In recent years Britain has seen a significant fall in deaths from cardiovascular disease — that is, diseases affecting the heart and circulation. Between 2000 and 2007 the number of deaths from coronary heart disease dropped by 37 per cent. That’s the good news. The bad news is that our approach to cardiovascular disease is still failing in two key areas.
The first is in treating patients who already have a disease. For these patients achieving therapeutic targets on cholesterol is crucial. In recent years, several research studies led by Professor David Wood found that a large number of coronary patients did not meet therapeutic goals set out in international scientific guidelines — that is, getting total cholesterol below four millimoles per litre and LDL cholesterol below two millimoles per litre.
The second failing is in preventing cardiovascular disease in patients who are at high risk. This is 15 million people in the UK. If these patients were treated with aspirin, a statin and two blood pressure lowering drugs, many premature deaths would be averted.
In fact only one in three of these patients receive statins. Instead statins are handed out to lots of other patients who don’t need them. One study found that they were inappropriately prescribed to one in 10 low-risk patients.
So why aren’t we treating the right patients? One problem is that the major private healthcare providers get distracted by offering screenings that aren’t useful. Full-body MRI or CT scans, electrocardiograms, tests of kidney or liver function — all these lack any proven benefit for patients without symptoms (asymptomatic patients).
Instead we should be focusing on tests that actually provide a diagnosis rather than merely show up slight abnormalities which may be irrelevant to health. An example of the second kind of test is ambulatory blood pressure monitoring in patients with abnormal blood pressure readings.
One option for patients is the NHS free health check. This is open to everyone over the age of 40. Unfortunately, uptake has been limited and a recent study found it did not have a significant impact in reducing cardiovascular disease mortality and morbidity. The health check also does not entirely follow guidelines for prevention of cardiovascular disease issued by international bodies. Imaging, for instance a CT scan for coronary calcium, is not offered to re-classify risk.
The best assessment of cardiovascular disease risk is offered at NHS lipid clinics which are generally attached to teaching hospitals. A map of where these are around the UK can be found here. Patients must ask their GP for a referral.
This is something I would encourage for everyone who is uncertain about their risk or is not sure if they should be taking statins.
A greater awareness of risk and of what we can do to lower it would make a significant difference in the fight against cardiovascular disease.
Success in this area of medicine would make a huge difference to NHS finances too. In the United States the cost of cardiovascular disease is predicted to triple in the next 20 years, from $273 billion to more than $800 billion a year. Britain is likely to follow a similar trajectory. But cardiovascular disease is preventable, and if we can prevent more of it then we can also free up large amounts of funding for other parts of our health service. To this end, setting up more lipid clinics should be seriously considered. The major investment would not be in the equipment, which is now relatively inexpensive and portable, but in trained staff.