Cardiovascular disease and deprivation

Br J Cardiol 2009;16:20-21 Leave a comment
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A busy and varied programme discussing some of the hottest topics in cardiovascular disease was presented at the 11th Primary Care Cardiovascular Society (PCCS) Annual Scientific meeting, held in Chester on 25th – 27th September 2008. It attracted over 250 people and inspired great interest and debate.

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More than just a postcode

The keynote session, ‘Cardiovascular disease and deprivation; more than a postcode’, heard from public figures and leading clinicians defining deprivation as it relates to cardiovascular disease from various perspectives. Professor Roger Boyle (National Director, Coronary Heart Disease and Stroke) said that, despite the “considerable progress” seen across all age groups and genders in cardiovascular disesase (CVD) reduction, there remains a gap between deprived and non-deprived areas, and between different social classes.

“Deprivation and social class are key risks for mortality in CVD, yet, the map of spend on CVD does not reflect the map of deprived areas and social class status across the UK.” He concluded “Primary care must take the opportunity to manage the health of all of their patients and tackle inequalities”.

Professor Klim McPherson (Chair, National Heart Forum) highlighted mortality trends according to deprivation. “There is an eight to nine year gap in mortality trends between deprived and less deprived areas,” he said, stressing the importance of long-term diet in the development of CVD.

Dr Kiran Patel (Consultant Cardiologist, Sandwell) highlighted inequalities of care within ethnic groups. He noted that CVD presentation is often atypical across different ethnic groups meaning that diagnosis can be missed or delayed. This, together with other factors, such as language barriers, the absence of support, access issues and long working hours can mean that the patient pathway is prolonged. “In order to address disparities, we need to focus on awareness, acceptability, accessibility and acquisition of services,” concluded Dr Patel.

Finally, Professor Richard Hobbs (Professor of Primary Care and General Practice, University of Birmingham) highlighted deprivation in the elderly and inequalities in the management of women with CV events. Quoting results from the OXVASC study, he noted that CV events increase with increasing age, with women presenting typically 10 years later than men and less likely to receive acute interventions.

If we know who and where they are, are they really that hard to reach?

A fascinating and lively session heard four successful risk assessment projects conducted in the community setting.

Deirdre Doogan (Lloyds Pharmacy) described a project in which Lloyds Pharmacy were part of an initiative to tackle inequalities in CV screening in deprived areas of Birmingham. The project reviewed 10,000 men in seven months. “The challenge is to engage specific groups in the community,” she said. This was achieved by inviting men identified from GP practice registers, to football grounds, church halls and health centres. “Community pharmacy has a key contribution to make in such CVD risk reduction projects,” she concluded.

Jane Deville-Almond (Wolverhampton) stressed “We need to understand men, their drivers, interests and language when trying to sell a health service to them”. Having taken her various heart, prostate and weight risk assessment clinics around the country, to such diverse places as farmers markets, barber shops, fishing fairs, truckers’ cafes and Harley Davidson showrooms, Ms Deville-Almond concluded: “We need to find new ways to motivate our patient populations so that they ultimately have the tools they need to look after their own health”.

Peter Heywood (Middlesbrough) described how social marketing techniques can be used in the health care arena. “Once we identify the type of patient that we want to target, such as younger males, older females, we can start to target our messages appropriately,” he advised. Such techniques are being implemented in the Tees Vascular Assessment Programme.

Catriona Jennings (London) described the 16-week ‘MyAction’ programme, a nurse-led, multi-disciplinary, family-based model of vascular prevention, already successfully running in the Bromley area. “With shared lifestyles between partners, we recognised that including the entire family is key to the success of this vascular prevention programme,” she said. Close co-operation between the Primary Care Trust (PCT) and local services is also important.

Keynote address

Chris Brinsmead (President of the Association of the British Pharmaceutical Industry [ABPI]) gave a rousing address, encouraging industry and clinicians to work together for maximal patient outcomes. He noted the advances in cardiovascular care over the last two decades stressing that cardiovascular disease remains a major priority for industry, as well as Government. Giving examples of successful projects with industry working closely with PCTs, Mr Brinsmead highlighted the importance of the ABPI Code of Practice to provide a clear framework for partnerships between industry and health care professionals.

Creative plenary sessions

Several creative plenary sessions kept the audience enlivened and educated throughout the meeting. ‘High risk high school’ (sponsored by Boehringer Ingelheim) saw four cardiovascular ‘pupils’ from primary care, nursing and secondary care (Dr Henry Purcell, London; Dr Terry McCormack, Whitby; Dr Michael Norton, Sunderland, and Delyth Williams, Hitchen) highlight projects they have undertaken over the past year to further advance CV risk prevention in their area. Chairing the session, ‘Headmistress’ Dr Kathryn Griffiths (General Practitioner, York) concluded: “It is fascinating to hear what others are doing and how much we can learn from one another.”

‘Lipids on trial’ (sponsored by Merck Sharp and Dohme) turned the audience into the ‘jury’ to vote on the debate entitled ‘By focusing on total cholesterol alone, primary care is guilty of not going far enough to address CV residual risk.’ The trial, adjudicated by TV presenter, Sue Lawley, heard from the ‘prosecution’, Professor Richard Hobbs and Dr Marc Evans (Cardiff), and the ‘defence’, Dr Mark Davis (Leeds) and Professor Julian Halcox (Cardiff). The prosecution noted that, despite a reduction in cardiovascular risk, many patients still suffer morbidity and mortality from CVD. They therefore argued that low-density lipoprotein (LDL) “cannot be the only CVD risk factor”. Furthermore, they pointed out, high-density lipoprotein (HDL) has as strong a correlation as LDL with CV risk. The defence argued that, despite there being epidemiological evidence that HDL is a risk factor for CVD, there is, as yet, no definitive clinical trial evidence that raising HDL leads to a reduction in CV events. After strongly argued battles, intermingled with heckling from the judge, 50% of the ‘jury’ voted for the motion and 50% against!

‘Welcome to the CV risk clinic’ (sponsored by the Merck Sharp & Dohme/Schering Plough Partnership) heard opinions from Dr Mike Norell (Wolverhampton), Dr Jonathan Morrell (Hastings) and Michaela Nuttall (Bromley) on patient case studies including patients with acute coronary syndrome, peripheral arterial disease, and obesity. The variety of issues that were discussed amongst the panel included patient compliance, drug choices and doses, cardiac rehabilitation, statin non-responders and intolerance, and random vs. fasting triglycerides.

In ‘Know your 3 ‘S’s: statins, sartans and savings’ (sponsored by Takeda), Professor Mike Kirby (Letchworth) highlighted the huge pressures on primary care that make switching more desirable. He presented data showing cost savings that can be made by switching surgery patients from atorvastatin 10 mg to simvastatin 30 mg, and losartan 50 mg to candesartan 8 mg. Of 122 patients, there were no significant differences in cholesterol control when switching, and blood pressure improved when switching to candesartan. Two years on, there were no increased adverse events from the switches. This exercise has resulted in five-year savings to the practice of £71,000 from the statin switch and three-year savings of £41,000 from the sartan switch.

Professor Richard Hobbs then argued for the case that ‘The wholesale substitution of drugs in the same class is safe and effective’ with Dr Sarah Jarvis (London) arguing against this. “We need to substitute our drugs to the cheapest options possible so we can treat more patients,” he said. Dr Jarvis argued “We can only do this if quality of care is not compromised and if financial gains are sufficient to warrant the time and cost of switching.” She cautioned, “We must consider efficacy, adverse effects, licensed indications and discontinuation rates”. The majority of the audience agreed.

Interactive cases: clinical problems and solutions

Dr Kathryn Griffith stressed that earlier stage chronic kidney disease (CKD) – up to stage 3b – is a primary care condition that can be diagnosed with simple blood tests. She noted that it is invariably part of a wider vascular disease picture, and reminded “we must always refer patients if needed, particularly those with more severe CKD”.

Professor Mike Kirby highlighted that erectile dysfunction (ED) is closely linked to CVD, and should also be considered an indicator of wider vascular issues. He advised that angiotensin-converting enzyme (ACE) inhibitors can make ED worse, and PD-5 inhibitors can help to improve endothelial function if given regularly – for three to six months, for example. “Our patients are often reluctant to talk about ED so we need to be proactive due to its important link with heart disease”.

Dr Khalid Khan (Wrexham) discussed ECG and atrial fibrillation. He advised that, generally, patients should be referred to secondary care if they have syncope >3 seconds, 2nd or 3rd degree block with symptoms, and tachycardia or bradycardia. He noted the low use of warfarin in older patients with AF, and advised “Using the CHADS 2 score, we can risk stratify who needs warfarin”.

Finally, Dr Matt Capehorn (Rotherham) highlighted the issues surrounding obesity in primary care. He said “We spend a lot of time in primary care treating the complications of obesity, and not enough time treating the actual cause, i.e. the excess weight”.

Summary

As the meeting drew to a close, everyone agreed that the 11th PCCS Annual Scientific meeting had been varied, educational, informative, interactive, entertaining and memorable. Planning is already underway for next year’s meeting on 1st–3rd October 2009 in Nottingham.

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