Reducing the CVD burden

Cardiovascular disease, including stroke, is the second biggest killer in the UK with 125,445 people dying from CVD in 2021 and 30 per cent of these dying prematurely. An estimated 6.4 million people live with heart disease, with people living in the most deprived areas being four times more likely to die prematurely than those in the least deprived areas.

“Worldwide CVD is the biggest cause of mortality and in the UK it is on a par with cancer,” says Huon Gray, cardiovascular consultant and former national clinical director for heart disease at NHS England. “For many decades the preventable mortality rate for CVD has been falling but in recent years that has stalled and some would argue that it is beginning to increase again.”

It is not just a matter of mortality, he adds, it is also morbidity: CVD can mean people prematurely dropping out of the workforce because of ill health or not being able to do the things they enjoy. That is bad for the individual and for the wider society.

But addressing some of these problems is challenging for an NHS still suffering from the impact of the pandemic. It will mean identifying people at risk of developing CVD or who are in the early stages of the disease as soon as possible, offering them diagnostic tests and then timely treatment. Currently, many people are undiagnosed until the disease has progressed: around 40 per cent of people with heart valve problems are undiagnosed – even though the condition is usually treatable. 

Addressing these challenges also calls for work on prevention and public health to reduce the burden of CVD in the years to come – and that will require investment and education.

According to Professor Gray, lack of awareness of the consequences of CVD among the public is part of the issue. People may know what a heart attack is but may not realise that CVD has other serious consequences such as damage to the brain, heart, kidneys and eyes. This contrasts with cancer where there seems to be greater public awareness and understanding of its implications.

In addition, people may not be aware that what they see as the normal consequences of ageing are actually early signs of CVD and that they should seek help. This misconception can be deadly – early diagnosis is important in CVD and some conditions have startlingly high death rates (severe untreated aortic stenosis has a 90 per cent mortality rate within two years – as bad, if not worse, than many cancers).

“Even if you are in your 80s or 90s aortic stenosis is treatable,” says Professor Gray. “Treatment may give you more years of life but is also likely to improve quality of life. But there is a real tendency for people to think ‘I’m in my 70s so it is not surprising that I can’t go uphill like I used to,’ not realising their exercise limitation is due to a heart condition. One of the challenges is getting people to seek help. A lot of these conditions are very treatable.”

It appeared the UK was getting the upper hand in tackling cardiovascular disease, however in the 2010s performance started to stall with the covid pandemic exacerbating the situation

Cardiovascular disease was a big killer in the 20th century but over the last few decades it seemed the UK was finally getting on top of some of it. Death rates had fallen rapidly – both men and women were half as likely to die of heart and circulatory disease in 2000 as in 1970, once age was adjusted for, and the fall for those under 75 was even more dramatic.

Part of this was better treatment but prevention and early diagnosis were also likely to have played a part.

But this very welcome trend seemed to stutter in the 2010s and there are worrying signs that the fall in age-standardised death rates has not only bottomed out but may have started to rise again: it is also contributing to the slowdown in life expectancy gains in several countries, according to the OECD.

The pandemic is likely to have been a part of this, says Dr Sonya Babu-Narayan, associate medical director at the British Heart Foundation, with its impact on health services coming on top of other challenging trends such as an ageing population. She describes covid as having “broken the pipeline” around CVD.

The BHF calculates there were 30,000 excess deaths just from ischaemic heart disease – caused by narrowing of the arteries – from the start of the pandemic to August 2022. There are likely to have been thousands more from conditions such as heart failure or stroke.

But there was also an impact on other patients who were diagnosed with CVD during or after the pandemic – or who may not even have been diagnosed yet. The people who are now known about represent a “tsunami” of CVD, she warns, “a ticking bomb of increased need.”

The BHF found that 42 per cent of heart patients had put off seeking NHS help and 20 per cent had had an appointment cancelled over the previous year.

Blood pressure was a particular concern with many patients with diagnosed hypertension not having their BP checked. The proportion who were checked fell from 89 per cent in March 2020 to 64 per cent in March 2022, although it has since risen. The proportion “treated to target” – given medications which reduced their BP to within range – also collapsed from 67 per cent to 46 per cent in the first year of the pandemic. Poorly controlled or undiagnosed hypertension is associated with more deaths from heart attacks and strokes.

Some of the changes to the NHS post-covid may also impact on diagnoses. Patients are more likely to have a telephone or video consultation with their GP than before the pandemic – which suits many and may be a better use of the GP’s time. But it does have its limitations.

Heart valve disease is one area where belief that breathlessness is just a consequence of age may have an impact, says Professor Gray, and less face-to-face contact with GPs may result in people with valve disease not being picked up.

“One of the common symptoms of CVD is breathlessness and reduced exercise capacity,” he points out. “You can ask about that over a Zoom call but you can’t listen to the chest and the heart with a stethoscope.” GPs may have had less practice of using a stethoscope to listen to heart murmurs and feel less confident in diagnosing them, he suggests.

Professor Simon Ray, the immediate past president of the British Cardiovascular Society, says of heart valve disease, “for most people it is only detectable by physically listening to the heart or doing an echocardiogram. Opportunities for the detection of heart disease are being missed. Patients are presenting later.”

This can mean their disease has progressed to a point which makes intervention less effective and also more risky, he says.

But for those who do get diagnosed with CVD, the route to treatment may have become more challenging. Waiting lists and times have soared. In July 2023, NHS England had 390,870 patients waiting for cardiology services, only 61.6 per cent of whom were seen within 18 weeks and 12,741 had waited more than 52 weeks. In July 2019, more than 88 per cent were seen within 18 weeks. The waiting list for echocardiography in July 2023 was 161,474 long – the largest number for a non-imaging diagnostic process and close to twice the number of four years earlier.

One of the common symptoms of CVD is breathlessness and reduced exercise capacity…You can ask about that over a Zoom call but you can’t listen to the chest and the heart with a stethoscope”

And for those waiting for transcatheter aortic valve implantation, where a valve which does not function properly is replaced, the waiting list at the 35 tertiary centres which offer this has increased to more than 2,000 – meaning that even when patients have been through the referral and diagnostic processes, they will still face around a three months wait before their procedure is carried out, says Nick Walker, country director of UK and Ireland at Edwards Lifesciences. “The average TAVI patient is 81,” he says. “Sadly, there is a high mortality rate with untreated aortic stenosis. Many will die before treatment.”

Meanwhile, the proportion of TAVIs being carried out on people admitted as an emergency has soared from approximately 10 per cent pre-pandemic to 37 per cent now. The Getting it Right First Time cardiology report has highlighted the huge fall in elective and acute cardiology activity during the peak of the first wave of the epidemic but also suggested ways in which the TAVI pathway could be optimised.

Non-elective TAVI patients – some of whom will have been on the waiting list for months before deteriorating and coming in as an emergency – have an average length of stay in excess of 30 days compared with under three for an elective case, says Mr Walker, “Some hospitals are reporting 50, 60 or even 70 per cent of their TAVI cases as non-electives,” he says. These patients will take longer to recover and will need more health and social care support during this time, he adds.

Part of these delays across the system for all forms of heart treatment is a lack of workforce – many areas have a shortage of people trained in echocardiography for example, and there are fears that community diagnostic centres may simply spread this resource more thinly.

Access to services can be variable – GP and president of the Primary Care Cardiovascular Society Jim Moore points out some areas may have significantly greater number of sub specialist cardiologists per head than others. “There are some areas of the country where there are no specific heart failure consultants and there are others with a similar population where there are two or more,” he says.

Here he suggests cardiac networks could work with integrated care systems to move towards more equitable access both to diagnostics and specialists.

Raj Thakkar, a GP partner in Buckinghamshire who has a particular interest in heart disease, believes integrated care boards do offer a chance to tackle CVD but it may mean demonstrating the links with other key priorities they have such as non-elective admissions, cost and health inequalities. “If we focus on CVD as a system, it may allow us to address some of our major concerns,” he says.

A recent paper showed women, people from Black or South Asian groups and those living in areas of high deprivation were less likely to receive heart valve surgery.

Dr Thakkar points out the cost of not addressing CVD and seeing patients go on to develop complications. If chronic kidney disease reaches the point where someone requires renal replacement therapy, for example, that will cost between £34,000 to £35,000 a year. Identifying those at risk of reaching this point offers potential savings. But it will require leadership to take this long view.

Dr Moore adds: “We can’t address health inequalities without addressing CVD disease and prevention – that is the biggest area of inequality.”

To learn more about the Break Free from CVD toolkit click here

Tackling CVD requires investing in prevention, identifying those who are at high risk of CVD, providing early intervention, optimising diagnostic and theatre capacity, and a long-term commitment from the government

There’s plenty of policy around CVD – but the implementation of it may have fallen short. CVD is in the NHS long-term plan, which was published back in 2019, and also in the more recent major conditions strategy. But it sometimes seems to be given a lesser priority than other serious conditions such as cancer.

“We are very good at making plans and writing reports and saying what should be done but we don’t give anything like the same priority or importance to detailing the implementation of these plans,” says Professor Gray. “What is being put in place to implement changes rather than highlight what needs to be done?”

Some CVD can be prevented by lifestyle changes – not smoking, staying a healthy weight and exercising are obvious aims. But it can be challenging to invest in prevention when the payback time may be one or two decades away and with finances tight. “There’s a huge part of the population who are at risk of CVD over the next five to 10 years and they need to be counselled for lifestyle changes and given medication if appropriate to avoid hospital admissions and deaths,” says Amitava Banerjee, who is vice president of the British Cardiac Society.

In the short term the focus may be much more on picking up those who are at risk or are developing CVD and ensuring there is early intervention. Healthcare practitioners should ensure that “every contact counts” suggests Dr Moore. “We should look on every healthcare encounter as an opportunity beyond what the encounter is based around,” he says. The challenge with this is often time, especially in a 10 or 15 minute consultation. But some appointments – for example blood pressure checks – should always be preceded by a pulse check which may indicate an underlying heart rhythm problem, he says.

Health checks – introduced 15 years ago – could help diagnose some people who are unaware they have either risk factors for CVD. But not all people come forward for these. However, there could also be other opportunities to screen people in mid-life for risk factors such as during vaccination drives.

But the question is what happens then if the GP feels there is a need for further tests? In principle community diagnostic centres should provide additional capacity for some common tests. However, as Dr Moore points out, staffing them may well involve attracting staff from other parts of the NHS such as secondary care which may be moving resources sideways.

However, there are things which can be done to ensure that the diagnostic capacity that is available is used to best effect. A specific blood test - B-type natriuretic peptide or NT-proBNP - can be used to rule out heart failure in some patients, Dr Moore says. But it is not in universal use in heart failure pathways in the UK. In Gloucestershire, where Dr Moore practises, the pathway prescribes that this test has to be done before an echo can be arranged for someone with suspected heart failure. In addition, providing other information with the referral such as a recent ECG can be very helpful, he adds, and getting specialists to triage referrals is an efficient use of resources.

Professor Gray is quick to say that it is not just a matter of money although more resources – including workforce – would help. There is no magic solution to the shortages in some areas and many solutions will take some years to deliver additional staff. Some trusts are training up staff to work as echocardiographers through apprenticeships – hoping that once qualified they will stay working in their organisations.

He is hopeful that AI and other new technologies may help to make the most of the experts the NHS does have by making it easier to diagnose early stage CVD.

A pilot scheme using a digital stethoscope, which records patients’ heartbeats and gives an indication of whether further investigations are needed, has been carried out by community pharmacists, says Mr Walker. It has also been acceptable to patients and can increase opportunistic testing such as when people are picking up medications.

Professor Banerjee calls for joined up care for people with multiple conditions. “We look at each of these conditions in isolation, in silos, and many of our patients who have multiple long-term conditions need [to see] multiple healthcare professionals and resources – to do that in silos is inefficient.”

But there is also a question mark around the capacity of the NHS to provide the treatments people may need once they are diagnosed – this can be cardiac surgery but also TAVI.

If valve disease is treated early in the course of the disease, patients not only do better but can also be less likely to have repeated hospital admissions, says Professor Ray. There will also be some patients who have heart valve disease but not to such an extent they need an operation: these require a follow-up pathway which allows them to be monitored and offered interventions if their condition deteriorates, he adds.

We look at each of these conditions in isolation, in silos, and many of our patients who have multiple long-term conditions need [to see] multiple healthcare professionals and resources – to do that in silos is inefficient

Mr Walker points out that NHS England released interim guidance during the pandemic which encouraged the use of TAVI in low to medium risk patients. TAVIs are a quicker procedure than open heart surgery and, crucially, don’t routinely involve time in an intensive care unit and have, on average, a shorter length of stay. This is good for patients, he says, but could also mean that trusts can treat more patients and keep their costs down.

But the number of TAVIs units do in a day can vary. At James Cook Hospital in Middlesbrough a team recently did 10 in a day, with most of the patients going home on the same day whereas some other units may only manage three. Improving this, together with ensuring that cath lab time is optimised, could increase capacity and cut waiting times, he adds.

In primary care, there are some contractual incentives which could be used. ICBs have a specific target around patients with diagnosed hypertension – getting 77 per cent of them to within target range by March 2024. Local enhanced service payments could be used to incentivise this.

But Dr Thakkar argues colleagues will need tools to improve care and offer early interventions– partly education and also access to information about the patient: currently GPs may not get some relevant information such as the patient’s blood pressure readings from hospital.

Contractual levers could be improved to make them more effective in improving care for patients who are at greatest risk, he says. “Then you can get wholesale change focusing on high-value interventions and dropping some of the low value things.” He points out, for example, the quality and outcomes framework system does not ensure that patients with heart failure are on the highest tolerated doses of drugs, despite the benefits to them.

“How enabled is the system to really focus on the high risk groups? That is the key issue.” He advocates wrapping the care around the individual rather than making patients fit into pathways, with single visits to hospitals and other healthcare facilities to make things easier for them.

But identifying more people will mean more bottlenecks in the system become evident. Dr Thakkar suggests there are ways to lessen this – not repeating tests unnecessarily and thinking carefully about what end of life and frail patients are offered and whether extensive testing or diagnostic tests would really be in their best interests.

And there is a need for a long-term commitment from the government and NHS England. There has been some money for CVD leadership and developing standardised pathways put into ICBs, for example, but this is only guaranteed in the short term.

Dr Babu-Narayan says: “I think if we want value for money we need consistent long-term investment rather than unpredictable boluses of money. To get back on track will take time, innovation and long-term investment in people and resources.”

Across deprived areas of Oxfordshire the ICS is identifying people at high risk of CVD and supporting them to take action

Cardiovascular disease is a high priority for the Buckinghamshire, Oxfordshire and Berkshire West integrated care system and features strongly in its integrated care strategy.

In a relatively affluent area there are still areas of deprivation and groups who are at higher risk of developing CVD and the diseases associated with it. The ICS’s strategy aims to identify those groups and support them to take action.

Narrowing these health inequalities is key to its strategy – including narrowing the gap in life expectancy between the most deprived areas and those with serious mental illness and others, and reducing death rates from CVD among the Black and South Asian population.

But part of narrowing that gap is identifying people at high risk of CVD in the first place. The ICS has been tackling early detection of CVD, building on work done by its predecessor clinical commissioning groups.

In Oxfordshire, several thousand blood pressure monitors have been distributed through GP practices. Starting with some legacy funding from 2018-19 and some money from public health, the initial scheme saw some 4,000 monitors distributed – mainly through practices to patients.

Initially, the distribution concentrated on practices in deprived areas: patients can buy their own monitors from pharmacies but they cost around £30 which may be enough to put off some in “at risk” groups. The first practice to be offered these monitors was in Blackbird Leys, a relatively deprived area in Oxford, but it was then rapidly expanded to 10 and then 20 practices.

“We engaged with 19 or 20 practices that served the most deprived parts of Oxfordshire,” says Ed Capo-Bianco, a Goring-based GP who led on the project while he was a locality clinical director at the CCG. A second tranche of funding from public health allowed another 1,200 to be sent out.

Eventually 88 per cent of Oxfordshire practices became involved. Distribution through community pharmacies was considered but not proceeded with because there may have been a conflict of interest for pharmacies which already sell monitors.

Practices were given a level of discretion over how they distributed the monitors: some loaned them to patients while others gifted them to patients. Patients could respond to text messages to give their blood pressure readings.

Many patients were selected to receive one because they were high risk but their blood pressure levels were unknown or only monitored on the odd occasion when they visited a GP surgery. These might be patients with diabetes or obesity.

The blood pressure monitors were also used for the “health on the move” bus which visited various sites in the county, such as a mosque in Banbury, and offered monitoring. This helped get to some groups which can be seen as “hard to reach”.

Promotional material on the scheme which also explained the importance of keeping a healthy blood pressure were distributed through foodbanks.

Webinars were used to launch the programme with GP practices. “People were slightly hesitant that it might give them more work,” says Dr Capo-Bianco. But once they understood what would be involved, there was general buy in. It also gave them something positive they could offer with patients who could not afford to buy their own monitor.

“In Oxfordshire CVD is one of the main focuses for health inequality, alongside maternity,” he adds.

Feedback from practices suggested the scheme has led to more cases of high blood pressure being detected – and therefore treated.

Some legacy CCG money, together with a contribution from the academic health science network, has been used to equip staff with 50 handheld ECG monitors which will take a basic heart trace and can flag up if the patient may have atrial fibrillation, a major risk factor for strokes.

Patients whose results look abnormal can then be invited for more extensive testing – but some can be reassured that no further action is needed. “It’s a good screening tool. It takes about 20 seconds to run, compared with 20 minutes for a normal ECG,” says Dr Capo-Bianco.

Nick Walker explores the role of community pharmacists in accelerating early detection and timely treatment of heart valve disease

Heart valve disease affects over 1.5 million people over the age of 65 in the UK. While there have been many advancements in the treatment of this disease, far too many people are not being diagnosed and treated early enough before their condition deteriorates. Up to 46 per cent of people with severe aortic stenosis, up to 41 per cent of patients with moderate to severe mitral valve regurgitation and up to 81 per cent of patients with moderate or greater tricuspid valve regurgitation are estimated to be undiagnosed or untreated each year in England.

HVD is often detected in primary care by identification of a heart murmur through cardiac auscultation – a stethoscope check – by a GP. Patients are then commonly referred to secondary care to confirm the diagnosis and its severity with echocardiography.

In recent years, particularly during the covid-19 pandemic, community pharmacy has taken on additional roles with the support of the NHS. With 11,200 community pharmacies in England, 89 per cent of the population can reach one within a 20-minute walk. Local pharmacists using technology such as digital stethoscopes have the potential to increase identification of HVD.

As evidence of this, a recent service evaluation in a community pharmacy highlighted the following:

• Technology can improve the quality of referrals to echocardiography clinics as the pharmacist, using a digital stethoscope to detect HVD, referred 70 per cent more patients with non-trivial HVD than GP practices during the evaluation period.
• Patients were accepting and comfortable with attending a service that checks for murmurs to investigate the presence of HVD by a community pharmacist in the pharmacy setting.
• Technology can support rapid, potentially lifesaving decision-making among HCPs, as rapid sharing of data was not only convenient to patients and the involved HCPs but was also crucial in identifying patients with critical severe AS requiring immediate treatment.

Such a service will inevitably improve outcomes for patients with HVD and save the NHS money and resources through proactive detection and timely treatment.

Nick Walker, country manager UK and Ireland, Edwards Lifesciences

To learn more about this service evaluation please visit Increasing detection of heart valve disease in Farnborough PCN. For more information on the How to Break Free from CVD toolkit, which includes best practice solutions and in-depth case studies click here.