Battling heart disease in an ageing population

Doing well, but could do bet­ter. That’s the report card on car­dio­vas­cu­lar care in the UK. It is hard to cav­il at data that shows a 36 per cent reduc­tion in deaths from car­dio­vas­cu­lar dis­ease between 2001 and 2010 – by any stan­dards that is an impres­sive result.

“We have seen a fan­tas­tic reduc­tion in car­dio­vas­cu­lar mor­tal­i­ty,” says Pro­fes­sor Huon Gray, nation­al clin­i­cal direc­tor for heart dis­ease at NHS Eng­land. “But the job’s far from being done.”

Car­dio­vas­cu­lar dis­ease still caus­es almost a third of all deaths and an age­ing pop­u­la­tion mul­ti­plies the risks. “By 2022, the 85-plus age group will have increased by 44 per cent and we’ll have near­ly a mil­lion peo­ple liv­ing with heart fail­ure,” says Pro­fes­sor Gray. Ris­ing obe­si­ty, if left unchecked, could chip away at the gains that have been made. The UK still lags behind oth­er Euro­pean coun­tries, and with­in the UK region­al and local inequal­i­ties remain stub­born­ly wide.

A major wor­ry is whether those at high­er risk are being picked up ear­ly enough

 Identifying symptoms

Most of the improve­ments have come from bet­ter con­trol of the risks, which remains the focus of the strat­e­gy launched in 2013. All car­dio­vas­cu­lar dis­eases have a com­mon ori­gin – ath­er­o­scle­ro­sis (fur­ring or stiff­en­ing of the walls of the arter­ies) – so they should be seen as a sin­gle fam­i­ly of dis­eases. Many patients with one dis­ease com­mon­ly suf­fer anoth­er, but this can be missed or care pro­vid­ed in a dis­joint­ed way.

A major wor­ry is whether those at high­er risk are being picked up ear­ly enough. To improve case find­ing, the last Labour gov­ern­ment intro­duced NHS Health Check, which was sup­posed to pro­vide 15 mil­lion adults between the ages of 40 and 74 with a car­dio­vas­cu­lar exam­i­na­tion by their GP. But by 2013 it had reached only a fifth of its tar­get pop­u­la­tion; less than 5 per cent of patients were iden­ti­fied as high risk and of these only a third were get­ting the right treat­ment, accord­ing to a study com­mis­sioned by the Depart­ment of Health.

Pub­lic Health Eng­land relaunched the pro­gramme, ignor­ing crit­i­cisms from the Roy­al Col­lege of Gen­er­al Prac­ti­tion­ers, among oth­ers, that it lacked evi­dence of effec­tive­ness. The Depart­ment of Health reject­ed a sug­ges­tion from the House of Com­mons Select Com­mit­tee on Sci­ence and Tech­nol­o­gy that the Nation­al Screen­ing Com­mit­tee should review the pro­gramme.

Dr Matt Kear­ney, a GP and a nation­al clin­i­cal advis­er to NHS Eng­land, says the pro­gramme is “a legit­i­mate, ratio­nal response” to the prob­lem. “We don’t have the lux­u­ry of wait­ing for 15 years for ran­domised con­trolled tri­als to tell us this is going to work,” he told a West­min­ster Forum sem­i­nar on car­dio­vas­cu­lar ser­vices in July.

GP check ups

One GP who’s not at all sur­prised it hasn’t worked so far is Dr Azhar Farooqi, co-chair­man of Leices­ter City Clin­i­cal Com­mis­sion­ing Group (CCG). “Only 8 per cent of prac­tices achieved the num­bers they were sup­posed to and 22 per cent of prac­tices didn’t do any checks at all. In Leices­ter our per­for­mance was real­ly low,” he says. So the CCG redesigned the scheme with tem­plates to ensure GPs did the right checks and act­ed on them. Instead of invit­ing peo­ple in, GPs did the checks oppor­tunis­ti­cal­ly when a patient of the right age attend­ed for some oth­er issue. £400,000 a year was pro­vid­ed to run the scheme.

This worked a lot bet­ter, he says, with many more patients seen and 13 per cent of them iden­ti­fied as high risk. Over­all a third of patients checked had either high blood pres­sure, dia­betes or a high risk of car­dio­vas­cu­lar dis­ease requir­ing action. But the scheme depends on pub­lic health fund­ing, which comes from local author­i­ties and is not ring-fenced. At least one coun­ty coun­cil has already stopped pay­ments to GPs half way through the finan­cial year.

New guid­ance sug­gests that any­body with a 10 per cent risk of devel­op­ing car­dio­vas­cu­lar dis­ease with­in a decade should be giv­en the option of tak­ing statins. But many with a much high­er risk as a result of an inher­it­ed con­di­tion – famil­ial hyper­c­ho­les­terolemia or FH – remain unde­tect­ed. Of the almost 200,000 esti­mat­ed cas­es in Eng­land, only 15 per cent have been iden­ti­fied.

Although peo­ple dread a heart attack, many don’t realise that the chance of sur­vival is high

This is despite guide­lines being in place since 2008 that show how to do it. It is a genet­ic con­di­tion so when­ev­er a case is iden­ti­fied, close rela­tions should have their DNA test­ed for the gene respon­si­ble, in a process called cas­cade test­ing. “Here we are in 2015 and it’s not hap­pen­ing,” says Dr Peter Weiss­berg, med­ical direc­tor of the British Heart Foun­da­tion. “It’s frus­trat­ing. Spe­cial­ist com­mis­sion­ers said it wasn’t their job because the con­di­tion was too com­mon, while local com­mis­sion­ers said it wasn’t their job either because it was too rare. It fell between two stools.”

Although the foundation’s  job  is sup­port­ing research, not fill­ing in the gaps where the NHS has failed, it has made an excep­tion in this case, co-fund­ing a pro­gramme in Wales, and in 2014 decid­ing to pay for spe­cial­ist FH nurs­es in 13 sites in Eng­land and Scot­land. “We’ve iden­ti­fied 215 cas­es already, although we’ve only just start­ed,” Dr Weiss­berg says. “We aim to show the test­ing scheme is cost effec­tive.”

Chance of survival

Although peo­ple dread a heart attack, many don’t realise that the chance of sur­vival is high – around 90 per cent. Con­fu­sion aris­es because peo­ple con­fuse heart attacks with car­diac arrest, a dif­fer­ent and much more lethal con­di­tion. In a heart attack, blood flow is blocked and heart mus­cle may be dam­aged, but in car­diac arrest the heart stops beat­ing alto­geth­er. Few­er than 10 per cent of peo­ple sur­vive a car­diac arrest that occurs out­side a hos­pi­tal.

Sur­vival is much high­er where more peo­ple are trained in car­diopul­monary resus­ci­ta­tion (CPR) and use it prompt­ly. In pub­lic places the avail­abil­i­ty of defib­ril­la­tors can help, but 80 per cent of car­diac arrests take place at home. Call­ing 999 quick­ly and pro­vid­ing CPR is the best a rela­tion or bystander can do, and it might dou­ble the sur­vival rate. The British Heart Foun­da­tion sup­plies train­ing DVDs and kits to all sec­ondary schools, and aims to train two mil­lion peo­ple a year in CPR. That could save 5,000 lives, says Dr Weiss­berg.

10 ACTION POINTS TO IMPROVE HEART HEALTH IN ENGLAND

Strat­e­gy agreed in 2013 sets out ten key actions to improve car­dio­vas­cu­lar health in Eng­land. But how like­ly are they to be achieved?

1. Improve man­age­ment of car­dio­vas­cu­lar dis­ease (CVD) as a fam­i­ly of dis­eases

This needs new ser­vice mod­els cross­ing pri­ma­ry, acute and com­mu­ni­ty care. NHS Improv­ing Qual­i­ty was sup­posed to be man­ag­ing the process, but it has since been abol­ished.

2. Improve data on risk fac­tors to reduce inequal­i­ties

Health­i­er lifestyles would be a major gain, but the strat­e­gy relies on per­sua­sion and vol­un­tary change by the food indus­try. Tax­es on unhealthy foods are ruled out. This may not be enough, crit­ics say.

3. Improve imple­men­ta­tion of the NHS Health Check

Six years after it began, the Heath Check lacks pro­fes­sion­al buy-in and evi­dence of effec­tive­ness. Poor imple­men­ta­tion so far and the doubt­ful com­mit­ment of local gov­ern­ment make suc­cess a long shot.

4. Improve case-find­ing in pri­ma­ry care

Soft­ware pack­ages can help GPs iden­ti­fy patients at risk, but not all use them. Improve­ment should be pos­si­ble.

5. Improve iden­ti­fi­ca­tion of inher­it­ed car­diac con­di­tions

NHS Eng­land will work with the chief coro­ner to improve process­es for iden­ti­fy­ing inher­it­ed con­di­tions. But is the death cer­ti­fi­ca­tion process in Eng­land up to it?

6. Improve man­age­ment of CVD in pri­ma­ry care

There is plen­ty of scope for recast­ing incen­tives for GPs to man­age care bet­ter. The best already do a good job, so this is more a case of chas­ing up lag­gards and nar­row­ing vari­a­tion.

7. Improve acute care

Train­ing in car­diopul­monary resus­ci­ta­tion or CPR, pro­vid­ing maps show­ing where defib­ril­la­tors are and aware­ness pro­grammes are one leg. The oth­er is pro­vid­ing fast access to the right treat­ment in hos­pi­tals, sev­en days a week.

8. Improve care of those liv­ing with CVD

Reha­bil­i­ta­tion after a heart attack is vari­able and often poor. There is plen­ty of room for improve­ment, but not much clar­i­ty on who will be respon­si­ble for the assess­ments and care plans promised.

9. Improve end-of-life care

Pal­lia­tive care has been large­ly restrict­ed to can­cer patients, but oth­ers could ben­e­fit. Some pio­neer­ing regions have already shown it can help.

10. Improve the use of infor­ma­tion to dri­ve improve­ment

Trans­paren­cy dri­ves improve­ment, the gov­ern­ment believes. If so, plans to make lots more data on qual­i­ty and out­comes pub­lic are a good idea.