South Eastern Health Board : Publications : Health of the South East

Cardiovascular Disease

Introduction

Background

Health Promotion and Primary Prevention

Secondary & Tertiary Services

Recommendations

Conclusion

1. Introduction

Cardiovascular disease is the single most common cause of death in Ireland, and in the South Eastern Health Board. In those aged under 65 years, Ireland has nearly twice the average death rate from heart disease in the European Union (60.7 per 100,000 v. EU average of 32.6 per 100,000), despite the fact that the rates have fallen since 1981.¹ Shaping a Healthier Future,² the National Strategy document for Health in 1994 set a "medium term target to reduce the death rate from cardiovascular disease in the under 65 year age group by 30% in the next 10 years. This compared with the approximate 30% reduction achieved in the preceding 20 years". The Department of Health intends to produce a Coronary Heart Disease strategy document in 1998.

2. Background

2.1 Mortality
Mortality rates from coronary heart disease have decreased in Ireland in recent years (Figure 3.1). In males the rate of decline accelerated in the mid 1980s (Figure 3.2). For females the rate of decline has been more gradual (Figure 3.3). The decrease in mortality is likely to be due, at least in part, to declining levels of risk factors and improved treatments.³

In general, the pattern in the SEHB parallels that of the national situation but as shown in Figures 3.1, 3.2 and 3.3, the match is not perfect. Although, caution must be used in interpretation, in view of the smaller numbers, it is evident that for the populations of Sth.

Tipperary and Carlow both females and males in the former and females in the latter, do less well than their peers in other counties.⁴

Figure 3.1 All Ischaemic Heart Disease (Males & Females) Direct Standardised Rate per 100,000 population

Source: Public Health Information System (Version 2)

Figure 3.2 All Ischaemic Heart Disease (Males) Direct Standardised Rate per 100,000 population.

Source: Public Health Information System (Version 2)

Figure 3.3 All Ischaemic Heart Disease (Females) Direct Standardised Rate per 100,000 Population

Source: Public Health Information System (Version 2)

2.2 Morbidity (Hospital In-Patient)
Morbidity data is limited to that available from the hospital in-patient enquiry (HIPE) i.e. ill people treated as inpatients in public hospitals. The 1997 data is based on that available to ESRI on 31/05/98. The completeness of coding compared with actual number of discharges was Waterford Regional Hospital 95.9%, St Luke's Kilkenny 87.1%, Cashel 99.9%, Wexford General 90.0%, Kilcreene Orthopaedic 26.6%, St. Joseph's Clonmel 56.1%. The completeness for non SEHB hospitals is unavailable. In terms of cardio-vascular disease, the 1997 figures for the region and especially Sth. Tipperary are likely to be an under-estimate.

Despite these caveats, ischaemic heart disease is a significant cause of morbidity for the population of the South Eastern Health Board and has a major impact on the health services. This is reflected in part by the fact that HIPE recorded 2,085 discharges for ischaemic heart disease in 1995 which used 13,651 bed days, 2,123 discharges in 1996 which used 13,561 bed days and 2,046 discharges in 1997 which used 13,576 bed days. Table 3.1 shows the in-patient discharge rate per 100,000 by county for ischaemic heart disease averaged for the two year period 1995-1996 (in view of the incomplete data for 1997, it was excluded).

Table 3.1 Ischaemic Heart Disease In-Patient Discharge Rate per 100,000 population (ICD 410-414) HIPE 1995 - 1996

County	Males Rate per 100,000	Females Rate per 100,000	Total Rate per 100,000
Carlow	709.6	431.6	572.8
Wexford	828.1	370.4	601.4
Kilkenny	698.3	356.5	530.3
Tipperary South	685.6	300.1	495.9
Waterford	719.3	359.6	539.2
SEHB	736.5	357.9	546.1

Source : HIPE Database ESRI

Two thirds (66.0%) of those in-patient discharges with ischaemic heart disease in 1997 were males. The age distribution of the total group as evident in figure 3.4 indicates the impact ischaemic heart disease has on those aged fifty.

Figure 3.4 Age distribution of Ischaemic Heart disease 1997

Source : HIPE Database ESRI

2.3 Epidemiology
The death rate from heart disease has fallen in Ireland and internationally over the past decade, albeit at different rates.⁵ There has been an increase in the prevalence of coronary heart disease in older age groups.⁶ Increased survival, increasing numbers with chronic disease and co-morbidities and an increase in the number of older people in the population impact both on prevalence, service needs and service demands.

Shaping a Healthier Future² emphasised the concepts of health gain, social gain and appropriate care. Given the relatively large numbers involved, nowhere are these concepts more important than in the primary, secondary and tertiary prevention and treatment of coronary heart disease at national and Health Board level.

3. Health Promotion and Primary Prevention

3.1 Introduction
In view of the numbers affected by coronary heart disease in Ireland and the South Eastern Health Board a strategy is needed for the total population with additional strategies for those groups and individuals known to have an increased risk of coronary heart disease. Lifestyle factors, including smoking, alcohol, nutrition and diet, exercise, cholesterol and blood pressure are known to be major risk factors for coronary heart disease. People with diabetes, the prevalence of which is rising, are at high risk, as are those with a family history of cardio-vascular disease.

Two approaches are required to decrease the prevalence of coronary heart disease. One is the population approach i.e. the aim is to reduce the risk of disease for everybody in the population, the other which compliments this, is the high risk approach i.e. those known to have a particular risk of the disease are targeted e.g. people with a positive family history or those with diabetes mellitus.

As part of the population approach, the World Health Organisation, and more locally the Irish Heart Foundation, have encouraged the development of networks of health promoting hospitals, health promoting institutions, health promoting communities, health promoting schools, health promoting workplaces and health promoting cities. The aim of these is to provide a health promoting environment for all involved and can include aspects such as provision of healthy food choices in restaurants/canteens, walking ways, smoking cessation programmes, stress management programmes and training in cardio-pulmonary resuscitation (CPR). A number of hospitals, schools and workplaces in the south east have joined these networks.

3.2 Risk Factor Targets
For many of the specific risk factors for ischaemic heart disease, the Department of Health¹ in its health promotion strategy set national targets:

Smoking

A reduction in the percentage of cigarette smokers in the population by at least 1% per annum so that more than 80% of the population aged 15 years and over are non-smokers by the year 2000.

Alcohol/Substance Misuse

The development of a national policy to promote moderation in alcohol consumption and reduce risks to physical, mental and family health associated with alcohol misuse.
Ensure that 75% of the population aged 15 years and over knows and understands the recommended sensible limits for alcohol consumption (14 units a week for a woman and 21 for a man) within the next 4 years. (These limits are subject to ongoing review, based on research findings).
Reduce substantially over the next 10 years the proportion of those who exceed the recommended sensible limits of alcohol consumption.
All pupils leaving school will have received information and education programmes on the dangers of substance misuse in the context of a comprehensive health education programme.

Blood Pressure

To achieve a situation where 75% of the population in the 35-64 age group will have a blood pressure of less than 140/90mm Hg by the year 2005.

Cholesterol

To achieve a reduction in mean serum cholesterol in the 35-64 year age group from a present level of 5.6mmol/L to 5.2mmol/L by the year 2005.

Exercise

A 30% increase in the proportion of the population aged 15 years and over who engage in an accumulated thirty minutes of light physical exercise most days of the week, by the year 2000.
A 20% increase in the proportion of the population aged 15 years and over who engage in moderate exercise for at least 20 minutes, 3 times a week, by the year 2000.

Nutrition

The national targets set in this area include the on-going implementation, within the next five years, of the Department of Health's Healthy Eating Guidelines including:-

Educating and motivating Irish people to eat a wide variety of foods in line with current recommendations as illustrated in the Food Pyramid.

The encouragement of the achievement and maintenance of a healthy weight through healthy eating and regular exercise.

The encouragement of a reduction in total fat intake (to no more than 35% of energy as fat) by the year 2005 and to attain an appropriate balance of fats.

The achievement of a moderate reduction of 10% in the percentage of people who are overweight and a reduction of 10% in the percentage of people who are obese by the year 2005.

Information relating to the South Eastern Health Board

Detailed baseline data on risk factors for coronary heart disease for the population of the SEHB is available from the Happy Hearts National Survey in 1994⁸ which included populations in Wexford and Carlow and the Kilkenny Health Project in 1992.⁹ These studies provide data on factors such as smoking, alcohol, blood pressure, cholesterol, weight, exercise and nutrition. As important as the overall figures are from the point of view of prevention, there are differences between social categories (see Chapter 2), gender and age groups. An example of this is shown in table 3.2. However, the pattern is the same for most of the other risk factors.

Table 3.2 Average Daily Physical Activity* for those in paid employment Carlow, Wexford Happy Hearts 1994

	Sedentary %		Moderate %		Active/V. Active %
	Carlow	Wexford	Carlow	Wexford	Carlow	Wexford
Men	22.7	15.0	29.5	22.5	47.7	62.5
Women	14.3	27.8	85.7	38.9	0.0	33.3
Men:
30-49yrs	30.0	14.2	26.7	25.0	43.3	60.7
50-69yrs	7.1	16.6	35.7	16.6	57.1	66.6
Women:
30-49yrs	18.2	28.5	81.8	50.0	0.0	21.4
50-69yrs	0.0	25.0	100	0.0	0.0	75.0
Social Class
1-3	18.2	12.0	51.5	40.0	30.3	48.0
4-6	24.0	25.0	32.0	18.8	44.0	59.3
Total	20.7	19.8	43.1	27.5	36.2	53.4

* Moderate:- Walking etc. > 4 hours per week.
Active:- Running etc. > 3 hours per week.
V. Active:- Regular training, competitive sports.
Source: Happy Hearts

More recent data on smoking behaviour and attitudes is available from the staff of the South Eastern Health Board who were surveyed in the past year about their smoking behaviour and attitudes. Over 25% were current smokers, the largest proportion of whom were aged under 25 years. Over a third of the smokers regularly smoked at work with an additional one third who smoked occasionally at work. Over half the staff, (smokers and non smokers alike) were exposed to smoke in their work area. Over two thirds were exposed to smoke in their canteen. The majority (90%) of respondents agreed that non smokers had a right to smoke free work, and rest/eating areas, and 70% of smokers felt that support at work would help them quit.

More recent data will be available from the questions included in the Folic Acid survey in 1997 (See Chapter 5.5.3) whose 300 participants - all postpartum - were asked in addition to questions on folic acid, about their smoking habits especially during pregnancy. Pregnant women are a particular target group in view of the known health effects of cigarettes not just on themselves but also on the foetus.

Both the Kilkenny Project and the Happy Hearts survey provide a baseline against which to measure the achievements of the national targets. Additional baseline information will be provided by the school lifestyle survey of 1998. The achievement of the targets require the co-operation not just of the health services but of other agencies, voluntary and statutory, including educational, recreational and employment.

High risk groups include those with a family history of ischaemic heart disease, those with high blood pressure and those with abnormal lipid patterns. Baseline data on many of these were obtained during the Happy Heart Survey⁸ and the Kilkenny Health Project.⁹ Another high risk group are those with diabetes mellitus. The health promotion strategy¹ document set the following national targets:

* Diabetes is an important public health problem which causes prolonged ill-health, increases the risk of heart attack and stroke and leads to premature death.

* General goals include improving life expectancy in terms of quality and quantity and the prevention and cure of diabetes and its complications.

The precise number of persons with diabetes in any particular population is influenced by the age and sex structure and ethnic mix. Estimates of the age adjusted prevalence of clinical diabetes of all types in England range from 0.05% to 1.36%. In the U.S.A., it is estimated that 6% of people aged over 65 years have diabetes.

In 1990, the Kilkenny Health Project reported a prevalence of Diabetes Mellitus of 1.6%. Based on prescription records, in the SEHB, 1.2% of the population in 1996 were known to be on drug treatment for diabetes (insulin or oral hypoglycaemics), suggesting at least a similar number unknown or on dietary treatment. People with diabetes, in view of the multi-organ nature of the disease, are at risk from many complications including cardio-vascular disease.

As is evident from the above, much baseline data is available. Although this is on two community care areas, there is no reason to believe that the populations of South Tipperary and Waterford are any different. To fill these information gaps and act on the information, data needs to be gathered in a comprehensive co-ordinated manner at local and regional levels to provide a total risk factor profile rather than each in isolation.

For the population as a whole and for those in the high risk categories, at regional and local level specific targets must be set, which take account of this baseline data, and local plans to achieve these targets should be implemented.

4. Secondary & Tertiary (Prevention, Diagnosis, Treatment, Rehabilitation) Services

4.1 Introduction
During recent decades the increased understanding of the epidemiology of coronary heart disease (facilitating effective prevention, the growth in scientific knowledge, development of investigative techniques, drug therapy, medical and surgical interventions, the increasing emphasis on documented evidence based health care), has resulted in dramatic improvements in the care of people with coronary heart disease. Reference was made earlier to the falling death rate internationally from coronary heart disease and the increased numbers of survivors with a now chronic disease.

All patients with coronary heart disease (CHD) require secondary prevention to modify lifestyle, e.g. avoid all tobacco, modify diet as appropriate, improve physical fitness, to modify risk factors e.g. optimal blood sugar and reduction of thrombotic tendencies and may need prophylactic medications e.g. Aspirin, Beta blockers, ACE Inhibitors, Anticoagulants.

In addition to these secondary preventive factors, is the diagnosis, treatment and care of people in the acute stages, the chronic stages and those with complications. Shelly et al⁵classify these as follows:

cardiopulmonary resuscitation (CPR) / care in the community,

medical treatment/secondary prevention,

interventions - percutaneous transluminal coronary angioplasty (PTCA), coronary artery

bypass graft (CABG),

rehabilitation.

4.2 Cardiopulmonary resuscitation (CPR) /care in the community
Training in CPR is included in many of the health promoting networks mentioned earlier. Ambulance personnel are also trained. The effectiveness of such skills in terms of lives saved is unclear unless a substantial proportion of the population has been trained.⁵ However, as training is linked with education on factors associated with the development of coronary heart disease, training may provide the necessary impetus to lifestyle change in those trained.

Access to care includes recognition of symptoms - Bury et al¹⁰ reported a "comprehensive grasp of risk factors, signals and appropriate actions in heart attack among members of the general public in Dublin". There is no reason to believe the knowledge of the people of the south east is any different. Yet there are delays in summoning help and reaching care which is all the more important given the potential benefit from agents such as aspirin and thrombolytic agents. O'Riordan et al¹¹ in 1991 in South Tipperary reported an average delay time from onset of pain to admission to CCU of 6.65 hours (range 0.3 - 18 hours, median 6 hours) and identified a number of factors, both outside and inside the hospital, which required attention if this was to be improved. These factors include patient factors, public awareness factors and health care practitioners factors.

4.3 Medical treatment/secondary prevention
There is evidence that low dose aspirin is effective in secondary prevention for those with established coronary heart disease.¹² Beta blockers, ACE inhibitors, anticoagulants and statins also have roles in selected patients. All patients who are suitable should be on aspirin at time of hospital discharge, but there is no systematic way of knowing ongoing compliance, of this or other drugs.

With regard to lifestyle and risk factor change, two hospitals have specific cardiac rehabilitation units while the other two provide required services through general hospital and community care services. At a regional level its not known the percent change in risk factors post MI, e.g. number still smoking six months later, likewise other factors such as lipid profile, exercise level and psychological profile.

4.4 Interventions
Many studies have reported on and compared coronary artery bypass grafts (CABG) and percutaneous coronary angioplasty (PTCA).^13-21 In clinical practice both techniques have advantages and disadvantages: technical considerations and the clinical status of the patient determines the treatment choice for the individual patient. Neither treatment cures the underlying conditions but does impact on symptom control, quality of life and in some cases prognosis.

The British Cardiac Society²² have advocated waiting times targets for coronary disease investigation and treatment as follows: one month for an initial consultation, three months for diagnostic tests and six months for treatment. The Audit Commission in 1995²² stated that the waiting time from the decision to intervene to revascularisation should not exceed one year. For services available in the SEHB, these targets are being achieved but for those services provided by tertiary centres, the waiting times are more variable.

The Irish Cardiac Society believes that 3,000 diagnostic investigations per million population are needed.²³ Internationally it is recognised that approximately twice the number of cardiac catheterisation procedures are required to provide the diagnostic support for a given number of patients destined for cardiac surgery.²² A CABG rate of 600/million population and a PTCA rate of 300/million population has been suggested.^22,24,25 In the SEHB this would translate as 228 CABGs, 114 PTCAs and 700 catheterisations.

The total number of PTCAs and CABGs procedures carried out on residents of the SEHB in public hospitals, i.e. excludes private hospitals such as Mater Private and Blackrock Clinic, for the years 1995 - 1997 are shown in table 3.3. Three quarters (76%) were males, 24% females.

Table 3.3 HIPE: Public Hospitals: PTCAs & CABGs (ICD 360-369). 1995-1997

	1995	1996	1997
PTCA:
Carlow	4	12	9
Wexford	19	15	42
Kilkenny	10	9	16
Tipp. Sth	8	6	0
Waterford	16	17	36
Total	57	59	103

CABG:
Carlow	14	10	7
Wexford	22	24	22
Kilkenny	16	23	10
Tipp. Sth	5	17	0
Waterford	26	27	19
Total	83	101	58

Source: HIPE database ESRI
1997 Data base as available to ESRI 31/05/98

In the absence of data from the two relevant private centres definitive conclusions cannot be drawn from the above, but it strongly suggests that the recommended procedures norms are not being achieved for the population of the south east.

4.5 Rehabilitation
Rehabilitation has many objectives, including improving compliance with secondary prevention medication, encouraging lifestyle changes, as well as providing social and psychological support for the patient and family. In addition to hospital based programmes, a network of patient support groups exist around the country, for those who have completed formal rehabilitation programmes. At present in the SEHB, the provision of these services vary.

5. Recommendations

The aim of the South Eastern Health Board's cardiac service is to reduce the incidence, prevent recurrence and improve quality of life together with the provision of effective services. In order to achieve this it is recommended that:

The SEHB focus on coronary heart disease by developing a regional coronary heart disease strategy with service plans agreed locally to implement the strategy.

Improve and co-ordinate the provision of information; on risk factors (primary and secondary prevention for the general population, individual and high risk groups), on mortality and morbidity, on service use, clinical audit and outcome data.

Develop, adopt, and audit protocols for prevention, diagnosis, medical and surgical intervention, rehabilitation for all services which impact on coronary heart disease.

Develop specific cardiac services in each general hospital.

6. Conclusion

In the South Eastern Health Board much is being done to combat coronary heart disease. Improved co-ordination between programmes, services, and service providers matched with accurate timely data ranging from health promotion to rehabilitation will ensure the achievement of best practice.

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