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Chapter 4 Coronary heart disease
Disease frequency and survival
In Scotland, mortality from coronary heart disease ( CHD) in people under 75 has fallen by 46% over the past decade. In the 1999 White Paper Towards a Healthier Scotland ( 1), the Scottish Executive set the target of a 50% reduction in CHD deaths among people under 75 years of age between 1995 and 2010. In the subsequent Coronary Heart Disease and Stroke in Scotland Strategy Update 2004 ( 2), this target was increased to 60%. As shown in Figure 4.1, Scotland is on track to meet this more stringent target.
Figure 4.1: Time trend in age-standardised coronary heart disease mortality under 75 years of age: actual and target figures
Expressed as annual rate per 100,000 population using European standard population
Source: Scottish Health Statistics ( http://www.isd.scotland.org) ( 3)
Figure 4.2: Age-standardised coronary heart disease mortality in men, by country
Figure 4.3: Age-standardised coronary heart disease mortality in women, by country
Source: British Heart Foundation for reference year 2000
Gratifyingly, Scotland no longer heads the international league table for CHD deaths ( Figures 4.2 and 4.3). However, as highlighted in Delivering for Health ( 4) there is clear evidence of a continuing gap between the most affluent and the most deprived communities in terms of mortality from CHD. For this reason, and to underline the determination of the Scottish Executive to closing the gap between affluent and deprived communities, an additional 15% increase in the rate of reduction of CHD mortality has been set for the most deprived communities, to be achieved by 2008.
The fall in mortality is due, in part, to a reduced risk of developing CHD and, in part, to improved survival among those who do. The overall incidence of CHD has fallen by 25% over the last decade. In particular, there has been a steady decline in the numbers of people suffering myocardial infarction ( MI). In 1995/1996, there were 11,732 emergency admissions to Scottish hospitals with a primary diagnosis of acute MI. ( 5) By 2004/2005, this figure had fallen to 8,579 admissions. The percentage of people who survive at least 30 days following admission for acute MI has increased from 81.4% in 1999 to 85.0% in 2004 ( 6).
Health service impact of heart disease
In contrast to emergency admissions for MI, the numbers of patients admitted electively to hospital for investigation or treatment of CHD has increased from 10,385 in 1995/1996 to 11,516 in 2004/2005 ( 7). In the Scottish population, 6.6% of adult men and 5.6% of adult women have been diagnosed as suffering from angina ( 8), rising to 25.3% and 20.6% respectively in people over 75.
In the 2003 Scottish Health Survey ( 9), 31% of men and 23% of women with cardiovascular disease reported consulting their general practitioner within the last two weeks. On average, people with cardiovascular disease had consulted their doctor on 10 occasions during the previous year. During the previous year, 54% of men with cardiovascular disease had attended hospital and 25% were admitted. The equivalent figures for women were 54% and 23% respectively ( 10). Heart disease is now more obviously a chronic disease resulting in fewer acute episodes and more out patient and primary care attendances.
Drug therapies and heart disease
Over the last decade, the total number of community prescriptions for cardiovascular drugs has doubled, from around 10 million in 1995 to almost 21 million in 2004 ( Figure 4.4). This includes drugs prescribed in the community from Chapter 2 (Cardiovascular) of the British National Formulary ( 11).
Figure 4.4: Number of community prescriptions for cardiovascular drugs by year
Source: Scottish Health Statistics ( http://www.isd.scotland.org) ( 12)
The greatest increase has been in the use of lipid-lowering drugs which have been shown to be very effective in both reducing the risk of developing CHD and improving prognosis among those with the condition. The number of prescriptions issued for statins has increased 13-fold, from 263,778 in 1996 to 3.4 million in 2005. The total cost of cardiovascular drugs issued in the community has increased from £73 million in 1995 to £233 million in 2004. Lipid-lowering drugs accounted for 11% of the cost in 1995, compared with 37% in 2004.
Operations for heart disease
Coronary revascularisation to improve the blood supply to the heart can be performed either by percutaneous coronary intervention ( PCI), which opens up the blocked or narrowed artery by stretching it, or coronary artery bypass grafting ( CABG) which involves surgery to bypass the blockage or narrowing.
Over the past decade there has been a major shift in the proportion of patients treated with PCI compared to CABG, with the number of CABG operations performed each year remaining relatively static. In stark contrast, the number of PCIs has more than doubled in the past 10 years, resulting in increased numbers of patients benefiting from revascularisation. Overall, two-thirds of coronary revascularisation procedures are now performed percutaneously, avoiding the need for major surgery in the majority of patients. Technical developments in both procedures mean improved outcomes and reduced risk of complications. The risk of dying within 30 days of CABG has fallen steadily from 3.1% in 1996/1997 to 2.0% in 2004/2005.
Waiting times
Delivering for Health ( 13) highlighted the fact that by the end of 2005, for the fourth successive quarter, no patient with a guarantee waited more than 18 weeks for angioplasty or coronary artery bypass grafting. The maximum waiting time for coronary angiography of eight weeks had also been consistently met over the preceding 12 months.
NHSScotland is now working towards new, more challenging, waiting time targets for cardiac disease. Fair to all, Personal to Each ( 14) committed to a total patient journey time of no more than 16 weeks for cardiac intervention from the end of 2007. For the first time, the target covers the period from GP referral through rapid access chest pain clinic ( RACPC) or equivalent, to cardiac intervention. For patients who do not present through the RACPC route, the new target is a maximum of no more than 16 weeks' wait for treatment after they have been seen as an outpatient by a heart specialist, and treatment has been recommended. Again, this target is to be met by the end of 2007. The National Waiting Times Unit, in conjunction with the Centre for Change and Innovation, is working closely with NHS Boards to achieve these new waiting time targets.
Risk factors for heart disease
In 1995, 35% of adults (age 16-64) in Scotland smoked. In A Breath of Fresh Air for Scotland ( 15), the Scottish Executive set targets of 33% by 2005, and 29% by 2010. By 2003, 29% of men and 28% of women smoked ( 16), thereby meeting the 2010 target ahead of schedule. Smoking prevalence is higher in the more deprived areas and separate smoking reduction targets were set in order to encourage more rapid reduction in deprived areas.
In December 2005, the Scottish Executive announced changes to the national population target. In the light of recommendations made by an expert group, the intention is to reduce the prevalence of smoking in Scotland to 22% by 2010. In the more deprived areas, the aim is to reduce the rate from 37.3% in 2004 to 33.2% in 2008. Targets for young people (aged 12-15) are currently under review. The population target was changed from 16-64 to over 16 years old, with no upper age limit. This underlines the message that it is never too late to stop and will also make the Scottish figures directly comparable with the rest of the UK. The ban on smoking in public places, together with improved access to smoking cessation programmes, is expected to make a major contribution to achieving these targets and in protecting those who do not smoke.
There have been some improvements in diet over the last four decades, with a reduction in average fat and salt consumption and an increase in the consumption of fresh fruit ( 17, 18). However, consumption of fresh vegetables has not improved ( 19) and is lower in Scotland than in England ( 20). Further improvements in diet are needed.
Between 1998 and 2003, the overall percentage of Scottish adults participating in some form of physical activity increased from 80% to 83%. The percentage meeting the recommendation of at least 30 minutes of moderate or vigorous activity on at least five days a week increased from 41% to 44% ( 21). The improvements were most marked in older age-groups. Among younger adults, there was a decline in overall participation rates and no change in the percentage meeting the target ( Figure 4.5). Therefore, additional efforts are required to increase physical activity in the young.
Figure 4.5: Time trends in overall participation in physical activity among men, and the proportion meeting recommendations, by age
Source: Scottish Health Survey 2003 ( 22)
Internationally, all Western countries are seeing increases in the prevalence of obesity and type II diabetes. The percentage of Scottish men who are overweight or obese has increased from 56% in 1995 to 65.4% in 2003 ( 23). The equivalent figures for women are 47% and 59.7% respectively. The prevalence of diabetes in men aged 16-64 increased from 1.5% in 1995 to 2.4% in 2003 and in women aged 16-64 from 1.5% to 2.0%. These trends were due to an increase in type II diabetes, which is associated with being overweight. These trends are consistent with other developed countries and need to be tackled in order to avoid an adverse impact on CHD in the future.
Future trends
Over the last decade there has been a significant decline in CHD mortality due to both a reduced incidence of MI and an increase in survival. However, the prevalence of CHD will, inevitably, increase due, in the main, to an ageing population. Therefore, the focus is shifting from dealing with high numbers of emergency admissions to managing people with chronic disease.
The landmark legislation to ban smoking in public places, supported by improved access to smoking cessation programmes, will build substantially on achievements to date. However, the issues of lifestyle-associated risk factors, particularly diet and physical activity, remain a challenge.
The anticipatory approach outlined in Delivering for Health ( 24) and Prevention 2010 ( see Chapter 6) will focus resources in areas of greatest health inequality. This will ensure that people at greatest risk of ill-health from diseases such as CHD are actively identified and offered opportunities for early diagnosis, advice and treatment.
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