Recent estimates suggest that The greater impetus to detect and treat AF has been advocated in clinical guidelines. The purpose of the present analysis was to investigate temporal trends in AF incidence, comorbidities, and mortality in a primary care population representative of contemporary clinical practice.
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Our aim was to gain insight into the future AF population profile and make projections of the likely change in AF prevalence to , in the UK. All patients in the UK are registered with a general practitioner GP. Information comprising patient demography, medical history, medications, hospitalizations, specialist referrals, and clinical events are captured electronically.
UK population data and projections were extracted from reference tables available from the ONS www. Ethics approval for the study was not required because these were secondary analyses of anonymized data. Patients with any type of valvular heart disease or past valve interventions were excluded. The inclusion period was from January 1, to December 31, to ensure availability of corresponding HES data. Only year of birth is provided by the CPRD; therefore, date of birth was assumed as June 15 for age calculation. Prescribed medications at AF diagnosis, including oral anticoagulation OAC and cardiovascular medications, were also recorded.
Baseline demographic and clinical characteristics of the incident AF population are presented as number and percentage, mean SD , or median interquartile range , as appropriate. We prespecified 3 time periods —, —, and — CIs were calculated according to Fay and Feuer.
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Effect of age on incidence is represented by a natural cubic spline and estimated by Poisson regression on the number of AF events on age and the year of diagnosis, with the natural logarithm of person time at risk as offset. The person time at risk per year and age group in each center was provided by the CPRD and was subsequently scaled to the UK proportion in each year.
Trend over years was tested by estimating the linear effect of year, complemented by a likelihood ratio test for reducing from a factorial to linear effect of year. The projection of the prevalence of AF, p ij , at age level i in year j was calculated iteratively based on age level incidence r i and mortality M i as.
Incidence was estimated as described above, whereas mortality rates were extracted from the UK population statistics provided by the ONS in This value was chosen as a conservative representation of previously published data. Person time was censored at the time of transfer out of clinic, the last data transfer from the clinic, or end of study December 31, All statistical analyses were performed using Stata software version Type of AF was not consistently reported.
The incidence of AF increased with age from 0.
Incident AF was greater in men compared to women 1. As expected, older patients had substantially higher mortality: 1. In patients aged 55 to 74 there was a reduction in mortality IRR per calendar year, 0. Sensitivity analyses for mortality all identified similar and consistent results data not shown. Estimated change from in the UK population and numbers of patients with AF in comparison to the predicted United Kingdom population, assuming increased incidence of AF. AF indicates atrial fibrillation. Second, mortality in these older patients has not decreased in line with younger patients with incident AF, despite apparent improvements in management, both pharmacological and interventional.
Third, the projected prevalence of AF based on our data will dramatically increase and pose a considerable public health burden, and even assuming no increase in the incident AF rate, this will still equate to almost 1. Accounting for the increasing incidence of AF, this figure could rise to over 1. The incidence of AF in was CPRD data linkage with hospital records and national epidemiological data provides us with a unique opportunity to assess incidence rates and comorbidity patterns in a sample of patients' representative of general practice in a developed country the UK.
Several studies have validated CPRD data and confirmed the data quality and completeness of the clinical records.
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Three previous analyses have been conducted using general practice data. Analysis of CPRD data captured between and show a temporal increase in incident AF, with a similar pattern over time by age group and sex to our findings. Whereas some are linked to an ageing population, others require further consideration of their impact on clinical management. For example, the increase in diabetes mellitus and hypertension we identified were out of proportion with the increase in age, probably reflecting better diagnosis or changes in prevalence.
Obesity, diabetes mellitus, and the risk of AF are closely related, and diabetes mellitus is both an independent risk factor for incident AF and associated with stroke in AF patients. Indeed, AF and heart failure are closely linked in pathophysiology and the combination is associated with high levels of morbidity and mortality, 33 regardless of ejection fraction. The temporal decrease we observed in ischemic heart disease is compatible with UK national statistics for the general population. With regard to the future prevalence of AF, 4 studies have reported a dramatic increase in projected AF.
As with any data linkage study, we are reliant on accurate coding of diagnoses and have limited capability to interrogate any discrepancy in diagnosis, type of AF, comorbidities, or prescribing data. Nevertheless, CPRD has demonstrated excellent levels of external validity. Data on ethnicity were missing for Given that ethnicity has been shown to influence AF incidence in other studies, this may impact future incidence and prevalence estimates.
Finally, awareness of AF has the potential to impact on incidence in a nonlinear way that would not be accounted for in our incidence and prevalence projections. Conversely, patients with asymptomatic AF may be less likely to come to the attention of their general practitioner, and hence our estimates on incidence and prevalence could be underestimates of the true burden of AF in the community. Projections suggest that between 1. Lane and Lip contributed to the conception and design of the study, acquisition of the data, and obtaining funding.
All authors contributed to the analysis and interpretation of the data, drafting and critical revision of the manuscript for important intellectual content, and supervision and material support. The funder did not participate in the design or conduct of the study, nor did they have access to the data or participate in the data management, analysis, or interpretation, or in the preparation or review of the manuscript, or the decision to submit the manuscript for publication.
J Am Heart Assoc. National Center for Biotechnology Information , U. Published online Apr Deirdre A. Gregory Y. Torben B. Author information Article notes Copyright and License information Disclaimer. Lane, Email: ten. Corresponding author. Received Nov 29; Accepted Jan Published on behalf of the American Heart Association, Inc.
This article has been cited by other articles in PMC. Abstract Background Incidence and prevalence of atrial fibrillation AF are expected to increase dramatically; however, we currently lack comprehensive data on temporal trends in unselected clinical populations. Today, no plague vaccine is licensed by the Food and Drug Administration 8, 11, , A plague vaccine is potentially of interest in countering bioweapon threats , but the previous whole-cell plague vaccine did not adequately protect mice against inhalation challenge with Yersinia pestis bacteria Modern technology may provide an improved plague vaccine containing F1 and V proteins as the principal antigens , , Early successful tests of pneumococcal polysaccharide vaccines occurred at Camp Upton, New York, and Camp Wheeler, Georgia, in — During the s, polyvalent pneumococcal polysaccharide vaccine was tested in five trials in , men at Civilian Conservation Corps camps 5, 8, 13, 14, 17, 82, — In , Frank Horsfall prepared a therapeutic rabbit pneumococcal antiserum.
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Equine or rabbit pneumococcal antiserum was available from several sources as late as 5, 8. Successful clinical trials of pneumococcal vaccine were conducted in military trainees in — at the Sioux Falls Army Air Force Technical School, where a high incidence rate of pneumococcal infections was found 3—5, 13, , Pneumococcal vaccines were not widely prescribed because of greater confidence in another newly introduced drug, penicillin.
The vaccines were voluntarily withdrawn by the manufacturer in , because of lack of acceptance and low sales. Today, valent pneumococcal polysaccharide vaccine is given to asplenic military personnel. On the basis of episodic outbreaks, the vaccine has also been given to selected Marine Corps and special operations trainees; its value in training settings is being evaluated 11, , In , the US government licensed Jonas Salk's inactivated poliovirus vaccine.
In , the first of several formulations of Albert Sabin's oral attenuated vaccine was licensed. One year later, the oral polio vaccine largely replaced the Salk vaccine in the United States 8, Basic training centers switched from injectable vaccine to oral vaccine once the trivalent oral product became available in the early s 10, 11, Several immunizations given to earlier generations of American troops, but no longer used, are worthy of brief mention.
The military immunization experience includes long-term follow-up of laboratory personnel who received multiple common and exotic vaccines , — A formalin-inactivated typhus vaccine was provided primarily to troops serving in Europe during World War II and then in the Korean and Vietnam wars. The vaccine prevented louse-borne epidemic typhus but not murine or scrub typhus.
The microbes, cultured in chicken-embryo yolk sacs and inactivated with formaldehyde, were first licensed for general use in 3—5, 8, 10, — However, subsequent attempts to purify this vaccine resulted in inadequate potency, so immunization eventually gave way to insecticides and antibiotics. Production ceased voluntarily in , and the last batch expired in During the late s, an inactivated tick-borne encephalitis vaccine produced in Austria was administered as an investigational vaccine to certain inspectors enforcing the Intermediate-Range Nuclear Forces Treaty 11, These inspectors regularly visited rural and forested areas of the Soviet Union that are highly endemic for tick-borne encephalitis.
A similar product was used in during the US military deployment to Bosnia 8, 11, , , , In the s, IGIM was used to treat patients deficient in the antibody-rich, gamma-globulin fraction of serum, first described by Colonel Ogden C. His discovery opened new approaches in passive immunization and the diagnosis and treatment of humoral antibody immune deficiencies.
Human hyperimmune globulins largely replaced corresponding equine antisera and antitoxins in the s 8, 10, In the s, Major Mark Fischer, Val Hemming, and their colleagues showed that a polyvalent, high-titer, respiratory syncytial virus immune globulin was effective prophylaxis in infants.
Their work at the Uniformed Services University of Health Sciences established the cotton-rat model of respiratory syncytial virus disease 8, , , Even with the success of immunization in reducing the incidence of the diseases discussed above, the military health system faces the same challenges that the civilian public-health sector does—increasing concerns about vaccine safety and adverse events experienced after immunization.
Vocal objection to military immunization programs occurred with variolation in the s 7, 17 , smallpox and typhoid vaccines in the s 28, 38 , various vaccines in World War II 15 , and anthrax vaccine in the s The military health system that implements immunization programs also has a responsibility to implement safety surveillance programs In recent times, these surveillance programs may be best exemplified by assessments of anthrax vaccine safety and smallpox vaccine safety, where the Department of Defense has been the primary user of these vaccines 29, —, , — A Navy allergist was among the first to recognize the role of gelatin in vaccine-associated anaphylaxis Most vaccines require continuous refrigeration.
A few require storage in a freezer. In World War II, smallpox vaccine was transported by propeller-driven aircraft over long distances, using kerosene-powered refrigerators or packed in dry ice. Improper vaccine storage was one of the principal factors in breakthrough infections. In January , a special shipment of smallpox vaccine was ordered from the US mainland, after doubts arose about the potency of vaccine on the Korean peninsula 27, Today, monitoring devices can record the temperature of vaccine shipments, allowing improperly handled product to be replaced rather than injected.
Documentation of immunizations is important to record a health-care encounter and to avoid redundant immunization at future health-care visits.
Increasingly since the s, the Department of Defense uses electronic immunization tracking systems i. The administration of immunizations to new military personnel is based on several assumptions. First, accession physical examinations establish that trainees comprise a healthy population without underlying conditions known to predispose people to serious adverse effects from immunization e. Second, most trainees are assumed to have been exposed to childhood vaccine antigens through natural infection or childhood immunization programs.
Vaccines with highest priority are those to prevent infections most transmissible in closed settings e. During training, accessions must acquire immunity to multiple infections within a short period of time. Thus, simultaneous immunizations have been provided to tens of millions of trainees since World War II 10, 11, , , , , , Similarly, an Institute of Medicine committee and others found that the evidence favors rejecting a conclusion that simultaneous immunization causes heterologous infection, type-1 diabetes, or other patterns of adverse events. Additional work is needed to identify risk factors that might predispose to rare problems.
Because American adolescents today have a high degree of preexisting immunity, the Department of Defense increasingly uses seroscreening to individualize immunizations according to personal vulnerabilities 11, —, — Training sites are planning to separate immunizations into clusters based on acute versus long-range need. The first cluster would protect against pathogens posing an imminent risk in closed communities e. The second cluster would protect against pathogens posing a threat later in military service e.
watch Additional vaccines can be given later during training.