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: 2016-01-27 12:20:38
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1. What are the key issues?

CVD and in particularly CHD mortality has declined steeply over the past decade with a decrease of 58% in early mortality from CHD. Overall CVD mortality in Stockton is similar (men) or just below (women) the national average. Early mortality (<75) however is higher in men. CHD mortality is lower than national average but again early mortality in men is higher. Early mortality from stroke is higher and later mortality is similar to England.

High prevalence The prevalence of CVD in Stockton is high for some but not for all associated diseases i.e. the prevalence of CHD, stroke and atrial fibrillation is higher compared to England average whereas the prevalence of diabetes and chronic kidney disease is lower.

Undiagnosed disease Prevalence figures are underestimating the true extend of disease because of a significant proportion disease remains undiagnosed.

Demographic change The future prevalence of CVD will be influenced by a range of different factors such as demographic change with an older population and increasing BME population as well as a significant proportion of the population still living in deprived areas.

Lifestyle choices and behaviours such as the local and national increase in obesity and physical inactivity and a high level of binge drinking in the population are also likely to contribute to a higher CVD prevalence.

Prevention and early identification of CVD is crucial. 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 is below the national target. Uptake is particularly low in men and people living in deprived areas.

Availability and access to services for advice, support and treatment following the identification of risk factors is inconsistent due to lack of awareness and information about lifestyle services and management of long term conditions in primary care.  

Treatment of risk factors for CVD, CHD, Stroke and associated conditions in primary care varies considerably between GP practices.

Treatment and care in secondary care varies compared to similar CCGs.

Last updated: 15/12/15

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

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 Stockton Borough Council 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: 17/12/15

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 Stockton has a comparably young age profile but also an increasing proportion of people over 60. There is a slightly larger female population (51%).

The population is predominately white British (93.4%), however there are minorities with white Irish and other white background (1.2%), south Asian (2.5%), other Asian (1.1%) and black African (0.5%) background. The Asian and south Asian populations are the largest BME groups.

Since 2004, the extend deprivation in the population of Stockton-on-Tees has decreased in comparison to other local authority areas in England.  However, there are areas with a high proportion of people living in poverty. Relative deprivation seems to have improved particularly for older people.

Modifiable and behavioural risk factors

Some behavioural risk factors in Stockton are slightly more common compared to the English population but not significantly worse. 19.8% of the population in Stockton smoke compared to 18.4% in England. 58.4% of adults in Stockton are physically active compared to 56% in England. 26.1% of the population in Stockton is obese and 63.6% are considered overweight compared to 23% and 63.8% respectively in England. It is estimated that 28% of people over 16 in Stockton engage in binge drinking compared to 20% in England.

Figure 1 Health Profile. Stockton-on-Tees. PHE 2015

When comparing the behavioural risk factors of people living in Stockton and Hartlepool CCG in 2014 the risk profile was high. 25.2% of the CCG population smoked compared to 19.5% nationally. 66.1% of adults were overweight or obese compared to 63.8% in England. 32.2% of adults were regarded as physically inactive compared to 28.5% in England. Only 21.1% 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 Stockton and Hartlepool 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 HAST CCG (yellow) to 10 comparator CCGs (blue). CVD commissioning for value packs 2014.

Hypertension

15% (43,658 people) of the registered GP population in Hartlepool and Stockton CCG was diagnosed with hypertension. The proportion of people diagnosed with hypertension varied between GP practices ranging from 2% to 22%. The estimated prevalence is 25.6%. This means that 30,000 people with hypertension may not have been diagnosed and therefore do not receive treatment.

Diabetes Type 2

5.8% (16,881) of the registered GP population in Hartlepool and Stockton CCG was diagnosed with diabetes. The proportion of people diagnosed with diabetes varied between GP practices ranging from 0.4% to 7.2%. The estimated prevalence is 7.2%. This means that across the CCG area 4075 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/00K_Diabetes.pdf

Atrial fibrillation

1.8% (5239) of the registered GP population in Hartlepool and Stockton CCG was diagnosed with atrial fibrillation. This is slightly higher than in comparable CCGs (1.7%) and England (1.6%). 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

4.2% (12,225 people) of the registered GP population in Hartlepool and Stockton 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% (3201 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/00K_Heart%20Profile.pdf

Cerebrovascular Disease

2% (5709 patients) of the registered GP practice population in Hartlepool and Stockton 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 2.2% (6520 patients). Atrial fibrillation was diagnosed in 1.8% compared to 1.5% in England. 

Figure 5 Stroke/ TIA prevalence. Source. NCVIN 2014

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

Kidney Disease

4.3% (9874 patients) of the registered GP population in Hartlepool and Stockton CCG have been 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 6.0% (13,777 patients).

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

Mortality

The mortality rate for cardiovascular disease in Stockton for men (350/100 000) is below the regional average and similar to England. CVD mortality in women (236/100 000) is below 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 Stockton for men (116/100 000) is below the regional average but above the England rate. CVD early mortality in women (47/100 000) is below the regional average and similar to England.

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

Between 2001 and 2012 early mortality (<75) from CVD has decreased significantly, in particular for women. The gap between Stockton and England has almost disappeared. 

Coronary heart disease

The mortality rate for coronary heart disease in Stockton for men (182/100,000) and women (84/100,000) is below the regional and national average.

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

The early mortality rate for coronary heart disease in Stockton for men (69/100,000) is below the regional but above the national average. The early mortality rate for women (23/100,000) is just above the regional rate and above the national rate.  

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 Hartlepool and Stockton was 46.2 per 100,000. Between 2002 and 2012 the coronary heart disease mortality rate has decreased by 58% and is now similar to the early mortality regionally but still higher than the national average. The early mortality rate from CHD in Hartlepool and Stockton has decreased faster than the regional and national rate.

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

Stroke

The mortality rate for people under 75 years for stroke in Hartlepool and Stockton was 19 per 100,000 compared to 14.1 in England in 2012. The later mortality rate for stroke was 661.4 per 100,000. The early and later mortality rates for stroke have decreased nationally, regionally and particularly fast at local level. The gap between Stockton and Hartlepool and national average has narrowed.

Figure 12 Stroke mortality under and over 75 years in Stockton and Hartlepool 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 local authorities and general practice. General practices in Stockton and Hartlepool have recorded the smoking status of 88.4% of patients and offered support and treatment to 84.7% 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 Stockton 50,070 people are eligible for an NHS Health Check between 2013 and 2018. Between April 2013 and September 2015 more than half (33,203; 66%) of the eligible population has been invited and 25% (12,786) of the eligible population has already received an NHS health check.  

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 has already been invited and also received their HHC.

Figure 14

The delivery of the NHS health check / Healthy Heart Check programme in Stockton has 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 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 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 compared well to the English average in giving lifestyle advice and management of blood pressure but did less well on performing cardiovascular risk assessments. When comparing to similar CCGs general practices in Stockton and Hartlepool could improve the following: recording of blood pressure in those over 40, management of blood pressure and provision of brief interventions and physical activity assessments. Please see the profiles at the Cardiovascular Intelligence network for further information. (http://www.yhpho.org.uk/ncvincvd/pdfs/Risk/00K_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. (insert link to

http://www.yhpho.org.uk/ncvincvd/pdfs/Diabetes/00K_Diabetes.pdf)

CHD

Care and treatment of patients with CHD in Hartlepool and Stockton 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, hyperlipidaemia and anti platelet therapy 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/00K_Heart.pdf)

Stroke

Care and treatment of patients with CHD in Hartlepool and Stockton CCG was similar than national average although there was significant variation between practices. For more detail please see the CHD profile (http://www.yhpho.org.uk/ncvincvd/pdfs/Kidney/00K_Stroke.pdf)

Chronic kidney disease

Care and treatment of patients with chronic kidney disease in Hartlepool and Stockton CCG was similar 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/00K_Kidney.pdf)

Secondary Care

Secondary care services for the population in Stockton and Hartlepool are provided at the University Hospital of North Tees and the University Hospital of Hartlepool as well as at the James Cook University Hospital in Middlesbrough.

The cardiology department at UHNT offers a full range of services

  • Rapid access chest pain clinic where patients are seen within two weeks of referral for further investigations and treatment.
  • Cardiac investigations unit where patients receive diagnostic investigations including ECG, 24/48 hour ECG and blood pressure monitoring, echocardiography, stress echocardiography as well as pacemakers and loop recorder follow ups. The hospital also has a cardiac CT scanner.
  • Cardiology day unit where coronary angiograms, transoesophageal echocardiograms, cardioversions, loop recorders and pacemaker implantations are carried out. This service is partly located at the University Hospital of Hartlepool.
  • Cardiac rehabilitation providing a structured community based rehabilitation programme in four phases including education, exercise and lifestyle changes
  • Community heart failure specialist nurses providing ongoing care and support to discharged patients in close cooperation with the patients GP.

 

Emergency admission rates for CHD have declined since 2002, with a faster decline locally. The admission rate for CHD (561/100 000) for Hartlepool and Stockton patients was just below the national average of 575/100 000) in 2012/13.

Emergency admission rates for heart failure has decreased by 35% over 10 years and is now significantly lower than the England average with 110 admissions per 100 000 population.

Figure 15 Emergency Admission rates for coronary heart disease and heart failure in Stockton and Hartlepool CCG. Source PHE, NCIN Cardiovascular disease profile Heart

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 in secondary care between 10 similar CCGs shows that patients in Hartlepool and Stockton CCG are more likely to receive an angiography (women and men) and Coronary Artery Bypass Graft (women) and are staying in hospital for longer for angioplasty (women) and CABG (women and men)

The Stroke Service at UHNT offers

  • assessment clinics for TIA and stroke and
  • thrombolysis to those eligible for treatment.
  • Physiotherapy, speech and language and occupational therapists are involved early in treatment and care to support recovery whilst at the hospital.
  • A community stroke team of physiotherapists, occupational therapists, speech and language therapists, dietitians, psychologist, rehabilitation assistants, specialist nurses and Stroke Association family and carer support officer supports patients at home during the weeks and months following discharge.

Emergency admission rates for stroke have changed only little since 2002/3. In 2012/13 emergency admission rates for stoke in Hartlepool and Stockton (199/100,000) were significantly higher than in England.

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 Stockton 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: 15/12/15

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?

In early Oct 2015, we surveyed 139 Stockton residents  through the Viewpoint online survey.  The residents told us that:

  • Six in ten of you in the target age range did not know that everyone aged between 40-74 was entitled to a free health Heart Check. People suggested to call for better promotion of availability of Free Healthy Heart Check.
  • Only 7 in 10 of those who had been offered a Check went ahead and has it done at their GP and also some at workplace or local library.
  • 99% of you who has a check said you were happy with the venue for and date of your appointment and 95% said they were happy with the time it was scheduled for.
  • 9 in 10 received their check results afterwards and 85% of you who said that felt that they were clearly explained to you. Of those who has a check, 1 in 3 of you said you had changed your diet afterwards, 1 in 4 of you said you had become more active and 1 in 5 had lost weight.
  • Most of you who offered suggestions about improving the way that free healthy heart checks are delivered – majority said GP opening hours could usefully be more flexible.
  • Whilst 8 in 10 of you who has a check were not referred to another services for care and/or information after the check. However, majority those have been referred to other services of care or information after the check felt that the information was useful.
Last updated: 03/02/16

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 Braun

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