Alastair Whitington summarises highlights from the Westminster Health Forum conference on cardiovascular disease in England
The Westminster Health Forum, Cardiovascular disease in England—next steps for prevention, innovation, and delivery of care, was held on 25 February 2020 in London.
Dr Nick Linker, National Clinical Director for Heart Disease, NHS England and NHS Improvement, provided an update on progress in implementing the ambitions of the NHS Long Term Plan for cardiovascular disease (CVD), stroke, respiratory disease, and diabetes.1 The Long Term Plan aims to prevent up to 150,000 heart attacks, strokes, and cases of dementia, increase cardiac survival, and raise the standard of cardiac rehabilitation to match that of the rest of Europe by 2028.1
Dr Linker said that there are two arms to the work programme—CVD prevention and delivery of cardiac rehabilitation, with particular focus on improving the detection of individuals with familial hypercholesterolaemia.1 More needs to be done to identify and manage patients with heart failure and valvular disease, to ensure that up to 85% of patients have access to and remain involved in a rehabilitation programme, and to improve our understanding of why many patients do not attend rehabilitation.1 Dr Linker also advised of the intention to increase the diagnosis of heart failure and valvular disease through more funding for blood tests for N-terminal pro-hormone B-type natriuretic peptide, abnormal levels of which are indicative of heart failure.2,3 Key elements to improving survival are training first responders to deliver good cardiopulmonary resuscitation (CPR) and availability of public-access defibrillators.
Workforce is key to the delivery of the Long Term Plan, not just in terms of numbers, but also in that it allows people to work smarter. Through the Getting It Right First Time process,4 variation in service delivery between hospitals, and how this variation can be reduced, will be examined.
More needs to be done to identify and manage patients with heart failure and valvular disease …
Katherine Thompson, Head of the Cardiovascular Disease Prevention Programme, Public Health England, stated that, although there have been dramatic reductions in mortality associated with CVD over the second half of the 20th century,5 this is starting to flatten out. Further effort through the Long Term Plan is needed to address the persistent inequality in CVD mortality: those who live in the poorest communities are four times more likely to be affected by CVD than the residents of more affluent communities.6 Improving morbidity is also a key factor for the 7 million people living with CVD, which remains a significant contributor to disability‑adjusted life years in the UK.7
Research such as the INTERHEART study shows that risk factors including abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity account for 90% of attributable risk, and much of this is preventable through lifestyle changes.8 Behaviour must be changed at the individual, community, and population levels through policy actions and interventions underpinned by NICE guidance, and supported by easy‑to‑understand risk-communication tools. Tackling the diagnosis and management of atrial fibrillation, high blood pressure, and high cholesterol are absolutely key, and modelling shows that taking focused action in these three areas would not only prevent 150,000 heart attacks and strokes as set out in the Long Term Plan,1 but also save about £2.30 for every £1 spent.6
Further effort through the Long Term Plan is needed to address the persistent inequality in CVD mortality …
Dr Rani Khatib, Consultant Pharmacist in Cardiology and Cardiovascular Research, Leeds Teaching Hospitals NHS Trust, stated that up to 50% of patients stop taking medicines prescribed following a myocardial infarction; by year two, this number rises to 75%.9 Dr Khatib said that improving patient adherence to post-myocardial infarction medications will require a patient-centred approach and multidisciplinary collaboration along the whole patient pathway.
Dr Riyaz Patel, Consultant Cardiologist and Clinical Lead for the Cardiovascular Disease Prevention Service, Barts Health NHS Trust, asserted that specialist centres had a role to play in prevention through developing and coordinating prevention strategies across secondary and community services in partnership with key stakeholders, such as the British Heart Foundation. In addition, Dr Patel advocated working with 175 schools across three London boroughs to educate children on CPR. Barts Health NHS Trust is trying to ensure that everyone involved in the care of people with CVD thinks about CVD prevention when they interface with patients, develops integrated risk services, and adopts a multidisciplinary approach to familial hypercholesterolaemia and the use of novel medicines.
… improving patient adherence to post-myocardial infarction medications will require a patient-centred approach and multidisciplinary collaboration along the whole patient pathway.
Helen Wilson, Head of Research, Heart Research UK, advised that heart failure affects just under 1 million people in the UK,7 and that this figure will rise because of the ageing population, rising levels of obesity, and improved survival of people with coronary heart disease. The prognosis for patients with heart failure remains poor: up to 20% die within a year of diagnosis, 50–60% within 5 years, and approximately 75% within 10 years.10 This is worse than the prognosis for many types of cancer. The cost of heart failure to the NHS is about £2 billion every year,11 mainly due to hospitalisation, but more important is the cost to patients in terms of quality of life. Helen emphasised the importance of research and innovation in the prevention, treatment, and cure of heart disease. Heart transplantation is the gold-standard treatment for end-stage heart failure; however, there is a shortage of suitable donor hearts. Current research using novel bioengineering techniques to produce sheets of stem cells to regenerate damaged heart tissue is yielding promising results.
The cost of heart failure to the NHS is about £2 billion every year … but more important is the cost to patients in terms of quality of life.
Professor Cathie Sudlow, Chair of Neurology and Clinical Epidemiology, Centre for Medical Informatics, Usher Institute, University of Edinburgh, highlighted work being undertaken by the British Heart Foundation Data Science Centre, which brings together data collected during routine clinical care to drive cardiovascular research and innovation. This includes the development of advanced analytical tools, particularly artificial intelligence research methodologies, to address research and innovation challenges such as understanding the causes of CVD and specifically heart failure, and performing faster and more efficient data-enabled clinical trials in which participants can be identified, recruited, and followed up using electronic methods.
This conference report was prepared by Specialised Medicine and the speakers have not had the opportunity to make corrections.
References
- NHS England. NHS Long Term Plan—cardiovascular disease. www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-quality-and-outcomes/better-care-for-major-health-conditions/cardiovascular-disease/ (accessed 7 April 2020).
- NHS. Heart failure—diagnosis. www.nhs.uk/conditions/heart-failure/diagnosis/ (accessed 7 April 2020).
- Lab Tests Online UK. B-Type natriuretic peptide (BNP) test. labtestsonline.org.uk/tests/b-type-natriuretic-peptide-bnp-test (accessed 7 April 2020).
- NHS Improvement. Getting it right first time. gettingitrightfirsttime.co.uk/ (accessed 7 April 2020).
- NHS Digital. Health survey for england 2017—cardiovascular diseases. London: NHS Digital, 2018. Available at: healthsurvey.hscic.gov.uk/media/78646/HSE17-CVD-rep.pdf
- Public Health England. Health matters: preventing cardiovascular disease. www.gov.uk/government/publications/health-matters-preventing-cardiovascular-disease/health-matters-preventing-cardiovascular-disease (accessed 7 April 2020).
- British Heart Foundation. UK factsheet. London: BHF, 2020. Available at: www.bhf.org.uk/-/media/files/research/heart-statistics/bhf-cvd-statistics-uk-factsheet.pdf?la=en
- Yusuf S, Hawken S, Ôunpuu S et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case control. Lancet 2004; 364 (9438): 937–952.
- Brown M, Bussell J. Medication adherence: WHO cares? Mayo Clin Proc 2011; 86 (4): 304–314.
- Jones N, R Hobbs, Taylor C. Prognosis following a diagnosis of heart failure and the role of primary care: a review of the literature. BJP Open 2017; 1 (3): 1–8.
- NICE. Resource impact report—chronic heart failure in adults: diagnosis and management (NG106). London: NICE, 2018. Available at: www.nice.org.uk/guidance/ng106/resources/resource-impact-report-pdf-6537494413