6 Saving lives: coronary heart disease and stroke

Target: to reduce the death rate from coronary heart disease and stroke and related diseases in people under 75 years by at least two fifths by 2010 - saving up to 200,000 lives in total

6.1 One group of diseases kills more commonly than any other, can strike within minutes and singles out people in their prime as well as in later life. Coronary heart disease and stroke, along with other diseases of the circulatory system¹, account for over 200,000 of the half a million deaths which occur in this country each year. And while death rates are improving substantially for the best off in society, the worst off have not benefited to anything like the same extent, thus widening the health gap. Many families
in our country have experienced the tragedy that these diseases can bring.

In this White Paper all references to coronary heart disease and stroke should be understood to cover all diseases of the circulatory system

6.2 Many more people who survive acute heart attacks and strokes suffer long-term pain and disability. They and their families know how difficult it is to cope with these consequences. Never feeling completely well, unable to work, often confined to the house, constantly reliant on others - these are some of the worst features which many people must endure.

'England has one of the worst rates of coronary heart disease'

How do we compare?

6.3 Death rates for coronary heart disease and stroke fell during the 1970s and 1980s in most western countries and England was no exception. Deaths from coronary heart disease dropped by 38 per cent between the early 1970s and late 1990s and from stroke by 54 per cent over the same period. But across the European Union (EU), England has one of the worst rates of coronary heart disease - for people aged under 65 years, we are two and a half times worse than France (the country with the lowest rate in the EU) amongst men and over four times worse for women. For stroke, at least in those aged under 65 years, the picture is rather better with our death rates in men being better than for many other EU countries, but for women our rate is closer to the average and is more than 50 per cent higher than France, the best-performing EU country.

Fig 6.1 Death rates from circulatory disease: UK amongst the highest in Western Europe

Fig 6.2 Death rates from stroke: English women one of the worst records in Western Europe and men one of the best

Causes

6.4 Several of the major risk factors which increase the chances of people developing coronary heart disease or having a stroke are now well established. The key lifestyle risk factors, shared by coronary heart disease and stroke, are smoking, poor nutrition, obesity, physical inactivity and high blood pressure. Excess alcohol intake is an important additional risk factor for stroke. Many of these risk factors are unevenly spread across society, with poorer people often exposed to the highest risks.

Fig 6.3 Levels of smoking have fallen more quickly in professional classes

Fig 6.4 Obesity in women: higher levels amongst manual social groups

'risk factors are unevenly spread across society'

6.5 Smoking is the most important modifiable risk factor for coronary heart disease in young and old. The fact that smokers of whatever age, sex or ethnic group have a higher risk of heart attacks than non-smokers has been known for a quarter of a century. All these effects have also been demonstrated in those exposed to other people's smoke (passive smoking). A lifetime non-smoker is 60 per cent less likely than a current smoker to have coronary heart disease and 30 per cent less likely to suffer a stroke.

6.6 While the proportion of young people starting to smoke is similar across social classes, by their 30s half of the better off young people have stopped smoking while three quarters of those in the lowest income group carry on. This is powerful evidence of how the cycle of social disadvantage contributes directly to the risk of premature death, avoidable illness and disability. About one third of smokers are concentrated in the bottom ten per cent of earners in this country. Smoking rates for those in professional social classes have fallen more rapidly than those for the unskilled. For example, in 1972, unskilled men were twice as likely to smoke as professional men; latest figures show that they are now three times as likely to smoke.

6.7 Poor diet - containing too much fat and salt and not enough fruit and vegetables - is another important cause of coronary heart disease and stroke. A diet high in fat, for example, raises cholesterol levels in the blood. A ten per cent reduction in cholesterol lowers the risk of coronary heart disease by 50 per cent at age 40 years falling to 20 per cent at age 70 years. Poor diet is a fact of life for many poorer families. They do not always enjoy easy access to shops selling a variety of affordable foods, which most of us take for granted.

'the cycle of social disadvantage contributes directly to the
risk of premature death'

6.8 Keeping physically active provides strong protection against coronary heart disease and stroke. It also has beneficial effects on weight control, blood pressure and diabetes - all of which are risk factors in their own right; protects against brittle bones and maintains muscle power; and increases people's general sense of well-being. Levels of physical activity vary by social group and occupation. People in unskilled occupations are more physically active at work but less so in their leisure time than people in professional occupations. Even so, across all social groups we do too little exercise. Six out of ten men and seven out of ten women are not physically active enough to benefit their health.

6.9 High blood pressure raises significantly the chances of someone having a stroke or developing coronary heart disease. A modest reduction of salt in the diet, reduction in excess alcohol intake or an increase in physical activity could greatly reduce the risk of stroke and significantly reduce the risk of coronary heart disease. Many people with high blood pressure go unrecognised or are treated ineffectively. These people remain at increased risk.

Fig 6.5 Well under half of people with high blood pressure are treated successfully

6.10 There are influences in very early childhood, including while a baby is still in the womb, which determine a person's risk of developing coronary heart disease later in life. For example, small size at birth is an important risk factor for coronary heart disease in adult life. Some argue that these influences are related to nutrition.

'In countries with greater income inequality, health inequality
is greater too'

6.11 There is mounting evidence of the impact of the underlying causes of coronary heart disease such as income differences. In countries with greater income inequality, health inequality is greater too. And there is evidence that social stress, reflected in the extent to which an individual has low control over his or her job, increases the risk of coronary heart disease and of premature death. Similarly the degree of social cohesion, the strength of social networks in a community and the nature of people's
work may all affect their risk of dying from coronary heart disease.

Fig 6.6 Unequal risk of heart disease death at different employment levels in the public sector: even after allowing for risk factors

Action: reducing risk and staying healthy

6.12 A number of big changes would put people at much reduced risk of developing coronary heart disease or stroke in the future:

• major changes in diet, particularly among the worst off, with increased consumption of such foods as fruit, vegetables, and oily fish

• large reductions in tobacco smoking particularly among young people, women and people in disadvantaged communities

• people keeping much more physically active - by walking briskly or cycling, for example - on a regular basis

• people controlling their body weight so as to keep to the right level for their physique

• avoiding drinking alcohol to excess

6.13 Deciding not to smoke is choosing life against chronic ill-health and premature death. Giving up smoking produces benefits even in those who have smoked for many years. The White Paper Smoking Kills set out our policies for addressing this major cause of stroke and coronary heart disease. In addition to a new three-year public education campaign costing up to £50 million, a network of smoking cessation services will be established around the country, initially in deprived areas known as Health Action Zones. £60 million over three years has been set aside for this vital service. Addiction to nicotine underlies the smoking epidemic and is the reason why people find it so difficult to stop smoking. There is good scientific evidence that a combination of behavioural support and nicotine replacement therapy substantially increases the chances of an ex-smoker remaining free from this addiction. On 17 June we published regulations which set out our intention to ban tobacco advertising with effect from 10 December 1999.

'To ban tobacco advertising from December this year'

Action: more effective treatment

6.14 Early effective treatment of people who are in high risk groups or who have the initial signs of circulatory disease can prevent or delay them developing full blown heart attacks or strokes. Experience shows that people's access to effective treatment is
very variable across the country.

6.15 Although we want to prevent as many cases of coronary heart disease as possible, we want to ensure that people who could benefit from operations to relieve their symptoms are able to gain access to these specialist services. In the past we have also seen inequality in access to coronary bypass operations or angioplasty according to where someone happens to live. These operations do not always prolong life but they do improve quality of life, relieve the pain of angina and allow people to live free of disability.

Fig 6.7 Differing rates of coronary bypass operations and angioplasties

6.16 Over time we want to ensure that the standards of the best services in the country apply to all parts of the country. That is why we are producing a National Service Framework for Coronary Heart Disease. The framework will set national standards and define service models for health promotion, disease prevention, diagnosis, treatment, rehabilitation and care. It will reduce variations in health care and improve service quality and will be published shortly.

'we want to ensure that the standards of the best services in
the country apply to all parts of the country'

6.17 National service frameworks are also planned for older people and for those with diabetes. These will also help to reduce the impact of stroke as well as coronary heart disease. These national service frameworks will be published in April 2000 and April 2001 respectively.

6.18 We are also taking action to improve the control of high blood pressure in the population - too many people remain at risk of heart attack or stroke because their high blood pressure is undetected or treated inadequately.

6.19 To reduce high blood pressure we will:

• through publication of a review of the evidence, promote good practice in GP referrals

• develop an alcohol strategy for publication during 1999

• review the way that high blood pressure is detected and brought under control

• in partnership with the food industry explore the scope for reducing the salt content of processed foods.

'building social capital by increasing social cohesion and
reducing social stress'

Integrated action

6.20 In our fight against coronary heart disease and stroke we can be successful only if everyone recognises that:

• A whole-generation approach is needed to reduce the impact of such factors as smoking, poor nutrition, obesity and physical inactivity by addressing the importance of influences that operate before birth through healthy pregnancy; laying the foundations for healthy values in early childhood; reinforcing knowledge about risks among young people and equipping them with the skills to take action; helping ensure that in middle and later life people's personal behaviour continues to promote their health and well-being

• Tackling underlying social, economic and environmental conditions is vital. Those factors operate independently as well as through the specific lifestyle factors. So health inequality can be reduced only by giving more people better education; creating employment so that people can achieve greater prosperity; building social capital by increasing social cohesion and reducing social stress by regenerating neighbourhoods and communities; and tackling those
  aspects of the workplace which are damaging to health

• More effective, high quality health services have an important part to play by providing support and advice to people who want to reduce the risks to their health; slowing disease progression in people with early signs and symptoms; limiting long-term incapacity for people who have been ill by well-targeted rehabilitation and follow-up care.

6.21 We will create an integrated strategy for action to reduce the burden of coronary heart disease and stroke through a contract for health. It will identify what the individual citizen must do, what local partnerships will do and what action we will take across Government.

'implementation of the contract by high-level Task Force'

6.22 Our Healthy Citizens initiative will help us in this task, through NHS Direct; through our Health Skills programme - including training for members of the public in the use of defibrillators; and through our Expert Patients programme which will enable people with vascular disease to manage their own condition.

6.23 We shall bring together the implementation of this contract for coronary heart disease and stroke with the implementation of the National Service Framework for Coronary Heart Disease by setting up a high-level Task Force, accountable to the Chief Medical Officer. The Task Force will ensure that the essential groundwork is laid to set us on course for achieving our target for saving lives which would otherwise be lost to coronary heart disease and stroke. We will identify someone of national prominence to act as its champion, whose function will be to build and maintain momentum for action, to communicate the purpose of the contract and to encourage individuals to commit themselves to it.

6.24 We will use the Public Health Development Fund to support the achievement of our target for coronary heart disease and stroke (see paragraphs 11.39 and 11.40).

Fig 6.8 Ways of beating heart disease and stroke: examples of how everyone can play their part

We welcome your comments on this site. Prepared 5 July 1999