tion

estim

ates

for E

ngla

nd, W

ales

, Sco

tland

, Nor

ther

n Ir

elan

d an

d th

e U

KM

ENW

OM

EN

Engl

and

Wal

esSc

otla

ndN

orth

ern

UK

Engl

and

Wal

esSc

otla

ndN

orth

ern

UK

Irel

and

Irel

and

0-4

1557

400

8780

015

4150

6172

918

6107

914

8070

083

500

1466

6758

662

1769

529

5-9

1671

400

9740

016

6372

6636

820

0154

015

9010

093

100

1590

5163

381

1905

632

10-1

416

4060

010

1500

1660

7569

146

1977

321

1556

400

9630

015

8309

6561

618

7662

515

-19

1564

700

9670

016

5394

6513

718

9193

114

7830

093

100

1582

0862

013

1791

621

20-2

414

9660

085

900

1631

6558

523

1804

188

1425

500

7730

015

6468

5498

117

1424

925

-29

1843

000

9790

019

0959

6551

321

9737

217

4260

090

700

1855

9361

548

2080

441

30-3

420

7450

010

7800

2075

7465

430

2455

304

1973

800

1039

0020

8414

6642

923

5254

335

-39

2021

700

1075

0020

1627

6178

823

9261

519

3580

010

6100

2020

9364

230

2308

223

40-4

416

9850

095

700

1764

1654

081

2024

697

1673

000

9580

017

9770

5592

820

0449

845

-49

1589

600

9530

016

4292

4915

318

9834

515

8520

095

800

1676

3949

592

1898

231

50-5

416

7890

010

1200

1615

5147

483

1989

134

1685

600

1020

0016

5748

4907

620

0242

455

-59

1306

600

8230

013

1588

4080

715

6129

513

2340

083

900

1415

9442

586

1591

480

60-6

411

6880

074

300

1217

0134

772

1399

573

1209

400

7690

013

5441

3772

314

5946

465

-69

1029

300

6670

010

8205

2939

112

3359

611

2630

073

300

1291

6735

174

1363

941

70-7

487

8900

5850

088

315

2472

610

5044

110

6330

070

900

1161

5232

419

1282

771

75-7

971

0000

4640

063

504

1854

583

8449

1017

000

6670

099

636

2823

512

1157

180

-84

3497

0022

900

3247

098

6641

4936

6303

0041

800

6481

218

144

7550

5685

+26

2600

1590

021

043

6139

3056

8271

3200

4420

060

837

1749

083

5727

All

Age

s24

5429

0014

4170

024

8440

182

8597

2929

7598

2521

0000

1495

300

2635

599

8632

2730

2041

26

Sour

ces:

Off

ice

for

Nat

iona

l Sta

tistic

s (2

000)

per

sona

l com

min

icat

ion;

Reg

iste

r G

ener

al fo

r Sc

otla

nd (2

000)

Ann

ual R

epor

t 199

9. G

ener

al R

egis

ter

Off

ice:

Edi

nbur

gh;

Gen

eral

Reg

iste

r O

ffic

e (2

000)

Ann

ual R

epor

t 199

9. S

tatis

tics

and

Res

earc

h A

genc

y: N

orth

ern

Irel

and.

Documents

Coronary heart disease statistics: morbidity supplement .../media/files/research/...Coronary heart disease statistics: morbidity supplement 1 Coronary heart disease statistics: morbidity