Cardiovascular disease Key contact/author: Dr Veena de Souza, Consultant in Public Health, Buckinghamshire County Council

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1 Cardiovascular disease Key contact/author: Dr Veena de Souza, Consultant in Public Health, Buckinghamshire County Council Introduction Cardiovascular disease (CVD) includes heart disease and stroke. It is the commonest cause of death in Buckinghamshire. Modifiable risk factors such as smoking and obesity are responsible for a large proportion of CVD. Although deaths from CVD have been falling in recent years, risk factors, particularly obesity and diabetes, are increasing rapidly. These factors plus the rise in numbers of older people mean that, without concerted efforts at prevention, the numbers of people having heart attacks and strokes are likely to increase in the future. Much has been done to improve treatment of people with heart disease and stroke. It is important that this continues and services keep up with advances in treatment. Other important areas to focus on are care after discharge from hospital, particularly preventing further heart disease and strokes and supporting independence. Need in the population Who is affected by cardiovascular disease Smoking, physical inactivity, diet (excess saturated fat or salt and not enough fruit and vegetables) and obesity are key modifiable risk factors that have a major impact on the development of CVD. For example, smokers have nearly double the risk of a heart attack compared to people who have never smoked. Similarly being physically inactive approximately doubles heart attack risk as does being obese, and obese people have a three-fold higher risk of stroke. Other risk factors for heart disease and stroke are excessive alcohol consumption, high cholesterol levels, high blood pressure, diabetes, atrial fibrillation (an irregular heart rhythm), transient ischaemic attack (TIA - stroke symptoms that resolve within 24 hours) and previous heart attack or stroke. CVD is more prevalent in men, those who are more socio-economically deprived, certain ethnic groups (mainly South Asian and Black) and people with severe mental health problems or learning disabilities. These are groups that are often harder to reach through prevention initiatives. Numbers affected by cardiovascular disease in Buckinghamshire More than 15,500 people in Buckinghamshire (3.0% of the population) are known to have coronary heart disease (heart attack or angina) and 8,100 (1.6% of the population) have had a stroke or TIA. This compares favourably with the national average of 3.4% and 1.7% respectively. Recorded prevalence rates vary between

2 GP practices from about 2% to 4% for coronary heart disease and from around 1% to over 2% for stroke and TIA. Over 3,500 people in Buckinghamshire died of CVD in 2009 to 2011 (three years), 980 dying of stroke. Death rates from heart disease and stroke are lower than national rates, which is to be expected given our relatively more affluent population. Trends The number of people in Buckinghamshire known by GPs to have coronary heart disease has increased between 2008 and 2012 by 6%. For TIA and stroke the increase was 9%. The mortality from CVD fell between 2001/03 and 2009/11 from 216 per 100,000 to 133 per 100,000 population, a 39% drop. It has fallen slightly faster than nationally (32% drop nationally). The fall in mortality was lowest in the most deprived fifth of our population (28%). For stroke there was a 42% fall in mortality in this time period from 59 to 34 deaths per 100,000, with the lowest reduction (33%) in the most deprived fifth of the population. Emergency admission rates for heart attacks fell from 74 to 57 per 100,000 (23% fall) between 2003/06 and 2009/12, and from 72 to 66 per 100,000 (8% fall) for strokes. Different groups Deprivation quintiles The percentage of patients recorded by GPs as having coronary heart disease is 3.0% in the most affluent fifth of practices in Buckinghamshire and 2.6% in the most deprived fifth. For stroke and TIA the corresponding figures are 1.7% and 1.2% respectively. Although the most deprived fifth has a younger population, the most deprived have a higher death rate from CVD, suggesting that there may be more undiagnosed patients who are not receiving optimal care in these practices. Figure 1 shows that mortality from CVD was 1.7 times higher in the most deprived fifth of the population compared to the least deprived fifth - an absolute gap of 78 deaths per 100,000 population in 2009/11 - and this gap has not changed significantly over eight years. For stroke the gap is 1.2 fold with an absolute gap of six deaths per 100,000 (figure 2).

3 DASR per 100,000 population Figure 1: Trend in mortality from cardiovascular disease in Buckinghamshire Mortality from Circulatory Disease, all ages, by Deprivation Quintile within Buckinghamshire County Year DQ1 DQ5 Buckinghamshire County England Source: ONS mortality data

4 DASR per 100,000 population Figure 2: Trend in mortality from stroke in Buckinghamshire Mortality from Stroke, all ages, by Deprivation Quintile within Buckinghamshire County Year DQ1 DQ5 Buckinghamshire County England Source: ONS mortality data When comparing the most and least deprived fifth of the population, it should be noted that admission rates for heart disease have been falling in the less deprived fifths but this trend is not so obvious in the more deprived (figure 3). The picture is similar for admissions for stroke (figure 4).

5 Figure 3: Trend in emergency admission rates for heart attacks in Buckinghamshire Source: SUS data

6 DASR per 100,000 population Figure 4: Trend in emergency admission rates for stroke in Buckinghamshire Stroke Emergency Person Admissions (Primary Diagnosis), FY 03/04 to FY 11/12, by Deprivation Quintile within NHS Buckinghamshire /04-05/06 04/05-06/06 05/06-07/08 06/07-08/09 07/08-09/10 08/09-10/11 09/10-11/12 Year Source: SUS data DQ1 DQ5 Bucks CCGs (combined) Deaths in people under 75 years of age (premature mortality) Premature mortality (deaths under the age of 75) from CVD fell by 38% between and However in this age group in 2009/11 the mortality rate was three times higher in the most deprived compared to the least deprived fifth of the population with 65 more deaths per 100,000 in the most deprived quintile. This gap has been increasing since 2004/6 when there were 50 per 100,000 more deaths in the most deprived quintile (figure 5).

7 DASR per 100,000 population Figure 5: Trend in mortality from cardiovascular disease in under 75s in Buckinghamshire Mortality from Circulatory Disease, under 75s, by Deprivation Quintile within Buckinghamshire County Year DQ1 DQ5 Buckinghamshire County England Source: ONS mortality data Gender Mortality rates from CVD are much higher in men than women, particularly for under 75s (164 vs 105 deaths per 100,000 respectively for all ages and 71 vs 29 deaths per 100,000 for under 75s). Mortality has been falling at similar rates in men and women. Ethnic group Ethnicity data are not recorded consistently enough on admission to hospital to allow analysis by ethnic group. The future Trends in obesity, diet, physical activity levels and diabetes prevalence are likely to affect future levels of CVD adversely, as is the increasingly ageing population. Although CVD mortality rates appear to be falling in quintiles 2 to 4, the trend appears to have flattened out in the most and least deprived fifths of the population (figure 1).

8 Evidence of what works/good practice Primary prevention There is good evidence that risk factors can be altered both by lifestyle change and, in some cases, medication and that this will reduce an individual s risk of having a heart attack or stroke. Tackling these key risk factors depends on individuals taking personal responsibility for their health and making lifestyle changes, as well as on opportunities and support being provided locally that will encourage, facilitate and support people in doing so. Evidence suggests that NHS Health Checks (see below) will be cost-effective in preventing CVD and diabetes i. Society-wide interventions on physical activity, diet and smoking (such as advertising restrictions) are also important ii. Secondary prevention There is good evidence that for those who already have CVD, lifestyle changes, medication and sometimes surgery can prevent further disease. For example, prompt treatment of people who have had a TIA, including treatment of high blood pressure, can reduce the risk of future stroke by as much as 80% iii. Acute care Research has highlighted, and will continue to highlight, new ways of treating patients with CVD that will reduce ill health and prevent deaths. For heart attacks an example is the use of angioplasty immediately to unblock a blood vessel, thus reducing the amount of damage to the heart. For stroke, rapid thrombolysis (treatment to dissolve blood clots) similarly reduces damage to the brain. Additionally we know that stroke patients cared for on multidisciplinary specialised stroke units have better outcomes iii. Longer-term care Evidence suggests that rehabilitation at home (early supported discharge) increases the number who are able to continue to live at home after a stroke iii. There is evidence that psychological / mood disturbance is associated with higher mortality, disability and health care need iv. Exercise-based cardiac rehabilitation after a heart attack has been shown to reduce heart-related deaths and ill health v. Current services in relation to need Primary prevention The NHS Health Check service is now running in Buckinghamshire, systematically inviting all year olds without known cardiovascular or related disease for assessment and estimation of ten-year risk of having a heart attack or stroke, followed by discussion and, where appropriate, support around reducing their risk. By September 2012 nearly 46,000 people had been invited and over 18,000 received this Health Check.

9 An evaluation of over 9,000 NHS Health Checks between October 2011 and May 2012 showed that many people with modifiable risk factors are being found: 16% were obese and 7.6% had a high blood sugar level. Overall 21% were found to have a 20% or higher risk of having a heart attack or stroke in the next ten years and 80% of those at higher risk were men. It is important that services to facilitate and support lifestyle changes are available to meet the needs of these people. The Health Trainer programme, programmes to tackle obesity, smoking, physical activity, unhealthy eating and excessive alcohol consumption will all prevent CVD and are discussed elsewhere in the JSNA. See the healthy eating and alcohol sections for more information. Much is done in primary care to prevent CVD, including treatment of high blood pressure and atrial fibrillation. GPs are incentivised through the Quality and Outcomes Framework (QOF) payments to encourage optimal treatment. From 2012/13 QOF payments relating to atrial fibrillation will incentivise anticoagulation of those at higher risk of stroke. Secondary prevention Support for lifestyle changes is available to patients who have already had a heart attack or stroke. QOF incentivises GP practices to optimise secondary preventive treatment, such as optimising blood pressure control in people who have had a stroke or TIA. Since June 2011 there are daily TIA clinics for people at high risk of stroke and the majority (92% in August 2012) are now seen and treated within 24 hours. Acute hospital services In June 2011 the stroke unit at Wycombe General Hospital was enhanced to include a hyperacute stroke unit with facilities to thrombolyse stroke patients rapidly 24 hours a day. This covers all patients in Buckinghamshire and many in Berkshire East also. Thrombolysis rates have risen steadily to being among the highest in the country, thus benefiting many more patients. The proportion of patients receiving 90% of their stroke care on a specialist stroke unit has also increased to over 80%. For people with heart problems, emergency angioplasty rates increased four-fold between 2003/6 and 2009/12 to 43 per 100,000 population. Post-hospital care An Early Supported Discharge service for stroke patients started in August 2011, allowing patients to be rehabilitated at home (where patient and carer are agreeable to this). A third of stroke patients are now discharged from hospital to this service. Support after discharge from hospital has been further strengthened through community stroke coordinators, improved information, support to voluntary stroke groups and other initiatives. A cardiac rehabilitation programme is available for patients who have had a heart attack.

10 Patient and public engagement A system for regular engagement with patients and carers in order to improve services is in place, with questionnaire surveys, conferences, a Users and Carers Group which feeds into the local Stroke Network and planned evaluation of new services such as the Expert Stroke Programme, including patient feedback. Unmet needs and service gaps Prevention Evaluation of the NHS Health Check service found that some of the groups with the highest risk of CVD, for example men, people from South Asia, people with severe mental illness or learning disability and smokers may be less likely to attend for Health Checks. It is important that all groups are engaged, not only having health checks but also making lifestyle changes as a result. 80% of those found to be at high risk were men and it is important that support for lifestyle change engages men. As a result of Health Checks a large number of people are being diagnosed with prediabetes (raised blood sugar level but not raised enough for a diagnosis of diabetes). These people have a high risk of heart disease and stroke and there is good evidence that progression to diabetes can be reduced by intensive lifestyle interventions. See the diabetes chapter for more information. Increasing the proportion of patients with AF who are at high risk of stroke who receive anticoagulation treatment will prevent strokes. There is considerable variation between practices in achievement of QOF targets related to prevention of CVD. For example, QOF data show that in Buckinghamshire 76% of patients with high blood pressure had a recent reading of 150/90 or less. The figure varied between practices from 65% to 85%, suggesting room for improvement in some practices. Understanding and reducing the variation between practices should help prevent CVD and reduce progression of CVD in patients who have already had a heart attack or stroke. Acute care There is further room for improvement, for example in the speed with which patients receive clot-busting treatment and specialised care for heart disease and stroke. Post hospital care It is important that psychological illness in people with CVD is identified and treated. Psychological illness is associated with higher mortality and long term disability. vi People with multiple conditions need to be managed effectively and efficiently.

11 Recommendations for consideration by commissioners Ensure that all eligible people are offered NHS Health Checks. Explore the reasons for lower uptake of NHS Health Checks by some of those likely to be most at risk including men, people of South Asian origin, smokers, people with learning disability and those with severe mental illness. Maintain services that support people to make lifestyle changes after Health Checks, ensuring that they can meet the increasing demand and cater for those most at need. Understand and reduce variations between practices in achievement of relevant QOF targets and in exclusions from QOF targets. Continue to monitor acute stroke patient care and reduce time to assessment and treatment. Evaluate the effects of the Early Supported Discharge service and other stroke service changes on outcomes. Improve the recognition of psychological problems and treatment of these among patients with CVD. Ensure services for stroke patients after discharge encourage increased independence and ability to self-manage. Understand the best way to manage patients with multiple conditions so as to maximise outcomes, independence and self-efficacy and optimise resource use. Tailor services to meet the needs of different groups of patients, for example patients and carers from ethnic minority groups. i Kerr, M. (2010) NHS Health Check costs, benefits and savings. NHS Diabetes and Kidney Care, 2010). Available at (Accessed 19 th Dec 2012). ii Integrated commissioning for the prevention of cardiovascular disease. National Institute for Health and Clinical excellence. CMG45, June Available at vd/cardiovasculardisease.jsp (Accessed 19th Dec 2012). iii National Stroke Strategy. Department of Health. March Available at statistics/publications/publicationspolicyandguidance/dh_ (Accessed 19th Dec 2012). iv Psychological Care After Stroke. NHS Improvement. August Available at (Accessed 19th Dec 2012). v Heran BS, Chen JMH, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson D, Taylor R. (2011) Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Collaboration. Available at (Accessed 19th Dec 2012). vi Psychological Care After Stroke. NHS Improvement. August Available at (Accessed 19th Dec 2012).