Cardiovascular Disease

Cardiovascular disease (CVD) comprises all heart and circulatory diseases, including coronary heart disease (CHD), angina, heart attack, congenital heart disease, hypertension (high blood pressure), stroke, and vascular dementia. CVD is a leading cause of ill health and death, and addressing its risk factors is key to improving population health outcomes (Source: Department of Health and Social Care). Risk factors such as smoking, obesity, physical inactivity, excessive alcohol consumption, and a poor diet, can all be modified to reduce a person’s risk of developing CVD. Research shows that social isolation is also a risk factor for CVD, due to increased peripheral vascular resistance and elevated blood pressure. (Source: PubMed)

CVD is the leading cause of death worldwide and a leading public health priority in England. There are 7.6 million people living with CVD in the UK (Source: BHF), CVD causes 1 in 4 deaths, equating to one death every four minutes (Source: Public Health England), and 12.9% of total disability-adjusted life years (DALYs). Despite a downward trend from 2001 to 2019 in under 75 CVD mortality, rates have increased from 2019 to 2023 (Source: Department of Health and Social Care). CVD creates a significant economic burden in the UK. The impact of CVD on the health and social care sector is significant. It is estimated that yearly healthcare costs in England related to CVD are estimated at £7.4 billion, with an annual cost to the wider economy of £15.8 billion. (Source: UK Health Security Agency (UKHSA))

A person’s risk of developing CVD can be reduced by risk factor modification, such as smoking cessation, increased physical activity, weight loss, healthy diet and reduced alcohol consumption. Furthermore, optimal management of CVD (for example hypertension, hypercholesterolaemia and Atrial Fibrillation (AF)) or other conditions that increase CVD risk (such as diabetes and chronic kidney disease) can reduce risk of heart failure and cardiovascular events, namely heart attack or stroke (Source: Public Health England). Modifiable risk factors explain 90% of CVD incidence, and 80% of premature deaths from CVD are preventable. (Source: The King’s Fund)

“Although there has not been a significant increase in inequality [of mortality rates] in recent years, in 2020 people living in the most deprived areas were still 4 times more likely to die prematurely from cardiovascular disease than people in the least deprived areas” (Source: OHID). The Office for Health Improvement and Disparities (OHID) now measure this inequality using the slope index of inequality (SII) method.

There are significant health inequalities in CVD due to deprivation in England. Smoking, obesity, physical inactivity and hypertension are all more prevalent in more deprived areas. CVD prevalence is 8.5% in the most deprived quintile, compared to 5.4% in the least deprived quintile. The rate of premature mortality due to CVD is twice as high in the most deprived decile compared to the least deprived decile. (Source: British Heart Foundation (BHF))

CVD has high levels of morbidity and mortality creating significant economic burden, demonstrates clear targets for prevention, and has significant health inequalities, meaning it is a national public health priority, which also requires attention locally.

The NHS Outcomes Framework measures health and care performance at national level and includes a number of indicators related to CVD. The Public Health Outcomes Framework (PHOF) aims to improve and protect health nationally, focussing on reducing health inequalities; measuring indicators which relate to CVD prevention, for example smoking prevalence.

CVDPREVENT is a national healthcare quality improvement plan aiming to reduce inequalities and improve health outcomes in cardiovascular disease. Key improvement goals are to optimise treatment of atrial fibrillation, hypertension and high cholesterol; and reduce inequality in treatment of these conditions between ethnic groups and between integrated care boards. The stated aim is to prevent up to 150,000 heart attacks, strokes and dementia cases between 2020 and 2030.

The 10 Year Health Plan for England builds on the NHS Long Term Plan by prioritising prevention, digital innovation, and community-based care. It outlines three major shifts: moving from treating illness to preventing it, relocating care from hospitals to neighbourhood teams, and transitioning from analogue to digital services. These reforms are directly linked to CVD prevention and management, with proposals to expand community pharmacy roles in screening for obesity, hypertension, and high cholesterol. The plan also supports public health goals such as creating a smoke-free generation and tackling obesity, while testing new models of secondary prevention through Neighbourhood Health Services. Although digital tools like wearable devices are highlighted, their integration with the NHS App remains in early stages. (Source: Fit for the future: 10 Year Health Plan for England)

Prevention is Better than Cure – details the government’s vision to:

• Stop health problems arising in the first place
• Support people to manage their health problems when they do arise
• Improve healthy life expectancy by at least 5 extra years by 2035
• Close the gap between the richest and the poorest

The Collection – Prevention is better than cure: case studies provides examples of best practice for preventing the development of health problems.

Guidance: Health matters: preventing cardiovascular disease details ambitions for the detection and management of atrial fibrillation, high blood pressure, and high cholesterol for England (for the 10 years to 2029).

Tackling High Blood Pressure outlines how providers and commissioners can reduce the population average blood pressure with improved prevention, detection, and management. It outlines how to address modifiable risk factors such as obesity, excess dietary salt, excess alcohol consumption and lack of physical activity.

The NHS Health Check is a national programme offered to people aged 40-74, every 5 years, who do not have pre-existing CVD, chronic kidney disease or diabetes. It is designed to identify people at risk of heart disease, stroke, kidney disease and diabetes. In Lincolnshire, GP practices are commissioned to provide this service and patients registered with a GP will receive an invite if they are eligible.

The National Institute for Health and Care Excellence (NICE) publishes a wide range of guidelines, quality standards, and pathways for CVD.

The General Medical Service Quality and Outcome Framework+ (QOF) financially rewards general practices for the provision of quality care and helps to standardise improvements in the delivery of primary medical services. Cardiovascular related indicators are used within the QOF. Furthermore, the latest update removed many indicators and re-allocated funding to CVD prevention indicators.

The Local Government Association (LGA) publishes a wide range of resources to support the delivery of Local Government public health responsibilities.

The NHS Right Care Commissioning for Value Programme aims to improve health outcomes and reduce inequalities in health access and patient experience.

The Joint Health and Wellbeing Strategy for Lincolnshire informs decisions, commissioning and delivery of health and care services in Lincolnshire. It outlines the priorities for Lincolnshire’s population, including healthy weight and physical activity, which are both key for CVD prevention.

Core20PLUS5 (adults) is an approach that identifies a target population to reduce health inequalities at both national and system level. ‘Core20’ describes the most deprived 20% of the national population identified by the Index of Multiple Deprivation (IMD). Deprivation is linked to increased prevalence of CVD risk factors and poorer CVD outcomes, hence why this group is an important target in CVD.  The ‘PLUS’ group is identified locally; in Lincolnshire this group includes the coastal and rural population, ethnic minority groups and the homeless. The ‘5’ relates to key clinical areas, one of which specifically relates to CVD – hypertension identification and optimal management of hypertension and high cholesterol to reduce CVD events.

The 2019 Global Burden of Disease (GBD) study revealed CVD to be the second highest burden of disease in Lincolnshire, and the number of years of life lost (either in terms of mortality or disability) match national figures. The study identified high blood pressure, diet, high cholesterol and high body mass index as the main risk factors for CVD.

The premature mortality rate from CVD in Lincolnshire remains higher than the national average but is improving relative to national figures (86.7 per 100,00). CVD mortality rates are particularly high with under 75s CVD mortality rates in Lincoln (109.9 per 100,00), East Lindsey (100.6 per 100,000) and Boston (97.6 per 100,000) in comparison to the rest of the county, showing potential correlation with deprivation indices and patterns of lifestyle behaviours. Those in the most deprived communities are 30% more likely to have high blood pressure – the number one risk factor for CVD mortality and morbidity in England (Source: Public Health England ). The Wider Determinants of Health Inequality in Lincolnshire report found that levels of premature CVD mortality in the areas with worse overall health outcomes were 3.6 times higher than in the areas with best health outcomes. (Source: DHSC)

The majority of deaths caused by CVD can be attributed to risk factors; they contribute to 89.2% of Ischemic Heart Disease (IHD) deaths and 77.2% of stroke deaths in Lincolnshire. Key lifestyle related risk factors contributing to CVD include smoking, physical inactivity and obesity; addressing these can contribute to primary prevention of CVD. Each of these risk factors are more prevalent in Lincolnshire than the national average (Source: DHSC). There is inequality in prevalence of these risk factors in Lincolnshire. Smoking in the most deprived decile is 16 percentage points higher than those in the least deprived decile, (Source: Optum PHM Dashboard) and those in the most deprived areas (deciles 1-3) are more likely to be physically inactive than those in the least (deciles 8-10) (Source: Sport England). Smoking and obesity are more common in coastal areas of Lincolnshire. Those in rural populations are more likely to be obese, whereas those in urban areas are more likely to smoke. (Source: Optum PHM Dashboard)

Hypertension and high cholesterol are also CVD risk factors; early detection and appropriate management can contribute to secondary prevention of IHD, stroke and heart failure. Hypertension prevalence in Lincolnshire (18.9%), is significantly higher than the national average (15.2%) and East Midlands average (16.5%). Prevalence is increasing locally and nationally (Source: DHSC). Estimates for undiagnosed hypertension are also higher in Lincolnshire than the national average (9.1% in Lincolnshire vs 8.6% in England), meaning it is unlikely higher prevalence is only attributable to earlier diagnosis (Source: DHSC). Prevalence of hypertension is highest in two PCNs that serve the coastal population of Lincolnshire (First Coastal and Meridian Medical), which have higher levels of deprivation. Lincoln Health Partnership PCN is the only PCN to have a prevalence lower than the national average (Source: DHSC), which is likely explained by their younger patient group profile. For patients under 80 with a diagnosis of hypertension, the proportion is higher in Lincolnshire compared to the national average (Source: DHSC). However, blood pressure is less likely to be treated to target CVD in people from ethnic minorities in Lincolnshire (Source: Optum PHM Dashboard). High Cholesterol prevalence in adults nationally is estimated at 59% (Source: NHS England Digital). Local data for Lincolnshire shows a prevalence of 23.7% (Source: Optum PHM Dashboard); it is likely the data does not capture the true prevalence, as risk factors would suggest prevalence would at least be in line with national estimates. Cholesterol is treated with lipid lowering therapy when QRISK score (predicted risk of stroke or heart attack over the next 10 years) is 10% or more. In Lincolnshire, 57.1% of people with a QRISK score of 10% or more, are treated with lipid lowering therapy, compared to 54.6% nationally. (Source: Regional & ICS Insights | CVDPREVENT)

The prevalence of hypertension, of stroke and of CHD across Lincolnshire have all been consistently higher than nationally, particularly in East Lindsey, West Lindsey and South Holland. Lincoln is the exception, possibly reflecting the younger age profile of the district. Prevalence of Atrial Fibrillation (AF) in Lincolnshire (3.0%) is also above the national average ((2.2%) (Source: DHSC), although over 95% of AF patients in the County are now on anticoagulation medication. (Source:  Lincolnshire ICB)

CVD is more common among South Asian, and African Caribbean ethnicities, for males, older individuals, and those experiencing severe mental illness (Source: PHE). People with severe and prolonged mental illness are at risk of dying 15 to 20 years earlier on average, than others. Two thirds of these deaths occur from avoidable physical illnesses such as CVD. (Source: NHS England)

Primary prevention of CVD focusses on preventing onset of disease, for example, by supporting the public to make healthier lifestyle choices. Secondary prevention focuses on early diagnosis, treatment, and management, to stop CVD progressing – and reduce the risk of future CVD events.

• The NHS Health Check Programme is a screening and risk management programme that aims to identify people at risk of CVD and other conditions amongst people aged 40-74 years.
• The general practice Quality and Outcome Framework (QOF) includes a range of indicators in relation to CVD prevention, for example, atrial fibrillation and hypertension. General practices maintain a register of patients identified with a high risk (based on QRISK calculator) of developing CVD in order to offer clinical reviews and treatment.
• The NHS Community Pharmacy Blood Pressure Check Service supports detection and prevention of CVD. The service identifies over 40s who have not previously been diagnosed with hypertension, and to refer those with suspected hypertension for appropriate management.
• The NHS Diabetes Prevention Programme means to reduce incidence of Type 2 diabetes, by reducing blood glucose parameters and reducing weight. For more information about diabetes, see the dedicated JNSA topic.
• Type 2 remission programme (low calorie diet)
• Making Every Contact Count(MECC) is an approach to behavioural change, utilising the millions of day-to-day interactions between professionals and the public, to encourage positive health choices and lifestyle behaviours.
• Local support is given to national campaigns, such as NHS Better Health, to encourage individuals to address the modifiable risk factors of CVD and poor health choices. This is supported by the One You Lincolnshire Integrated Lifestyle Service, which offers evidence-based health improvement interventions across Lincolnshire that address CVD risk factors. They support the people of Lincolnshire to ‘Be Smoke Free’, ‘Eat Well, Lose Weight’, ‘Drink Less’, and ‘Move More’. Patients can refer themselves or can be referred by healthcare professionals.
• In the last two full years Local NHS Trusts provide Stroke Services, Cardiology and Cardiac Rehabilitation services. United Lincolnshire Teaching Hospitals NHS Trust provide inpatient care and outpatient clinics for specialist stroke and cardiology management. Lincolnshire Community Health Services NHS Trust provide community-based specialist services for cardiac rehabilitation, heart failure and stroke.
• The Quality and Outcomes Framework (QOF) provides incentivised funding for general practices based on their ability to meet specific performance indicators. Many of these performance indicators relate to prevention and treatment of CVD; ensuring CVD remains a high priority for practices.

Whilst not specific to CVD, engagement takes place with the public, patients and other stakeholders to ascertain views about many issues.

Healthwatch Lincolnshire carries out work to understand the needs, experiences and concerns of people who use health and social care services. Some areas of work are related to CVD, for example, the views of local people who have suffered a stroke. (Source: Healthwatch Stroke Report)

Lincolnshire NHS Citizens Panel are residents who volunteer to provide regular feedback and research, allowing residents the opportunity to share opinions and views on health and care services within the county.

Lifestyle CVD risk factors remain an important area for improvement in Lincolnshire to prevent CVD. Rates of smoking, obesity and physical inactivity remain higher than the national average. There also remains significant health inequality in these risk factors, particularly in relation to deprivation. Consideration should be given to how we can support more of the Lincolnshire population, with the aim to reduce rates of CVD risk factors, in line with the government’s mandate to shift from treatment to prevention. This should begin with those that are most in need. Although people from the three most deprived deciles are overrepresented, this representation needs to increase further given health inequalities persist. Consideration could be given to align key performance indicators to the Core20PLUS5 model by aiming for overrepresentation of people in the two most deprived deciles (the most deprived 20%), to ensure those that are most in need receive support.

Obesity is an important CVD risk factor, that is more prevalent in Lincolnshire than the national average.  Lincolnshire is developing a 3 tier specialist weight programme (also known as tier 3 and tier 4 services). The phased introduction of tirzepatide (a weight loss medication) prescription in primary care (Source: Weight loss medicine – Lincolnshire ICB) may partially address gaps in service, and meet the government mandate to move care from hospital to community. There is more information about healthy weight in the dedicated JNSA topic.

Undiagnosed hypertension, which is a preventable cause of CVD events, remains high in Lincolnshire. Nationally, undiagnosed high cholesterol and atrial fibrillation (AF) are also problematic. Improved diagnosis and treatment of these risk factors is vital to improve secondary prevention of CVD in Lincolnshire and shift away from the need to treat more severe CVD. General Practice can support this through opportunistic testing and completion of NHS health checks. However, consideration could be given as to whether other community settings (in addition to pharmacies) could also support with Blood Pressure (BP) checks and signposting to GPs when required, embracing the governments shift towards community-based care. These could be situated in areas that aim to reach those that are less likely to access their GP; venues could include supermarkets, places of worship, community centres and barber shops or hairdressers. Finally, improving technology could be utilised given smart watches can identify irregular heart rhythms, this technology may have a place in screening for undiagnosed atrial fibrillation without requirement for contact with a healthcare professional.

Although the number of health checks completed in Lincolnshire is slightly above the national average, it is still less than a third of the eligible population. Furthermore, the most deprived 20% of the population are receiving the fewest referral outcomes. Men are less likely to receive health checks, despite having a higher risk of CVD. This suggests those that are receiving health checks are unlikely to be those at the highest CVD risk. This means the positive impact of the programme will be lower, as for many that receive health checks preventative advice or intervention may not be needed and could lead to widening health inequalities (Source: DHSC). The local authority and primary care providers should collaborate to ensure health checks are made more accessible to those most in need.

There is no cohesive county-wide or system-wide programme of prevention for CVD in Lincolnshire.

We need to develop closer links across health partners (United Lincolnshire Teaching Hospitals NHS Trust (ULTH), Lincolnshire Partnership Foundation Trust (LPFT), local authorities, Lincolnshire County Council (LCC) directorates). By understanding the data landscape, and the story it tells, a robust understanding of gaps will develop.

The stated aim of the government to shift from treatment to prevention is particularly pertinent to CVD, and Lincolnshire should aim to incorporate this approach. While there is scope to strengthen primary prevention, significant progress is still needed to address the high prevalence of lifestyle related CVD risk factors locally. Secondary prevention through better identification and management of risk factors such as hypertension must also be a priority, and whilst general practice must continue to improve in this regard, innovative methods that utilise alternative community settings and digital technology may improve identification and ease the burden on GP surgeries.

Underpinning this work must be an aim to target health inequalities that exist in CVD in Lincolnshire. Services must be modified or designed to support those at high risk of CVD who are less likely to access healthcare services.

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