Despite great strides in cutting the death rate, there is still some way to go in improving the treatment and prevention of heart disease in parts of the UK, writes Nigel Hawkes
The reduction in deaths from cardiovascular disease has been one of the greatest success stories of the past decade. Death rates for coronary heart disease fell in England by 43 per cent between 2001 and 2010, and for stroke by 37 per cent. The figures were even better for premature mortality, with a 46 per cent reduction in death rates from heart disease in those under 75 and a 42 per cent decline in stroke.
Yet cardiovascular disease remains the commonest cause of death, responsible in 2010 for 180,000 deaths in the UK – just under a third of the total – and for 46,000 deaths in people under 75. The burden varies by sex, age, social class and where you live. Death rates in Scotland have fallen more slowly than those in England and remain significantly higher. The relative gap between rich and poor has widened slightly.
And international comparisons, such as the Global Burden of Disease Study published in The Lancet last year, show that although things have got a lot better in the UK, the same is true of other countries, some of which have done better still. Looking at the years of life lost to heart disease, the UK has moved from 17th out of 19 to 14th between 1990 and 2010, a modest improvement in the league table; for stroke, it has moved down one place, from 12th to 13th. It remains below the EU15 average for heart disease and about average for stroke. It is clear that there is more to be done.
Disability has declined along with death, but remains large, imposing a burden on individuals, the NHS and the economy as a whole. A total of 2.3 million people in the UK have coronary heart disease and 1.3 million have had a stroke, the British Heart Foundation estimates. It puts the cost of caring for them at just under £10 billion a year and the total cost at more than £21 billion a year.
FOCUSING ON IMPROVEMENT
How can outcomes be improved? The plan produced by NHS England relies on better detection of those at risk, improved control of risk factors and enhanced organisation of care. The overriding principle is to manage cardiovascular disease as a family of diseases, since patients who have one often develop another, linked by common risk factors: heart disease, peripheral arterial disease and vascular dementia, for example.
Acute care for heart attack and stroke varies widely from excellent to poor
The NHS Health Check programme, which offers tests for all those aged between 40 and 74 without previous evidence of disease, aims to identify those at risk. But take-up has been slow, costs are high and many of those found to be at risk could have been identified anyway through GP records.
Once identified, those at risk are offered advice on lifestyle, diet and exercise; giving up smoking is the single most effective change. But behavioural advice is notoriously hard to follow and tends to widen inequalities, with better-educated people who already have lower risks more likely to comply.
Drugs to reduce blood pressure and blood cholesterol may also be prescribed. Already 7.5 million people are prescribed statins, a number that could increase by a further 4.5 million if the advice from the National Institute for Health and Care Excellence (NICE) to lower the bar to prescribing the drugs is followed. NICE believes this could save an additional 4,000 lives a year at a cost of £52 million. But influential doctors have questioned the wisdom of medicalising so many outwardly healthy people.
High blood pressure is poorly identified and treated, The Lancet study found, with many cases undetected and only around a third of those identified adequately treated. Improving this provides a large scope to improve outcomes
Acute care for heart attack and stroke varies widely from excellent to poor. The plan is to build on what is already good by concentrating care in fewer more specialised centres, a change often opposed by local interests. The reconfiguration of stroke services in London has reduced mortality by 28 per cent by concentrating specialist care in fewer stroke units and is a model commissioners in other parts of the country are being urged to follow.
Some quick wins might come from focusing on areas where services are poor. For example, too little is done to follow up with patients who suffer mini-strokes – transient ischaemic attacks – though one in twenty will go on to have a stroke within a week. And while patients with the most severe heart attacks are already routed by ambulance crews to cardiac centres, this should be extended to less severe cases, avoiding later transfers. Heart failure, increasingly common in an ageing population, has suffered relative neglect. And the UK lags other European countries in its use of implantable defibrillators to control heart rhythm disorders.