A silent pandemic
Cardiovascular disease (CVD) is the primary cause of death worldwide, with an estimate of nearly 18 million lives lost each year, as figures from the World Health Organisation suggest.1,2 As life-expectancy and industrialisation have increased, a significant epidemiological transition has taken place, leading to a long-standing global pandemic in CVD.3 CVD is an umbrella term including disease states of both the heart and the vessels, and, therefore, has pathological implications and associations with most organs, including brain and kidney. It has a multi-faceted impact, not only in terms of mortality and morbidity but also relevant to healthcare economics, social care and quality of life.
Despite improvements in the prevention and management of CVD, leading to reductions in its burden in the UK, the numbers remain daunting.4 More than 10% of the UK population (7.6 million) live with CVD, with an estimated prevalence that is double that of Alzheimer’s disease and cancer combined.5 In addition, 27% of all deaths in the UK are caused by CVD-related conditions, with more than 40,000 deemed premature.5 As such, CVD was the leading cause of mortality in the UK prior to the COVID-19 pandemic.5 During the COVID-19 pandemic, CVD-related mortality remained high, and in months where the incidence of COVID-19 declined, CVD remained as one of the most common causes of death in the UK.
Steering away from statistical figures on mortality and morbidity, it is important to note how CVD impacts on health and social care economics, posing a problem of significant magnitude. The annual healthcare cost of CVD in England stands at £7.4 billion, with £15.8 billion per year representing a cost to the wider community in terms of social care, employment and indirect costs.6 Additionally, looking more specifically at stroke, it is projected that the average cost of NHS and social care for each person following a stroke is over £40,000 within the first year,7 with a significant component of total cost being unpaid care.
CVD prevalence is distinctly affected by health inequalities. Its incidence and prevalence is associated with deprivation, ethnic origin and presence of severe mental illness. Figures published by Public Health England indicate that people living in more deprived areas are four times more likely to suffer from CVD.6 Evidence presented by the King’s Fund highlights that people of South Asian origin have a higher incidence, prevalence and mortality from CVD in a fashion similar to that exhibited across the Indian diaspora,8 while black groups display lower than expected rates of access and use of appropriate care.9
As noted, CVD represents a significantly complex problem that extends beyond treatment and hospital management – as life-expectancy rises, one would expect the impact of CVD to amplify. CVD is affected by a number of determinants that not only focus on the individual, but also extend to population dynamics and the environment.10 It is, therefore, important to understand the risk factors behind CVD and focus on the plans of the NHS to address these.
Evolution of risk factors
It is over 70 years since the Framingham Heart Study was established, a key project that enabled doctors and other healthcare professionals to better understand CVD risk factors, and instigate policies directed towards disease prevention. It took nearly 10 years from the initial participant being enrolled to identify that hypertension was associated with the incidence of coronary heart disease and stroke.11 Indeed, as greater understanding has evolved, risk factors are divided into non-modifiable (age, ethnicity, family history) and modifiable (hypertension, diabetes mellitus, alcohol intake, hyperlipidaemia/hypercholesterolaemia, physical inactivity, obesity) following large-scale research studies such as MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) and INTERHEART (The Effect of Potentially Modifiable Risk Factors Associated with Myocardial Infarction).12,13 Linking observations to phenotype, the UK Biobank imaging enhancement study has recently shown that all modifiable risk factors affect the heart structurally prior to clinical presentation.14 Such findings highlight the need to address modifiable risk factors early, in order to minimise the impact of CVD in the population.
Beyond the traditional risk factors, we are now armed with a better understanding of the impact of atrial fibrillation on morbidity and mortality, relevant to CVD and renal disease. A large meta-analysis (n=9,686,513) has highlighted the impact of atrial fibrillation on the risk of developing cardiovascular events and ischaemic stroke.15
Table 1. Prevalence of key modifiable risk factors in the UK
|Risk factor||Number of cases|
|* England and Scotland only
‡ England only
Adapted from Chapter 5 in British Heart Foundation. Heart & Circulatory Disease Statistics 2021.16
Risk factors alone account for a significant proportion of the disease burden in the UK. A review of the Heart & Circulatory Disease Statistics 2021, released earlier this year by the British Heart Foundation, highlights the impact of modifiable risk factors on CVD mortality.16 Over the last decade (2009–2019), nearly 80% of mortality secondary to CVD was associated with modifiable risk factors with a similar trend regarding burden of disease measured through disability-adjusted life years (DALYs); this is not surprising given their high prevalence (table 1).16 Public Health England, the NHS, and the UK government have identified the scale of the problem, which it aims to address through the NHS Long Term Plan.
The NHS Long Term Plan
Table 2. The six-point platform of the NHS Long Term Plan to improve CVD prevention and management17
|Early detection of CVD risk factors (target: atrial fibrillation, hypertension, hyperlipidaemia/hypercholesterolaemia)
Improved identification of high-risk conditions through optimisation of NHS Health Check (collaboration of Public Health England and local authorities)
Early and timely management of high-risk conditions enabled
Shift focus of management of heart failure/valvular disease to community setting via multi-disciplinary team functioning in a primary care environment
Increased availability of community cardiac defibrillators and community first responders
Improved accessibility to cardiac rehabilitation services
The NHS Long Term Plan17 marks an ambitious effort to improve NHS provision so that it is more suitable for the modern population it serves. It looks deeply into digitalisation and technology enhancement in order to address healthcare ‘from cradle-to-grave’. As part of this strategy, much focus has been placed on CVD prevention with an aim to avert 150,000 strokes, heart attacks and cases of vascular dementia over the next decade. It represents an ambitious, yet pragmatic approach to the issues surrounding CVD and understands the importance that many stakeholders, as well as healthcare professionals, play. As a six-point plan, it highlights the need for cooperation, interdisciplinary action and focused interventions spanning from local authorities, to clinical commissioning groups, primary and secondary care and other allied healthcare professionals (such as pharmacists, therapists, etc.), research organisations and patient representatives (table 2).17
The NHS Long Term Plan17 aims to support prevention and management of CVD through primary care networks, with multi-disciplinary roles in the community, utilising pharmacists, nurses and social prescribing link workers. In addition, it promotes the notion of multi-disciplinary teams working together across primary and secondary care to lead in prompt identification and management of heart failure and valvular heart disease at a community level. It further highlights the need for improvement in detection of high-risk conditions such as familial hypercholesterolaemia, aiming to identify at least 25% of patients with such conditions (currently 7%) within the next five years.
Public Health England established a National CVD Prevention System Leadership Forum (CVDSLF), a consortium of 40 organisations targeting CVD through an ABC approach of risk factors: Atrial fibrillation, Blood pressure, Cholesterol,18 which fed in to help establish the ambitions in the Long Term Plan.
In addition, certain media campaigns have been launched, such as the ‘May Measurement Month’ and Blood Pressure UK’s ‘Know Your Numbers’ week, in an effort to increase awareness on the topic of hypertension. Furthermore, updated guidelines on the diagnosis and management of hypertension have recently been released by the National Institute for Health and Care Excellence (NICE),19 while new online modules have been created and published targeting the education of healthcare professionals.20
However, the vision does not stop there. As there is a huge awareness on the importance of data analysis, a national primary care audit is being created (CVDPrevent), responsible for data extraction relevant to the risk factors leading to cardiovascular disorders.21,22 CVDPrevent will act as a reference point, increasing awareness of issues relevant to diagnosis, management and inequalities.
A national CVD Prevention Clinical Leadership Group has now been in operation for a year, bringing together clinical leaders from across the country. There has been some impressive work over the past 12 months. An example is the recent work between the Oxford Academic Health Science Network, the Getting It Right First Time (GIRFT) programme and the Association of Directors of Public Health that have produced guidance for Integrated Care Systems regarding CVD prevention and management.23 The National Cardiovascular Intelligence Network has also produced some excellent CVD Prevention Packs for Sustainability and Transformation Partnerships,24 which help understand CVD prevention down to the practice level. Additionally, the recently released NICE impact CVD management report has identified areas of significant gaps in uptake (heart failure, and cardiac rehabilitation) and has led to the engagement between NICE and 20 external stakeholders to identify implementation barriers and challenges leading to the successful implementation of the NHS Long Term Plan.25
The efforts above are multi-factorial and do not simply target CVD from the ‘biomedical angle’. They are strategies constructed such that they can address health inequalities and follow on from the teachings of the former National Support Team for Health Inequalities who rationalised that preventing CVD can rapidly impact on these inequalities. Many regions and Integrated Care Systems are following the example of the national CVD Prevention Clinical Leadership Group and are developing CVD prevention groups, which will be at the heart of reducing mortality and health inequalities. Furthermore, the Public Health England Segment Tool is an enabler that allows local and regional groups to see and quantify which conditions contribute to their local gap in life-expectancy, while the PHE CVD Prevention Packs, as discussed above, can be used to alert practices and primary care networks towards challenges and prompt relevant action.
A lesson from COVID-19
The global pandemic of COVID-19 has undoubtedly changed healthcare and has affected CVD-associated routine practice. On a collective level, it reminded us of the need for adaptability and ingenuity and has instigated change.26,27 It also pinpointed the increased risk that patients with CVD face in such pandemics, regarding mortality and morbidity, as noted in a recent meta-analysis of 51 studies (n=48,317).28 Patients with CVD risk factors including hypertension or diabetes had a significantly higher relative risk of developing severe COVID-19 or death compared with the rest of the population (odds ratio [OR] 2.50, 95% confidence interval [CI] 2.15 to 2.90; and OR 2.25, 95%CI 1.89 to 2.69, respectively). A similar significant trend was established in patients with CVD (OR 3.11, 95%CI 2.55 to 3.79).28 Considering the effects of COVID-19, healthcare needed to evolve in such a way that it addresses CVD holistically and effectively, at an early stage and with greater primary healthcare involvement in order to avoid further impact and minimise its effects on healthcare, economics and patients. NHS England and NHS Improvement reacted by developing a programme called Blood Pressure @home.29 The Academic Health Science Networks, Accelerated Access Collaborative and the Primary Care Cardiovascular Society have collaborated in support of familial hypercholesterolaemia identification and creation of resources and educational material supporting primary care practitioners and patients.30 This is leading to increased detection of familial hypercholesterolaemia and optimised treatment pathways.
Need for future interdisciplinary cooperation
CVD remains the leading cause of death worldwide. Despite advances in management, the impact of CVD remains significant. Addressing a problem as multi-factorial as CVD prevention is not easy, especially following COVID-19. It is, therefore, important to answer the call to action in an effort to control and manage the impact of CVD, with a key ambition being the reduction of health inequalities. In order for this to be successful, healthcare providers from different disciplines and fields, need to cooperate in a true multi-disciplinary fashion. Our biggest asset is the huge number of NHS and non-NHS colleagues, who are determined to narrow the gap in life-expectancy and protect the most vulnerable from CVD, a condition with highly evidence-based prevention interventions. There are real reasons for optimism. As we have seen during the COVID-19 pandemic, the collaborative work between the NHS, the research community, other stakeholders and the community can achieve significant successes; learning from those experiences and following the vision of the NHS Long Term Plan can aid in the reduction of another global pandemic, of CVD.
- Cardiovascular disease (CVD) represents a global pandemic with significant healthcare, social care and financial implications for the UK
- CVD represents a collection of diseases, and its prevention is multi-factorial and not only reliant on medical interventions
- In an ambitious effort, the NHS Long Term Plan aims to prevent 150,000 CVD deaths within 10 years
- The lessons learnt from the COVID-19 pandemic should aid in tackling CVD more successfully
Conflicts of interest
National Clinical Director of CVD Prevention, NHS England and NHS Improvement
NHS England, 6th Floor, Zone B, 80 Skipton House, London Road, London, SE1 6LH
Clinical Research Fellow
Renal Research Department, Alderson House, Hull Royal Infirmary, Kingston upon Hull, HU3 2JZ
Consultant Cardiologist, Associate Medical Director for Cardiology
Department of Cardiology, Hull University Teaching Hospitals NHS Trust and Northern Lincolnshire and Goole NHS Foundation Trust, Castle Hill Hospital, Castle Hill Road, Cottingham, HU16 5JQ
Articles in this supplement
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