The UK National Health Service

Abstract

Background— Social gradients in cardiovascular mortality across the United Kingdom may reflect differences in incidence, disease severity, or treatment. It is unknown whether a universal healthcare system delivers equitable lifesaving medical therapy for coronary heart disease. We therefore examined secular trends in the use of key medical therapies stratified by socioeconomic circumstances across a broad spectrum of coronary disease presentations, including acute coronary syndromes, secondary prevention, and clinical angina. Methods and Results— This was a cross-sectional observational analysis of nationally representative primary and secondary care data from the United Kingdom. Data on treatments for all myocardial infarction patients in 2003 and 2007 were derived from the Myocardial Ischemia National Audit Project (n=51 755). Data on treatments for patients with chronic angina (n=33 211) or requiring secondary prevention (n=32 976) in 1999 and 2007 were extracted from the General Practice Research Database. Socioeconomic circumstances were defined using a weighted composite of 7 area-level deprivation domains. Treatment estimates were age-standardized. Use of all therapies increased in all patient groups, both men and women. Improvements were most marked in primary care, where use of β-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for secondary prevention and treatment of angina doubled, from ≈30% to >60%. Small age gradients persisted for some therapies. No consistent socioeconomic gradients or sex differences were observed for myocardial infarction and postrevascularization (hard diagnoses). However, some sex inequality was apparent in the treatment of younger women with angina. Conclusions— Cardiovascular treatment is generally equitable and independent of socioeconomic circumstances. Future strategies should aim to further increase overall treatment levels and to eradicate remaining age and sex inequalities.

Sex Differences in Outcomes Following Percutaneous Coronary Intervention According to Age

“…Koopman et al, showed that women less than 55 years of age were less likely to be prescribed a lipid lowering agent for primary prevention [35]. Hawkins et al demonstrated that the rate of prescriptions for secondary prevention in stable angina was 10% lower in younger women than men [36]. In the Virgo study, at 1 year, women <55 years were less likely to be on optimal therapy following a myocardial infarction due to a disparity in treatment initiation rather than treatment adherence despite more likely to have had a previous PCI [37,38].…”

Trends in Myocardial Infarction Secondary Prevention: The National Health and Nutrition Examination Surveys (NHANES), 1999–2012

“…For comparison, recent analysis of treatment trends in MI patients in the United Kingdom during this same time period showed improvements in blood pressure and cholesterol levels as well as treatment rates in coronary heart disease secondary prevention. 33 …”

Sex Disparities in Post-Acute Myocardial Infarction Pharmacologic Treatment Initiation and Adherence

“…9,24 Our findings are also consistent with secondary prevention studies that report sex differences in treatment by age group. 10,13,25 A cross-sectional observational analysis of national data for the United Kingdom showed that prescribing rates for secondary prevention therapies were ≈10% lower among women than men <55 years. 10 A study investigating post-AMI use of statins in Denmark found that young men used more statins than young women but there were no sex differences in use in older patients.…”

“…10,13,25 A cross-sectional observational analysis of national data for the United Kingdom showed that prescribing rates for secondary prevention therapies were ≈10% lower among women than men <55 years. 10 A study investigating post-AMI use of statins in Denmark found that young men used more statins than young women but there were no sex differences in use in older patients. 25 A large database study of cardiovascular drug use in the Netherlands showed that younger women showed the lowest use of antithrombotics, statins, BBs, and other blood pressure-lowering drugs; they were also less likely to be on combination therapy than men (P>0.001).…”

“…Cross-sectional studies report lower rates of the use of secondary prevention medications among women than men. [10][11][12][13] However, it is unclear if this is a result of lower treatment initiation among women or lower treatment adherence. Therefore, it is important to examine the full continuum of care, from the event to discharge to outpatient use of medications.…”