Cardiovascular disease (also called circulatory disease) is one of the most important causes of premature death in London. Targets for reducing early deaths from cardiovascular disease are central to the national health strategy - Saving Lives: Our Healthier Nation. The NHS plan, published in 2000, states that the treatment of heart disease will improve and the Coronary Heart Disease National Service Framework which was published in 2000, aims to reduce death and ill health from coronary heart disease.

Within the broad category of cardiovascular disease are a number of more specific health problems of which the two most important, in terms of causes of death, are Coronary Heart Disease (CHD, also known as Ischaemic Heart Disease - IHD) and Cerebrovascular Disease (stroke). The precursors to these include angina, and hypertension (high blood pressure) - both of which can be commonly found as health problems in the population. Cardiovascular disease is also linked with other conditions, notably respiratory problems and diabetes.

Coronary heart disease (CHD) is the leading cause of death, and accounted for 10,679 deaths in London in 2001 (Compendium of Clinical Indicators 2002). The incidence of CHD is not known precisely, however estimates suggest that around 80-90 cases per 10,000 population are diagnosed each year, with incidence in men being about twice as high as that in women. The fact that CHD is one of the most common causes of death makes even slight differences in relative mortality especially important as factors determining overall health within London. Coronary Heart Disease includes angina (chest pain on exertion), heart attacks (myocardial infarction) and heart failure.

Cerebrovascular disease (stroke) was responsible for another 5,765 deaths in 2001 in London (Compendium of Clinical Indicators 2002). For every 100,000 people there are an estimated 240 acute strokes per year (Wade, 1994). Non-fatal strokes can lead to some forms of disability, for example, about half of stroke survivors are unable to use public transport (about 300 per 100,000). For London this would mean about 42,000 people who have had a stroke, and about 21,000 who are unable to use public transport as a consequence.

These, and most other cardiovascular diseases, are caused by atherosclerosis (blocked arteries). Other diseases caused by atherosclerosis include aortic aneurysm (ballooning of the main artery) and peripheral vascular disease (usually blocking the blood supply to the legs or feet) leading to 'claudication' (leg pain on walking) or even gangrene or the need for amputation.

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Cardiovascular diseases are common in the general population. If high blood pressure is included, these conditions affect over a quarter of the population. The more severe forms of CVD tend to be more common in men than women, in particular angina, heart attacks in the past 12 months and stroke.

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There is quite extensive research into the range of risk factors that are important in cardiovascular disease. They include a number of physical and 'lifestyle' risk factors such as blood lipid levels, smoking, raised blood pressure, diabetes, obesity and physical activity.

There are also a range of more recently identified risk factors where the evidence is not always clear, for example, maternal nutrition and intrauterine environment, antioxidant vitamins, folic acid and homocysteine, inflammation, infection and the role of stress.

Risk of these diseases increases with age. Women are at lower risk of CHD than men until after the menopause. People who have inherited 'familial hyperlipidaemia', a common genetic disease resulting in high blood lipids, are not particularly at risk.

Apart from these 'fixed' risk factors, peoples way of life has a major impact on their risk of developing or dying from these diseases. The highest risk for an individual comes from smoking. Stopping smoking reduces this risk very quickly. For more information see the section on smoking.

Across the UK, a sedentary lifestyle contributes to even more cases of heart disease because such a high proportion of the population (25% of English adults were sedentary in 1995) is not regularly active.

Dietary factors are important determinants of CHD. Dietary fats, especially saturated fatty acids are important in raising blood cholesterol levels. The proportion of energy in the diet derived from fat affects our chances of being overweight or obese. Being overweight or obese is a significant risk factor for high blood pressure, hyperlipidaemia and diabetes. This is in turn associated with level of physical activity, which is one factor affecting weight and obesity. People with a sedentary lifestyle are more likely to be overweight. The level of salt in the diet is also a factor in the development of high blood pressure. Increased consumption of fruit and vegetables can provide protection against CHD.

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Ethnic differences in coronary heart disease have been the subject of many epidemiological studies. Mortality rates amongst South Asians are around 40 percent higher than the white population Balarajan, 1995) and early onset of the disease can be 2-3 times higher. These higher rates of CHD mortality are not necessarily explained by differences in individual risk factors such as smoking, although obesity is seen as a critical factor in the burden of disease (McKeigue & Chatuvedi, 1996). Similar results have been found in South Asian communities living in different parts of the world and although the links are not well understood, higher prevalence of CHD among South Asian groups has been linked with factors leading to higher diabetes incidence in these ethnic groups. It is not clear why mortality from CHD among African Caribbeans is low, given their higher rates of diabetes and hypertension. Mortality rates from stroke are higher in some black ethnic groups (Wild & McKeigue, 1997; Balarajan, 1995). One of the key risk factors for stroke is hypertension,and there is evidence of raised levels amongst African Caribbean populations in the UK and the US (Chaturvedi et al, 1993), which responds less well to treatment.

The Health Survey for England (1999) found that for almost all CVD conditions with the exception of diabetes, Chinese men and women had lower rates than the general population. In general all South Asian groups showed higher rates than the general population for most conditions, and both Pakistanis and Bangladeshis showed higher rates than Indians. In particular, for diabetes Pakistanis and Bangladeshis of both sexes showed rates over five times higher than the general population and Indians almost three times higher. Black Caribbean men (but not women) had significantly lower prevalence of angina (1.9%) (age-adjusted risk ratio 0.32) and heart attack (0.14) than the general population. The observed prevalence of angina was also low amongst Chinese men (1.8%) while it was highest among Indian men (5.4%), who had virtually the same prevalence as men in the general population (5.3%).

The observed prevalence of stroke among Black Caribbeans was 3.2%. After adjusting for age, rates of stroke among Black Caribbean men were over two-thirds higher than in the general population (risk ratio 1.66). Indian men also had higher rates than the general population (1.42). (Primatesta & Brookes, 1999)

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There are large social class inequalities in mortality from cardiovascular disease. These effects can be seen in the relative mortality rates in the most and least deprived areas within London. In terms of SMRs, when all ages are considered, the SMR for London is significantly lower than England (97), although there are 10 boroughs which have an SMR significantly above the England average (1998-2002 data) When mortality for people under 75 is considered, the London average is significantly higher than England (SMR - 106) with 16 of the boroughs having SMRs significantly higher than England. The worst affected PCT (Newham), having an SMR of 164. 8 boroughs had SMRs which were significantly lower than the England average, the lowest being 72 (Kensington and Chelsea). For Coronary Heart Disease, when all ages are considered, the SMR for London is again, significantly below the England average. For ages under 75 the SMR for London is slightly lower than the England average, although not significantly so. The highest SMR is 163 (Newham), and the lowest 59 (Kensington and Chelsea) (Information taken from PCT indicators ).

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Cardiovascular mortality rates in the country as a whole have been falling fairly steadily.

Historically, mortality from cardiovascular disease in London has been lower than average. However within Inner London and amongst younger people mortality rates are higher. In the 10 - 15 years to 1996, the decline in rates in London did not keep pace with national changes, especially in Inner London (Bardsley et al, 1996). Since 1996, rates of death from cardiovascular disease have continued to reduce in London, although still at a lower rate than nationally (Compendium 2002). Mortality from cardiovascular disease is a national target area in Our Healthier Nation.

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The National Service Framework (NSF) for CHD was published in March 2000. The aims of the national strategy are to reduce death and ill health from CHD by:

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These recommendations apply for both preventing disease and preventing complications of early disease.

All of the above greatly reduce the risk of cardiovascular diseases developing and improve the outlook (prognosis) in people with established disease.

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Prevalence: Estimates of the prevalence of common circulatory conditions are not routinely recoded at a local level. National estimates tend to be based on information from health and lifestyle surveys - notable the Health Survey for England. See DoH website.

General Practice Consultations: Information from General Practice on consultation rates is also available at a national level in the GP research database.

Health and lifestyle surveys: These provide important information on key risk factors such as smoking, obesity, diet, exercise. Some surveys also include direct measurements such as blood pressure or serum cholesterol levels. Information on the Health & lifestyle indicators for Strategic Health Authorities 1994-2002 is available on the Department of Health Website.

Hospital admission: Cardiovascular diseases form a significant proportion of all hospital use with London recording over 100,000 admissions per year. This includes a combination of emergency, elective and investigative admissions and does not necessarily equate to the local prevalence of disease. Admission rates below age 45 are small compared to the 45 plus age group.

The Commission for Health Improvement (CHI) performance ratings contained several indicators relating to cardiovascular disease in 2003 including: Deaths within 30 days of a heart bypass operation, Emergency readmission to hospital following treatment for a stroke (acute trusts), and Death rates from circulatory diseases, ages under 75 (change in rate) (PCTs). See CHI website for further details.

Mortality: The fact that cardiovascular diseases are one of the most common causes of death means that there is more potential for using relative mortality rates for smaller geographic areas. Thus mortality rates for cardiovascular disease (under age 75) is one of the key indicators in the national health strategy. In addition to the broad category, mortality rates can also be calculated for more specific diagnostic groupings, these are most commonly Coronary Heart Disease, stroke, Acute Myocardial Infarction and hypertension.

Date	Title	Format	View
9 Aug 2006	Local variations in NHS spending priorities
5 Jan 2006	The London primary care quality series 1: coronary heart disease
26 Aug 2004	Prevalence of Cigarette Smoking, 2001, London
26 Aug 2004	Proportion of People with High Blood Pressure, 1994-1996, by Health Authority
8 Jan 2004	Proportion of Current Cigarette, Pipe or Cigar Smokers, 1994-1996, Health Authority level

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• Health Action Zones Network
• National Heart Forum
• British Heart Foundation
• Stroke Association
• British Association of Stroke Physicians
• British Hyperlipidaemia Association
• University College London
• London School of Hygiene and Tropical Medicine
• Department of Public Health Sciences, St George's Hospital Medical School
• Division of Primary Health are and General Practice (Imperial College London)
• Department of Epidemiology and Public Health
• Kings College

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• A Toolkit For Developing A Local Strategy To Tackle High Blood Pressure
• Saving Lives: Our Healthier Nation
• Department of Health National Service Framework for Coronary Heart Disease
• Effective Health Care Bulletins
• Health Survey for England 1998
• National Heart Forum. Looking to the Future. Making coronary heart disease an epidemic of the past. Imogen Sharp (Ed). London: The Stationery Office, 1999.
• National Heart Forum. Social Inequalities in Coronary Heart Disease. Opportunities for action. Imogen Sharp (Ed). London: The Stationery Office, 1998
• Department of Health. Central Monitoring Unit. Epidemiological Overviews: of Coronary Heart Disease (ISBN 0 11 321667) and Stroke (ISBN 0 11 321668)
• Bardsley et al (1996). Health of Londoners Project
• Wild S, McKeigue P. BMJ. 1997 Mar 8;314(7082):705-10.
• McKeigue P & Chaturvedi N (1996). Epidemiology and control of cardiovascular disease in South Asians and Afro-Caribbeans' in NHS Centre for Reviews and Dissemination (1996). Ethnicity and health. York: University of York.
• Wild S & McKeigue P (1997). 'Cross sectional analysis of mortality by country of birth in England & Wales'. British Medical Journal, 314: 705.
• Kingsley S (1999). Addressing black and minority ethnic health in London: A review and recommendations. London: NHS Executive London.
• Balarajan R (1995). 'Ethnicity and variations in the nation's health'. Health Trends, 27: 114-119.
• N Chaturvedi et al (1993). 'Resting and ambulatory blood pressure differences in Afro-Caribbeans and Europeans' Hypertension, 22, 90-96
• Primatesta & Brookes, (1999).

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