Cardiovascular disease
Key findings for Lancashire-12
Simon Collins, Public health knowledge and intelligence analyst
April 2017
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Contents
1.
OVERVIEW..................................................................................... 1
1.1
2.
Key findings .......................................................................... 3
ANALYSIS OF THE LATEST FIGURES ........................................... 4
2.1
2.2
2.3
2.4
Prevalence ............................................................................ 4
Hospital activity ..................................................................... 6
Prescribing ............................................................................ 7
Mortality ................................................................................ 8
3.
CONCLUSIONS ............................................................................ 11
4.
APPENDICES ................................................................................. 1
Cardiovascular disease in Lancashire 2016
1. Overview
Cardiovascular disease (CVD), sometimes referred to as circulatory disease, refers to
diseases of the heart and blood vessels, including angina, coronary heart disease (CHD),
heart attack, high blood pressure (Hypertension), peripheral arterial disease (PAD) and
stroke. Such diseases are caused by reduced blood flow to the heart, brain or body caused
by atheroma or thrombosis and is common in people aged over 60. CVD is one of the
biggest causes of death and disability in the UK and is largely preventable with a healthy
lifestyle.
The main causes of CVD include tobacco use, physical inactivity, an unhealthy diet and
harmful alcohol use.
Main CVD diseases and their causes
Coronary heart disease (CHD), also known as Ischaemic heart disease
Coronary heart disease is the term that describes what happens when your heart's
blood supply is blocked or interrupted by a build-up of fatty substances in the
coronary arteries. Over time, the walls of your arteries can become clogged up with
fatty deposits in a process known as atherosclerosis.
Atherosclerosis can be caused by lifestyle factors and other conditions, such as:
 smoking
 being physically inactive
 high cholesterol
 high blood pressure (hypertension)
 diabetes
Atherosclerosis is known to cause angina and heart attacks.
Hypertension (high blood pressure)
Persistent high blood pressure can increase your risk of a number of serious and
potentially life-threatening conditions, such as heart disease, heart attack, heart
failure, stroke, kidney disease and vascular dementia.
An Individual is at an increased risk of high blood pressure if they:
 are over the age of 65
 are overweight or obese
 are of African or Caribbean descent
 have a relative with high blood pressure
 eat too much salt and don't eat enough fruit and vegetables
 don't do enough exercise
 drink too much alcohol or coffee (or other caffeine-based drinks)
 smoke
 don't get much sleep or have disturbed sleep
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Cardiovascular disease in Lancashire 2016
Stroke
Ischaemic strokes are the most common type of stroke. They occur when a blood
clot blocks the flow of blood and oxygen to the brain. These blood clots typically form
in areas where the arteries have been narrowed or blocked over time by fatty
deposits known as plaques. Whilst arteries can narrow naturally as a person ages,
things that can accelerate the process include:
 smoking
 high blood pressure (hypertension)
 obesity
 high cholesterol
 diabetes
 excess alcohol intake
Haemorrhagic strokes (also known as cerebral haemorrhages or intracranial
haemorrhages) are less common than ischaemic strokes. They occur when a blood
vessel within the skull bursts and bleeds into and around the brain. The main cause
of haemorrhagic stroke is high blood pressure.
Things that increase the risk of high blood pressure include:
 being overweight or obese
 drinking excessive amounts of alcohol
 smoking
 a lack of exercise
 stress
Atrial fibrillation
Atrial fibrillation is a heart condition that causes an irregular and often abnormally fast
heart rate. When the heart beats normally, its muscular walls contract (tighten and
squeeze) to force blood out and around the body. They then relax, so the heart can
fill with blood again. This process is repeated every time the heart beats. The cause
isn't fully understood, but it tends to occur in certain age groups (65+) and may be
triggered by certain situations, such as excessive drinking of alcohol or smoking.
Heart failure
Heart failure means that the heart is unable to pump blood around the body properly.
It usually occurs because the heart has become too weak or stiff. It is often the result
of a number of problems affecting the heart at the same time. For example having
coronary heart disease, high blood pressure or heart rhythm problems.
Peripheral arterial disease
Peripheral arterial disease (PAD) is a common condition, in which a build-up of fatty
deposits in the arteries restricts blood supply to leg muscles. A persons chances of
developing PAD can be increased if they smoke, have high blood pressure, have
high cholesterol or have diabetes.
2
Cardiovascular disease in Lancashire 2016
1.1 Key findings
The latest recorded prevalence figures (QoF 2015/16) show that all six Clinical
Commissioning Groups (CCGs) of the Lancashire-121 have significantly higher
prevalence of coronary heart disease (CHD), also known as Ischaemic heart
disease, hypertension (high blood pressure) and stroke than the England average.
However modelled estimates, suggest that the true prevalence could be much
higher, suggesting more work is required in identified and diagnosing patients. It was
also found that the majority of CCGs have significantly higher levels of recorded atrial
fibrillation, heart failure and peripheral arterial disease than the national average.
High levels of CVD prevalence was also noted in the two neighbouring authorities of
Blackburn with Darwen and Blackpool.
Significantly high levels of hospital admissions for CHD were seen across the
Lancashire-142 with some CCGs also seeing significantly high levels of heart failure
and stroke admissions. Highlighting the impact on secondary care providers that
cardiovascular diseases have. Local analysis, looking at hospital admissions
recorded by patients registered to the six Lancashire-12 CCGs during the 2015/16
period, found that the majority of CVD admissions had a primary diagnosis of
Ischaemic heart disease with persons aged 50+ and males found to be at greatest
risk of admission.
Prescribing figures for 2015/16, show that the six CCGs of the Lancashire-12 spent
over £24 million on prescribing items for cardiovascular diseases, with drugs for
lowering cholesterol levels and those used for treating patients with high blood
pressure and heart failure accounting for the majority of items prescribed. At the
CCG level, as expected East Lancashire CCG, which is the biggest CCG, prescribed
the most items. However, on a cost per item prescribed basis, this CCG was often
found to have spent less per item than most other CCGs in Lancashire-14.
Whilst CVD mortality is declining it still accounts for 28% of all deaths in Lancashire12 and compared to the national average, the Lancashire-12 and a number of
districts within it, continue to record all-age and premature (under 75) mortality rates
that are significantly above the England. Local analysis, looking at mortality amongst
Lancashire-12 residents found that CHD is the leading cause of premature mortality,
amongst those who died with a CVD related underlying cause of death, accounting
for over half (55%) of such deaths between 2013 and 2015. Further analysis finds
that males and those living in the poorest parts of Lancashire-12 are more likely to
die prematurely from CVD.
1 The Lancashire-12 refers to the Lancashire county council boundary, which encompasses the districts of Burnley, Chorley,
Fylde, Hyndburn, Lancaster, Pendle, Preston, Ribble Valley, Rossendale, South Ribble, West Lancashire and Wyre. The six
CCGs are Chorley & South Ribble, East Lancashire, Fylde & Wyre, Greater Preston, Lancashire North and West Lancashi re.
2 The Lancashire-14 encompasses the Lancashire-12 districts and CCGs as well as the unitary authority areas of Blackburn
with Darwen and Blackpool and their CCGs.
3
Cardiovascular disease in Lancashire 2016
2. Analysis of the latest figures
2.1 Prevalence
Prevalence refers to the number of cases of a particular disease, which are present
in a population at a given time. It can be presented as a modelled estimate and as
recorded prevalence. With the latter of these referring to the number of known
(recorded) cases of a particular disease within a population group. In the case of
CVD, the recorded prevalence is based on the GP registered population.
The latest modelled estimates of CVD prevalence were developed in 2011 by the
East of England Public Health Authority (now part of Public Health England).
According to the data, the estimated (aged 16+) prevalence of cardiovascular
disease in Lancashire-12 is 12.35% significantly above the England (11.76%) and
North West (12.27) estimates. Among the 12 Lancashire local authorities, Burnley
(13.99%), Fylde (14.34%), Lancaster (12.29%), Ribble Valley (13.06%), West
Lancashire (12.06%) and Wyre 13.90%) are all estimated to have significantly higher
prevalence than England.
Table 1: Modelled estimates of prevalence of CVD (2011) England, North West region,
Lancashire-12 and the unitary authorities of Blackpool and Blackburn with Darwen 3
Area
ENGLAND
North West
Blackburn with Darwen
Blackpool
Lancashire-12
Burnley
Chorley
Fylde
Hyndburn
Lancaster
Pendle
Preston
Ribble Valley
Rossendale
South Ribble
West Lancashire
Wyre
Total estimated
number of CVD
cases (16+)
4,950,969
687,101
13,308
17,442
117,361
9,523
9,802
9,253
7,597
14,267
8,457
11,806
6,142
6,321
10,440
10,833
12,920
Prevalence
11.76%
12.27%
12.57%
15.24%
12.60%
13.99%
11.43%
14.34%
11.92%
12.29%
11.91%
10.79%
13.06%
11.80%
11.80%
12.06%
13.90%
Total estimated
female CVD
cases
2,487,585
347,119
6,653
8,792
59,118
4,829
4,795
4,726
3,837
7,307
4,264
5,806
3,092
3,166
5,218
5,435
6,643
Female
prevalence
11.54%
12.07%
12.38%
15.03%
12.11%
13.65%
11.24%
14.31%
11.74%
12.13%
11.72%
10.60%
12.73%
11.47%
11.47%
11.57%
13.67%
Total estimated
male CVD
cases
2,463,384
339,982
6,656
8,649
58,240
4,694
5,007
4,527
3,760
6,959
4,193
5,999
3,050
3,155
5,223
5,397
6,276
Male
prevalence
11.99%
12.48%
12.76%
15.47%
12.35%
14.36%
11.62%
14.38%
12.11%
12.45%
12.10%
10.98%
13.41%
12.15%
12.15%
12.61%
14.15%
3 Source: East of England Public Health Observatory, 2011
4
Cardiovascular disease in Lancashire 2016
Recorded prevalence of CVD comes from the Quality and Outcomes Framework
(QOF) disease register and is divided up over following conditions: Atrial fibrillation
(AF), coronary heart disease (CHD), heart failure, hypertension, peripheral arterial
disease (PAD) and stroke & transient Ischaemic attack. Patients may be present on
more than of these CVD registers, making it difficult to determine the total recorded
CVD prevalence.
Using the latest figures (2015/16) and concentrating on three of the key
cardiovascular disease groups, the following observations were made:
Coronary heart disease (CHD) / Ischaemic heart disease




There are 47,742 persons on the coronary heart disease (CHD) register,
accounting for 4% of the total GP-registered population of Lancashire-12.
The 2011 estimates suggested that there were 60,042 persons living in
Lancashire-12 with CHD, an increase on the recorded prevalence of 12,300
persons.
All six CCGs in Lancashire-12 have a significantly higher prevalence of CHD
than England. The CCGs of the two neighbouring unitary authorities of
Blackburn with Darwen and Blackpool also recorded a prevalence significantly
above the national average.
Since 2008/09 the number of people on the QoF CHD registers of the six
Lancashire-12 CCGs has decreased by 7% (3,648 persons).
Hypertension (high blood pressure)

There are 174,289 persons on the hypertension disease register, accounting for
14.6% of the GP registered population of Lancashire-12.
 In 2014 it was estimated that across the six CCGs of the Lancashire-12 there
was an estimated 290,638 persons living with hypertension, giving the CCGs a
combined prevalence of 24.6%. An increase on the current recorded
prevalence of 67% (116,349 persons).
 All six CCGs in Lancashire-12 have a significantly higher recorded prevalence
of hypertension than England. The two neighbouring unitary authority CCGs
also recorded prevalence significantly above England.
 The number of persons on the hypertension registers of the six Lancashire-12
CCGs has increased by 11% (17,034) since 2008/09.
Stroke




There are 24,259 persons on the stroke and transient ischaemic attack disease
register, accounting for 2% of the total GP registered population of Lancashire 12.
The 2011 estimates suggested that the stroke prevalence in the GP registered
population of Lancashire-12 was 2.73% (26,090), an increase on the current
recorded prevalence of 1,831 persons.
All six CCGs in Lancashire-12 have a significantly higher stroke and transient
ischaemic attack prevalence than England.
There has been an increase in the number of persons on the stoke registers of
the six Lancashire-12 CCGs of 9% (1,940) since 2008/09.
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Cardiovascular disease in Lancashire 2016
Where the recorded prevalence was found to be significantly above the national
prevalence, it is important to note that this could be interpreted as a positive finding,
indicating that the CCGs in question have effective screening and diagnosis practices
that are successfully at identifying patients with CVD. However it was found, that for
each of the indicators examined the recorded prevalence was below the estimated
prevalence. Suggesting that there could be a large number of people living with
undiagnosed cases of CVD across Lancashire-12.
Appendix A provides a CCG level breakdown of the CVD patient registers for
2015/16.
2.2 Hospital activity
The Public Health England cardiovascular disease profiles provide nationally
benchmarked all-age hospital admission figures for coronary heart disease (CHD),
heart failure and stroke at a CCG level. The latest figures they have are for the
2014/15 period and show that for CHD five of the six CCGs were found to have
significantly higher admission directly standardised rate (DSR) per 100,000 than
England, these being Chorley & South Ribble (641.6), East Lancashire (711.9), Fylde
& Wyre (600.0), Greater Preston (676.9) and Lancashire North (704.8).
Looking at the heart failure figures, it was found that the Chorley & South Ribble
CCG recorded a DSR admission rate significantly above the England national
average of 142.3. Elsewhere, the Lancaster North (120.6) and West Lancashire
(94.8) CCGs recorded rates that were significantly below the national average, whilst
the remaining CCGs all recorded rates in line with England.
The stroke admission figures show that both the Fylde & Wyre (129.5) and West
Lancashire (137.6) CCGs recorded DSR's per 100,000 that were significantly below
the national average (171.9), whilst the remaining CCGs all recorded rates in line
with England.
In the two unitary authorities, Blackburn with Darwen CCG was found to have
significantly high rates of CHD and stroke admissions, whilst the Blackpool CCG was
found to have significantly high rates of CHD and heart failure admissions.
Analysis of locally held hospital activity extracted from the Secondary Uses Service
(SUS) datasets, reveals that over the course of 2015/16 there were 27,324
admissions involving patients registered to the six Lancashire-12 CCGs that were
recorded having a cardiovascular disease primary diagnosis. Further analysis
identified that 50% (13,687) of these admissions were unplanned/emergency
admissions, 84% (22,986) involved patients aged 50 or over with the average age
found to be 66, 56% (15,288) were for male patients and 27% (7,502) related to
Ischaemic heart diseases which is another term for coronary heart disease.
6
Cardiovascular disease in Lancashire 2016
2.3 Prescribing
Prescribing figures for drugs recorded under cardiovascular system chapter show
that over the 2015/16 financial year the six CCGs of the Lancashire-12, prescribed a
total of 7,740,432 items at a cost of £24,045,801.
Almost 60% (4,562,526) of cardiovascular items prescribed were coded under just
three different sub-sections these being Lipid-Regulating drugs (21.9%) which tend to
be statin based cholesterol lowering drugs, used to prevent major cardiovascular
events, drugs for hypertension and heart failure (21.5%) and Nitrates, calciumchannel blockers, and other antianginal drugs (15.5%), which are used for treating
patients with angina.
Table 2 : Total cardiovascular prescriptions by the six Lancashire-12 CCGs in 2015/164
Looking at the total items prescribed by CCG reveals that whilst East Lancashire, the
biggest of the six CCGs, prescribed the most items (2,428,724), they actually
recorded one of the lowest NIC per item (£2.98). Further analysis finds that East
Lancashire CCG prescribed the most items against nearly every sub-section of the
cardiovascular chapter, but only once were they found to have spent the highest NIC
per item. Something which remains true, even when the analysis is expanded to
include the CCGs of the two neighbouring authorities (Appendix B). Suggesting
there may be some value in the East Lancashire CCG sharing their prescribing
practices with other CCGs of the Lancashire-14 area. As this may potentially lead to
future cost savings and improvements in treatment methods.
4 The actual cost is the basic price of the drug less an approximation of discount, based on the National Average Discount
Percentage (NADP) plus the container cost. The net ingredient cost is the basic price of the drug as stated in Part II Clause 8 of
the Drug Tariff, this is the cost that is charged back to the CCG
7
Cardiovascular disease in Lancashire 2016
2.4 Mortality
Mortality from cardiovascular diseases (CVD) has been gradually decreasing since
1995 with studies suggesting that this decline is due to a combination of improved
cardiac treatments5 and a drop in the associated risk factor levels such as the decline
in smoking prevalence and the national smoking ban which has greatly reduced the
impact and risk of passive smoking6. Additionally, local analysis shows that in recent
years the Lancashire-12 has seen fewer deaths recorded with a cardiovascular
disease underlying cause of death, than malignant cancer. However, CVD still
accounted for 28% of all deaths across Lancashire-12 between 2012 and 2014, with
just over a 10,000 deaths being recorded. Giving the area an all-age directly
standardised mortality rate per 100,000 of 292.57 significantly above the national rate
of 267.31. Furthermore, at a district level, it was found that Burnley (351.58),
Hyndburn (344.13), Lancaster (296.84), Pendle (307.32), Preston (301.17) and
Rossendale (340.84) all recorded all-age 2012-14 CVD mortality rates significantly
above the national rate.
The two neighbouring unitary authorities of Blackburn with Darwen (355.44) and
Blackpool (341.53) also recorded all age CVD mortality rates that were significantly
above the national average.
Reducing premature mortality, referred to as mortality in persons aged 74 or under, is
a major priority of both Public Health England and the NHS, with the NHS Health
Check programme playing a key role. Around two-thirds of deaths among the under
75's are caused by diseases and illnesses that are largely avoidable such as heart
disease and stroke (Department of Health's 'Living well for longer: a call to action to
reduce avoidable premature mortality' 2013).
The latest published figures for Lancashire-12 show that 27% of all CVD deaths
recorded between 2012 and 2014 were considered premature deaths, giving the
area a directly standardised premature mortality rate per 100,000 of 85.53,
significantly above the England rate of 75.72. Looking at the figures by gender it was
found that the Lancashire-12 has both male and female premature mortality rates
significantly above the national average and that a district level the areas of Burnley,
Hyndburn, Preston and Wyre also all recorded all-person, male and female
premature mortality rates that were significantly above the national average.
Figure 5 below, provides a detailed breakdown of premature mortality for CVD by
district and gender for the both the Lancashire-12 districts and the neighbouring
authorities of Blackburn with Darwen and Blackpool.
5 Smolina Kate, Wright F Lucy, Rayner Mike, Goldacre Michael J. Determinants of the decline in mortality from acute
myocardial infarction in England between 2002 and 2010: linked national database study BMJ 2012; 344 :d8059
6 Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Legislative smoking bans for reducing
harms from second hand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database of Systematic
Reviews 2016, Issue 2. Art. No.: CD005992. DOI: 10.1002/14651858. CD005992.pub3
8
Cardiovascular disease in Lancashire 2016
Table 3 : CVD premature (under 75) mortality Directly standardised rate per 100,000,
2012-2014 by England, North West region and the unitary authorities of Blackpool and
Blackburn with Darwen
As with the all-age CVD mortality rate, the premature mortality (under 75) rate is also
declining at both a national and local level. However, Lancashire has experienced a
slower decline in the total number of premature deaths from CVD between 1995 and
2014 compared to England (-55% vs -53%), with several increases in the rate
causing the Lancashire-12 to consistently report a figure that is significantly above
the national average.
Chart 1 below shows the decline of both the total premature mortality count and the
premature mortality rate for the Lancashire-12, whilst Chart 2 benchmarks the
Lancashire-12 rate against the England rate.
9
Cardiovascular disease in Lancashire 2016
Chart 1 : Lancashire-12 CVD premature (under 75) mortality count and premature
mortality directly standardised rate per 100,000 – 1995 to 2014
Chart 2 : CVD premature (under 75) mortality directly standardised rate per 100,000 –
1995 to 2014 – England and Lancashire-12
Using locally held mortality data sets to establish the main cardiovascular diseases
that are causing premature (under 75) death in Lancashire-12, it was found that
between 2013 and 2015 there were 9,706 CVD deaths amongst Lancashire-12
residents, of which 28% (2,707) were premature deaths. Over half (55%, 1,497), of
these deaths, had an underlying cause of death of Ischaemic heart diseases, also
known as coronary heart disease (CHD). Which is caused by a build-up of fatty
deposits on the walls of the arteries around the heart.
Cerebrovascular diseases, also known as stroke, were found to have accounted for
18% of deaths during this period. Stroke has the same risk factors as coronary heart
disease and is linked to excessive drinking.
10
Cardiovascular disease in Lancashire 2016
Chart 3 : Proportion of premature (under 75) mortality from CVD 2012-2014 by ICD-10
block
More detailed analysis found the following:





67% (1,815) of those that died were male
The average age was 64
33% came from just three of the Lancashire-12 districts
o Wyre (11%, 303), Lancaster (11%, 300) and Preston (11%, 295)
30% (802) lived in LSOAs classed within deprivation quintile 1, meaning that
they are amongst the poorest 20% of communities in England.
57% (1,555) died in a hospital setting
3. Conclusions
All-age and premature mortality rates from CVD are reducing with advances in
medical care and treatment playing their part in this decline alongside successful
national and local public health initiatives such as the 2007 smoking ban, stop
smoking services and healthy weight programmes. However, mortality rates in
Lancashire-12 are still significantly above the national average, the area also has
increasing levels of recorded prevalence and significantly high levels of hospital
admissions relating to CVD. There also continues to be differences in the way CVD
impacts male and females, as well as those living in the poorest communities.
In order to continue this decline in mortality and address health inequalities, the
health and local government bodies of Lancashire-12 will need to continue to support
intervention programmes such as those aimed at reducing smoking prevalence and
improving levels of physical activity, two areas Lancashire-12 perform badly in when
benchmarked against the national average. The Health Checks programme can also
play an important role in helping to identify and diagnoses patients earlier, ensuring
that they receiving treatment sooner which could lead to improved outcomes and
longer, healthier lives. This work will also support demand reduction projects and
long term cost reduction initiates.
The differences in prescribing spending between the different CCGs of Lancashire12 also opens up the potential for shared learning, cost reductions and improved
treatment practices.
11
Cardiovascular disease in Lancashire 2016
4. Appendices
Appendix A: CCG level recorded disease prevalence - cardiovascular group, 2015/16
1
Cardiovascular disease in Lancashire 2016
Appendix B: CCG level prescribing figures 2015/16, cardiovascular system chapter breakdown showing total items prescribed and
total net ingredient cost (NIC) per item.
2