Prevention is the name of the CVD game

Dr Dawn Lombardo is the director of UC Irvine Medical Center's Heart Failure Program. [Cove @UCI / Flickr]

This article is part of our special report Cardiovascular health in the UK.

Early prevention is the name of the game these days for the UK’s National Health Service (NHS) when it comes to tackling cardiovascular disease (CVD).

CVD can be prevented through drug treatments but this requires at-risk patients to be identified before they become ill. The NHS Health Check programme offers free check-ups to adults over the age of 40 but CVD experts are increasingly looking towards programmes targeted at those most at risk.

Birmingham University research published in November suggests that calculating a patient’s risk of getting CVD based on their electronic medical records, including age, gender and smoking habits, is a more cost-effective way to tackle CVD.

Using data from The Health Improvement Network database (THIN), the researchers simulated the outcomes of different screening strategies for a group of 10,000 patients aged between 30 and 74.

The results suggest that the most cost-effective strategy for screening and early prevention was to rank patients by their calculated CVD risk and invite those at highest risk first. This would involve inviting 8% of the population for screening, rather than everyone aged over 40.

Birmingham University Professor and research leader Tom Marshall contended that “a focused screening programme targeted at those at highest risk, rather than everyone aged over 40, would result in significant cost savings for the NHS while retaining most of the health benefits. Our research also raises the question of whether other mass screening programmes might be better targeted.”

“If you calculate your 10-year risk score and it comes out as higher than 13% it is probably worthwhile having a check-up. A lot of people in this category could benefit from drug treatment. But if your risk score is less than 5% it is very unlikely you need treatment and a check-up would not be a good use of NHS staff time,” he explained.

Secondary prevention

The NHS’s Cardiovascular Disease Prevention Optimal Value Pathway, launched in October, is essentially about picking the low-hanging fruit of prevention, early detection and improved management of high-risk conditions such as hypertension, atrial fibrillation (AF), high cholesterol, diabetes, ‘pre-diabetes’ and chronic kidney disease. Models such as the Birmingham University programme are likely to form part of the new approach.

More advanced at the moment is the NHS’s programme of secondary prevention for those who already have CVD related conditions. The NHS England Cardiovascular Disease (CVD) Outcomes Strategy aims to increase uptake of cardiac rehabilitation from 45% to 65% among patients with coronary heart disease (CHD), and it is gradually edging towards its target.

Cardiac rehabilitation offers physical activity support and lifestyle advice, such as exercise classes and dietary guidance, to help people living with heart disease manage their condition and reduce their risk of heart attacks or stroke.

Figures released in December indicate that the uptake rate cleared 50% in 2015, although this still means that 6,000 heart patients missed out on cardiac rehabilitation.

“It is hugely encouraging that more patients are accessing rehabilitation services, but there is still much more to be done,” said Dr Mike Knapton, associate medical director of the British Heart Foundation.

“There is variation between services which needs to be ironed out to ensure that every patient has access to cardiac rehabilitation which can reduce their risk of suffering another heart attack.”

UK leads the world on cardiac rehabilitation

Knapton’s assessment is corroborated by Professor Patrick Doherty, director of the national audit of cardiac rehabilitation at the University of York.

“The UK now leads the world in uptake to cardiac rehabilitation and prevention for patients following a cardiac event or procedure, with 50% of patients accessing services,” said Doherty, although he conceded that “half of patients are still not accessing these services and those that do attend may receive inadequate care as nearly half of programmes are failing to meet the minimum standards”.

For a system like the UK’s NHS, built around the concept of universal availability of care, targeted services go against the grain. But a publicly-funded service is always alive to managing costs, and the UK already spends an estimated £9 billion on CVD healthcare, a sum which is only expected to rise.

If the UK’s CVD strategy is to work, a regime based around targeted early prevention is probably going to be more efficient and cost-effective.

The number one killer in Europe, cardiovascular disease, is set to become an even greater burden on the already recession-hit continent's health systems.

Cardiovascular disease accounts for 52% of female deaths and 42% of male deaths in the EU. Approximately four million people in Europe and 1.9 million people in the EU die of cardiovascular disease each year, according to the European Society of Cardiology. Cardiovascular disease and strokes are usually caused by high levels of bad cholesterol, high blood pressure, obesity, unhealthy diet and physical inactivity.

The European Society for Cardiology (ESC) and the European Heart Network (EHN) estimate the cost to the EU economy at over €196 billion per year, with healthcare expenditure varying from 4% in Luxembourg to 17% in Estonia, Latvia and Poland.

To reduce the number of deaths from heart diseases, EU countries agreed in November 2013 to tackle the underlying health determinants behind cardiovascular disease in the common health programme for 2014-2020 through “promoting health, preventing diseases and fostering supportive environments for healthy lifestyles”.

The EU wants cost-effective prevention measures for addressing tobacco, alcohol, and unhealthy dietary habits. It also aims to promote physical activity among EU citizens.

Sanofi have provided the funding for this report. Sanofi have had no editorial input or involvement in the content of this report.

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