Cardiovascular Disease

Cardiovascular disease (CVD) refers to a group of related diseases and conditions of the heart and blood vessels linked by a common set of risk factors leading to atherosclerosis. Atherosclerosis is the gradual build up of fatty material ‘atheroma’ in the walls of arteries leading to narrowing and stiffening of the arteries. Cardiovascular conditions include:

  • Coronary heart disease (CHD) is a disease in which the coronary arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to the heart muscle. This leads to angina, heart attack and heart muscle damage  
  • Cerebrovascular disease is a disease in which the cerebral arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to the brain.  This leads to transient ischaemic attacks (TIA) and stroke.
  • Peripheral vascular disease is a disease in which the arteries of the arms and legs are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to arms and legs. This leads to claudication.

Other conditions such as vascular dementia, chronic kidney disease, cardiac arrhythmias, sudden cardiac death, and heart failure are related because they either share common risk factors or have an impact on the prognosis and outcome of CVD.

Nearly five million people in the UK aged 16 and over are a estimated to suffer from CVD. This means that about every 7th adult in the UK suffers from a cardiovascular condition. The older people get the more likely they are to develop CVD. .

Deaths from CVD have fallen by over a third between 2001 and 2010, but CVD is still one of the main causes of death in the UK and accounts for about one-third of all deaths. In 2011, almost 160,000 people in the UK died from CVD. 74,000 of these deaths were caused by coronary heart disease - the UK's single biggest cause of death. 

A number of common risk factors are known increase the risk of arthrosclerosis leading to CVD. These risk factors can be divided into three broad groups.

  • Non-modifiable and non-behavioural risk factors including age, sex, family history/genetic factors, ethnicity and deprivation are considered to estimate the overall risk of CVD for an individual.
  • Modifiable and behavioural risk factors such as smoking, physical inactivity, poor diet, obesity and binge drinking are reflecting individual circumstances and choices which can be prevented or changed by lifestyle changes.
  • Conditions associated with an increased risk such as hypertension (blood pressure) , hyperlipidaemia (blood fats), diabetes and atrial fibrillation can be prevented or reversed in their early stages but usually need medical treatment.

This topic links with the following JSNA topics:

Smoking

Physical inactivity

Diet and nutrition

Diabetes mellitus

Obesity

 

 

Last updated: 2016-10-12 10:34:12
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1. What are the key issues?

Prevention and early identification of risk factors for and early disease of CVD is crucial. The population living in Middlesbrough has high levels of smoking, physical inactivity, overweight, obesity and higher risk drinking. The NHS Health Check aims to identify risk factors for CVD and refer those at higher risk to lifestyle services and treatment. The uptake of the NHS health check in Middlesbrough is higher than in other neighbouring local authorities and above the national average but varies considerably between GP practices. Men are less likely to access a health check.

Undiagnosed disease Prevalence figures underestimate the true extend of disease for hypertension, diabetes, CHD, stroke and kidney disease because of a significant proportion disease remains undiagnosed.

High prevalence and mortality The prevalence of CVD including CHD and cerebrovascular disease in Middlesbrough is higher than the England average.

CVD mortality and in particularly CHD mortality has declined steeply over the past decade with a decrease of 47% in early CVD mortality. The decline has slightly slower than the national rate of 51%. The gap between Middlesbrough and the national average remained and since 2010 there has been even a slight increase in mortality resulting in a significantly higher CVD mortality than the national average.

Overall CVD mortality is much higher in men than in women. Male mortality in Middlesbrough is higher for CVD (all age and <75), CHD (all age and <75) and stroke (all age and <75) compared to national average. Female mortality is higher for CVD (all age) and CHD (<75) and stroke but similar to the national average for early CVD and all age CHD mortality.

Availability and access to services for advice, support and treatment following the identification of risk factors is inconsistent often due to lack of awareness and information about lifestyle service in the community and management of long term conditions in primary care.  Treatment of risk factors for CVD, CHD, Stroke and associated conditions in primary care is generally good except for blood pressure control. Care varies considerably between GP practices with high numbers of patients expected from follow up.

Treatment and care in secondary care varies compared to similar CCGs with lower CHD and higher stroke admissions rates.

Last updated: 17/12/15

2. What commissioning priorities are recommended?

Commissioning priorities stretch across the five key areas identified by the Cardiovascular Disease Outcomes Strategy including

  • prevention and risk management,
  • identification of high risk individuals and case finding,
  • early management and secondary prevention,
  • acute care and
  • rehabilitation and end of life care.

2015/01

Prevention and risk management

  • Prevent and reduce smoking, obesity and binge/ higher risk drinking in population.
  • Identify clear and easily accessible pathways into lifestyle services and follow up in primary care for those identified as high risk or with CVD or associated conditions.

2015/02

Identification of high risk individuals and case finding

  • Improve uptake of the Healthy Heart Check (NHS health check) for the general population aged 40-74 but particularly among men and those living in deprived areas to identify at risk patients and those with undiagnosed disease
  • Ensure consistent follow up of those identified as at high risk of CVD to identify and manage disease early  – reducing exemptions and variation between practices

2015/03

Early management and secondary prevention

  • Ensure a minimum standard of disease management for hyperlipidaemia, hypertension, and diabetes in every general practice – reducing exemptions and variation between practices
  • Prevent repeat CVD events through effective secondary prevention including lifestyle changes and management of hyperlipidaemia, hypertension, and diabetes in every general practice
  • Targeted awareness for BME at risk groups to improve early management

2015/04

Acute care and rehabilitation

  • Ensure 24/7 access to effective treatment for acute CVD events
  • Ensure access to high quality ward and community based rehabilitation following a CVD event

2015/05

End of life care

  • Offer appropriate end of life care for patients with CVD 

2012/01

NICE guidance CG95 Chest Pain of Recent Onset recommends use of CT calcium scoring as the first-line diagnostic investigation for CAD, and the removal of exercise ECG to diagnose or exclude stable angina for people without known CAD. These changes will need to be reflected in locality pathways; (Update 2015 TBC)

2012/02

Anticoagulant therapy is embedded in primary care, but will require ongoing close monitoring moving forward; (Update 2015 GP practices are prescribing and monitoring anticoagulant therapy.)

2012/03

Patient involvement. It will be important to ensure systematic patient involvement on CVD moving forward, possibly through Local Health Watch; (Update 2015 a population survey on the NHS health check/ Healthy Heart Check has been conducted through local authorities in 2015)

2012/04

Undiagnosed disease There will be benefit in utilising the Health Inequalities National Support Team (HINST) approach to active disease register management and QOF support for GP practices as recommended in ‘Closing the gap - finding the missing thousands’; As part of this it will be important to ensure that this target group are engaged to consider reasons why they have not previously engage/taken up offers of support; (Update 2015 GP practices are maintaining disease registers and offer clinical follow up.)

2012/05

The NHS Health Checks programme is currently undergoing an economic evaluation and also an evaluation of compliance – it will be vital to ensure the learning from this is adopted to improve this programme further. (Update 2015 The evaluation by Teesside University concluded that the Healthy Heart Check is a cost effective universal risk assessment programme  which should be continued,  the evaluation also found that compliance could be improved if patients received clearer communication and advise as well as support to make lifestyle changes)

Last updated: 31/12/15

3. Who is at risk and why?

A number of common risk factors are recognised to increase the risk of an individual to develop atherosclerosis leading to CVD. The more risk factors a person has the higher is the risk of developing CVD. Although some risk factors cannot be changed, the risk of developing CVD can be reduced by prevention, lifestyle changes and medical treatment.

Non modifiable and non behavioural risk factors

Age The risk of CVD increases with age. The health survey for England in 2011 has shown that 3.3% of men and 4.8% of women aged 16-24 suffer from CVD compared to 53.8% of men and 31.1% of women aged over 85.

Gender In people aged 35 and over 13.9% of men and 13.4% of women suffer from CVD. Men are more likely to develop CVD at an earlier age and to suffer from more than one condition.

Family history/ genetic factors There is an increased risk if a first-degree blood relative has had CVD before age 55 (male relative) or 65 years (female relative).

Ethnicity The risk for CVD is higher is some BME groups, whilst it is lower in others. The Health survey for England found that Irish men and women were most likely to have been diagnosed with CVD. People with South Asian origin are one and a half times more likely to die early from coronary heart disease than the general population. There are also differences in specific conditions and risk factors. People from black African and black Caribbean ethnic groups are more likely to develop hypertension, whilst South Asian and black ethnic groups have an up to 6 times greater likelihood of developing diabetes. The risk of stroke is highest in South Asian, African and Caribbean populations.

Deprivation CVD is more common in adults living in the more deprived areas. CVD mortality of those living in the most deprived areas is 1.8 times higher than in people in the least deprived areas.

Modifiable and behavioural risk factors and conditions

Smoking is a major risk factor for CVD. About 20% of all CVD and 15% of all deaths are caused by smoking. Smoking has a number of harmful effects on the body which increase the risk for CVD. It damages the lining of the arteries thus leading to atherosclerosis and increases the levels of blood clotting factors such as fibrinogen. The carbon monoxide in tobacco smoke also reduces the amount of oxygen in the blood and in addition nicotine stimulates the body to produce adrenalin which accelerates heart rate and raises blood pressure.

Physical inactivity contributes to CVD, particularly to coronary heart disease and stroke as well as being a major cause of obesity, Type 2 diabetes and high blood pressure. Regular physical activity reduces early deaths even among those with an otherwise high CVD risk profile or with established CVD. Physical activity reduces the  likelihood of developing of coronary heart disease and stroke and reduces long term blood pressure in both those with raised and with normal blood pressure.

Diet A diet based on fruit, vegetables, pulses, wholegrain foods, fish and poultry is consistently associated with lower levels of CVD risk factors and fewer deaths from CVD. Vegetarian and ‘Mediterranean’ diets are also associated with lower CVD mortality. Encouraging people to eat more healthily has been shown to be effective in reducing blood pressure, cholesterol and subsequently CVD. Salt intake is a key determinant of CVD in the UK, mainly because of its effect on blood pressure. High levels of salt in the diet are linked to high blood pressure which, in turn, can lead to stroke and coronary heart disease.

Obesity As well as being an independent risk factor for CHD, obesity is a major risk factor for serious chronic diseases such as Type 2 diabetes, hypertension and high blood fats (hyperlipidaemia).

Alcohol The relationship between alcohol consumption and cardiovascular diseases is complex. Light to moderate drinking can have a beneficial impact on reducing ill health and death from coronary heart disease and ischaemic stroke. However, the beneficial protective effect of drinking disappears with higher levels of drinking including binge drinking.

Conditions associated with an increased risk

Conditions such as hypertension, raised cholesterol, diabetes and chronic kidney disease can be prevented or reversed in their early stages but often need medical treatment.

Hypertension (High blood pressure) is generally defined as blood pressure over 140/90 mmHg. Uncontrolled hypertension damages the wall of the arteries and increases the risk of CVD. The risk of hypertension increases with age. Whilst only 7.4% of people aged 16 to 24 years have hypertension, 44.0% of people aged 55 to 64 years and 72.6% of people aged 75 years or older had hypertension.

Diabetes is a disease resulting from high levels of glucose in the blood due to a imbalance between insulin and glucose. High blood sugar levels damage the walls of the arteries, and make them more likely to develop fatty deposits (arteriosclerosis) leading to CVD. People with diabetes are more likely to suffer from a heart attack (48%), heart failure (65%) and stoke (25%) and up to 4 times more likely to develop peripheral vascular disease.

Hyperlipidaemia (High blood fats) is defined by high levels of LDL-cholesterol and other fats such as triglycerides cause in the blood causing fatty deposits (arteriosclerosis) in the artery walls. The risk is particularly high if there are low levels of protective HDL cholesterol. Hyperlipidaemia leads to a higher coronary heart disease (CHD) risk, but CVD risk and life expectancy is restored to near normal with early preventive treatment.

Atrial fibrillation AF is the most common form of irregular heart beat (arrhythmia) and can increase the risk of stroke five to six-fold.

Last updated: 15/12/15

4. What is the level of need in the population?

Risk prevalence

The population of Middlesbrough has a comparably young age profile but also an increasing proportion of people over 65 (insert link to population). There is a slightly larger female population (51%).

The population is predominately white British (86.1%), however there are minorities with white Irish (0.4%) and other white background (1.8%), South Asian (6.2%), other Asian (1.7%), black African (1.1%) and Arab (0.7%) background. The Asian and other white are the largest BME groups (link to ethnicity).

Since 2004, Middlesbrough has become more deprived relative to other local authority areas.  In 2004, Middlesbrough was the 10th most deprived area but in 2010 it was 8th most deprived of 326 local authority areas in England. (link to poverty)

Modifiable and behavioural risk factors

Behavioural risk factors in Middlesbrough such as smoking and physical inactivity are significantly more common compared to the English population. 25.5% of the population in Middlesbrough smoke compared to 18.4% in England.  49.3% of adults in Middlesbrough are physically active compared to 56% in England. 24% of the population in Hartlepool is obese and 68.4% are considered overweight compared to 23% and 63.8% respectively in England.

Figure 1 Health Profile. Middlesbrough. PHE 2015

When comparing the behavioural risk factors of people living in South Tees CCG in 2014 the risk profile was high. 25.5% of the CCG population smoked compared to 18.4 % nationally. 68.4% of adults were overweight or obese compared to 63.8% in England. 49.3% of adults were regarded as physically active compared to 56% in England. Only 20.2% were estimated to eat at least 5-a-day of fruit or vegetable compared to 28.7% in England. When comparing behavioural risk factors in South Tees CCG to the average of a number of CCGs with similar population the proportion of binge drinking, smoking, unhealthy eating and low physical activity was higher (worse). For more detail please see the risk profiles at the Cardiovascular Intelligence network.

Figure 2 CVD risk factors comparing South Tees CCG (yellow) to 10 comparator CCGs (blue). CVD commissioning for value packs 2014.

Hypertension

14.9% (43,376 people) of the registered GP population in South Tees CCG was diagnosed with hypertension in 2012/13. The proportion of people diagnosed with hypertension varied between GP practices ranging from 2% to 24%. The estimated prevalence is 26.1%. This means that 33,000 people with hypertension may not have been diagnosed and therefore do not receive treatment.

Diabetes Type 2

6.4% (14,860) of the registered GP population in South Tees CCG was diagnosed with diabetes in 2012/13. The proportion of people diagnosed with diabetes varied between GP practices ranging from 1.3% to 8.4%. The estimated prevalence is 7.8%. This means that across the CCG area 3500 patients (1.4%) may have undiagnosed and untreated diabetes. Among people with diabetes the risk of stroke was 38% higher and the risk of a heart attack was 72% higher compared to the general population.

Figure 3 Diabetes prevalence. Source NCVIN 2014. http://www.yhpho.org.uk/ncvincvd/pdfs/Diabetes/00M_Diabetes.pdf

Atrial fibrillation

1.6% (4,384) of the registered GP population in South Tees CCG was diagnosed with atrial fibrillation in 2012/13. This is similar than in comparable CCGs (1.6%) and England (1.6%). The estimated prevalence is 2.5% which means that an additional 2,400 patients could be undiagnosed. More than a quarter (26.3%) of all stroke patients admitted to hospital in Hartlepool and Stockton had a secondary diagnosis of atrial fibrillation. This proportion is similar to national average.

Disease prevalence

Coronary Heart Disease

4.3% (12,511 people) of the registered GP population in South Tees CCG was diagnosed with coronary heart disease compared to 3.3% in England. The proportion of patients diagnosed with CVD varied between GP practices ranging from 0.1% - 6.9%.  The estimated prevalence is 5.3%. This means that 1.1% (3,201 patients) of the practice population may have undiagnosed coronary heart disease. 0.8% of the registered GP practice population were diagnosed with heart failure compared to 0.7% in England. 

Figure 4 Cardiovascular disease prevalence. Source. NCVIN 2014 http://www.yhpho.org.uk/ncvincvd/pdfs/Heart/00M_Heart%20Profile.pdf

Cerebrovascular Disease

2% (5,886 patients) of the registered GP practice population in South Tees CCG had a stroke or TIA compared to 1.7% in England. The proportion of patients who had a stroke varied between GP practices ranging from 0.1% to 2.6%. The estimated prevalence is 2.4% (7,040 patients). Atrial fibrillation was diagnosed in 1.6% compared to 1.5% in England. 

Figure 5 Stroke/ TIA prevalence. Source. NCVIN 2014

http://www.yhpho.org.uk/ncvincvd/pdfs/stroke/00M_Stroke.pdf

Kidney Disease

4.2% (9,660 patients) of the registered GP population in Hartlepool and Stockton CCG were diagnosed with chronic kidney disease which is similar to the English average. The proportion of patients with chronic kidney disease varied between GP practices ranging from 0.2% to 8%. The estimated prevalence is 6.2% (14,260 patients).

Figure 6 Chronic kidney disease prevalence. Source NCVIN 2014 www.yhpho.org.uk/ncvincvd/pdfs/Kidney/00M_Kidney.pdf

Mortality

The mortality rate for cardiovascular disease in Middlesbrough for men (411/100,000) and women (261/100,000) was above the regional and national average.

Figure 7 CVD mortality rate all age 2010-12. Source: BHF Cardiovascular disease statistics 2014

The early mortality rate for cardiovascular disease in Middlesbrough for men (132/100,000) is above the regional and national average. CVD early mortality in women (55/100,000) is similar to the regional average and above the national average.

Figure 8  CVD mortality rate <75 2010-12. Source: BHF Cardiovascular disease statistics 2014

Early mortality (<75) from CVD fell sharply between 2001 and 2012. The gap between Middlesbrough and England narrowed considerably and nearly closed in 2008-2010 but started to widen again. The recent increase was most notable in women.

Coronary heart disease

The mortality rate for coronary heart disease in Middlesbrough for men (219/100,000) was above the regional and national average. The mortality rate for women (93/100,000) was less than half the male mortality rate and below the regional but above the national rate. 

Figure 9 CHD mortality rate (all age) 2010-12. Source: BHF Cardiovascular disease statistics 2014

The early mortality rate for coronary heart disease in Middlesbrough for men (83/ 100,000) and women (25/ 100,000) was above the regional and national average.  

Figure 10 CHD mortality rate <75 2010-12. Source: BHF Cardiovascular disease statistics 2014

The mortality rate for people under 75 years for coronary heart disease in Middlesbrough and Redcar (South Tees CCG) was 54.5 per 100,000. The coronary heart disease mortality rate has decreased between 2002 and 2012 by 47% compared to 51% nationally. The CHD mortality rate in 2012/13 was higher than the regional and national average. The steep decline between 2007 and 2010 resulted in the lowest rate in 2010 which was even below the regional and national average.

Figure 11 Early mortality rate (n/100.000) from CHD 2002-12 in South Tees CCG. Source: PHE, NCIN Cardiovascular disease profile. Heart disease

Stroke

The mortality rate for people under 75 years for stroke in Middlesbrough and Redcar was 17/ 100,000 compared to 14/100,000 in England in 2012. The later mortality rate for stroke was 830/ 100,000. The early and later mortality rates for stroke decreased nationally, regionally and locally. The gap between Middlesbrough and Cleveland and the national average narrowed for early mortality rates but not for late mortality. Again in 2010 the local early mortality rate for Stroke was at regional and national level.  

Figure 12 Stroke mortality under and over 75 years in South Tees CCG. Source: PHE, NCVIN Cardiovascular disease profile Stroke

Last updated: 17/12/15

5. What services are currently provided?

Prevention

Lifestyle services such as stop smoking services, weight management, dietary advice, exercise referral programmes, drug and alcohol services are offered by the local authority and general practice. General practices in Middlesbrough and Redcar and Cleveland recorded the smoking status of 86.7% of patients and offered support and treatment to 82.4% of those in 2012-13.

NHS Health Check – Healthy Heart Check

The NHS Health Check programme – locally branded as the Healthy Heart Check – is a national risk assessment programme for CVD. It aims to prevent heart disease, stroke, diabetes, kidney disease and certain types of dementia through early detection, lifestyle advice and referral for further management of risk factors and conditions which can lead to the development of CVD. Everyone between the ages of 40 and 74, who has not already been diagnosed with one of these conditions, will be invited once every five years to assess their risk of developing CVD.

In Middlesbrough 36,447 people are eligible for an NHS Health Check between 2013 and 2018. Between April 2013 and September 2015 more than half (24,934; 68%) of the eligible population was invited and 27% (9,971) of the eligible population received an NHS health check.  Both, invitations and health checks were above the Tees and national average.

Figure 13 NHS Health Check/ Healthy Heart Check invitations and uptake April 2013- September 2015. Source: PHE NHS health check.

Further analysis by gender showed that a higher proportion of women is eligible for NHS Health Checks/ Healthy Heart Checks (HHC) between 2013-18. In 2014/15 a higher proportion of eligible women were invited and also received their HHC.

Figure 14 NHS Health Check/ Healthy Heart Check invitations and uptake by gender and local authority. 2014/15. NECS

The delivery of the NHS health check/ Healthy Heart Check programme in Middlesbrough focussed on reducing health inequalities through prioritising and incentivising invitations and health checks for the eligible population living in the most deprived areas.

Local data shows that the uptake of the health check varies and was generally lower in men but not any more in people living in more deprived areas. There was also considerable variation in the delivery and uptake of the programme between GP practices

Primary Care

Patients with hypertension, high blood fats, diabetes, atrial fibrillation, CHD, stroke and peripheral arterial disease are mostly identified and treated in primary care. Many GP practices offer nurse-led clinics for the management of chronic disease and secondary prevention in those who have had a heart attack or stroke.

Hypertension

Treatment and lifestyle advice for patients with hypertension is measured by the Quality Outcomes Framework. On average GP practices within the CCG were comparable to similar CCGs and national average in giving lifestyle advice but less likely to manage high blood pressure well and to offer cardiovascular risk assessments. When comparing to similar CCGs general practices in Middlesbrough and Cleveland could improve the following: identification and management of high blood pressure. Please see the profiles at the Cardiovascular Intelligence network for further information. (http://www.yhpho.org.uk/ncvincvd/pdfs/Risk/00M_Risk.pdf)

Diabetes

Treatment and lifestyle advice for patients diagnosed with diabetes was similar to national average although there was significant variation between practices. For more detail please see the risk profiles at the Cardiovascular Intelligence Network. (http://www.yhpho.org.uk/ncvincvd/pdfs/Diabetes/00M_Diabetes.pdf)

CHD

Care and treatment of patients with CHD in South Tees CCG was similar or slightly better than national average although there was significant variation between practices. When comparing to similar CCGs the treatment for high blood pressure could be improved for those with CHD and following a heart attack. For more detail please see the CHD profile (http://www.yhpho.org.uk/ncvincvd/pdfs/Heart/00M_Heart.pdf)

Stroke

Care and treatment of patients with CHD in South Tees CCG was similar or slightly better than national average for management of blood cholesterol and anticoagulation. Blood pressure control was slightly below the national average. There was significant variation between practices. For more detail please see the CHD profile (http://www.yhpho.org.uk/ncvincvd/pdfs/Kidney/00M_Stroke.pdf)

Chronic kidney disease

Care and treatment of patients with chronic kidney disease in South Tees CCG was similar or better than national average although there was significant variation between practices. For more detail please see the CVD profile for kidney disease (http://www.yhpho.org.uk/ncvincvd/pdfs/Kidney/00M_Kidney.pdf)

Secondary Care

Secondary care services for the population of South Tees CCG are provided at the James Cook University Hospital (JCUH)in Middlesbrough.

The cardiology department at JCUH offers a full range of services

  • Acute Chest Pain Management Paramedics will perform ECG (electrocardiograph) in patients who call 999 with suspected cardiac chest pain. ECG will be sent directly to the coronary care unit (CCU) for decision on admission route and treatment e.g. A&E, acute admissions, coronary care unit or angioplasty.
  • Rapid Access Chest Pain Clinic for patients with recent onset of chest pain (within 12 weeks) where cardiac origin is likely or suspected. Patients can be referred to the service by their GP patients and are seen within two weeks of referral for further investigations and treatment.
  • Cardiac investigations These include facilities for, echocardiography, exercise stress testing, ECG and BP monitoring, angiography and percutaneous coronary interventions, insertion and follow-up of pacemakers electrophysiology including radiofrequency, ablations and implantable defibrillators.
  • Specialist (outpatient) clinics for hypertension, chest pain, arrhythmia, heart failure, cardiac genetics and adults with congenital heart disease.
  • Coronary care unit (14 beds), general cardiology ward (40 beds), day unit (13 beds), monitored beds (9)
  • Cardiac rehabilitation supports patients recovering from heart conditions or surgery through a structured community based rehabilitation programme in four phases including education, exercise and lifestyle changes

Admission rates for CHD declined since 2002, with a faster decline locally. The admission rate for CHD (388/100,000) for Middlesbrough and Redcar and Cleveland patients was below the national average of 575/100,000 in 2012/13.

Admission rates for heart failure (123/100,000) decreased by 17% over 10 years and are now lower than the England average.

Figure 15  Admission rates for coronary heart disease and heart failure in  South Tees CCG. Source PHE, NCIN Cardiovascular disease profile. Heart Disease.

Time from calling for help to primary coronary intervention (PCI) for eligible patients in Durham, Darlington and Tees in 2012/13 was on average 94 minutes compared to a national average of 112 minutes. 81.3% of patients received PCI within 120 minutes.

A comparison of treatment indicators for heart disease in secondary care between 10 similar CCGs shows that patients in South Tees CCG were more likely stay in hospital for longer for CVD, angioplasty (women) and CABG (women).

The Stroke Service at JCUH offers

  • Thrombolysis to those eligible for treatment.
  • Stroke Early Supported Discharge Service  for enabling patients to be discharged for further specialist stroke therapy including dietetics, occupational therapy, physiotherapy and speech and language at home
  • Specialist stroke rehabilitation for community inpatient rehabilitation with specially trained nurses and rehabilitation services such as physiotherapy, occupational therapy and speech and language therapy.

The hospital admission rate for stroke in Middlesbrough and Redcar & Cleveland increased by 12% between 2004/5 and 2012/13. The hospital admission rate (233/100,000) was significantly higher than the England rate of (179/100,000).

Figure 16 Hospital admission rate for stroke 2002/3-2012/13. Source: PHE, NCVIN Cardiovascular disease profile Stroke

Last updated: 05/01/16

6. What is the projected level of need?

There is currently no authoritative information on the estimated or projected incidence, morbidity and mortality of cardiovascular disease.

Last updated: 15/12/15

7. What needs might be unmet?

Health needs of vulnerable or at risk groups

Health needs for CVD are generally well understood, however there are specific risk profiles and barriers to access services for vulnerable or at risk groups e.g. BME, migrants, people with learning difficulties which are currently not sufficiently recognised and addressed through mainstream care and interventions. 

Lifestyle interventions and services

The high and still increasing proportion of overweight and obese people in the population is expected to lead to increasing numbers of people with diabetes. A high proportion of people in Middlesbrough engage in binge drinking which is a risk factor for CVD. There is a need for effective and accessible lifestyle interventions and services that meet the demand.

Undiagnosed disease

The gap between the actual and estimated prevalence for hypertension, diabetes, CHD, stroke and chronic kidney disease indicates that there are high numbers of people with undiagnosed and untreated disease.

Screening for disease

The uptake of the NHS Health Check/ Healthy Heart Check varies and is generally lower in men and in people living in more deprived areas. There is also considerable variation in the delivery and uptake of the check between GP practices.

Management of risk

The referral pathway into lifestyle services following the identification of risk is not well understood by patients and practice staff. Documentation of risk management through lifestyle services and primary care is not linked to health check.

Quality and variation in care

Treatment and care for patients with hypertension, diabetes, CHD, Stroke and chronic kidney disease varies considerably between GP practices and are only partially explained by differences in practice population.  Admission, interventions and outcomes in secondary care – compared to similar CCGs show the potential for improvement particularly for cost and length of stay.

Last updated: 08/01/16

8. What evidence is there for effective intervention?

Public Health England

NHS Health Check: our approach to the evidence.  PHE 2013

NHS Health Check LGA Frequently Asked Questions Update. PHE 2013

The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management, PHE 2012 

NICE Guidance, Quality Standards, Pathways

Prevention and lifestyle change

Prevention of cardiovascular disease. NICE PH25 (2010)

Identifying and supporting people most at risk of dying prematurely.  NICE PH15 (2008)

Community engagement to improve health NICE PH9 (2008) 
Behaviour change: the principles for effective interventions NICE PH6 (2007 updated 2014)

Smoking NICE pathway

Tobacco: harm-reduction approaches to smoking. NICE 45 (2013)

Smoking cessation in secondary care: acute, maternity and mental health services. NICE48 (2013)

Obesity. NICE pathway

Obesity: working with local communities. NICE PH42 (2012)

Managing overweight and obesity in adults – lifestyle weight management services NICE PH53 (2014)

Physical activity. NICE pathway

Physical activity: brief advice for adults in primary care. NICE PH44 (2013)

Exercise referral scheme to promote physical activity. NICE PH 54 (2014)

Alcohol use disorder NICE pathway

Alcohol use disorders – preventing harmful drinking NICE PH24 (2010)

Management of risk factors

Hypertension. NICE pathway

Hypertension- Management of Adults with Hypertension. NICE CG127 (2011)

Atrial fibrillation- the Management of Atrial Fibrillation NICE CG180 (2014)

Lipid modification NICE pathway

Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. NICE CG181 (2014)

Diabetes. NICE pathway

Preventing type 2 diabetes: population and community-level interventions. NICE PH35 (2011)

Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. NICE PH38(2012)

Atrial Fibrillation. NICE Pathway

Management of atrial fibrillation. NICE CG180 (2014)

Clinical management of CVD

Acute coronary syndromes pathway

Chest Pain of Recent Onset. NICE CG95 (2010)t

Management of Stable Angina. NICE CG126 (2011)

Unstable Angina and NSTEMI. NICE CG94 (2010)

MI – secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction. NICE CG172 (2013)

Heart Failure. NICE pathway

Chronic Heart Failure. NICE CG108 (2010)

Stroke. NICE pathway

Stroke. NICE CG68 (2008)

Stroke Rehabilitation CG162 (2013)

Lower limb peripheral arterial disease. NICE pathway

Last updated: 15/12/15

9. What do people say?

No content currently available.

Last updated: 15/12/15

10. What additional needs assessment is required?

The overall health and care needs of people with CVD are generally well established. Care standards have been defined by NICE.

Additional needs assessments should focus on the understanding of risk of CVD, access and uptake of early identification and interventions within the most deprived and/or vulnerable groups of the population. The information could be useful in understanding how best to engage with those at risk who are currently not or not complying once identified.

Last updated: 15/12/15

Key contact

Name: Dr Tanja Baun

Job title: Consultant in Public Health

Email: tbraun@nhs.net

Phone number: 01642 745286  

References

PHE. National Cardiovascular intelligence network. Key facts: Cardiovascular disease. 2014. http://www.yhpho.org.uk/default.aspx?RID=185796

British Heart Foundation.

PHE. Health Profile http://www.apho.org.uk/resource/view.aspx?QN=HP_RESULTS&GEOGRAPHY=C5

PHE. National Cardiovascular intelligence network. Commissioning for value packs: Hartlepool and Stockton CCG. http://www.yhpho.org.uk/ncvina/pdfs/00K_SlidePack.pdf

PHE. National Cardiovascular intelligence network. Commissioning for value packs: South Tees CCG http://www.yhpho.org.uk/ncvina/pdfs/00M_SlidePack.pdf

PHE. National Cardiovascular Intelligence Network. Cardiovascular Disease Profiles. 2014.  http://www.yhpho.org.uk/ncvincvd/Default.aspx

LAPE. Local alcohol profiles for England. http://www.lape.org.uk/LAProfile.aspx?reg=X25003AE

DH. Living well for longer: a call to action on avoiding premature mortality. 2013

DH. CVD Outcomes Strategy: Improving outcomes for people with or at risk of cardiovascular disease.  2013

DH. Free NHS Health Check. Helping you prevent heart disease , stroke , diabetes, kidney disease and dementia. 2013