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Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation / EDWARD HARRIS

Swansea University Author: EDWARD HARRIS

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DOI (Published version): 10.23889/SUthesis.58169

Abstract

BACKGROUND Implementation of evidence-based medicine is often suboptimal. The objectives of this thesis are to explore the delivery of evidence-based medicine and outcomes in patients with ischaemic heart disease (IHD) and atrial fibrillation (AF). METHODS Retrospective observational cohort studies...

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Published: Swansea 2021
Institution: Swansea University
Degree level: Doctoral
Degree name: Ph.D
Supervisor: Halcox, Julian ; Gravenor, Mike
URI: https://cronfa.swan.ac.uk/Record/cronfa58169
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first_indexed 2021-10-01T17:13:47Z
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spelling 2021-10-01T18:44:18.5626829 v2 58169 2021-10-01 Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation 5d1ef02be0c0f5035691f2dff922e01d EDWARD HARRIS EDWARD HARRIS true false 2021-10-01 BACKGROUND Implementation of evidence-based medicine is often suboptimal. The objectives of this thesis are to explore the delivery of evidence-based medicine and outcomes in patients with ischaemic heart disease (IHD) and atrial fibrillation (AF). METHODS Retrospective observational cohort studies were conducted using linked anonymised data from the secure anonymised information linkage (SAIL) databank. Patients included (i) those undergoing percutaneous coronary intervention, (ii) patients prescribed vitamin K antagonist (VKA) for AF, and (iii) patients with AF who had undergone successful PCI. RESULTS Amongst patients directed to take clopidogrel for one-year post-PCI, discontinuation was far lower (~6%) than in previous studies where the treatment duration was not known. Despite this, early discontinuation and/or bleeding was associated with an increased risk of adverse events. In a national cohort of PCI patients, we observed a low rate of achievement of international guideline target lipid levels (<25%) and low prescribing of intensive lipid lowering therapy amongst those not at target. Females and patients who had undergone elective PCI were least likely to have their lipid levels documented and be at target. In patients prescribed VKA for AF guideline defined poor anticoagulation control was common and associated with significantly higher bleeding event rates, independent of common comorbidities that are recognised as risk factors for stroke and bleeding. In patients with AF who had undergone PCI outcomes were poor: approximately 1 in 5 had either a stroke, acute coronary syndrome (ACS) or died in the year follow-up. Bleeding events were also common and associated with a five, three and four-fold increased risk of stroke, ACS, and death. CONCLUSION This thesis has characterised the nature of multiple therapeutic gaps and associated adverse outcomes with common clinical conditions. Thus, identifying opportunities to improve outcomes in individual patients and at population level. E-Thesis Swansea Pharmacoepidemiology, ischaemic heart disease, coronary artery disease, atrial fibrillation, antithrombotic, percutaneous coronary intervention 1 10 2021 2021-10-01 10.23889/SUthesis.58169 A selection of third party content is redacted or is partially redacted from this thesis due to copyright restrictions.ORCiD identifier https://orcid.org/0000-0003-4885-637X COLLEGE NANME COLLEGE CODE Swansea University Halcox, Julian ; Gravenor, Mike Doctoral Ph.D 2021-10-01T18:44:18.5626829 2021-10-01T18:02:39.7160213 Faculty of Medicine, Health and Life Sciences Swansea University Medical School - Medicine EDWARD HARRIS 1 58169__21073__e9c828173c124110bd2632d5215e40e9.pdf Harris_Daniel_PhD_Thesis_Final_Redacted.pdf 2021-10-01T18:23:37.3904791 Output 9618783 application/pdf Redacted version - open access true Copyright: The author, Daniel Harris, 2021. true eng
title Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation
spellingShingle Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation
EDWARD HARRIS
title_short Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation
title_full Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation
title_fullStr Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation
title_full_unstemmed Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation
title_sort Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation
author_id_str_mv 5d1ef02be0c0f5035691f2dff922e01d
author_id_fullname_str_mv 5d1ef02be0c0f5035691f2dff922e01d_***_EDWARD HARRIS
author EDWARD HARRIS
author2 EDWARD HARRIS
format E-Thesis
publishDate 2021
institution Swansea University
doi_str_mv 10.23889/SUthesis.58169
college_str Faculty of Medicine, Health and Life Sciences
hierarchytype
hierarchy_top_id facultyofmedicinehealthandlifesciences
hierarchy_top_title Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id facultyofmedicinehealthandlifesciences
hierarchy_parent_title Faculty of Medicine, Health and Life Sciences
department_str Swansea University Medical School - Medicine{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}Swansea University Medical School - Medicine
document_store_str 1
active_str 0
description BACKGROUND Implementation of evidence-based medicine is often suboptimal. The objectives of this thesis are to explore the delivery of evidence-based medicine and outcomes in patients with ischaemic heart disease (IHD) and atrial fibrillation (AF). METHODS Retrospective observational cohort studies were conducted using linked anonymised data from the secure anonymised information linkage (SAIL) databank. Patients included (i) those undergoing percutaneous coronary intervention, (ii) patients prescribed vitamin K antagonist (VKA) for AF, and (iii) patients with AF who had undergone successful PCI. RESULTS Amongst patients directed to take clopidogrel for one-year post-PCI, discontinuation was far lower (~6%) than in previous studies where the treatment duration was not known. Despite this, early discontinuation and/or bleeding was associated with an increased risk of adverse events. In a national cohort of PCI patients, we observed a low rate of achievement of international guideline target lipid levels (<25%) and low prescribing of intensive lipid lowering therapy amongst those not at target. Females and patients who had undergone elective PCI were least likely to have their lipid levels documented and be at target. In patients prescribed VKA for AF guideline defined poor anticoagulation control was common and associated with significantly higher bleeding event rates, independent of common comorbidities that are recognised as risk factors for stroke and bleeding. In patients with AF who had undergone PCI outcomes were poor: approximately 1 in 5 had either a stroke, acute coronary syndrome (ACS) or died in the year follow-up. Bleeding events were also common and associated with a five, three and four-fold increased risk of stroke, ACS, and death. CONCLUSION This thesis has characterised the nature of multiple therapeutic gaps and associated adverse outcomes with common clinical conditions. Thus, identifying opportunities to improve outcomes in individual patients and at population level.
published_date 2021-10-01T04:14:29Z
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