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Cardiovascular Disease

Introduction

Cardiovascular disease (CVD) is the collective term for a group of related conditions affecting the heart, arteries or blood vessels, including coronary heart disease (accounting for about 50%) and stroke (about 25%). It represents a huge burden to patients, to the health services and to the economy. To a large part they are avoidable due to modifiable risk factors.

 

A study in 2009 conducted by the Care Quality Commission, ‘Closing the gap’, reported that up to 90% of the risk of a first heart attack is due to lifestyle factors that can be changed. The combined cost of CVD to the NHS and the UK economy was £30.6 billion. Smoking is one major cause of CVD and the biggest single avoidable cause of death, accounting for 82,000 deaths a year (see Tobacco Control chapter). Obesity is another of the major causes of CVD (see Excess Weight chapter).

 

The Department of Health has recently published ‘Living Well for Longer’, 2014, which is about reducing avoidable, premature mortality caused by the big killer diseases, among which is cardiovascular disease. ‘Premature Mortality’ is death aged less than 75 years and it is hoped that England’s premature mortality will become the lowest among our European peers. It has been shown that we have a long way to go. The Longer Lives website compares premature mortality from overall and specific diseases from similar local authorities. It shows that Bedford Borough is 2nd best out of 15 for premature mortality caused by heart disease and stroke for 2012-14; overall it is 32nd out of 150.

 

CVD is an overarching term that describes a family of diseases (including stroke, heart attack, peripheral vascular disease, chronic kidney disease and diabetes) sharing a common set of risk factors.

 

There are effective interventions that can reduce risk factors, prevalence and deaths from CVD. In addition to medical interventions, people making healthier choices, such as stopping smoking, taking regular physical activity, eating healthier foods, using alcohol in moderation and promptly accessing services can reduce the risk and deaths from CVD.

 

There are variations in the prevalence of CVD across the population that demonstrate inequalities in health, for example in relation to occupational group and ethnicity. Deaths from coronary heart disease are three times higher among unskilled men than among professionals, and around 50% higher in South Asian communities than in the general population.

 

Coronary Heart Disease

Coronary heart disease (CHD) is the failure of coronary circulation leading to lack of blood supply to heart muscle and surrounding tissue. CHD is most commonly linked with coronary artery disease although it can be due to other causes such as spasm of the coronary vessels. It is caused by atherosclerosis within the walls of the arteries that supply the heart muscle resulting in angina pectoris (chest pain) and myocardial infarction (heart attack).


What do we know?

Facts, Figures, Trends 

Prevalence

5,248 (2.97%) of persons registered in Bedford Borough were diagnosed to have CHD and were on the disease register in 2015.  This is similar to the prevalence for Bedfordshire CCG (3.01%).

The observed prevalence for CHD in Bedfordshire CCG was thought to be about 78% of the estimated prevalence indicating about a quarter of the population with CHD have unrecognised or undiagnosed disease.  The estimated CHD prevalence in Bedfordshire CCG was 4.0% compared to 4.6% for England and 4.2% for the comparator CCGs (see Figure 1).

Figure 1 Observed prevalence versus estimated prevalence CHD (2013/14)

CVD Fig 1

Clinical Management

Figure 2 illustrates the percentages of patients with CHD, monitored through recommended care management indicators and the state of the person’s health. There is not a large gap in the results between the Bedfordshire CCG and Bedford Borough.

Figure 2 Primary care clinical management of patients with CHD in Bedford Borough 

CVD fig 2

 

Coronary Heart Disease (CHD) admissions

In 2013/14 the admission rate for CHD in Bedfordshire CCG was 579.5 per 100,000 (2,196 admissions). This is higher than England (559.6 per 100,000) (Figure 3).

 

CVD

Local is Bedfordshire CCG

Source: Cardiovascular disease prolife, 2015

 

Mortality

Premature mortality (before the age of 75 years) due to CHD increases with age and is highest in people in the age group of 64-75 years. Bedfordshire CCG had premature mortality rate of 36.4 per 100,000 (2013). This is a decrease of 50% since 2003 (Figure 4).

Figure 4 Trend of premature mortality due to Coronary Heart Disease, 2003-13

CVD 4

Local is Bedfordshire CCG

SCN is Strategic Clinical Network

 

Stroke

Stroke is due to loss of blood supply to brain cells. This affects the body which are controlled by these brain cells. A TIA (Transient Ischaemic Attack) or a ‘mini stroke’ occurs when a temporary loss of blood supply affects the brain cells and parts of body temporarily for less than 24 hours

The most important modifiable risk factors are high blood pressure and atrial fibrillation and other factors associated with them. These are high blood cholesterol levels, diabetes, smoking (active and passive), heavy alcohol consumption and drug use, lack of physical activity, obesity and unhealthy diet.

 

Facts, Figures, Trends

Prevalence

In 2015, the observed prevalence of stroke was 2,577 (1.50%) in Bedford Borough; it is the same rate as Bedfordshire CCG (1.50%). Estimated prevalence has been calculated, 2013/14, and takes into account age, sex, smoking status and deprivation (Figure 5).

Figure 5 Stroke: observed prevalence versus estimated in 2013/14

CVD 5

Local- Bedfordshire CCG

SCN- Strategic Clinical Network

Source: stroke profile, 2015

 

Clinical Management

Diagnosis and management

Figure 6 shows the diagnosis and management in 2014/15 for Bedford Borough and Bedfordshire CCG. 96.16% of patients who had a stroke in Bedford Borough were taking anti-coagulants out of those considered suitable. This was slightly lower than Bedfordshire CCG (96.4%).

Figure 6 Diagnosis & management for stroke & TIA, 2014/15

CVD 6

Source: QOF, 2014/15

Admissions

In 2013/14 the admission rate for stroke was 134.3 per 100,000 (493 admissions) in Bedfordshire CCG. This was significantly lower than England (174.3). The admission rate for stroke in the CCG decreased by 13.8% between 2003/04 and 2013/14 (Figure 7).

Figure 7 Standardised stroke admission rates for all ages, 2003/04-2013/14

CVD 7

Local is Bedfordshire CCG

Source: stroke profile, 2015

 

Premature mortality

The premature mortality rate due to stroke in Bedfordshire CCG was 12.9 per 100,000 in 2013, Figure 8

Figure 8 Trend of standardised premature mortality from stroke per 100,000, 2003-13

CVD 8

Local is Bedfordshire CCG

SCN is Strategic Clinical Network

Source: stroke profile, 2015

 

Atrial Fibrillation (AF)

In AF, a form of irregular heartbeat, the upper chambers of the heart contract in a fast and irregular way. As a result, blood pools in the heart and this increases the risk of blood clots forming in the heart chambers. These can release tiny embolus and can cause either TIA or ischaemic stroke. Detection and treatment of AF is an effective strategy for the reduction of stroke among those with this condition.

 

Facts, Figures, Trends

In 2014/15, the prevalence of AF recorded was 2,695 (1.57%) in Bedford Borough; Bedfordshire CCG was similar (1.59%).

 

Clinical Management

In 2014/15, Bedford Borough practices had 97.9% of the patients with Atrial Fibrillation were treated with anti coagulants or anti platelets of those who had CHADS2 score greater than 1.

 

Hypertension

Hypertension, or high blood pressure, is a chronic condition in which pressure exerted by the blood on the walls of the arteries rises; the heart then has to work harder to pump blood through the blood vessels.

Most cases are diagnosed as ‘Essential hypertension’ which means that the high blood pressure is with no obvious underlying medical cause. Hypertension is a risk factor for stroke/TIA, heart attacks, heart failure, arterial aneurysm, peripheral vascular disease and is a cause of chronic kidney disease.

 

Facts, Figures, Trends

The observed prevalence of hypertension in 2014/15 was 23,256 (13.5%) in Bedford Borough which was slightly lower than Bedfordshire CCG prevalence of 13.8%.

 

The estimated prevalence and the known incidence in various subgroups of the population are shown in Figure 9. The gap between recognised and actual hypertension levels have been long recognised.

Figure 9 Diagnosed versus Estimated prevalence of Hypertension (2014)

 

CVD 9

 

Clinical Management

In Bedford Borough, 83% of the patients on the hypertension disease register have their blood pressure under 150/90 (Figure 10).

 

Figure 10  The percentage of patients with hypertension in whom the last blood pressure measured in the preceding 12 months is 150/90 or less

CVD 10

Heart Failure

Heart failure (HF), also called congestive heart failure (CHF), is defined as the inability of the heart to pump sufficient blood to meet the requirement of tissues. Common causes of heart failure include myocardial infarction, ischaemic heart disease, hypertension, valvular heart disease and cardiomyopathy. HF is a common, expensive, disabling cardiac condition and patients are rarely seen in the below 45 year age group.

Facts, Figures, Trends

Observed prevalence of heart failure in Bedford Borough is 0.7% for all age groups compared with 0.6% for England, 2014/15.

The expected prevalence in Bedford Borough and England in persons of 45 years and above was thought to be 1.7% and 2.30% respectively (2012). It is forecast nationally that the numbers of HF patients will increase by 20-30% by 2031 mainly due to the demographic changes over that time-period.

Clinical Management

In 2013/14 the admission rate for heart failure all persons was 119.9 per 100,000 (445 admissions) in Bedfordshire CCG. This is higher than England (559.6 per 100,000). The admission rate for heart failure in Bedfordshire CCG has decreased by 34% between 2003/04 and 2013/14 (Figure 11).

Figure 11 Trend for heart failure admissions rate (standardised), for all ages, 2003/04—2013/14

CVD 11

Local: Bedfordshire CCG

Source: Heart disease profile, 2015

 

Multi-morbidity

Multi-morbidity is often defined as the co-existence of two or more long-term conditions in an individual including mental illness. It is the norm rather than the exception in primary care patients, and will become more prevalent as the population of Bedford Borough ages. The prevalence of multi-morbidity increases substantially with age and is present in most people aged 65 years and older.

Figure 12 Emergency admissions: Number of chronic conditions, 2014/15

 

CVD 12

 

People with long-term conditions and co-morbid mental health problems disproportionately live in deprived areas and have access to fewer resources of all kinds. The interaction between co-morbidities and deprivation makes a significant contribution to generating and maintaining inequalities.

Collaborative care arrangements between primary care and mental health specialists can improve outcomes with no or limited additional net costs. An innovative form of liaison psychiatry demonstrated that providing better support for co-morbid mental health needs can reduce physical health care costs in acute hospitals.

 

Abdominal Aortic Aneurysm Screening

An abdominal aortic aneurysm (AAA) is a weakening and expansion of the aorta, the main blood vessel in the body. Large aneurysms are rare but can be very serious. Approximately 3,000 men aged 65 and over in England and Wales die every year from ruptured abdominal aortic aneurysms.

Men aged 65 and over are eligible for AAA screening and the NHS invites men during the year they turn 65. Men over 65 who have not been screened previously can arrange a screening appointment by contacting their local programme directly.

The proportion of men eligible for Abdominal Aortic Aneurysm screening to whom an initial offer of screening is made is recorded; acceptable results are at least 90%. In 2013/14, Bedford Borough the results were 99.7%

 

NHS Health Checks

The NHS Health Check programme is for adults aged 40-74 living without pre-existing CVD including: heart disease, high blood pressure and high cholesterol, diabetes, kidney disease, stroke or vascular dementia. The main components of the NHS Health Check include a cardiovascular risk assessment and individualised support and advice to help patients reduce or manage any potential risks identified. For more detail about the NHS Health Checks programme in Bedford Borough, please click here.

Service provision

 

Cardiology services

Primary care

There are 55 practices in Bedfordshire, all involved in the care of patients with cardiovascular diseases, 27 of these practices are principally providing primary care services to the population residing in Bedford Borough. There are also staff members employed by Bedfordshire Community Health and local Acute Trusts who provide services in the community for people with heart failure rehabilitation, these services are however not provided universally across the county.

Bedford Hospital Trust

Cardiology services at Bedford Hospital include a dedicated coronary care unit in the main ward block, cardiology outpatients and investigations, a cardiac catheterisation and intervention suite and a cardiac rehabilitation service in Beeden House. The department employs over seventy members of staff, including five consultant cardiologists, cardiology specialist nurses, technicians and radiographers.

The department has a cardiac catheterisation suite, which is used for diagnostic angiograms and implantation of pacemakers and coronary interventions. It has close links with Papworth Hospital for cardiothoracic surgery and follow-up and rehabilitation is provided at Bedford Hospital.

Bedford Hospital offers cardiac rehabilitation programmes to patients who have had a heart attack, cardiac surgery and in-house angioplasty. Patients attend an assessment clinic and then booked on to attend eight weekly outpatients’ sessions which includes exercise, relaxation and health education.

Stroke Service

Victoria Stroke Unit at Bedford Hospital is a 15-bedded ward, which includes three-bedded hyper-acute rooms. There is also a day room. The stroke consultant together with a multidisciplinary team, leads the Victoria Stroke Unit. The team is made up of doctors, a stroke specialist nurse, nurses, physiotherapists, occupational therapists, speech and language therapists and dieticians. The team works closely with other professionals such as pharmacists, social workers and community rehabilitation teams.

Cost and implication of Stroke/TIA on health economy

Faster access to better stroke care, each new patient with a stroke costs £15,000 over 5 years (rising to £29,000 if informal care costs are taken into account). Stroke costs the economy about £7 billion a year; £2.8 billion in direct costs to the NHS, £2.4 billion of informal care costs and £1.8 billion in income lost to productivity and disability3

 

Local Views

Cardiology user group Feedback obtained through a group discussion in cardiology workshop held on 21/03/2012:

Drug review: Not enough review of medications prescribed by the treating doctors and clinicians

Gaps in communication:

When patient is released into the community after 8 weeks of rehabilitation;

Lack of support from GPs, patients are not informed adequately about the process of rehabilitation, also not enough published information on cardiology is available;

Whole process of treatment is not explained well to all the patients

There should be more effort to reach out to the patients who do not participate in the treatment process

 

National & Local Strategies (Best Practices):

NICE guidelines:

• The National Institute for Health and Clinical Excellence (NICE) has published guidance on reducing premature deaths from CVD in disadvantaged groups, thereby narrowing the gap in health inequalities. This guidance focuses on primary care practitioners undertaking outreach work, or proactive case finding to identify adults who are at risk and disadvantaged, and identifies prescribing statins and stopping smoking as effective and cost-effective interventions

• Myocardial infarction with ST-segment elevation (2013): available at (www.nice.org.uk/guidance/CG167)

• Stable angina (2011): available at (www.nice.org.uk/guidance/CG126)

• Chronic heart failure (2010): available at (www.nice.org.uk/guidance/CG108)

• Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin (2010): available at (www.nice.org.uk/guidance/CG95)

• Prevention of cardiovascular disease (2010) www.nice.org.uk/guidance/PH25

• CG 68 Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) (2008) (updated Jan 2011) : http://guidance.nice.org.uk/CG68/NICEGuidance/pdf/English

 

National service framework:

• The national service framework for coronary heart disease (NSF CHD), published in March 2000, sets out a strategy to modernise CHD services

• Stroke services are part of the National Service Framework for Older People, published in March 2001

• National service framework (NSF) for coronary heart disease: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/Coronaryheartdisease/Nationalserviceframework/index.htm

 

• The Coronary Heart Disease National Service Framework: Building on excellence, maintaining progress - Progress report for 2008 (online) accessed at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_096555

• NSF: chapter 8: sudden cardiac death: http://www.cardiov.ox.ac.uk/inherited-heart-disease/national-service-framework-chapter-8

• Long term conditions: http://www.dh.gov.uk/health/category/policy-areas/nhs/long-term-conditions/

• NSF standard Five- stroke (last updated 2008): http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Olderpeople/OlderpeoplesNSFstandards/DH_4002292

 

NHS England

In January 2015, NHS England published three new handbooks to support commissioners and practitioners in planning services for people with long term conditions (LTCs), in order to achieve more effective, personalised care for this group. They are case finding and risk stratification, personalised care and support planning and multi-disciplinary team (MDT) working http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/ltc-care/

 

Government policies

Government policy in many areas influences CVD. The policy documents published include (see prevention chapters):

• ‘Living Well for Longer’, 2013, which is about reducing avoidable, premature mortality caused by the big killer diseases, among which is cardiovascular disease.

• Improving quality of life for people with long term conditions (Department for Health, 2013)

• 'Health inequalities: progress and next steps' (DH 2008b)

• 'National stroke strategy' (DH 2007b)

• 'NHS 2010 – 2015: from good to great. Preventative, people-centred, productive' (DH 2009b)

• 'Putting prevention first – vascular checks: risk assessment and management' (DH 2008d)

• 'Tackling health inequalities: 2007 status report on the programme for action' (DH 2008a)

 

What are the key inequalities?

There are variations in the prevalence of CVD across the population that demonstrate inequalities in health, for example in relation to occupational group and ethnicity. Deaths from coronary heart disease are three times higher among unskilled men than among professionals, and around 50% higher in South Asian communities than in the general population.

The Department of Health in 2009 stated, ‘Tackling vascular disease is key to achieving the inequalities target relating to life expectancy. In particular, reducing smoking and increasing the use of statins are two interventions that can rapidly reduce the number of early deaths, especially in disadvantaged groups.’

In 2008-10, the mortality gap between the 20% most deprived and 80% least deprived was 77.7 per 100,000 (standardised) due to cardiovascular disease in aged less than 75 (see Figure 13). This appears to be increasing.

 

Figure 13 Mortality from circulatory disease, aged <75, persons. Bedford Borough

CVD13

Source: Fingertips, Public Health England

 

 

What are the unmet needs/ service gaps?

In those indicators below, the BCCG are in the lower half of 10 demographically similar CCGs or below the England average:

 

· Percentage of patients with a long term condition who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months, 2012/13

Percentage of inactive adults, 2013

Atrial fibrillation observed prevalence compared to expected prevalence, 2012

People with diabetes who had the eight recommended care processes by CCG, 2012/13

Chronic kidney disease (CKD) observed prevalence (2012/13) compared to expected prevalence (2011)

Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less, 2012/13

Percentage of patients with heart failure due to left ventricular systolic dysfunction (LVSD) who are treated with ACE-I / ARB, 2012/13

Percentage of patients with CHD with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken, 2012/13

 

Recommendations

Bedford Borough

Health promotion and community action: Greater public and professional awareness of the problems of cardiovascular disease is needed, including the links between lifestyle factors such as diet and exercise and with disease and disability. In particular, people need to be made more aware of the health benefits of physical activity, eating at least five portions of fruit and vegetables each day, reducing the amount of sodium/salt and reducing saturated fat in the diet. The population should be empowered to identify signs and symptoms of stroke and TIA to seek timely help

 

Bedfordshire Clinical Commissioning Group

Vertical integration of care between primary and secondary care with active involvement of community pharmacist in prevention, medicines management and ongoing care plans

Improve Primary Prevention: The majority of patients who are offered NHS Health Checks can be supported with lifestyle interventions with improved access to physical exercise, smoking cessation and sport activities over and above the current provision particularly for the most vulnerable and disadvantaged. Improve uptake of NHS Health Checks through raising awareness to the population and empowering them to make right decision of accepting the invitation of health checks. Practices should make sure that once they have completed a NHS Health Check that the outcome is recorded

Support GP practices with low detection rate for CVD; improve case-finding of their missing patients and management of patients once identified

Roll out GRASP-AF to identify people with AF who are undertreated with anticoagulation therapy

Education and training:

  • to support delivery of behaviour change interventions for CVD risk reduction in primary care in detection and management of Chronic Kidney Disease primary care to improve detection and management of heart failure including the GRASP-Heart failure audit tool that identifies people with heart failure who are underdiagnosed or under treated

 

Joint Bedford Borough Council & Bedfordshire Clinical Commissioning Group

Improve service model: Bring services closer to home and provide services in integration with primary care, secondary care, social services and other participating agencies. That will provide more choices of location (community or acute) for various interventions with probable increased uptake in services to meet the needs of a greater number of patients

Improve early detection: Detection and treatment of high blood pressure and detection and treatment of Atrial fibrillation to reduce stroke (NSF standard five)

 

This chapter links to the following chapter in the JSNA:

· NHS Health Checks

 

 

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