Claire Alexandra Lawson

Background: Individuals with cardiovascular disease (CVD) experienced high mortality during coronavirus disease 2019 (COVID-19), yet most live with multiple long-term conditions (MLTCs). We examined the association between MLTCs burden and mortality following COVID-19 among people with CVD. Methods: In this population-based cohort study, linked national electronic health records from England were analysed. Adults aged ≥18 years with CVD and a positive COVID-19 test between 31 January 2020 and 31 October 2022 were included. MLTCs burden was defined as the number of additional long-term conditions beyond CVD (0, 1, 2, or ≥3). One-year mortality was assessed using adjusted flexible parametric Royston–Parmar models. Results: In 1 081 695 individuals with CVD and COVID-19, 89.7% had at least one long-term condition (LTC) and 67.9% had two or more. Increasing MLTC burden showed a dose–response association with mortality. Compared to individuals without additional LTCs, mortality risk was doubled for those with one LTC (adjusted hazard ratio: 1.86, 95% CI: 1.76–1.96), tripled among those with two LTCs (3.00, 2.85–3.16), and five-fold higher in those with ≥3 LTCs (5.00, 4.75–5.27). Associations were consistent across CVD subtypes. Conclusions: MLTCs burden was a stronger determinant of mortality risk than CVD subtype alone. Findings support moving beyond single-disease models towards integrated, MLTC-informed care, and pandemic preparedness.

Aims: Participation in cardiac rehabilitation (CR) by ethnic minorities is poor, despite evidence supporting its effectiveness. This study evaluated CR participation and completion by South Asian compared with White European service users and assessed factors associated with non-completion in both groups. Methods and results: The National Audit of Cardiac Rehabilitation data (January 2014–February 2023) was used to identify South Asian and White European service users referred for CR following myocardial infarction, percutaneous coronary intervention, and coronary artery bypass graft. Logistic regression and backwards selection were used to examine differences in participation and completion between groups and identify associated factors. Discussion: From 421 281 service users eligible for CR (383 833 White European, 37 448 South Asian, 115 812 women, median age 67 years), 222 928 participated (53%), of which 171 297 (77%) completed. After adjustment for age, sex, index of multiple deprivation, and comorbidities, South Asian service users were 12% more likely to participate in CR than White Europeans [adjusted odds ratio (aOR) 1.12, 95% confidence interval (CI) 1.09–1.15], but 22% less likely to complete (aOR 0.78, 95% CI 0.75–0.82). In both groups, strongest associations with non-completion were higher deprivation, diabetes, and being single. In White European and South Asian men, stroke and depression were also key factors. Non-completion was also associated with respiratory conditions in White Europeans and with rheumatism and family cardiovascular history in South Asian men. South Asians are more likely to participate but less likely to complete CR than White Europeans. Programmes tailored to individual needs are required to reduce disparities in care.

Background: Many patients with heart failure (HF) remain undiagnosed until acute hospital admission for decompensation. Think-HF is a clinical decision support tool (CDST) designed to identify possible undiagnosed HF in primary care and trigger timely, guideline recommended assessment. Methods: Think-HF was developed through epidemiological evidence and codesign. Integrated within SystmOne, it analyses routine primary care data (codes, medications, test results, free text) to detect missed or emerging HF signals. When a record is opened, if a patient has ≥ two comorbidity indicators plus an HF-suggestive symptom, an alert is triggered and a structured template opens with one-click options for natriuretic peptide (NP) testing, echocardiography, specialist referral and coding. Additional algorithms identify unresolved investigations, coding inconsistencies and medication-based signals, generating a marker on the patient’s record. A mixed-methods feasibility study across six primary care practices assessed reach, usability, acceptability, and early implementation signals, using the RE-AIM framework. Results: Six socioeconomically and ethnically diverse general practices participated (63 GPs; 78,640 patients [47.5% women, 59.4% White, 17.8% South Asian, 8.5% Black, 3% Chinese and 2.8% mixed ethnicities]). At baseline, 876 patients (1.1%) met the main alert criteria and 2,805 (3.6%) met additional algorithm criteria. Of 801 patients on the HF register, 665 (83%) lacked a refined HF left ventricular phenotype code. During four months of testing, Think-HF generated 299 clinically relevant main trigger alerts (75% during consultations). Early improvements included (i) 31 new HF diagnoses (+4.2%), with higher gains (+10%) in practices with lower baseline prevalence; (ii) a 14% increase in refined HF phenotype coding; (iii) fewer raised NT-proBNP results without follow-up (−7%); and (iv) fewer patients prescribed loop diuretics without NP testing (−14%, up to −45% in one practice with pharmacist-supported review). Clinicians reported improved awareness, more systematic assessment, and better follow-up of missed investigations or coding anomalies. Identified gaps aligned with patient-reported delays and misattributed symptoms. Conclusions: Think-HF is feasible, acceptable and well aligned with routine primary care workflows. Early gains in diagnostic processes and coding accuracy highlight its potential to improve patient care. Team-based implementation will be essential for scale-up. Larger evaluation is required to assess clinical impact.

Background: Heart failure (HF) is frequently diagnosed during hospital admission, often after symptoms have been present for some time. Those diagnosed in hospital typically experience higher mortality reflecting not only possible diagnostic delay but also greater illness severity at presentation. The reasons behind delayed HF diagnosis are multifaceted and complex. This study aimed to achieve consensus on a priority list of patient, clinical, and service-level factors associated with delayed HF diagnosis, and to identify indicators that could support earlier detection of undiagnosed HF in primary care. Methods: A three-round modified e-Delphi process involved patients and clinicians from primary and specialist care. Participants rated sociodemographic and clinical factors for their importance in delayed HF diagnosis and clinicians also rated service-level factors and identified indicators of undiagnosed HF. Consensus was defined as two-thirds agreement with stable opinions across rounds (McNemar p ≥ 0.05). Indicators of undiagnosed HF required additional ranking in the top 5 by > 50% of clinicians. Results: The first survey was completed by 18 patients (67% women, median age 61) and 27 clinicians (67% nurses/allied health professionals, 33% doctors). Consensus was achieved, comprising 15 factors and 5 indicators. Key sociodemographic factors were patients lacking HF knowledge, lack of access to GP/cardiologist appointments, symptom confusion, younger age (< 50), and learning difficulties. Clinical factors included multimorbidity, respiratory/mental health conditions, obesity, and depression. Service-level factors included poor HF knowledge, limited N-terminal pro–B-type Natriuretic Peptide (NT-proBNP) testing and echocardiogram access in primary care, and fragmented care. The top 5 indicators of undiagnosed HF included elevated NT-proBNP without referral, loop diuretic use, and overlapping cardiac and respiratory histories. Conclusions: This study identifies critical factors and indicators that can aid earlier HF diagnosis in primary care. These indicators could be embedded into electronic health record–based alerts and used to support decision-making in primary care.

Aims: South Asian individuals living outside the Indian subcontinent are under-represented in cardiac rehabilitation (CR), despite facing higher rates of cardiac-related mortality and hospitalizations compared with White ethnic groups. Understanding how cultural differences affect CR participation and completion after referral requires the examination of barriers and enablers specific to South Asian populations. This review aims to summarize evidence on barriers and enablers to CR for South Asian minorities outside the Indian subcontinent. Methods and results: A systematic review of six databases (MEDLINE, CINAHL, APA PsycINFO, Cochrane, Scopus, and Web of Science) was conducted in January 2024 (updated November 2024), with no language or date limitations. Studies from countries outside the Indian subcontinent were included. Barriers and enablers were identified, followed by thematic analysis. Thirteen studies (n = 384 South Asian participants) from the UK (n = 10) and Canada (n = 3) were included. Five key themes were generated: (i) communication and knowledge, (ii) motivation to attend CR or follow medical advice, (iii) religion, (iv) programme delivery, and (v) practical considerations. Key factors influencing CR participation included language barriers, family support, fatalistic beliefs, and motivation. Each theme encapsulates barriers and enablers and shapes participation at both service and patient level. While some barriers were common across different ethnic groups, they had stronger impact on South Asians due to distinct social determinants of health. Conclusion: Barriers and enablers are closely linked to cultural and societal norms. Recognizing these factors enables CR services to better address the needs of underserved populations, ensuring equitable healthcare provision and support. Registration: PROSPERO CRD42023482611

Aims: Heart failure (HF) following acute myocardial infarction (AMI) is a global health concern, but data on risk factors associated with HF hospitalization post-AMI are limited. Methods and results: We analysed data from the Myocardial Ischaemia National Audit Project, including patients admitted with AMI from 1 January 2006 to 31 March 2019. Data linkage with Hospital Episode Statistics Admitted Patient Care and the Office for National Statistics facilitated a longitudinal analysis. High-risk patients were identified using dapagliflozin in patients without diabetes mellitus with acute myocardial infarction (DAPA-MI) and EMPAgliflozin on Hospitalization for Heart Failure and Mortality in Patients With aCuTe Myocardial Infarction (EMPACT-MI) criteria. We assessed clinical outcomes, adherence to European Society of Cardiology quality indicators, and predictors of HF-related hospitalizations. Out of 1 046 480 AMI patients, 9.1% overall, 17.2% in the DAPA-MI cohort, and 16.6% in the EMPACT-MI cohort experienced HF hospitalization within a year post-AMI. High-risk patients, defined by the presence of five risk factors, had nearly one in four hospitalizations with HF at 1-year follow-up. The predicted adjusted incidence rate for heart failure within 1 year almost doubled from 64.5 cases per 1000 person-years [95% confidence interval (CI): 51.1 to 78.0] in 2005, to 118.2 cases per 1000 person-years in 2019 (95% CI: 115.0 to 121.5). Heart failure hospitalization was associated with a three-fold increase in 1-year mortality (hazard ratio 3.01, 95% CI 2.95–3.13). Conclusion: One in 10 AMI patients experienced HF hospitalization within the first-year post-AMI, with rising trends in high-risk subgroups. These findings highlight the need for targeted post-AMI care strategies to improve outcomes and address the increasing burden of HF in the modern percutaneous coronary intervention era.

Background: Health inequalities in cardiovascular care have been identified in the UK. The sociodemographic characteristics of patients undergoing intervention for aortic stenosis (AS) in England, and the impact of COVID-19, is unknown. Methods: National linked data sets identified all surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) for AS, and post-intervention cardiovascular mortality, between 2000 and 2023. Results: Of 179 645 procedures, there were 139 990 SAVR (mean age 71±10.8 years, 64% male, 96.0% white) and 39 655 TAVI (mean age 81±7.7 years, 57% male, 95.7% white). Rates of SAVR declined during COVID-19 for all groups, but TAVI rates increased steadily. Women were older; ethnic minority groups and those from most deprived areas were younger, with greater comorbidities. Women and more deprived groups had lower rates of SAVR (age-standardised rates per 100 000 in 2020–2023: 17.07 vs 6.65 for men vs women; 9.82 vs 10.10 for Index of Multiple Deprivation (IMD)-1 vs IMD-5) and TAVI (20.20 vs 9.79 for men vs women; 9.55 vs 13.36 for IMD-1 vs IMD-5). These discrepancies widened over time. Ethnic differences were observed for SAVR, with the lowest rates in black patients. Cardiovascular mortality post-intervention was lower in female patients and with decreasing deprivation, with no ethnicity-based differences. Conclusions: There are differences in intervention rates for AS in England, with lower rates in female patients and to a lesser extent, those from the most deprived areas and ethnic minority groups. These variations have widened over time. Post-intervention cardiovascular mortality is lower in women and with decreasing deprivation. Public health measures and research are needed to identify the true prevalence of AS in different populations, and the reasons for potential inequalities.

Despite significant progress in cardiovascular pharmacotherapy and interventional strategies, cardiovascular disease (CVD), in particular ischaemic heart disease, remains the leading cause of morbidity and mortality among women in the UK and worldwide. Women are underdiagnosed, undertreated and under-represented in clinical trials directed at management strategies for CVD, making their results less applicable to this subset. Women have additional sex-specific risk factors that put them at higher risk of future cardiovascular events. Psychosocial risk factors, socioeconomic deprivation and environmental factors have an augmented impact on women’s cardiovascular health, highlighting the need for a holistic approach to care that considers risk factors specifically related to female biology alongside the traditional risk factors. Importantly, in the UK, even in the context of a National Health Service, there exist significant regional variations in age-standardised mortality rates among patients with CVD. Given most CVDs are preventable, concerted efforts are necessary to address the unmet needs and ensure parity of care for women with CVD. The present consensus document, put together by the British Cardiovascular Society (BCS)’s affiliated societies, specifically portrays the current status on the sex-related differences in the diagnosis and treatment of each of the major CVD areas and proposes strategies to overcome the barriers in accessing diagnoses and treatments among women. This document aims at raising awareness of the scale of the current problem and hopes to stimulate a multifaceted approach to address sex disparities and enable future comprehensive sex- and gender-based research through collaboration across different affiliated societies within the BCS.

Background: A growing population of patients with chronic kidney disease (CKD) presents with non–ST‐segment–elevation myocardial infarction, although little is known about their longer‐term mortality. Methods and Results: Using the MINAP (Myocardial Ischaemia National Audit Project) registry, linked to Office for National Statistics mortality data, we analyzed 363 559 UK patients with non–ST‐segment–elevation myocardial infarction, with or without CKD. Cox regression models were fitted, adjusting for baseline demographics. Compared with patients without CKD, patients with CKD were less frequently prescribed P2Y12 inhibitors (89% versus 86%, P P P P P P <0.001). There was no significant difference in proportion of deaths attributable to cardiovascular disease at 30 days (CKD; 76% versus no CKD; 76%), or 1 ‐year (CKD; 62% versus no CKD; 62%). Conclusions: Patients with CKD were significantly less likely to receive invasive investigation or undergo percutaneous coronary intervention and had significantly higher risk of short‐ and longer‐term mortality. Risk of mortality increased with reducing CKD stage. Cardiovascular disease was the main cause of mortality in patients with CKD, but at comparable rates to the general population with non–ST‐segment–elevation myocardial infarction.