Circulatory Diseases

Introduction

Cardiovascular diseases (CVD) are the main cause of death in the UK causing around 156,800 deaths in England in 2008 (around a third of all deaths). Around 45% of all deaths from CVD are from coronary heart disease (CHD) and more than a quarter from stroke (28%). CHD is the most common cause of death in England and Wales and accounts for 15% of all deaths (Watson et al, 2011).

Coronary Heart Disease

  • CHD is caused by a gradual build up of fatty deposits in the walls of the coronary arteries, which can then cause them to narrow. The medical term for this condition is atherosclerosis and the fatty material is known as atheroma.
  • Over time, the artery may become so narrow that it can’t deliver enough oxygen to the heart, especially on exertion. This can lead to angina – a pain or discomfort in the chest.
  • If a piece of this fatty material breaks away from the artery wall it can cause a clot to form, which will then starve the heart of blood and oxygen. This is known as a heart attack (or myocardial infarction).

Stroke and Transient Ischaemic Attack (TIA)

Stroke is caused by a disturbance to the blood supply to the brain causing ‘an earthquake in the brain’ (NAO, 2005). Stroke can have a lasting and profound impact on how people move, see, speak, feel or understand their world. Stroke is a medical emergency in which time is critical; the faster someone reaches expert help, the greater their chances of making a full recovery or reducing the risk of long term disability. Patients who are left with residual disability need timely, high quality services and longer term support in many aspects of their lives.

There are two main types of stroke:

  • Ischaemic-the most common form of stroke, caused by a clot narrowing or blocking blood vessels so that blood cannot reach the brain. This leads to death of brain cells due to lack of oxygen
  • Haemorrhagic-caused by bursting blood vessels producing bleeding into the brain and brain damage

A Transient Ischaemic Attack (TIA), sometimes called a ‘mini-stroke’ is also a medical emergency. During a TIA, blood supply to part of the brain is interrupted for a very short time. The symptoms are the same as for a stroke but usually last only for a few minutes, up to a few hours, and disappear completely within 24 hours. Nearly one in four patients who have an ischaemic stroke recall having a TIA at some point before their stroke, almost half of these occur in the week prior to the stroke (Rothwell and Warlow 2006).

Problems of rhythm

Problems of rhythm include a range of conditions collectively known as arrhythmia, and are abnormal rhythms or an irregular heartbeat. Arrhythmias may cause symptoms such as palpitations or light-headedness, but many have more serious consequences, including sudden death. Diabetes shares many of the risk factors associated with CVD and also increases cardiovascular risk (Healthcare for London, 2009). Diabetes is dealt with in another section.

Details on Smoking, Diabetes, Physical Activity, Tackling Life Expectancy Gap and Adult Obesity are dealt in other sections.

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Key Issues and gaps

  • Mortality rates from CVD higher than the national rate, decreased since 1995-7.
  • Higher rates of mortality in more deprived areas of Haringey
  • Emergency admissions for CHD, Stroke, heart failure all higher in more deprived areas of Haringey
  • Certain ethnic groups at higher risk of CVD
  • Prevalence of these diseases reported in primary care lower than would be expected, suggesting under diagnosis and/or reporting.
  • These emphasise the need to work with primary care and the public to raise awareness and improve diagnosis and management of these conditions particularly in the more deprived areas and with certain Black and minority ethnic (BME) groups.
  • Future prevalence likely to increase for CHD and hypertension but remain static for stroke.
  • There has been significant stroke service re-configuration in recent years in line with the Health Care for London care pathway and national strategy. Key service gaps remaining are provision of early supported discharge from the Hyper Acute Stroke Unit, effective primary prevention measures and effective secondary care management.
  • CHD is a major cause of mortality and morbidity in Haringey. Limited work has been done on reviewing and developing services for CHD.
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Who is at risk and why

The following risk factors are recognised for CVD (NICE, 2010):

  • Age
  • Smoking / tobacco use
  • High blood pressure
  • High blood cholesterol
  • Physical inactivity
  • Being overweight or obese
  • Family history
  • Diabetes
  • Ethnicity - certain ethnic groups have a higher risk. South Asian people living in the UK are one and a half times more likely to die from CHD before the age of 75 than the rest of the UK population
  • People in unskilled manual groups, lower socio-economic groups have higher rates of stroke, CHD, hypertension and the most of the associated risk factors
  • Psychosocial stress (linked to people’s ability to influence the potentially stressful environments in which they live)
  • Excess alcohol consumption

Estimated numbers of people with some of these risk factors include:

  • 48,816 16+ years people currently modelled to be hypertensive in Haringey
  • The prevalence of cardiovascular disease increases significantly after the age of 40 years. The percentage of the population aged 40 yrs and over is expected to increase in Haringey from 18.3% to 20.6% for males and increase from 20.0% to 20.9% for females by 2030
  • Diabetes - 11,748 people aged 17 and older were diagnosed (2010/11 London Health Programmes)
  • The London Boost (2006) for the Health Survey for England (LHO) modelled smoking prevalence as 28.6% males and 24.2% females in Haringey compared to 25.3% for males and 18.8% for females in London; 26,006 males and 24,108 females smoke in Haringey
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The level of need in the population

GPs record information on whether their patients have CHD, stroke, hypertension, heart failure and atrial fibrillation. The actual numbers recorded by GPs is then compared to the number estimated to be living with that condition within the relevant catchment area. The observed prevalences are as follows (Watson et al, 2011):

  • The observed prevalence for CHD in Haringey is 32.7% of the estimated prevalence. This compares to 61.2% for England and 48.9% for London.
  • The observed prevalence for stroke in Haringey is 36.4% of the estimated prevalence. This compares to 67.9% for England and 52.2% for London.
  • The observed prevalence for hypertension in Haringey is 39.6% of the estimated prevalence. This compares to 43.9% for England and 41.1% for London.
  • The observed prevalence for heart failure in Haringey is 0.47%. This is lower than London (0.50%) and England (0.72%).
  • The observed prevalence for atrial fibrillation in Haringey is 0.59%. This is lower than London (0.84%) and England (1.39%).
  • In 2009/10 the emergency admission rate for CHD, all persons, in Haringey was 217.9 per 100,000 (418 admissions). This is higher than England (205.3 per 100,000) and higher than London (216.1 per 100,000).
  • Male CHD emergency admission rates are significantly higher than female CHD emergency admission rates.
  • The emergency admission rate for CHD in 2009/10 for persons who live in the most deprived areas of Haringey was 286.2. This is 2.7 times greater than the emergency admission rates for persons who live in the least deprived areas of Haringey (106).
  • The absolute gap in CHD emergency admission rates between the most and least deprived areas in Haringey was 180.2 in 2009/10. This has increased from 121.3 since 2003/04.
  • In 2009/10 the emergency admission rate for heart failure, all persons, in Haringey was 119.4 per 100,000 (247 admissions). This is significantly higher than England (60.4 per 100,000) and significantly higher than London (76.5 per 100,000).
  • Male heart failure emergency admission rates are significantly higher than female heart failure emergency admission rates.
  • The emergency admission rate for heart failure in 2009/10 for persons who live in the most deprived areas of Haringey was 160.9. This was 2.3 times greater than the emergency admission rates for persons who live in the least deprived areas of Haringey (71.3).
  • The absolute gap in heart failure emergency admission rates between the most and least deprived areas in Haringey was 89.6 in 2009/10. This has increased from 51.1 since 2003/04.
  • In 2009/10 the angiography rate, all persons, in Haringey was 216 per 100,000 (398 procedures). This is significantly lower than England (261 per 100,000) and significantly lower than London (296.4 per 100,000).
  • In 2009/10 the emergency admission rate for stroke, all persons, in Haringey was 148.2 per 100,000 (304 admissions). This is significantly higher than England (104.2 per 100,000) and significantly higher than London (112.7 per 100,000).
  • The emergency admission rate for stroke in 2009/10 for persons who live in the most deprived areas of Haringey was 195.2. This is 1.5 times greater than the emergency admission rates for persons who live in the least deprived areas of Haringey (127).
  • The absolute gap in stroke emergency admission rates between the most and least deprived areas in Haringey was 68.2 in 2009/10. This has increased from 26.6 since 2003/04.
  • Mortality rates from CVD are significantly higher than the national rate, and have decreased by 46.4% since 1995-7.
  • The absolute gap in CVD mortality for persons under 75 years between the most deprived and least deprived local areas has increased by 11.5% between 2001 and 2009. The relative gap has increased from 55.4% to 109.1% respectively.
  • There are a slightly lower proportion of stroke patients under 75 years discharged back to their usual place of residence compared to the national average.
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Current services in relation to need

CVD Awareness and Prevention Services

(Details on smoking cessation, physical activity and adulty obesity can be found in other sections).

A number of preventative programmes are provided within Haringey that help reduce the risk of CVD and other long term conditions. These include:

  • Smoke Free Enfield and Haringey - NHS Stop smoking Service (external link) - supports people in stopping smoking and offers brief intervention training to staff.
  • The Haringey Community Sport and Physical Activity Network (CSPAN) (external link) works with partners from the NHS, council, Smarter Travel and voluntary and community providers to ensure people of all ages and abilities have the opportunity to participate in high quality physical activity.
  • Programmes include: council owned leisure facilities, leisure provision by a number of voluntary and community sector partners, and 600 acres of parks and open spaces. The ‘Active for Life’ exercise GP Referral Scheme which focuses on people with long term conditions who are among the least active.
  • Weight management support is limited (see Obesity Section).
  • NHS Health Trainers are a key workforce drawn from local communities in the East of the borough; they are trained to help people make positive lifestyle changes, including stopping smoking.
  • Some community staff are trained in brief interventions.
  • The work to tackle alcohol-related harm is informed by Haringey’s annual Alcohol Action Plan.
  • Helping communities in the East identify signs and symptoms of illness through the “FAST” campaign (external link) for stroke and diabetes champions community health champions.
  • NHS Health Checks programme started in February 2010. It is a high priority programme offering systematic assessment of risk of CVD followed by appropriate advice, medication and support in life style changes. It is being rolled out across East Haringey through GP surgeries and community venues.
  • ‘Affordable warmth strategy’, flu vaccination and a community matron service aim to reduce excess winter deaths in people with long term conditions including CVD.

Stroke services

Following re-configuration, stroke services are delivered in line with the National Stroke Strategy (DH, 2007) and Health Care For London Stroke Pathway (CSL, 2009a; CSL, 2009b; CSL, 2010). These are described below in more detail:

TIA clinics

TIA clinics provide rapid diagnostic assessment and access to a specialist within 24 hours for high- risk patients and 7 days for low-risk patients. To access the clinic, patients need to be referred by their GP. The TIA clinics for Haringey residents are located at:

  • During working hours - either North Middlesex University Hospital or Royal Free Hospital
  • Out of hours - University College London Hospital

Hyper-Acute Stroke Units (HASU)

There are 8 HASUs in London – location of HASU was dependent on ensuring every patient in London should have access to a HASU within a 30 minute ambulance journey. UCLH is the main HASU for Haringey residents.

Stroke units (SU)

SUs provide multi-therapy rehabilitation and ongoing medical supervision following a patient’s hyper-acute stabilisation. Length of stay varies (currently an average of 16 days for Haringey residents) and will last until the patient is well enough for discharge from an acute in-patient setting. The SU that patients are transferred to depends on residential postcode. For Haringey stroke survivors:

  • Those living in the west will generally be transferred to the Royal Free Hospital
  • Those living in the east will generally be transferred to the North Middlesex University Hospital
  • Those living in the south-east will generally be transferred to the Homerton Hospital

Current In-patient Rehabilitation

Up to one-third of patients will require a longer period of in-patient rehabilitation than the expected 20 days average length of stay on the SUs In-patient rehabilitation is currently provided on Chestnut Ward, Greentrees, St. Ann’s Hospital. We have recently completed a procurement exercise for this service and the successful bidder was the Homerton University Hospital. The Homerton will commence service delivery in May 2012.

Early Supported Discharge (ESD) and Community Rehabilitation (CR) for Stroke

ESD and CR are the two pathways for rehabilitation by physiotherapy (PT), occupational therapy (OT) and speech and language therapy (SLT) that patients receive (if they are assessed as needing it) once discharged from hospital back to the community (CSL, 2009a). The difference between the two services relates to the intensity of therapy that one receives.

  • ESD patients receive therapy 5 times per week. Each session should last for 45 minutes. Patients receive the therapy(s) (PT, OT, SLT) that they have been assessed as needing. This is the same level of intensity that patients receive on the SU and also the in-patient rehabilitation service. ESD supports people for a maximum of six weeks (Monday to Friday, 8.30am - 5.00pm) in their home, and has the capacity to support up to 3 – 4 people. It is estimated that the average person will receive 2 weeks of ESD, and 36 – 48 people will require the service per year.
  • CR patients receive therapy 3 times per week. Each session should last for 45 minutes. Patients receive the therapy(s) (PT, OT, SLT) that they have been assessed as needing. The number of weeks that patients will receive therapy depends on their assessed need.

Both services are delivered by the stroke rehabilitation team (Whittington Health).

Stroke Clubs

The Haringey Stroke Clubs (external link) are run by Age UK and are affiliated to the Stroke Association. They offer a social opportunity for those affected by stroke. Carers are always welcome. As well as meeting to chat members also take part in various social activities, outings, and light refreshments. Transport can be provided.

Activities for Younger Stroke Survivors

Different Strokes provides a service for people of working age who have suffered a stroke. It is run by stroke survivors and offers free help, advice, information and support. Services include:

  • Communication groups for aphasia
  • Exercise groups
    • Alternative therapies
    • Skills training

Stroke Information Committee

Run by volunteers including stroke survivors and carers, the Stroke Information Committee

  • Monitor the accessibility of stroke related information.
  • Run monthly stroke information drop-in sessions in Hornsey and Wood Green Library aimed at providing stroke survivors and members of the public with stroke related information.

CHD services

  • Cardiac rehabilitation services for lower risk patients are provided as part of the Active For Life exercise referral scheme. There are limited cardiac rehabilitation services for higher risk patients.
  • The cost of total statin prescribing relative to the local population with CHD was higher compared to the national picture.
  • For myocardial infarction reperfusion there were less than 10 thrombolytic procedures performed from 2007 to 2009. The median call to treatment time to receive angioplasty was higher than the national time.
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Service users and carers opinion

Haringey recently set up a Stroke Performance Monitoring group which had its first meeting in January 2012. Stroke survivors and carers comprise 50% of the group membership. The objectives of the group are:

  • Improve treatment delivered across the stroke pathway
  • Decrease the number of strokes in Haringey
  • Decrease disability following stroke
  • Ensure information is accessible

Several questionnaires and focus groups have been undertaken with stroke survivors and carers around issues faced on re-integrating back to meaningful life roles. Main issues identified were:

  • Lack of psychological support
  • Ensure provision of a wide range of information and advice that is appropriate and accessible to stroke survivors, family members, carers, professionals and members of the public
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Expert opinion and evidence base

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Projected service use in 3-5 years and 5-10 years

Figure 1 below shows the projected increase for hypertension, CHD and stroke for 2010, 2015 and 2010. CHD and hypertension prevalence are expected to increase whilst stroke prevalence will remain stable.

Figure 1: Projected increase in prevalence of Hypertension, CHD and stroke, adults (16+) 2010-2020, Haringey

Figure 1 All Circulatory Diseases

Source: ERPHO modelled estimates and projections for Local Authorities in England for CHD and stroke respectively

Modelled estimates of prevalence of hypertension, CHD and stroke for 2010, 2015 and 2020 show that the greatest increase in prevalence will occur in the 45-64 age group.

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Unmet needs and service gaps

  • Mortality rates and emergency admissions for CVD are higher in more deprived areas and amongst certain ethnic groups.
  • Prevalence of these diseases reported in primary care are lower than would be expected, suggesting under diagnosis and/or reporting of these conditions.
  • Future prevalence likely to increase for CHD and hypertension but remain static for stroke. Thus service demands are likely to increase in the future.
  • Coronary heart disease is a major cause of mortality and morbidity in Haringey. Limited work has been done on reviewing and developing services for Coronary Heart Disease. One gap identified is the provision of cardiac rehabilitation services for those at higher risk.
  • Key service gaps for Stroke patients are a lack of neuro psychological support for stroke survivors and access to a wide range of information and advice that is appropriate and accessible to stroke survivors, family members, carers, professionals and members of the public
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Recommendations for consideration by commissioners

Recommendations for Commissioning as follows:

  • Work with primary care to improve diagnosis and management of hypertension, Atrial Fibrillation (AF), heart disease particularly in the more deprived areas and with certain Ethnic Minority Groups. Develop robust care pathways for heart disease including heart failure.
  • Achieve a yearly decrease in number of patients admitted with stroke with undiagnosed AF or known AF not on warfarin (where it would have been appropriate).
  • Reduce the difference between the expected vs actual numbers on GP registers for cardiovascular conditions.
  • Develop community health champions to raise awareness of signs and symptoms of CVD and risk factors
  • Continue to strengthen preventative programmes aimed to: Reduce smoking, increase physical activity, encourage sensible drinking (see Smoking, Physical activity, Alcohol sections). In particular ensure the exercise referral scheme for patients with Long Term Conditions who are inactive is maintained and strengthened and further develop weight management services.
  • Review cardiac rehabilitation services against need.
  • Increase therapy provision to 6 days a week therapy on in-patient stroke units.
  • Ensure the emotional needs of CHD survivors, stroke survivors, family members and carers are assessed and their needs addressed throughout the pathway.
  • Encourage the development of services to support self management for CVD and other long term conditions.
  • Promote stroke specific community activities to facilitate re-integration into work and meaningful life roles.
  • Ensure provision of a wide range of information and advice that is appropriate and accessible to stroke survivors and commission stroke navigator to provide support to stroke survivors across the stroke pathway.
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Recommendations for further needs assessments

Needs assessment for CHD and heart failure.

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Key Contacts

References

  • Commissioning Support for London, (2009a). ‘Stroke acute commissioning and tariff guidance, London.
  • Commissioning Support for London, (2009b). ‘Stroke rehabilitation guide: supporting London commissioners to commission quality services in 2010/11’, London.
  • Commissioning Support for London, (2010). ‘Life after stroke: commissioning guide’, London.
  • Department of Health, (2000). ‘National Service Framework for Coronary Heart Disease’, London.
  • Department of Health, (2001). ‘National Service Framework for Older Adults’, London.
  • Department of Health, (2005). ‘National Service Framework for Limiting Long Term Conditions’, London.
  • Department of Health, (2007). ‘National Stroke Strategy’, London.
  • Department of Health, (2008). ‘National End of Life Care Strategy’, London.
  • Healthcare for London (2009). ‘Diabetes Guide for London' (PDF, 5.51MB - external link).
  • NAO, (2005). ‘Reducing brain damage: faster access to better stroke care’, DH.
  • NICE, (2010). ‘Prevention of cardiovascular disease at population level’, NICE public health guidance 25.
  • NICE, (2011). ‘Quality standards programme – stroke’.
  • Rothwell, PM and Johnston, SC, (2006). ‘Transient Ischaemic Attacks – stratifying risk’, Stroke, 37: 320-322
  • Watson, K., Hughes, A. and Kammerling, M (2011). ‘Cardiovascular disease PCT health profile – Haringey’, SEPHO.