Heart disease remains a major cause of death and disability in Scotland, accounting for around 10,000 deaths each year.1 Ischaemic heart disease is still Scotland’s single biggest killer, responsible for 11.3% of all deaths in 2018, and accounts for 25,000 hospital admissions each year. While it is true that there have been improvements in survival from heart attacks and other acute events in Scotland over the last half century, it is also the case that significant challenges remain.
The reduction in deaths from heart attacks means that more people are living with heart disease as a long-term condition. On top of this, the population is getting older,2 and increasingly people are living with associated comorbidities, many requiring long-term support. The number of people living with cardiovascular risk factors in Scotland continues to increase, health inequalities persist and in some cases, have worsened.3
Beyond ischaemic heart disease, the incidence of conditions like heart failure,4 heart valve disease,5 and atrial fibrillation are increasing. There is also a need to consider the impact of less common, but no less important conditions, such as congenital heart disease and inherited heart conditions. Around 28,000 people in Scotland have an inherited heart condition, the most common of which is hypertrophic cardiomyopathy. Congenital heart disease is one of the most common birth defects in Scotland, affecting around one in every 150 births. Improved survival rates mean that a growing number of people are living into adulthood with congenital heart disease.
Impact of pandemic
The COVID-19 pandemic has brought this into even sharper focus, having had a significant impact on people with heart disease and on the services that support them. A recent study of severe COVID-19 cases across the UK revealed that the most common comorbidity is chronic heart disease (29%).6 Ischaemic (coronary) heart disease has been the second most common pre-existing condition for COVID-19 fatalities in Scotland, behind dementia and Alzheimer’s disease.7,8
Furthermore, during the initial lockdown period of the pandemic, overall attendance at Accident and Emergency (A&E) decreased,9 and this period coincided with a 30% decrease in emergency cardiology admissions in Scotland.10 There was also a deferral and reduction of other services, including diagnostics, access to specialist support in the community and cardiac rehabilitation. This has resulted in longer waiting times for specialist assessment and investigation, and increased strain on an already stretched health service. There are concerns this will also have long-term implications for mortality and morbidity for people with heart disease in Scotland.
It is vital that new or updated national plans are developed and agreed to address these challenges and keep pace with the changing needs of people living with heart disease. At present, the Scottish Government’s priorities for heart disease in Scotland are set out in the Heart Disease Improvement Plan, which was published in 2014. We believe that now is the right time to set a new, updated Heart Disease Strategy for Scotland to tackle these challenges over the next five years.
Since May 2019, British Heart Foundation (BHF) Scotland has been consulting with clinicians and people living with heart disease to identify and prioritise these challenges and how best to tackle them. In August 2020, we published a consultation document, and distributed it widely into the clinical and patient forums for feedback and comment. Following the incorporation of the feedback, BHF Scotland launched our vision for a national heart disease plan endorsed by Scottish Cardiac Society, Royal College of Physicians Edinburgh, Royal College of Surgeons Edinburgh, Royal College of Physicians, and Surgeons Glasgow and Scottish Heart & Arterial Disease Risk Prevention, which was a recommendation for Scottish Government policy.We have identified three key priorities that should be addressed and have ensured that these align with the current health policy paradigms in Scotland, namely Realistic Medicine and the National Clinical Strategy. Alignment with the National Clinical Strategy for Scotland is shown in the infographic (figure 1).
The first of these is tackling the risk factors for heart and circulatory diseases. Millions of people in Scotland are living with conditions, such as high blood pressure and high cholesterol, increasing their risk of heart disease and stroke. Many of these people have not been diagnosed, while others who have a diagnosis may not be receiving optimal treatment. Establishing services to identify risk factors then supporting people with self-management will reduce their risk of developing heart disease.
Second, we need to ensure that everyone in Scotland with heart disease has access to timely diagnosis, treatment and care, no matter what condition they have or where they live. There are many barriers to this, including resources and workforce issues.
We believe, as part of a national strategy, there should be support for the spread and adoption of innovative models of care, including community cardiology, and addressing some of the barriers including a focus on tackling key workforce issues – in particular a national approach to addressing the crisis in staffing levels in cardiac physiology in Scotland. Primary and secondary care should work seamlessly together to support people with heart disease and help them to live well with their condition. This should include ensuring access to the emotional and psychological support that so many people with heart disease tell us they would benefit from. Where necessary, it also includes ensuring that people with heart disease approaching the end of their life can access palliative care.
Our third priority centres on the effective use of data to improve services for people with heart disease. We have a large variety of data currently being collected and held within the healthcare systems across Scotland. However, these data are not always collected, accessed or used in the same way. These data can be used to help standardise and evaluate the care being given. We believe a national agreed approach to data collection, storage, access and use is vital to support health professionals to measure, learn and improve care and outcomes for people with heart disease in Scotland.
In summary, the key areas to be addressed in the National Heart Disease Strategy are risk factor identification and management, particularly high cholesterol and hypertension, a reduction of inequity of services and ensuring effective utilisation of data for quality improvement in the care for patients with heart disease in Scotland. The national strategy proposal will explain and expand on these three common, crucial and central fields, on achievable goals, and most of all, how to implement this strategy within Scotland. We hope this will be adopted at government level as policy.
In 2021, heart disease management and services need to change to meet the challenges identified above. We believe a
new heart disease strategy will allow us to do this. In March 2021, the Scottish Government broadly adopted the majority of our proposed strategy as policy.11 We hope this will come with adequate funding to be able to deliver these important changes in heart disease management for the people of Scotland over the next 10 years.
Conflicts of interest
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2. National Records of Scotland. Scotland’s population: the Registrar General’s annual review of demographic trends. Edinburgh: NRS, 2018. Available from: https://www.nrscotland.gov.uk/statistics-and-data/statistics/stats-at-a-glance/registrar-generals-annual-review/2018 [accessed 4 March 2020].
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8. National Records of Scotland. Deaths involving coronavirus (COVID-19) in Scotland, week 24 (8 to 14 June 2020). Edinburgh: NRS, 2020. Available from: https://www.nrscotland.gov.uk/news/2020/deaths-involving-covid-19-week-24-8th-to-14th-june [accessed 2nd July 2020].
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11. Scottish Government. Heart disease action plan 2021. Edinburgh: Scottish Government, March 2021. Available from: https://www.gov.scot/publications/heart-disease-action-plan/pages/2/