The patient population
Cardiovascular disease (CVD) is a leading cause of premature death and disability. A number of modifiable risk factors are known to impact on people’s risk of developing cardiovascular disease including smoking, poor diet, obesity, high salt intake and sedentary lifestyle. The resulting epidemiology of cardiovascular disease in the UK is well described and summarised by the British Heart Foundation, with annual statistical data on cardiovascular morbidity and mortality.
- from black African or South Asian backgrounds
- with severe mental health problems
- from deprived communities.
There are also marked geographical variations in the incidence of cardiovascular disease. For example there is a 30% higher CVD mortality rate in Scotland compared to the south-west of England. These variations link to differences in risk factors within the population as well as differences in accessing healthcare services. Broadly speaking, mortality and morbidity rates show a north-south divide in the UK with higher rates in Scotland but also parts of Northern Ireland and south Wales.
Age is also a factor with the sustained increase in atrial fibrillation (AF) in older people contributing significantly to stroke disease. There is wide variation in the detection and management of AF in primary care that does not reflect population levels of disease.
The effectiveness of interventions for congenital heart disease means that there is an increasing population of patients surviving into adulthood who need ongoing highly specialised care.
Prevention of disease
There is strong evidence for the effectiveness of primary prevention programmes in reducing the prevalence of risk factors in the population. The approach to assessment and management of risk is described in the Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease and in National Institute for Care and Health Excellence (NICE) guidance.
The key general recommendations are summarised as:
- Use the JBS3 risk calculator to estimate both 10-year risk and lifetime risk of CVD in all individuals except for people with existing CVD or certain high-risk diseases (see below)*
- Non-fasting blood samples should be used to measure:
- total cholesterol and HDL-cholesterol for lipid profile estimates of CVD risk
- non-HDL-cholesterol (calculated as total cholesterol minus HDL-cholesterol). This should be used in preference to LDL-cholesterol as the treatment goal for lipid-lowering therapy
- Some people should have intensive risk factor modification with diet, lifestyle intervention and pharmacological therapy without the need for estimation of CVD risk. These include:
- people with existing CVD
- people at particularly high risk of developing CVD*
- Diet and lifestyle intervention should be recommended to those with high short-term risk and those with increased modifiable lifetime risk (as informed by JBS3 calculator metrics)
- Pharmacological therapy should be recommended to those with high short-term risk and some of those with increased modifiable lifetime risk
- Thresholds for treatment with statins based on 10-year CVD risk will be informed by NICE guidelines.
*People at high risk of developing CVD include those with diabetes age >40, those with chronic kidney disease stages 3-5 and familial hypercholesterolaemia
Primary prevention is partly managed with public health under local authority control as well as in primary care. Services specific to the local population are important to improve uptake. Targeted screening and the NHS Health Check programme are part of a strategy to identify people at high risk and provide an opportunity to identify more vulnerable populations with poor preventive care uptake.
There is a strong evidence base for secondary prevention using lifestyle and pharmacological interventions undertaken through multidisciplinary programmes for people with diagnosed coronary artery disease and/or heart failure. Hospitals play a vital role in identifying and signposting these higher risk patients to appropriate interventions. NICE has published guidance on preventing cardiovascular disease.
Prevention of sudden cardiac death in people with inherited cardiac disease is now possible, linked to case identification (sport pre-participation and family screening) and electrophysiological intervention (ICD implantation) as described in NICE technology appraisal guidance.
Planning effective services
The majority of preventive care in cardiology is based in community and primary care settings and is well described by NICE guidance. Models of effective primary and secondary prevention programmes are described by the British Association of Cardiac Prevention and Rehabilitation Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation.
Regional secondary and tertiary services for adult congenital heart disease (hub and spoke model based around congenital cardiac surgical centres) and inherited cardiomyopathy provide effective care for these groups of patients.
Healthcare planning in cardiovascular disease has been historically enhanced by regional networks that have operated with variable influence since their establishment following the publication of the National Service Framework for coronary heart disease in 2000. More recently, networks covering wider disease spectrums and other collaborative efforts to integrate cardiac care are being established including clinical senates and academic health science networks.
Local commissioning of cardiac services increasingly emphasises collaborative working between primary, secondary and tertiary care.
Access to, and the effectiveness of, secondary prevention programmes are monitored through the National Audit of Cardiac Prevention and Rehabilitation. Similarly, data on variation in elements of cardiovascular healthcare are increasingly available, helping local planning and prioritisation of care pathways.