George, JL; (2013) Gender, Smoking and Blood Pressure and the Initial Presentation of a Wide Range of Cardiovascular Diseases: Prospective Cohort Study in 1.5 Million Patients Using Linked Electronic Health Records. Doctoral thesis , UCL (University College London).

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Abstract

Background: Myocardial infarction (MI) and stroke are the predominant endpoints of large-scale epidemiological research on cardiovascular disease (CVD) in healthy populations. This thesis capitalised on opportunities presented by linked electronic health records (EHR) to investigate the association of risk factors with the initial presentation of a wide range of pathologically diverse CVDs, with a focus on gender differences. Objective: To determine whether gender, smoking and blood pressure have homogeneous associations with the initial presentation of a range of CVDs. Design: Cohort studies using data from the CALIBER research platform linking four data sources (primary care, disease registry, hospitalisation and mortality records) for 1,758,584 patients free from symptomatic CVD registered with 225 UK general practices between 2001 and 2010. Main outcome measures: Initial presentation of CVD with stable angina, unstable angina, MI, heart failure, ventricular arrhythmias, coronary death, stroke, abdominal aortic aneurysm (AAA) and peripheral arterial disease (PAD). Results: 69% of initial presentations of CVD (N=95,267) were neither MI nor stroke. Men had higher rates of all presentations, with age-adjusted gender rate ratios from 1.23 (95% confidence interval 1.19-1.27)) for stroke to 4.27 (3.92-4.65) for AAA. The association of current smoking (compared to non-smoking) varied from an age-adjusted hazard ratio (HR) of 1.01 (0.90-1.13) for arrhythmia to 4.71 (4.15-5.35) for AAA. Gender differences were found only for MI (women: 2.59 (2.37-2.83); men: 2.20 (2.05-2.37)) and AAA (women: 7.00 (5.64-8.70); men: 3.88 (3.33-4.53)). The association of systolic blood pressure was similar across all CVD presentations, excepting AAA, ranging from age-adjusted HR of 1.19 (1.16-1.22) per standard deviation (SD) for heart failure to 1.28 (1.24-1.31) for PAD, with minimal gender differences. Conclusions: Gender, smoking and blood pressure had heterogeneous associations across a wide range of initial CVD presentations. The implications of these findings for public health, clinical practice and research are discussed.

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