British Journal of General Practice最新文献

{"title":"How do GPs' new ways of working affect community nurses? A qualitative study.","authors":"Louisa Polak, Kristian Pollock, Stephen Barclay, Ben Bowers","doi":"10.3399/BJGP.2024.0534","DOIUrl":"https://doi.org/10.3399/BJGP.2024.0534","url":null,"abstract":"<p><p>Background A growing literature examines the way two changes in primary care - the shift towards remote working, and the diversification of practice teams to incorporate, for instance, physician associates and paramedics - affect patient care within the practice. However, little is known about these changes' effects on community nurses. Aim To explore community nurses' experiences of delivering palliative care in the context of GPs' new ways of working. Design and Setting Qualitative study using focus groups. Method Focus groups were conducted on Zoom with community nurses working in the UK. Data were analysed thematically, using constant comparison. Results Community nurses described extending their roles in palliative care. Alongside pride and satisfaction about this, participants raised several concerns and dissatisfactions, some of which they associated with changes in GPs' ways of working. Two dissatisfactions concerned remote working. First, remote communication with colleagues was seen as creating obstacles to nurses' everyday collaboration with GPs, damaging important working relationships. Second, nurses increased their workload by taking the lead in person-centred care where they saw remote provision by GPs as unsatisfactory. Where workforce diversification led to delegating home visits to paramedics or nurse practitioners, community nurses described feeling a lack of the \"GP back-up\" that many identified as essential for community palliative care. Conclusion When considering and evaluating interventions that change the way GPs work, policy-makers and commissioners should look not only at consequences affecting primary care teams, but also at effects across the complex ecosystem within which these teams operate.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143069615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Practitioner perspectives on symptomatic faecal immunochemical testing: a qualitative interview study.","authors":"Christina Dobson, Adam Biran, Colin Rees, William Hamilton, Christian von Wagner, John Whelpton, Linda Sharp","doi":"10.3399/BJGP.2024.0358","DOIUrl":"https://doi.org/10.3399/BJGP.2024.0358","url":null,"abstract":"<p><strong>Background: </strong>Faecal Immunochemical Testing (FIT) is now core to the management of patients presenting in primary care with symptoms of possible colorectal cancer. Patients with a positive FIT (≥10μg Hb/g faeces) qualify for an urgent suspected cancer referral. FIT negative patients are typically managed in primary care or referred through routine pathways.</p><p><strong>Aim: </strong>To examine practitioners' experiences of delivering symptomatic FIT, identifying perceived benefits, disbenefits and implementation issues, to inform potential future service improvements.</p><p><strong>Design and setting: </strong>Qualitative interview study with primary and secondary care health professionals, from across the UK, involved in delivering symptomatic FIT pathways.</p><p><strong>Method: </strong>30 semi-structured interviews with professionals from a range of specialties. An iterative topic guide informed interviews while allowing freedom to explore novel lines of inquiry. Pseudo-anonymised transcripts were coded and themes identified and developed.</p><p><strong>Results: </strong>Symptomatic FIT was seen to be beneficial for increasing confidence in clinical decision-making and enriching the pool of patients being definitively investigated for colorectal neoplasia. There were varying views on the impact of symptomatic FIT on workload with the burden of additional workload generally seen to be located in primary care. Concerns about current practice included over-use of FIT, burden of investigations in patients with false-positive results and diagnostic delays, for both cancer and benign disease. Uncertainties existed around management of patients with rectal bleeding, appropriate strategies for safety-netting, and the value of repeat FIT.</p><p><strong>Conclusion: </strong>Symptomatic FIT is largely seen as beneficial; however, health professionals would welcome further evidence and guidance around optimal application.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143043416","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"An ethnography of General Practice inpatient discharge summary management for older patients.","authors":"Rachel Spencer, Zakia Shariff, Jeremy Dale, Graeme Currie","doi":"10.3399/BJGP.2024.0284","DOIUrl":"https://doi.org/10.3399/BJGP.2024.0284","url":null,"abstract":"<p><strong>Background: </strong>Post-inpatient discharge is a risky time for older patients, especially those with polypharmacy and multi-morbidity. General practice care at this time, including the processes for managing hospital discharge summaries, lacks standardisation and is of variable quality. Understanding these processes will support the design of interventions and guidance to improve general practice management of the post-discharge period.</p><p><strong>Aim: </strong>Understand and visualise how ongoing care for older people after discharge from hospital is organised in general practice, including the processes for managing discharge summaries.</p><p><strong>Design and setting: </strong>10 practices in the West Midlands, England took part in a rapid ethnography in which we mapped their systems of post-discharge care.</p><p><strong>Method: </strong>Data sources included: informal conversations with staff, practice policies and direct observations of discharge summary handling. Fieldnotes and quotes were subject to an interpretivist framework analysis. A systems modelling technique (FRAM) was used to present visual representations of the professional roles working in these complex systems.</p><p><strong>Results: </strong>Three basic typographies of system emerged based on professional roles: GP led, Pharmacist led and Administrative led. We report on three themes which weave around the FRAM process maps: comfort with demands of administrative role; general practice team dynamics; and interaction with patients.</p><p><strong>Conclusion: </strong>General practice systems for inpatient discharge summary processing are complex and varied. New roles in general practices are being used extensively, often requiring significant input in supervision by GPs. Our findings highlight safety features of different systems and should help practices understand the advantages/limitations of models they work within.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016760","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Development and internal validation of a diagnostic prediction model for life-threatening events in callers with shortness of breath: a cross-sectional study in out-of-hours primary care.","authors":"Michelle Spek, Roderick P Venekamp, Anne A H de Hond, Esther de Groot, Geert-Jan Geersing, Anna Sm Dobbe, Mathé Delissen, Frans Rutten, Maarten Smeden, Dorien Zwart","doi":"10.3399/BJGP.2024.0538","DOIUrl":"https://doi.org/10.3399/BJGP.2024.0538","url":null,"abstract":"<p><strong>Aim: </strong>To develop and internally validate a model predicting life-threatening events for out-of-hours primary care callers with shortness of breath.</p><p><strong>Method: </strong>This cross-sectional study includes data from 1,952 patients with shortness of breath who called out-of-hours primary care between September 2020 and August 2021. Four logistic regression models were developed with life-threatening events as the outcome. We started with a model of age and gender (model 1) and successively added call characteristics (calling at night and someone else calling on behalf of the patient; model 2), symptoms (cough, fever, inability to speak full sentences and wheezing; model 3), and medical history and medication use (cardiovascular and/or pulmonary; model 4). The models were internally validated using optimism correction via bootstrap with 1000 repetitions. Performance measures of discrimination (c-statistic) and calibration (calibration intercept and slope) were determined.</p><p><strong>Results: </strong>Approximately 17% of callers with shortness of breath had a life-threatening event. Model 3 performed best. This model exhibited good discriminative ability (internal validation c-statistic of 0.764 (95% CI: 0.739 to 0.792)) and was well calibrated. All models had a high net benefit compared to using no model. Models 3 and 4 had a higher net benefit compared with models 1 and 2. As models 3 and 4 were similar in terms of net benefit, the model with fewer parameters (model 3) is preferred.</p><p><strong>Conclusion: </strong>A prediction model consisting of age, gender, call characteristics, and symptoms holds promise for improving telephone triage of callers to out-of-hours primary care with shortness of breath.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016838","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Antidepressants and risk of postural hypotension: a self-controlled case series study.","authors":"Cini Bhanu, Kate Walters, Mine Orlu, Daniel Davis, Reecha Sofat, Irene Petersen","doi":"10.3399/BJGP.2024.0429","DOIUrl":"https://doi.org/10.3399/BJGP.2024.0429","url":null,"abstract":"<p><p>Background Antidepressants are associated with postural hypotension (PH), but it is not typically recognised as a common adverse effect. PH is linked with serious complications in older adults (e.g. falls, stroke, cognitive decline). Randomised Controlled Trials (RCTs) examining antidepressants often exclude older people and do not focus on adverse effects. Aim To examine risk of PH associated with antidepressants in adults aged ≥60 in UK primary care. Design & setting Self-controlled case series using routinely collected primary care data from the IQVIA Medical Research Database (IMRD). Method We obtained data from >41,000 adults aged ≥60 in IMRD between 1 Jan 2000 to 31 Dec 2018. Antidepressant prescriptions were determined using code lists based on British National Formulary classification. Risk of PH was examined during four risk-periods (90-days pre-prescription; day 1-28, 29-56, 57+) compared with periods outside these risk windows. Results Amongst 41,005 people with incident PH in the study period, 8,313 were prescribed a selective-serotonin reuptake inhibitor (SSRI); 8,899 were prescribed a tricyclic antidepressant (TCA); and 4,656 were prescribed an \"Other antidepressant\". We observed a consistent increased risk of PH in day 1-28 in all antidepressants, that reduced thereafter. Risk of PH was highest with SSRIs (IRR 4.22, 95% CI: 3.76-4.74), followed by \"Other antidepressants\" (IRR 2.17 (95% CI: 1.76- 2.68), TCAs (IRR 2.12, 95% CI: 1.79-2.50). Conclusion A striking increased risk of PH was observed with all antidepressants in the first month, particularly SSRIs. Prescribers should be aware of this risk and may consider PH monitoring when initiating antidepressants.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016761","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Symptom appraisal and help-seeking before a cancer diagnosis during pregnancy: a qualitative study.","authors":"Afrodita Marcu, Emma Ream, Karen Poole, Jo Armes, Faith Gibson, Lisa Whitaker, Jenny Harris","doi":"10.3399/BJGP.2024.0208","DOIUrl":"https://doi.org/10.3399/BJGP.2024.0208","url":null,"abstract":"<p><p>Background Estimated incidence of cancer diagnosis during or shortly after pregnancy is 1 in 1,000 women. Pregnancy can impact symptom appraisal and help-seeking for symptoms subsequently diagnosed as cancer. Little is known about the pathway to cancer diagnosis in pregnancy or delays that women can encounter. Aim To explore symptom appraisal, help-seeking decisions, and experience of receiving a cancer diagnosis during pregnancy. Design and setting Semi-structured interviews with women diagnosed with cancer during or shortly after pregnancy in the previous four years, recruited between January and May 2022 via the charity Mummy's Star. Method Reflexive Thematic Analysis of 20 interviews. Analysis was largely inductive, and the themes generated were mapped onto the intervals of the Model of Pathways to Treatment. Results Symptoms were often interpreted through the lens of pregnancy by both participants and most of the healthcare professionals from whom they sought help. Participants who found breast lumps were likely to suspect cancer and be referred promptly for tests in secondary care. While most participants sought timely help for their symptoms, some subsequently encountered health system delays, partly due to both the vague nature of their symptoms and the COVID-19 pandemic. Conclusion Health services need to better support women presenting with possible cancer symptoms during pregnancy to ensure timely diagnosis. Recommendations include prioritising symptoms over attributing them solely to pregnancy, ensuring timely referrals to rule out serious conditions, and emphasising clear communication alongside robust safety-netting practices. A full assessment is essential before dismissing symptoms as pregnancy related.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016860","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Identifying people at risk of rheumatoid arthritis in primary care: qualitative study.","authors":"Anna M Anderson, Suzanne Richards, Caroline Flurey, Heidi J Siddle","doi":"10.3399/BJGP.2024.0590","DOIUrl":"https://doi.org/10.3399/BJGP.2024.0590","url":null,"abstract":"<p><strong>Background: </strong>Identification of rheumatoid arthritis (RA) in primary care is challenging and often delayed. Anti-cyclic citrullinated peptide (anti-CCP) antibody testing of people presenting to primary care with new-onset musculoskeletal symptoms without synovitis could help address this; those testing positive are at increased risk of developing RA.</p><p><strong>Aim: </strong>To explore how primary care clinicians currently identify and refer patients with suspected RA, and the behaviours required to implement a prediction model for guiding targeted anti-CCP testing for non-specific musculoskeletal symptoms in primary care.</p><p><strong>Design and setting: </strong>Qualitative descriptive study in primary care in England.</p><p><strong>Method: </strong>Eight GPs and eight Musculoskeletal First Contact Practitioners participated in semi-structured interviews to explore their experiences of identifying/referring patients with suspected RA and their views of a potential implementation package for the anti-CCP prediction model. Data were analysed using framework analysis.</p><p><strong>Results: </strong>Variations in practice were evident across the pathway for identifying/referring patients with suspected RA, including in access to and use of the anti-CCP test. Implementing the anti-CCP prediction model would require clinicians to believe its benefits outweigh its risks, engagement of primary and secondary care teams, and incorporation of the prediction model within an easily accessible and useable clinical decision support system. Participants' views of implementing the anti-CCP prediction model varied but were mostly positive overall.</p><p><strong>Conclusion: </strong>Implementing a prediction model to guide targeted anti-CCP testing in primary care could be feasible. Further research is required to explore the potential benefits, risks, and costs of a pathway for identifying/managing people at risk of RA.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016856","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effectiveness of low-dose amitriptyline and mirtazapine in patients with insomnia disorder with sleep maintenance problems: a randomised, double-blind, placebo-controlled trial in general practice (DREAMING).","authors":"Mette Bakker, Jacqueline G Hugtenburg, Pierre M Bet, Jos W R Twisk, Henriëtte van der Horst, Pauline Slottje","doi":"10.3399/BJGP.2024.0173","DOIUrl":"https://doi.org/10.3399/BJGP.2024.0173","url":null,"abstract":"<p><strong>Background: </strong>Low-dose amitriptyline and mirtazapine are widely prescribed off-label for insomnia disorder. However, evidence from placebo-controlled studies is lacking.</p><p><strong>Aim: </strong>To assess the effectiveness of low-dose mirtazapine and amitriptyline in patients with insomnia disorder.</p><p><strong>Design and setting: </strong>Pragmatic, double-blind, randomised, placebo-controlled trial in general practice.</p><p><strong>Methods: </strong>Patients (18-85 years) with insomnia disorder with sleep maintenance problems for whom non-pharmacological treatment was insufficient were randomised to either mirtazapine (7.5-15 mg/day) or amitriptyline (10-20 mg/day) or placebo for 16 weeks (optional double dose regime in week 3-14).</p><p><strong>Primary outcome: </strong>Insomnia Severity Index (ISI) total score at week 6 (range 0-28, assessed at baseline, 6, 12, 20 and 52 weeks), clinically relevant 'improvement' (>7 points lower than baseline) and 'recovery' (total score ≤10).</p><p><strong>Results: </strong>80 participants were included. At 6 weeks, in the intention-to-treat analyses, mirtazapine and amitriptyline led to statistically significantly lower ISI scores compared to placebo (mean difference -6.0 points, 95% confidence interval -9.0 to -3.1; and -3.4 points, -6.3 to -0.4, respectively). From 12 weeks onwards no statistically significant differences in ISI scores were observed. Mirtazapine, but not amitriptyline, resulted in statistically significantly higher improvement and recovery rates compared to placebo at week 6 (52 and 40 compared to 14%, 56 and 36 compared to 14% respectively).</p><p><strong>Conclusion: </strong>Compared to placebo low-dose mirtazapine provided a statistically significant and clinically relevant reduction of insomnia severity at 6 weeks, but not at later time points. Low-dose amitriptyline resulted in a statistically significant reduction at 6 weeks only which was not clinically relevant.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of an SMS intervention to support type 2 diabetes self-management: DiabeText clinical trial.","authors":"Rocío Zamanillo-Campos, María Antonia Fiol-deRoque, María Jesús Serrano-Ripoll, Joan Llobera-Canaves, Joana María Taltavull-Aparicio, Alfonso Leiva-Rus, Joana Ripoll-Amengual, Escarlata Angullo-Martínez, Isabel María Socias-Buades, Lluís Masmiquel-Comas, Jadwiga Konieczna, María Zaforteza-Dezcallar, María Asunción Boronat-Moreiro, Sofía Mira-Martínez, Elena Gervilla-García, Ignacio Ricci-Cabello","doi":"10.3399/BJGP.2024.0206","DOIUrl":"10.3399/BJGP.2024.0206","url":null,"abstract":"<p><strong>Background: </strong>Complications arising from uncontrolled type 2 diabetes mellitus (T2DM) pose a significant burden on individuals' wellbeing and healthcare resources. Digital interventions may play a key role in mitigating such complications by supporting patients to adequately self-manage their condition.</p><p><strong>Aim: </strong>To assess the impact of DiabeText, a new theory-based, patient-centred, mobile health intervention integrated with electronic health records to send tailored short text messages to support T2DM self-management.</p><p><strong>Design and setting: </strong>A pragmatic, phase-three, 12-month, two-arm randomised clinical trial involving primary care patients with T2DM in the Balearic Islands, Spain, including in urban and rural areas.</p><p><strong>Method: </strong>In total, 742 participants with suboptimal glycaemic control (glycated haemoglobin [HbA1c] level >7.5) were randomly allocated to a control (usual care) or intervention (DiabeText) group. In addition to usual care, the DiabeText group received 167 messages focused on healthy lifestyle and medication adherence. The primary outcome was HbA1c level. Secondary outcomes were: medication possession ratio; health-related quality of life (measured using the EQ-5D-5L questionnaire); diabetes self-efficacy (measured using the Diabetes Self-Efficacy Scale [DSES]); and self-reported adherence to medication, Mediterranean diet (measured using the 14-Item Mediterranean Diet Adherence Screener [MEDAS-14]), and physical activity (measured using the International Physical Activity Questionnaire [IPAQ]).</p><p><strong>Results: </strong>Over the 12-month period, no statistically significant differences in HbA1c were observed between the intervention and the control groups (ß = -0.025 [95% confidence interval {CI} = -0.198 to 0.147; <i>P</i> = 0.772]). In comparison with the control group, the DiabeText group showed significant (<i>P</i><0.05) improvements in self-reported medication adherence (odds ratio = 1.4; 95% CI = 1.0 to 1.9), DSES (Cohen's <i>d</i> = 0.35), and EQ-5D-5L (Cohen's <i>d</i> = 0.18) scores, but not for the rest of the secondary outcomes.</p><p><strong>Conclusion: </strong>DiabeText successfully improved quality of life, diabetes self-management, and self-reported medication adherence in primary care patients with T2DM. Further research is needed to enhance its effects on physiological outcomes.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11755587/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142373623","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Stroke incidence in heart failure and atrial fibrillation: population cohort study.","authors":"Nicholas Robert Jones, Margaret Smith, Sarah Lay-Flurrie, Yaling Yang, Fd Richard Hobbs, Clare Taylor","doi":"10.3399/BJGP.2024.0470","DOIUrl":"https://doi.org/10.3399/BJGP.2024.0470","url":null,"abstract":"<p><strong>Background: </strong>Heart failure (HF) is a risk factor for stroke among people with atrial fibrillation (AF). Prognosis following a HF diagnosis is often poor, but this is not accounted for in existing stroke risk scores.</p><p><strong>Aim: </strong>To examine stroke incidence in people with HF and AF compared to AF alone, considering the competing risk of death.</p><p><strong>Design and setting: </strong>Population-based cohort study.</p><p><strong>Methods: </strong>We identified 2,381,941 people aged ≥45 years in the Clinical Practice Research Datalink (2000-2018). HF and AF were included as time-varying covariates; 69,575 had HF and AF, 141,562 had AF alone and 91,852 had HF alone. We report hazard ratios for first stroke using Cox and Fine and Gray models.</p><p><strong>Results: </strong>Over median follow-up of 6.62 years, 93,665 people (3.9%) had a first stroke and 314,042 (13.2%) died. Over half (51.3%) of those with HF and AF died. In the fully-adjusted Cox model, relative stroke risk was highest among people with AF alone (HR 2.43, 95%CI: 2.38-2.48) than HF and AF (HR 2.20, 95%CI: 2.14-2.26). In a Fine and Gray model accounting for all-cause mortality, the relative risk of stroke was similar for people with AF alone (HR 2.38, 95%CI: 2.33-2.43), but there was significant attenuation among those with HF and AF (HR 1.48, 95%CI: 1.44-1.53).</p><p><strong>Conclusion: </strong>HF is an aetiological risk factor for stroke yet its prognostic significance is reduced by the high incidence of death. Use of the CHA2DS2VASc score may over-estimate stroke incidence in some people with HF, particularly those with a poor prognosis.</p>","PeriodicalId":55320,"journal":{"name":"British Journal of General Practice","volume":" ","pages":""},"PeriodicalIF":5.3,"publicationDate":"2025-01-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142959044","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}