Coronary heart disease and stroke

4 Coronary heart disease and stroke Overview of cardiovascular disease Cardiovascular disease (CVD), also called circulatory disease, describes a group of diseases which are caused by blockage or rupture of blood vessels. CVD embraces a range of conditions including atherosclerosis (blocked arteries), cerebrovascular disease (stroke), aortic aneurysm (ballooning of the main artery) and peripheral vascular disease (PVD), which usually involves blockage of the blood supply to the legs. (1) The two most important causes of death are coronary (ischaemic) heart disease (CHD) and stroke. The precursors of these include angina (chest pain) and hypertension (high blood pressure). CVD accounts for nearly one third of all deaths in Southwark and over one quarter of premature deaths, under 75 years of age, Figure 4.1. Figure 4.1 Causes of death among people under 75 in Southwark (2004-06) Cardiovascular diseases in Southwark Table 4.1 compares the prevalence of cardiovascular diseases, reported in the Quality and Outcome Framework (QOF) for 2006/2007. The crude prevalence (unadjusted for age) is lower than the national average for all these conditions. This might be due to Southwark s relatively young population, although we cannot exclude the possibility of under diagnosis of this condition. However, the standardised prevalence ratio (SPR), which is adjusted for age, is above average for hypertension and stroke. 20

Table 4.1 Prevalence of CVD in Southwark, 2007 number on GP crude national prevalence in Southwark 95% CI disease register prevalence crude (%) SPR lower/upper limit Hypertension 28565 12.5 (%) 9.8 (%) 146.9 145.2/148.6 CHD 4998 3.6 (%) 1.7 (%) 84.4 82.1/86.8 Stroke/TIA 2591 1.6 (%) 0.9 (%) 105.9 101.9/110.1 Heart failure 1211 0.8 (%) 0.4 (%) Source QMAS 2007 Note: number too small to standardise The Standardised Mortality Ratio (SMR) is the ratio of the number of deaths observed in a specified population to the number that would be expected if that population experienced the same mortality rate, age and sex structure as a reference population (in this case England). A locality with the same death rate as the standard population would have a SMR of 100. The SMR for CVD for men and women aged under 75 years in Southwark is 120. This means the death rate from CVD in Southwark is 20 percent above the national average, Figure 4.2. Figure 4.2 SMR for CVD in males under 75 years of age by ward and ranked according to IMD 2007 score, Southwark Source: LHO, 2001-05 Note: insufficient data Inequalities within Southwark It can be seen from Figure 4.2 that five wards (pale green) had SMRs for men more than 50 percent above the national average. Interestingly Cathedrals and Village wards are not highly ranked for deprivation within the borough, and it is likely that other risk factors are contributing to the elevated SMR observed in here. Figure 4.3 looks at the difference in life expectancy of men and women in Southwark compared with England. For women CVD accounts for 17 percent of the life expectancy gap, and slightly more in men, 20 percent. 21

Figure 4.3 Breakdown of life expectancy gap by disease groups in Southwark Source: LHO, 2008 Figure 4.4 shows that premature mortality as a result of circulatory disease has declined over recent years. It can be seen that the SMRs for Southwark and England are showing signs of converging, indicating that the life expectancy gap for both sexes is narrowing in line with the national health inequalities targets. Figure 4.4 Trend in the directly standardised mortality rates for CVD, >75 years, 1993-2005 Source: LHO, 1993-2005 22

Hospital admissions Cardiovascular disease imposes a considerable demand on acute health services. In the year ending March 2007, there were 2631 registered in-patients accounting for 3577 admissions. As might be expected, Figure 4.5 shows that people aged over 55 years had more admissions, the average stay, for all ages, was nine days. Figure 4.5 CVD inpatient admissions in Southwark, April 2006 March 2007 Source: Dr Foster, 2006/07 Risk factors and inequalities There are a range of physical and lifestyle risk factors associated with CVD. These include high levels of blood fats (lipids which include cholesterol), smoking, raised blood pressure, diabetes, obesity and low rates of physical activity. The two most important modifiable risk factors, are smoking and high cholesterol. (3) Men experience higher rates of angina, heart attacks and stroke, and more severe forms of CVD. Women are at lower risk of CVD than men until after the menopause. (1) There is also a strong association between CVD and social class, ethnicity and age. The elderly, and more socially deprived are doubly disadvantaged generally having greater prevalence of risk factors and lower rates for early detection of cardiovascular problems. (4) This reinforces the argument for better targeting of CVD prevention activity in primary and secondary care. National policy The national policies and strategies concerning the prevention and management of CVD including CHD and stroke include: National Service Frameworks (NSFs) for coronary heart (5, 6, 7) disease, older people, and diabetes. Nationally the Government is committed to reducing the gap in life expectancy between spearhead PCTs and the population as a whole by at least ten percent by 2010; reducing cardiovascular disease mortality by 40 percent by 2010 from its 1997 baseline, as well as decreasing the gap in CVD mortality rates between the national average and the worst fifth of local authorities by 40 percent. Southwark is likely to achieve its life expectancy targets but is only just beginning to close the CVD mortality gap. Action in primary care to reduce deaths from CVD is a priority in order to achieve targets on increasing life expectancy and decreasing cardiovascular disease mortality. (3) Effective measures to reduce premature deaths include smoking cessation, primary prevention of CVD in hypertensives under 75 years, by antihypertensive coverage and statin 23

therapy, as well as secondary prevention of CVD. It is important to target disadvantaged groups and ethnic groups with high prevalence. What we are doing in Southwark? l A well-established multidisciplinary Local Implementation Team (LIT) supports and monitors the implementation of the Coronary Heart Disease NSF in Southwark. l The NSF requires GP practices to develop registers of those patients who are at high risk (i.e. with a 20 percent or more chance of developing CVD over ten years). The register is intended to allow the targeting of prevention and treatment and so reduce or delay the onset of a cardiac event. (8) l In 2006 a locally enhanced service (LES) was developed to promote the identification and management of patients at high risk of developing CVD within the next ten years. l The PCT has a tobacco control and smoking cessation strategy which is delivered through strong partnership working involving the local authority (trading standards and environmental health), education, the smoking cessation team, primary care and community pharmacy services, the Drug Action Team, Healthy Schools and public health. However QOF data for Southwark shows that smoking status is recorded for only 58 percent of 15 to 75 year olds. Coronary heart disease CHD is a condition where the arteries of the heart muscle become narrowed and blocked, starving it of oxygen. CHD manifests as angina and heart attack and is the most common cause of death under 75 years in the UK and Southwark. There were 785 deaths from CHD in Southwark in 2006, nearly one in six of all deaths. (1) Premature deaths in Southwark as a result of CHD are seven percent above the national average for males, and eleven percent above the national average for females. For two decades, in both sexes, there has been a steady decline in the premature deaths due to CHD, Figure 4.6. Although conforming to the general trend it can be seen that the values plotted for males in Southwark fluctuate. Figure 4.6 Trend in mortality for CHD, 1993-2005, aged under 75, males and females, Southwark, London, England Source: LHO, 1993-2005 24

Prevalence of CHD In 2006/07, Southwark GP registers recorded a total of 4,998 patients with CHD, an unadjusted local prevalence of 1.7 percent compared to 3.6 percent nationally, Table 4.1. Even after adjusting for age (standardised prevalence ratio, SPR), the rate remains 15.6 percent below England, which suggests under-diagnosis. Patients with CHD who are not diagnosed are more likely to suffer disease progression and premature death. Figure 4.7 shows that reported CHD prevalence in practices across Southwark varies between 0.2 percent and 5.3 percent. Figure 4.7 Unadjusted prevalence of CHD by practice (2006-07) Inequalities within Southwark Source: QMAS, 2006/07 Figure 4.8 plots the SMR for males aged less than 75 years by individual ward. Three wards plotted in light green The Lane, Livesey and Cathedrals report SMRs around 50 percent above the national rate. As with CVD deaths there is no consistent association between a ward s CHD SMR and the ward rank order for deprivation. Figure 4.8 SMR for CHD among males under 75 years of age by ward and ranked according to IMD 2007 score, Southwark Note: insufficient data Source: LHO, 2001-2005 25

Hospital admissions Hospital admission rates for CHD for Southwark for 2004-6 were approximately 18 percent below the national average. There were 889 admissions in 2006/07, against 596 admissions in 2005/06. Admissions for heart attack were also below national rates, two-thirds of local admissions were men aged 55 to 74 (Dr Foster). Quality of care Performance targets for most Quality and Outcomes Framework (QOF) CHD indicators were achieved by Southwark general practices. Figure 4.9 illustrates practices performance for the control of patients cholesterol, expressed as a percentage of patients with CHD. Exception reported patients A GP practice can exclude a patient from an indicator for a variety of reasons which include: the treatment being clinically inappropriate; the patient not attending or refusing treatment; or the patient only having been diagnosed/registered with the practice very recently. If exceptions are included all but five practices achieve the QOF target of 70 percent for controlling cholesterol (target, 5mmol/L or less), Figure 4.9/top. However, with no exceptions, 17 practices failed to meet the target, Figure 4.9/below. Figure 4.9 Percentage of patients with CHD, with well controlled cholesterol, with and without exceptions, Southwark (2006-07) Source: QMAS, 2006/07 26

Figure 4.10 illustrates practices performance for blood pressure control, expressed as a percentage of patients with CHD (the QOF target is 70 percent of CHD patients with a BP 150/90, or less, measured within the last 15 months). Exception reporting does not greatly affect performance for blood pressure control. All but one practice achieves the 70 percent target with exceptions (4.10/top) and only two do not reach the target with no exceptions. Good control of cholesterol and blood pressure are important in preventing further CVD events in this group of patients. Figure 4.10 Percentage of patients with CHD in whom the last blood pressure reading (measured in the previous 15 months) is controlled with and without exceptions, Southwark (2006-07) Source: QMAS, 2006/07 What is the evidence about risk reduction? In England and Wales, there were 68,230 fewer CHD deaths in 2000 compared with 1981. Fifty-eight percent of the decline has been attributed to reduction in risk factors, particularly a fall in smoking prevalence and the balance to improved medical and surgical treatments. Eleven percent of the decrease in mortality was due to secondary prevention the treatment of risk factors in those who already had CHD. Only four percent was attributable to (14, 15) angioplasty and coronary artery bypass surgery. This reinforces the importance of health promotion initiatives and primary care services for CHD. It also highlights the need for effective use of QOF data relating to diabetes, hypertension and CHD to focus evidence-based interventions that target high-risk groups. 27

What are we doing to address inequalities? l There is close working on smoking cessation and CHD with the Southwark Tobacco Alliance. l There are strong links with the Healthy Southwark Partnership through the obesity strategy group on promotion of healthy diets and physical activity. l K CH and Guy s and St. Thomas Hospital were part of a pilot looking at the use of angioplasty rather than clot busting drugs for the treatment of acute myocardial infraction (heart attack) in appropriate patients. This approach is now being promoted nationally. (15) l A community-based cardiac rehabilitation service has been developed in South Southwark with the aim of improving uptake particularly among women and ethnic groups who may not have accessed the hospital-based service. We are also conducting an equity audit on access to cardiac rehabilitation services. l We are conducting an audit of secondary prevention with Lambeth PCT, K CH and Guy s and St. Thomas in a sample of heart attack patients. l Risk registers are being developed to identify patients at an increased risk of CVD. Stroke A stroke occurs when the blood supply to a part of the brain is suddenly cut off as a result of a blockage or rupture to a blood vessel. The resulting harm to brain cells can leave lasting damage, affecting mobility, cognition, sight or communication. (17) A transient ischaemic attack (TIA) is a minor stroke which is less damaging. It is often an important warning sign of a more serious stroke, heart attack, or other vascular event. The risk of stroke in the first 24 hours after TIA is higher than the risk of a heart attack after an episode of chest pain. (18) The risk of stroke increases with age but the most important risk factor amenable to intervention is hypertension. Other important risk factors include a previous TIA, atrial fibrillation, diabetes, and smoking. (19) Southwark has a high proportion of people from Black ethnic groups, who have stroke rates twice that for White ethnic groups. On average Black people experience their first stroke at 61 years, about twelve years earlier than White people (average first stroke aged 73). (19) Incidence and prevalence of stroke in Southwark There are estimated to be 340 strokes and 170 TIAs per year in Southwark. (21, 22) Stroke is the main cause of adult disability. (18) Applying National Audit Office rates there will be 1,060 people in Southwark with a moderate to severe stroke-related disability. (23) Mortality In Southwark, five percent of all deaths below the age of 75 are stroke-related, Figure 4.1. The risk of premature death from stroke in Southwark is 19 percent above the national average for males and three percent higher for females (2003-5 pooled years data). Fiftythree percent of all stroke deaths were males. (19) Figure 4.11 shows an overall downward trend in the mortality rates reported since 1993. For England and London, locally although the trend is also down, the mortality rate for both sexes fluctuate sharply year-to-year. 28

Figure 4.11 Trends in standardised mortality rates for stroke, <75 years, 1993-2006. Source: NCHOD, 1993-2006 Hospital admissions During April 2006 to March 2007, there were 293 hospital admissions for acute cerebrovascular disease for Southwark residents. Admissions were related to age, with numbers of admissions increasing with age 57 percent were patients aged 65 and over, figure 4.12. Figure 4.12 Hospital admissions for acute cerebrovascular disease by age, 2006-07 Source: Dr Foster, 2006/07 A study of the South London stroke register showed that 26 percent of persons died within 28 days of their stroke, and 37 percent within 180 days. Many survivors are left with a disability such as speech or swallowing problems, mobility problems, cognitive impairment, and mood disorders. In the South London stroke register study, a fifth of patients recovered, but half were left with severe disability as measured using the Barthel Activities of Daily Living index (ADL). Most patients who make a functional recovery do so within 13 weeks of their stroke, but the more severe the stroke the longer the period of recovery. (18) In 2006/7 Southwark GPs recorded 2591 people with stroke on practice registers. This is an unadjusted prevalence of 0.89 percent compared with 1.61 percent nationally (QOF 2007). An estimate based on the Health Survey for England 2003, suggests that Southwark should have 3296 patients. (20) However, the QOF prevalence amounts to 79 percent of this figure. This suggests that there may be under diagnosis or under recording in primary care and hence an unmet need in Southwark. 29

Table 4.2 Comparison of QOF performance on stroke, Southwark GP practices, & England stroke indicator number (n) England Southwark performance (%) QOF Southwark practices and brief description (%) with exceptions no exceptions target (%) not achieving QOF target no exceptions 6 blood pressure check 86.9 82.3 76.0 70 7 7 cholesterol measured 91.5 88.2 82.0 90 33 8 cholesterol level controlled 76.2 72.2 62.1 60 20 11 referred for investigations 93.8 92.9 n/a 80 n/a 12 being treated 94.1 93.9 n/a 90 n/a Notes STROKE 6 % TIA/stroke patients with a last blood pressure reading (within 15 months) below 150/90 STROKE 7 % TIA/stroke patients with total cholesterol measured in the last 15 months STROKE 8 % TIA/stroke patients with total cholesterol measured (within 15 months) of 5 mmol/l or less STROKE 11 % new stroke patients referred for further investigation STROKE 12 % patients with a stroke shown to be non-haemorrhagic, or a history of TIA, taking anti-platelet, or anti-coagulant (unless contra-indication/side-effects recorded) Primary care service provision related to stroke in Southwark The quality of care a patient receives in primary care has a direct impact on their risk of developing a stroke or other cardiovascular event. For patients who have had a TIA or stroke correct treatment by primary care can reduce future risk. Table 4.2, summarises data in respect of five key indicators for stroke as reported within general practice QOF returns. If exception reported patients are excluded (see p26) on average Southwark practices meet the target for all but one indicator, STROK E 7 recording of cholesterol level, achieving 88 percent against a 90 percent target. However with no exceptions in the analysis, a number of practices failed to meet STROK E 6, 7 and 8 Targets and the results for two further indicators: referral for investigation (STROK E 11), and prescription of anti-coagulant drugs (STROK E 12) are incomplete so no conclusions can be drawn. Evidence of what works for stroke and TIA There is consistent evidence that the following interventions reduce stroke risk: l managing hypertension so systolic blood pressure is below 140 mmhg; l warfarin for individuals with atrial fibrillation; l statin therapy for all people with more than 20 per cent risk of cardiovascular disease within ten years; and l smoking cessation for all individuals who have had a stroke or TIA. (17) Thrombolysis (clot busting drugs) if started within 3 hours of onset of a non-haemorrhagic stroke reduce the risk of death and disability. (14) Stroke units reduce death and disability through the delivery of high quality, well coordinated multidisciplinary care and rehabilitation. (31) 30

Policy l Standard 5 of the Older People NSF identifies milestones to focus on the development of specialised stroke services; primary care protocols for risk management; and referral and treatment of TIA. (24) l The National Stroke Strategy (DH, 2007) provides a quality framework for the development of stroke services in England over the next ten years. (17) l ASSET is an evaluation toolkit to help NHS commissioners deliver high quality stroke services. (25,26) l Both the Government s 2005 White Paper on health and social care, Our health, our care, our say and the Commissioning Framework for Health and Well-being emphasise the need to include those who have had a stroke in discussions about commissioning their (27, 28) care. What are we doing to address inequalities? Southwark Integrated Stroke Pathway Guy s and St. Thomas Charity funded a major programme to support the improvement of stroke services across Southwark and Lambeth (Stroke Modernisation Initiative). The project was driven forward by a partnership across Southwark and Lambeth PCTs, K CH and GSTFT, as well as users. A number of new initiatives have resulted: l Public awareness campaign on hypertension, clinical and organisational and changes in primary care to improve the detection and management of hypertension (in the most culturally diverse/deprived area in Southwark). l Introduction of thrombolysis drugs for patients whose stroke is caused by a clot; an acute response service to improve the early management of stroke; and better access to specialist TIA clinics, which has reduced waiting times by 14 days. (29) l The redesign of community therapy services has improved the handover of care from hospital to community services. Initiatives include: better discharge planning; intensive rehabilitation at home; and regular review by a multidisciplinary team, including specialist stroke consultants. 31

Coronary heart disease and stroke summary l CVD accounts for one third of all deaths and one quarter of premature deaths l the mortality rate for CVD is higher than the national average and rates are particularly high in some parts of Southwark l the age adjusted prevalence for CHD is low, indicating underdetection of the condition. Recommendations for the JSNA process l improve recording of ethnicity data in primary care l closer monitoring of exception reporting in primary care l monitor quality of care in general practice and support practices to improve their detection and management of CVD Service priorities l continue health promotion interventions in smoking cessation, physical activity and diet l commitment to the development of risk registers for CVD l develop a better understanding of the low prevalence of CHD in Southwark l continue to improve the management of CVD using QOF data to highlight areas of concern l develop an integrated stroke care pathway and ensure Southwark adopts the ten point plan for action outlined in the National Stroke Strategy. 32