Cardiovascular disease

Recommendations can be found in the Kent and Medway Cardiac Strategy 2011 to 2016 and cover:

Prevention and Detection

• Ensure monitoring of CVD prevalence at practice level.

• Prioritise smoking cessation, lipid modification and hypertension management.

• Support development and rollout of Health Check programme, build on early evaluation results from Medway pilot.

• Improve joint health and social care commissioning arrangements to effectively target high risk, social disadvantaged, apply evidenced based social marketing techniques as well as robust evaluation.

Cardiac Imaging and Diagnostics - As per NICE Guidance, support the introduction or increase in:

• Cardiology imaging equipment such as CT, Stress Echo and appropriate software.

• Diagnostic pathways.

• Agreed local tariffs.

• Appropriate staffing ie. cardiologist and / or radiologist with specialist interest in the above per acute trust.

• Local Cardiac Resonance Imaging (CMR) service for the patients of Kent & Medway to reduce referrals into London.

Arrythmias

• Practices should undertake validation of their AF registers and work with Medicines Management to carry out medication reviews to optimise prescribing (hyperlink to MM QIPP chapter if available) for anticoagulation.

• Opportunistic screening for AF(in patients over 65). (hyperlink to LTC chapter)

• Manual pulse check prompts should be inserted into all appropriate long term conditions monitoring templates and be embedded in daily practice particularly for those at high risk.

Devices

Further analysis is required exploring variation in methods of device implantation including indications, complications, expenditure, etc.  

Revascularisation and Cardiac Surgery

• Review current diagnostic and surgical intervention activity and capacity, and care pathway development.

• Consider feasibility of new and emerging services and targets such as tertiary cardiology services, primary angioplasty 150 minute call-to-balloon target can consistently, High Sensitive Troponin test for chest pain patients presenting to A&E.

Heart Failure and End of Life Care

• Service and care pathway development focusing on latest NICE Guidance Personalised Care Plans, BNP provision, Heart Failure registers development, integrated community teams, identify patients in acute trusts, tele-technology and improved access to EoLC.

Risk factors for Cardiovascular Disease (CVD) include getting older, being male or a family history of CVD. These are not reversible.

There are multiple risk factors to prevention of CHD. These included:

• high cholesterol,

• excessive salt intake,

• high blood pressure,

• excess weight,

• a high-fat diet,

• smoking,

• diabetes,

• and a sedentary lifestyle.

We can deduce that by increasing awareness of these factors and tackling these as being the root cause of CVD we should be able to reduce CHD health events and NHS service needs.

Kent PCTs list CHD as one of the top killers in their area. Cancer, coronary heart disease and stroke are the three leading causes of death, responsible for more than half of all deaths.

Prevalence

Figure 1 shows the top four district authority areas of Swale, Thanet, Shepway and Dover appear to have relatively higher CHD mortality rates compared to the rest.

Deprivation is strongly linked to CHD and lower life expectancy. Analysis of life expectancy at Kent and Medway level shows that there are stark differences. A significant contributory factor is people dying prematurely from CVD (Figure 2).

CHD prevalence in Kent is expected to increase in future, in line with England trends (Figure 3).

Figure 1: Directly age standardised mortality ratio due to coronary heart disease 2007-2009 in those aged less than 75

Figure 3: Modelled projections of CHD prevalence in people aged 16+ Kent districts

Revascularisation and surgical activity   

In 2005 the Network developed a revascularisation strategy, which set out plans to the decrease the number of Coronary Heart Bypasses (CABG) required, and increase the number of Angioplasties or Percutaneous Coronary Interventions (PCIs), in line with national trends and guidance.

The strategy also detailed plans to repatriate activity from London so that increasing numbers of angiograms and PCIs were done in Kent and Medway rather than London. Angiography activity is being repatriated to Kent and Medway centres and that overall activity levels have increased. PCI activity is also being repatriated to local centres, with local centres now undertaking the largest proportion of the work, and that overall activity levels have increased.

However over the last five years, activity has not occurred as originally planned, with the number of CABG decreasing but at a lesser than expected rate. The number of PCIs has increased over the years, but in 2008-09 levelled out at a lower than expected level. Figures 4, 5 and Table 1 illustrate the change in activity over this period for the above mentioned three procedures.

Figure 4: Number of Angiograms 2004-05 to 2009-10 Kent and Medway

Heart Failure

There is considerable variation in the prevalence of heart failure by PCT (0.19% to more than 5%). Some of this may be legitimate local variation secondary to public health differences but such a wide variation would suggest considerable differences in referral for or access to diagnostics.

2009/10 QOF prevalence for heart failure in Kent is broadly similar in all three PCTs. West Kent reports the lowest prevalence rate at 0.58%, Medway is 0.60% and East Kent 0.64%.

Figure 6: Shows a steady rise in admissions for Heart Failure over the last five years for Kent.

Figure 6: Number of admissions due to heart failure (ICD10 I50) for Kent and Medway residents admitted to any hospital provider

Source: Secondary Uses Service (SUS)

Cardiac rehabilitation

Cardiac rehabilitation programmes are divided into 4 phases:

• After hospital admission with CHD

• Early discharge period

• Formal rehabilitation programme

• Long-term maintenance

It is important is that it must be integrated across traditional sector boundaries, including secondary care, primary care, public health, local authorities and community and voluntary organisations and be appropriate to local need and preference.

Table 2 - The current provision of Phase 1-3 cardiac rehabilitation is delivered through the following providers:

West Kent 

Phases I and III services in the south of west Kent are delivered by specialist nurses from the acute trust. The service at Maidstone Hospital is offered on the hospital site and available mainly to post Myocaridal Infarction (MI) and surgical patients. Some heart failure patients are also offered a cardiac rehab service by the heart failure specialist nurse.

In December 2007 the service from the Kent and Sussex Hospital was devolved to the community and is now delivered in two sports centres by the specialist nurses from the acute trust. This service also concentrates on post MI and surgical patients. Some heart failure patients are also offered cardiac rehabilitation. In the future the service would like to expand to offer cardiac rehab to all cardiology patients and instigate the angina plan.

There is a limited Phase II provision

East Kent

Phase I for all appropriate patients except those which have been treated at the William Harvey Hospital, the East Kent Community Services Provider conducts an in-reach programme, which means that staff from the community go into the hospitals on a regular basis and find the patients who are suitable for Phase I cardiac rehabilitation.

Phase II and III - The east Kent service now provides a broad based service offering exercise, lifestyle advice as well as counselling. The service is offered to post MI and surgical patients including PCI patients, as well as stable angina and stable heart failure. It is a community based programme delivered in community leisure centres and as well as a home based programme. All patients are offered the choice of a home or community based service.

In addition to the core cardiac rehabilitation programme which is offered, other initiatives have also been put in place, including: 
  

• Cognitive behavioural therapy (CBT) for obese patients - staff have had training on CBT for managing weight loss, and there is a specialist who runs weight loss clinics.

• Expansion of home based exercise programme - this is now one of the cardiac rehab menu options.

• Chair based classes run within the group exercise programme.

• ·Structured walks – a walking programme is run when capacity allows and there is the demand.

• Increased dietetic and pharmacist input.

• Counselling support for ICD patients -these patients can access any element of rehab if they are referred.

Health checks

The NHS Health Check programme is an initiative which offers preventative checks to all those aged 40 -74 to assess their risk of vascular disease (heart disease, stroke, diabetes and kidney disease) followed by personalised advice and individually tailored management plus treatment as appropriate. This programme is designed to improve the detection and improve treatment of the risk factors associated with CVD.

Heart failure services 

The newly formed Kent Community Health is expected to tackle the historically differing models of care across west and east Kent. West Kent has a similar geographical and population size to east Kent but fewer specialist nurses. The subsequent nurse: patient ratio is less. The nature of Heart Failure means that the patient pathway must include a Multi Disciplinary Team [MDT] meeting so that all professionals, clinicians and specialists involved in their care can communicate and ensure that the best package of care is delivered. MDTs are not as embedded in west Kent as they are in Medway and east Kent.

The Department of Health has re-modelled revascularisation rates up to 2015 using three activity rates (low, medium, high) based around

a) needs,

b) existing trends (UK and Europe),

c) professional bodies recommendations.

The three intervention rates modelled were: 1300, 1400 and 1700 per million population by the year 2015. The actual population needs for revascularisation, when adjusted for age and deprivation varies across Kent and Medway, so this needs to be described in detail particularly in line with the new and emerging GPCC boundaries in Kent.

Key unmet needs and service gaps includes:

• Role out of the National Health Checks Programmes
• Planned increase in the availability of Cardiac CT, MPS, CT Calcium scoring and Stress echo in order to comply with NICE guidance CG95 (Chest Pain of Rapid Onset)
• Validation of AF registers and opportunistic case finding
• Reduction in variation in device implantation rates
• Agree heart failure pathway across Kent.
• Improve CHD detection and treatment in Kent prisons
• Increase the numbers of cardiology physiologists

Recommendations can be found in the Kent and Medway Cardiac Strategy 2011 to 2016 and cover:

Prevention and detection

• Ensure monitoring of CVD prevalence at practice level.

• Prioritise smoking cessation, lipid modification and hypertension management.

• Support development and rollout of Health Check programme, build on early evaluation results from Medway pilot.

• Improve joint health and social care commissioning arrangements to effectively target high risk, social disadvantaged, apply evidenced based social marketing techniques as well as robust evaluation.

Cardiac Imaging and Diagnostics - As per NICE Guidance, support the introduction or increase in:

• Cardiology imaging equipment such as CT, Stress Echo and appropriate software.

• Diagnostic pathways.

• Agreed local tariffs.

• Appropriate staffing ie. cardiologist and / or radiologist with specialist interest in the above per acute trust.

• Local Cardiac Resonance Imaging (CMR) service for the patients of Kent & Medway to reduce referrals into London.

Arrythmias

• Practices should undertake validation of their AF registers and work with Medicines Management to carry out medication reviews to optimise prescribing (hyperlink to MM QIPP chapter if available) for anticoagulation.

• Opportunistic screening for AF(in patients over 65). (hyperlink to LTC chapter)

• Manual pulse check prompts should be inserted into all appropriate long term conditions monitoring templates and be embedded in daily practice particularly for those at high risk.

Devices

Further analysis is required exploring variation in methods of device implantation including indications, complications, expenditure, etc.  

Revascularisation and cardiac surgery

• Review current diagnostic and surgical intervention activity and capacity, and care pathway development.

• Consider feasibility of new and emerging services and targets such as tertiary cardiology services, primary angioplasty 150 minute call-to-balloon target can consistently, High Sensitive Troponin test for chest pain patients presenting to A&E.

Heart failure and end of life care

• Service and care pathway development focusing on latest NICE Guidance Personalised Care Plans, BNP provision, Heart Failure registers development, integrated community teams, identify patients in acute trusts, tele-technology and improved access to EoLC.

These include:

• Cardiac rehabilitation

• ICD device numbers and selection
• CHD needs as part of prison health needs assessments
• Possibly work around familial hypercholesterolemia
• Benchmark intervention rates by GPCC boundaries