Nottingham Insight

Introduction

Cardiovascular disease (CVD) includes coronary heart disease (CHD), stroke and peripheral arterial disease. These conditions are frequently brought about by the development of atheroma and thrombosis (blockages in the arteries).

This chapter covers issues relating to cardiovascular disease risk and overall mortality, CHD and heart failure. Lifestyle risk factors - including physical activity, smoking, diet and nutrition, alcohol - along with stroke, diabetes and obesity are all considered in detail in their own chapters.

Key non-modifiable risk factors for CVD include getting older, being male, or having a family history of CVD. These account for about 14% of the risk for CVD.

Crucially, modifiable risk factors account for 86% of the risk of CVD. This is why tackling premature CVD death is so important in addressing health inequalities and increasing life expectancy. These risk factors include:

• Lifestyle factors: smoking, lack of physical activity, poor diet and nutrition, and higher levels of alcohol consumption;
• Physiological/metabolic risk factors: high blood pressure (hypertension); high blood sugar (diabetes); high blood fats (hyperlipidaemia);
• Poor access to quality primary care, in particular to cholesterol and blood pressure-lowering treatments and smoking cessation services; and
• Wider determinants: poverty, poor housing and education.

Having one cardiovascular condition increases the likelihood of the individual suffering others.

Unmet needs and gaps

Cardiovascular disease (including stroke) is the largest cause of death when all ages are considered, and the second largest cause of death after cancer in people aged under 75 years.

• Coronary heart disease causes 16% of all deaths in both age categories.
• Whilst the rates of premature CVD mortality are declining in Nottingham, the inequality gap between the City and England average remain and the narrowing of the gap has decreased in recent years.
• The CVD mortality rate in the city is significantly higher amongst men than women.
• There is under-detection/diagnosis of important risk factors for CVD, such as hypertension and diabetes, and some CVD conditions, such as heart failure and atrial fibrillation.
• People with severe and enduring mental health problems are at high risk of cardiovascular disease, makes a significant contribution to their shortened life-expectancy.
• The recorded prevalence of coronary heart disease in GP practices is significantly less than the national average and that of comparator cities. 
• There is significant variation in the identification of CHD patients in GP practices, and in the use of optimal drug and other treatments.
• National data shows that people born in South Asia, the Caribbean or East Africa are more likely to die from CVD than the general England population (CHD for South Asians, stroke for people of African Caribbean ethnicity).
• The increased prevalence of diabetes in the Asian population contributes to the increased risk of CHD.
• Men born in Pakistan, Bangladesh and East Africa are more likely to die from CHD than women born in the same countries.
• Qualitative research with middle aged men in areas with higher levels of CVD suggest that men can be resigned to a short life expectancy, disinterested in long term benefits, have low aspirations regarding their life, and therefore are unable or unwilling to change.
• A small scale survey with Asian men suggests that long working hours and perceptions that services are not for men are key barriers to accessing commissioned services.
• Patients with severe and enduring mental disorders are more at risk of having and dying from CVD than the general population due to increased CVD risk factors, poorer access to healthcare and the effect of antipsychotic medication on their metabolism.
• The CVD and CHD mortality rate is significantly higher in the most deprived fifth of the city than in the least deprived. This gap has, however, narrowed over the last decade.
• During 2012-2014 the 4 wards with the highest under 75 CVD mortality rate were Arboretum (highest), Radford & Park, Bridge and Bulwell, none of the wards had statistically significantly higher under 75 CVD mortality rates compared to the city average. Wollaton West had rates significantly lower than the city average. Arboretum also had the highest rate in 2011-2013.
• The prevalence of CHD recorded in Nottingham City GP Practices is significantly less that the national average and in comparable areas, despite the CHD mortality rate being significantly higher than average; this partly reflects the differing age structures of the populations, but also indicates significant under-detection/diagnosis.
• There is wide variation in the proportion of patients at high risk of CVD who are prescribed statin in Nottingham City GP Practices.
• In the Quality and Outcomes Framework, Nottingham City GP Practices performance well in several CHD, Hypertension and Heart Failure domains. But they are significantly worse than the England average with regard to referral of angina patients for exercise testing, recording of cholesterol amongst CHD patients, and the detection of hypertension.
• In 2015/16, 74,834 people were eligible (not already diagnosed as having a cardiovascular condition and aged 40-74 years) for a Health Check. The Health Check programme aims to invite all of those eligible over a five-year period. Two years into the programme, 25,196 people (33.7%) had been invited to take part, short of the intended 40%. Of those invited, 12,412 (49.3% of those invited and just over 16.6% of the entire eligible population) took up the invitation (NHS Health Check, 2015/16, PHE http://fingertips.phe.org.uk/profile/nhs-health-check-detailed/data#page/1/gid/1938132726/pat/6/par/E12000004/ati/102/are/E06000018 ).
• Angiography rates for city patients are significantly lower than the England average showing lower uptake of this diagnostic technique. It is possible that services may be under-utilised by people from Asian and African-Caribbean groups.

Recommendations for consideration

1. Continue the emphasis on the primary prevention of CVD through the NHS Health Checks programme and CVD Prevention Services, particularly the detection of risk factors, including high blood pressure.
2. Address Practice variation in the management of patients identified as being at high risk of CVD through the Health Checks Programme.
3. Nottingham City’s representatives on the committee overseeing the local AAA screening programme should influence the programme to increase uptake in the City, particularly amongst BME communities, and to reduce the rate of non-visualisation at screening.
4. Continue having performance targets for groups most at risk of CVD in the prevention services commissioned by Public Health. Consider revising the geographical targeting of services using more recent statistics and wards as the unit of geography rather than LSOA.
5. Encourage uptake of NHS Health Checks, particularly among those who may be at-risk.
6. Utilise services within the CVD prevention pathway commissioned by Public Health for the secondary prevention and management of CVD as well as primary prevention of CVD and cancer.
7. Include similar performance targets for groups most at risk of CVD, in CVD treatment services commissioned by the Clinical Commissioning Group.
8. Address Practice variation in the identification and management of patients with CHD.
9. Improve the access to CVD prevention interventions and CHD management and interventions for patients with severe and enduring mental health problems. This should include management within primary care.
10. Pending the completion of the research, consider making use of the findings of the Interim Report Increasing the uptake of primary and community long-term conditions services in Black and Minority Ethnic (BME) communities in Nottingham - an exploratory research study, to improve access to long-term conditions services for people from BME communities.
11. The CCG should continue to support a new service for those with Familial Hypercholesterolaemia, in line with recommendations from NICE.
12. Increase identification of patients with atrial fibrillation and, possibly, rates of ablation procedures.
13. Support appropriate uptake of a range of diagnostic procedures in light of the revised pathway for the investigation of chest pain.
14. Heart Failure nurses in the community currently support patients with one type of heart failure (left-sided); there is an outstanding need for a service for those with right heart failure.
15. Increase the uptake and performance of cardiac rehabilitation services.
16. Improve the coverage, uptake, speed and outcomes of cardiac rehabilitation programmes.
17. Encourage service providers to provide more complete data for future national and local audits and consider improvements to care pathways in ways suggested by current audit data.

Rachel.Sokal@nottinghamcity.gov.uk Public Health Consultant, Nottingham City Council

Hazel.Wigginton@nottinghamcity.nhs.uk Assistant Director of Community Services and Integration, Nottingham City CCG