How Does Cardiovascular Disease First Present?

Study Questions:

What are the types of first presentation for cardiovascular disease (CVD) among men and women?


Patients ≥30 years and free of CVD at baseline, who received care from 225 general practices across England, were included in this analysis. Data from January 1997 and March 2010 were included. The investigators linked data from electronic health records covering primary care, hospital admissions, acute coronary syndrome registry, and mortality using the CALIBER (CArdiovascular research using Linked Bespoke studies and Electronic Records) research platform. Deidentified patient information was linked across several data sources including the Clinical Practice Research Database (CPRD), the Myocardial Ischaemia National Audit Project (MINAP) registry, Hospital Episodes Statistics (HES), and the death registry, from the Office for National Statistics (ONS). Patients registered in practices with linkable data to CPRD, which is a representative sample of the English population. Primary endpoints were the first recorded diagnosis of the 12 most common CVD types including angina (stable, unstable), myocardial infarction (MI), coronary death, stroke (ischemic, hemorrhagic), abdominal aortic aneurysm, peripheral arterial disease (PAD), and CVD death. Twelve different CVD diagnoses in all were examined.


A total of 1,937,360 patients (51% women, 90% white) from 225 general practices across England were included. Over a median follow-up of 6 years, 114,859 patients experienced a first CVD diagnosis. In general, the majority of incident events (66%) were not MI or ischemic stroke, but rather heart failure, angina, transient ischemic attack (TIA), and PAD. Male sex was strongly associated (age-adjusted hazard ratios, 3.6-5.0) with incident CVD diagnoses of abdominal aortic aneurysm, MI, and unheralded coronary death (particularly under 60 years). Overall, 51.3% of men and 41.2% of women experienced some form of CVD during their lifetime. For young men, nonfatal MI accounted for 27.9% of events in the 30- to 39-year age group, in contrast to an 11.2% incident rate among similar women. For men under the age of 60 years, the risk for MI of sudden cardiac death was over 4 times higher compared to women of a similar age. These gender differences diminished with age. Rates of angina (stable and unstable) were similar among women and men.


The investigators concluded that most initial presentations of CVD are not MIs or ischemic strokes. Men and women have different rates of CVD presentations. These findings have implications for prevention efforts, risk prediction, and CVD management.


The ability to link large data sets allows for an in-depth examination of current diagnoses to identify patterns of CVD. As the authors suggest, such information can be used to target prevention efforts where they are needed most. However, future efforts must include more diversity in patient populations, if we are going to reduce CVD on a global level.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), SCD/Ventricular Arrhythmias, Acute Heart Failure, Chronic Angina

Keywords: Acute Coronary Syndrome, Angina, Stable, Angina, Unstable, Aortic Aneurysm, Abdominal, Cardiovascular Diseases, Death, Sudden, Cardiac, Heart Failure, Ischemic Attack, Transient, Myocardial Infarction, Peripheral Arterial Disease, Primary Prevention, Risk Factors, Stroke

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