2 Public health need and practice

Cardiovascular disease (CVD) is generally due to reduced blood flow to the heart, brain or body caused by atheroma or thrombosis. It is increasingly common after the age of 60, but rare below the age of 30. Plaques (plates) of fatty atheroma build up in different arteries during adult life. These can eventually cause narrowing of the arteries, or trigger a local thrombosis (blood clot) which completely blocks the blood flow.

The main types of CVD are: coronary heart disease (CHD), stroke and peripheral arterial disease (PVD) (British Heart Foundation 2009a).

Globally, CVD is the leading cause of death (World Health Organization 2007). It is also associated with a large burden of preventable illnesses.

CVD in England and the UK

In England in 2007, CVD led to nearly 159,000 deaths (accounting for nearly 34% of all deaths in England). This includes 74,185 deaths from coronary heart disease (CHD) and 43,539 from stroke (British Heart Foundation 2009b).

Most premature deaths from CVD – that is, among people aged less than 75 – are preventable. In 2006, CVD accounted for around 30% of premature deaths among men and 21% among women, accounting for just over 40,000 premature deaths in that year. The purpose of preventing premature death from CVD is to enable high quality life for as long as possible.

An estimated 2.8 million men and 2.8 million women in the UK are living with CVD. The British Heart Foundation estimates that around 111,000 people have a stroke for the first time every year. (Its report notes that national stroke audit data is more conservative, putting the estimated 'first time' strokes a year at approximately 72,000 [33,000 among men and 39,000 among women] (British Heart Foundation 2009c).

In addition, there are an estimated 96,000 new cases of angina in the UK each year (52,000 among men and about 43,000 among women) and around 113,000 heart attacks per year (67,000 among men and 46,000 among women) (British Heart Foundation 2009c). New cases of heart failure total around 68,000 a year (about 38,000 among men and 30,000 among women).

Overall, CVD costs the UK approximately £30 billion annually (Luengo-Fernandez et al. 2006).

Despite recent improvements, death rates in the UK from CVD are relatively high compared with other developed countries (only Ireland and Finland have higher rates). There is also considerable variation within the UK itself – geographically, ethnically and socially. For instance, premature death rates from CVD are up to six times higher among lower socioeconomic groups than among more affluent groups (O'Flaherty et al. 2009). In addition, death rates from CVD are approximately 50% higher than average among South Asian groups (Allender et al. 2007).

The reduction in CVD-related risks among younger men (and perhaps women) over previous years seems to have stalled in England from around 2003. This is also the case in a number of other countries including Scotland (O'Flaherty et al. 2009), Australia (Wilson and Siskind 1995) and the United States (Ford and Capewell 2007).

The higher incidence of CVD is a major reason why people living in areas with the worst health and deprivation indicators have a lower life expectancy compared with those living elsewhere in England. For males, it accounts for 35% of this gap in life expectancy (of that, approximately 25% is due to CHD and 10% due to other forms of CVD). Among females, it accounts for 30% of the gap (DH 2008a).

Risk factors for CVD

Lifetime risk of CVD is strongly influenced by diet and physical activity levels since childhood (National Heart Forum 2003). The risk among adults is determined by a variety of 'upstream' factors (such as food production and availability, access to a safe environment that encourages physical activity and access to education). It is also influenced by 'downstream' behavioural issues (such as diet and smoking).

In more than 90% of cases, the risk of a first heart attack is related to nine potentially modifiable risk factors (Yusuf et al. 2004):

  • smoking/tobacco use

  • poor diet

  • high blood cholesterol

  • high blood pressure

  • insufficient physical activity

  • overweight/obesity

  • diabetes

  • psychosocial stress (linked to people's ability to influence the potentially stressful environments in which they live)

  • excess alcohol consumption.

Other factors, such as maternal nutrition and air pollution may also be linked to the disease (Allender et al. 2007).

How these risk factors cause many other illnesses

Addressing diet, physical inactivity, smoking and excessive alcohol consumption to reduce CVD will also help reduce a wide range of other chronic conditions. This includes many of the other main causes of death and illness in England such as type 2 diabetes and many common cancers (see also 3.73).

Type 2 diabetes, which affects over two million people in the UK, is associated with being overweight and sedentary. (It also accounts for an estimated 5% of UK healthcare expenditure.) Between 8% and 42% of certain cancers (endometrial, breast, and colon) are attributable to excess body fat.

The report 'Food matters' (Cabinet Office 2008) estimates that a total of around 70,000 lives would be saved each year in the UK if people's diet matched the nutritional guidelines on fruit and vegetable consumption and saturated fat, added sugar and salt intake.

Tackling the risk factors

Reducing the risks, for example, by quitting tobacco or improving the diet (so reducing cholesterol or blood pressure levels) can rapidly reduce the likelihood of developing CVD. Actions which impact on the whole population most effectively reduce these risk factors (Kelly et al. 2009a).

Some population-based prevention programmes have been accompanied by a substantial reduction in the rate of CVD deaths. However, the degree to which these are attributable to the programme is contested. This is due to a number of reasons including:

  • It is difficult to design studies which evaluate entire cities, regions or countries or are of sufficient duration.

  • Control sites can become 'contaminated' (that is, if the intervention affects people living in the control area).

  • There may be unreasonable expectations about the speed of change.

  • Behaviour change is often erratic or slow.

  • Failure to address 'upstream' influences such as policy or manufacturing and commercial practices.

The crucial importance of using policy to modify population-wide CVD risk factors has been recognised on an international, European and national level. For example, the World Health Organization's (WHO) first global treaty on health, the 'Framework convention on tobacco control' (2003) undertook to enact key tobacco control measures, such as tobacco tax increases, smokefree public places and tobacco advertising controls. Parties to the treaty included the UK.

In 2004, WHO member states also agreed to a non-binding global strategy on diet, physical activity and health. In addition, since 1993 the European Union (EU) has legislated on issues such as advertising and the labelling of consumer products like food and tobacco.

In 2009, the Cardio and Vascular Coalition published 'Destination 2020', the voluntary sector's plan for cardiac and vascular health in England (Cardio and Vascular Coalition 2009).

Government policy

Government policy in many areas influences CVD. The 'Choosing health' white paper (DH 2004) set priorities for action on nutrition, physical activity, obesity and tobacco control. It was supported by delivery plans on food, physical activity and tobacco control, including the provision of NHS Stop Smoking Services.

Since that time, a wide variety of policy documents have been published including:

  • 'Active travel strategy' (Department for Transport 2010)

  • 'A smokefree future: a comprehensive tobacco control strategy for England' (DH 2010)

  • 'Be active be healthy. A plan for getting the nation moving' (DH 2009a)

  • 'Commissioning framework for health and well-being' (DH 2007a)

  • 'Delivering choosing health: making healthier choices easier' (DH 2005a)

  • 'Food 2030' (Department for Environment, Food and Rural Affairs 2010)

  • 'Health challenge England – next steps for choosing health' (DH 2006a)

  • 'Health inequalities: progress and next steps' (DH 2008b)

  • 'Healthy weight, healthy lives: a cross-government strategy for England' (DH 2008c)

  • 'National stroke strategy' (DH 2007b)

  • 'NHS 2010 – 2015: from good to great. Preventative, people-centred, productive' (DH 2009b)

  • 'Our health, our care, our say' (DH 2006b)

  • 'Putting prevention first – vascular checks: risk assessment and management' (DH 2008d)

  • 'Tackling health inequalities – a programme for action' (DH 2003)

  • 'Tackling health inequalities: what works' (DH 2005b)

  • 'Tackling health inequalities: 2007 status report on the programme for action' (DH 2008a)

  • 'The NHS in England: the operating framework for 2006/7' (DH 2006c)

  • 'The NHS in England: the operating framework for 2008/9' (DH 2007c)

  • 'Wanless report: securing good health for the whole population' (Wanless 2004).

  • National Institute for Health and Care Excellence (NICE)