Scotland has one of the highest mortality rates from coronary heart disease (CHD). Antiplatelet therapy, ß-blockers, statins and ACE inhibitors have been shown to be effective in the secondary prevention of CHD. However, there has been a collective failure of medical practice to achieve the substantial potential to reduce mortality among patients with CHD using secondary preventative measures (EUROASPIRE 2001). Gender and age bias exists in the secondary prevention of CHD (Hippisley-Cox et al., 2001). We wished to determine whether such biases exist in Scottish general practice.

Using 55 continuous morbidity recording (CMR) general practices (n = 365,539), broadly representative of the Scottish population (Milne et al, 1998), the secondary preventative management of CHD within Scotland was determined. CHD patients were stratified by age, gender and deprivation. Of the patients registered in 2002 with the study practices, 14,633 (4%) had a diagnosis of CHD as defined by Read codes, which compares to a prevalence of 5% in a Scottish epidemiological study. The sensitivity of nitrate prescribing for identifying patients with CHD was 66%, which increased incrementally with the addition of statins (81.4%), antiplatelets (92.2%) and ß-blockers (94.7%). Over a 5-year period, the percentage of patients who were reviewed by their doctors in each year for CHD and who were prescribed any secondary preventive therapy in the same year increased from 68.62% in 1995/6 to 95.04% in 2001/2 (standardised against 1995/6 for age and sex). Using binary logistic regression analyses, adjusting for age, sex and deprivation, females with ever CHD (n-6,508) were prescribed significantly fewer ACE inhibitors OR 0.68, CI 0.63,0.73), antiplatelets (OR 0.87, CI 0.81,0.93),ß-blockers (OR 0.83 CI 0.78,0.89) and statins (OR 0.79 CI 0.74,0.84). Women with CHD had higher odds of receiving nitrates (OR 1.17, CI 1.09,1.26), benzodiazepines (OR 2.26, CI 1.95,2.62), and antidepressants (OR 2.15, CI 1.96, 2.35) and had an increased odds of being diagnosed with anxiety (OR 2.29, CI 1.96, 2.68) when compared with their male counterparts. Whilst females without CHD were more likely to be prescribed benzodiazepines this was to a lesser extent than in patients with CHD (OR 1.78, CI 1.68, 1.88). Patients aged 75+ years were more likely to be prescribed an ACE inhibitor (OR 6.49, CI 4.91, 8.56) and antiplatelet therapy (OR 3.18, CI 2.65, 3.95) but were less likely to be prescribed a beta-blocker (OR 0.74, CI 0.60, 0.91) and statin (OR 0.63, CI 0.53, 0.82).

This representative subset of Scottish practices have shown an increasing secondary preventative prescribing for CHD patients demonstrating the accumulation of evidence for the effectiveness of these therapies. Despite this, females with CHD are still under-treated when compared to males, whilst they receive more treatment for anxiety and depression. The sensitivity of nitrate prescriptions for identifying patients with IHD can be increased by the addition of statins, antiplatelets and b-blockers. There is evidence for an age and gender bias in the prescription of important secondary preventative therapies, which could lead to increased mortality in these patient groups.

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Milne RM et al.,(1998) J Epidemiol Commun Healt,. 52(Suppl 1): 20s-24s.