Cardiovascular Disease

his topic area covers statistics and information relating to cardiovascular disease in Hull including local strategic need and service provision. Cardiovascular disease is also called heart and circulatory disease, is an umbrella name for conditions that affect the heart or circulation. This includes coronary heart disease or ischaemic heart disease, stroke, atrial fibrillation, heart failure, hypertension (high blood pressure), and peripheral arterial disease.

This page contains information from the Office for Health Improvement & Disparities’ Fingertips. Information is taken ‘live’ from the site so uses the latest available data from Fingertips and displays it on this page. As a result, some comments on this page may relate to an earlier period of time until this page is next updated (see review dates at the end of this page).

In July 2022, Clinical Commissioning Groups (CCGs) ceased to exist and were replaced by the Integrated Care System. Data will still be available at CCG level for some time after July 2022 so this page continues to refer to CCGs and Hull CCG, and continues to present data at the CCG geographical level. Six local CCGs were also combined to form the Humber, Coast and Vale geographical area, which has also ceased to exist. It has been replaced by the Humber and North Yorkshire ICS. However, data will still be available at Humber, Coast and Vale geographical level, and will be presented within our JSNA.

Headlines

• Cardiovascular disease is caused by atherosclerosis (furring or stiffening of the walls of arteries). Although it may manifest itself differently in individual patients, in practice represents a single family of diseases and conditions linked by common risk factors and the direct effect they have on mortality and morbidity. These include coronary heart disease, stroke, hypertension, hypercholesterolemia, diabetes, chronic kidney disease, peripheral arterial disease and vascular dementia. Cardiovascular disease affects the lives of millions of people and is one of the largest causes of death and disability in England.
• The prevalence of diagnosed coronary heart disease and hospital admissions in Hull are 15% higher than England, but mortality rates are over 60% higher. There are 10,730 (3.5%) patients registered with Hull GPs who have been diagnosed with CHD in 2020/21, and there were 1,040 CHD admissions in 2019/20 (785 in 2020/21 reduced because of the pandemic) and 374 deaths among people aged under 75 years over the three year period 2017-19.
• There were 4,752 (1.6%) patients diagnosed with stroke or a transient ischaemic attack (‘mini’ stroke) in 2020/21 among those registered with Hull GPs. There were 382 hospital admissions for stroke in Hull in 2019/20. There were 123 deaths from stroke among people aged under 75 years and a further 355 death among people aged 75+ years in Hull over the three year period 2017-19. Compared to England, mortality rates were around 66% higher in Hull among people aged under 75 years and 48% higher among people aged 75+ years for 2017-19.
• Among patients registered with Hull GPs, 5,215 (1.7%) were diagnosed with atrial fibrillation, 2,360 (0.8%) were diagnosed with heart failure and 43,148 (14.2%) patients had diagnosed hypertension (high blood pressure) in 2020/21 and 2,294 (0.8%) with peripheral arterial disease in 2019/20. Consistently nine in ten patients aged 45+ years in Hull also had a record of having had their blood pressure measured within the last five years which was similar to England, although this fell to 87% for 2020/21 due to the pandemic.
• Perhaps unsurprisingly, practices who had a higher average age of their patients tended to have a higher prevalence of diagnosed cardiovascular disease.

The Population Affected – Why Is It Important?

All Cardiovascular Disease

Cardiovascular disease (CVD) is a common condition caused by atherosclerosis (furring or stiffening of the walls of arteries). Although CVD may manifest itself differently in individual patients, CVD in practice represents a single family of diseases and conditions linked by common risk factors and the direct effect they have on CVD mortality and morbidity. These include coronary heart disease, stroke, hypertension, hypercholesterolemia, diabetes, chronic kidney disease, peripheral arterial disease and vascular dementia. Many people who have one CVD condition commonly suffer from another and yet opportunities to identify and manage these are often missed. Cardiovascular disease (CVD) affects the lives of millions of people and is one of the largest causes of death and disability in England. Significant improvements have been made in the prevention and treatment of CVD in the past ten to fifteen years following the publication of the National Service Frameworks for coronary heart disease, diabetes and renal services, and the National Stroke Strategy, with mortality rates in under 75 year olds falling by 40%.

In some people, a high cholesterol concentration in the blood is caused by an inherited genetic defect known as familial hypercholesterolaemia (FH). Siblings and children of a person with FH have a 50% risk of inheriting the condition, and those with heterozygous (defective gene from one parent only) FH have a 50% risk of coronary heart disease in men by the age of 50 years and at least 30% in women by the age of 60 years. The prevalence of heterozygous FH is estimated to be 1 in 500. Homozygous (defective gene from both parents) FH is rare with around one case per million, but symptoms appear in childhood and is associated with early death from coronary heart disease. FH also increases the risk of other CVD.

The diagnosed prevalence of a number of CVD diseases and medical conditions can be examined from data collected as part of the Quality and Outcomes Framework within primary care. Quality of care indicators are also included, and it means that high percentage of the patients diagnosed with these specific diseases and medical conditions have annual reviews which gives medical staff the opportunity to provide information and encourage their patients to improve their lifestyle behaviours to improve their health, and lower their risk of morbidity and mortality from their condition. Local analysis of the QOF data has been completed for 2021/22 with the prevalence calculated for each GP practice and Primary Care Network group.

Coronary Heart Disease

Coronary heart disease (CHD) 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. The main causes are smoking, high cholesterol, high blood pressure and diabetes. CHD is a leading cause of death both in the UK and worldwide.  It is responsible for more than 73,000 deaths in the UK each year. About one in six men and one in ten women die from CHD. In the UK, there are an estimated 2.3 million people living with CHD. CHD generally affects more men than women, although from the age of 50 the chances of developing the condition are similar for both sexes. As well as angina (chest pain), the main symptoms of CHD are heart attacks and heart failure. However, not everyone has the same symptoms and some people may not have any symptoms before CHD is diagnosed. Nationally, CHD has the second highest disability adjusted life years and thus has a substantial impact on the quality of people’s lives.

Stroke

A stroke is a serious, life-threatening medical condition that occurs when the blood supply to part of the brain is cut off. Strokes are a medical emergency and urgent treatment is essential because the sooner a person receives treatment for a stroke, the less damage is likely to happen. A transient ischaemic attack (TIA) is caused by a temporary disruption in the blood supply to part of the brain, causing sudden symptoms similar to those of a stroke. However, a TIA does not last as long as a stroke. The effects often only last for a few minutes or hours and fully resolve within 24 hours. A TIA can be a precursor to a stroke. The two major types of strokes are ischaemic strokes resulting from a blood clot reducing the blood supply to the brain (85%) and haemorrhagic strokes resulting from a bleed on the brain (15%).

A national campaign Stroke ACT FAST has improved awareness of treating stroke as a medical emergency. Face: “has their face fallen on one side?” – Arms: “can they raise both arms and keep them there?” – Speech: “is their speech slurred?” – Time: “time to call 999 if you see any single one of these signs”.

Strokes can cause lasting damage, affecting mobility, cognition, sight, movement of the upper limb or communication. Thus strokes can have a major impact upon individual lives and their families, and is the one of the largest causes of adult disability in the UK. Nationally, stroke has the third highest disability adjusted life years. There is also a high social and economic cost to the community. Stroke is often preventable and there are more treatment options than ever before. After stroke individual recovery can be enhanced through specialist therapy and wider social support.

One survey, by examining the population attributable risk (PAR), found that history of hypertension (PAR 35%), current smoking (19%), waist-to-hip ratio (27%), diet risk score (19%), regular physical activity (29%), diabetes (5%), alcohol intake (4%), psychosocial stress (7%), depression (5%), cardiac causes (7%) and the ratio of apolipoproteins B to A1 (25%) collectively accounted for 88% of the PAR for all stroke. Atrial fibrillation is also a risk factor for stroke.

Apoliopoprotein B is the main apolipoprotein of chylomicrons and low density lipoproteins (LDL) “bad cholesterol” and apoliopoprotin A1 is the major protein component of high density lipoproteins (HDL) “good cholesterol”.

Atrial Fibrillation

Atrial fibrillation is a heart condition that causes an irregular and often abnormally fast heart rate. A normal heart rate should be between 60 and 100 beats a minute when resting, and is regular. In atrial fibrillation, the heart rate may be over 140 beats a minute, although it can be any speed.

If left untreated atrial fibrillation is a significant risk factor for stroke and other morbidities. Men are more commonly affected than women and the prevalence increases with age. The increase with age is relatively marked; the prevalence is estimated to be less than 2% for men aged under 65 years and around 1% or lower for women aged 65 years, but is estimated to be around 5% for men and 3% for women aged 65-74 years, then doubling to around 9% for men and 7% for women aged 75-84 years and 11% for men and women aged 85+ years.

Heart Failure

Heart failure occurs when the heart is unable to pump blood at a rate sufficient for metabolic requirements. It is caused by structural or functional abnormalities of the heart. The most common causes of heart failure in the UK are coronary artery disease and hypertension. It has a poor prognosis with 30-40% of patients diagnosed with heart failure dying within a year; thereafter mortality is less than 10% per year.

Hypertension (High Blood Pressure)

Blood pressure is measured in millimetres of mercury (mmHg) and is recorded as two numbers: the first is systolic pressure (pressure of the blood when the heart beats to pump blood out) and the second is diastolic pressure (pressure when heart rests between beats). People with hypertension (high blood pressure) rarely have noticeable symptoms. Around 30% of people in England have high blood pressure but many don’t know it. If left untreated, high blood pressure increases the risk of a heart attack or stroke. It is often referred to as a “silent killer”. The only way of knowing there is a problem is to have blood pressure measured. All adults should have their blood pressure checked at least every five years. As well as having trained staff who have periodic review of their performance, and properly validated and calibrated equipment, guidelines recommend that hypertension should be diagnosed using (24 hour) ambulatory blood pressure monitoring. The chances of having high blood pressure increase with age. Whilst there is often no clear cause, the following increase the risk of high blood pressure: obesity; family history; smoking; African or Caribbean descent; eating too much salt; not eating enough fruit and vegetables; lack of physical activity; drinking too much coffee or caffeine-based drinks; and drinking too much alcohol. Just a 2mmHg increase in systolic blood pressure increases the risk of cardiac death by 7% and stroke by 10%. Given the high prevalence of risk factors for hypertension in Hull, this puts a large proportion of Hull patients at an avoidable risk of stroke, other serious cardiac events, diabetes and chronic kidney disease.

Peripheral Arterial Disease

Peripheral arterial disease (PAD) is a common condition, in which a build-up of fatty deposits in the arteries (a process called atherosclerosis) restricts blood supply to leg muscles. It is also known as peripheral vascular disease (PVD). Many people with PAD have no symptoms. However, some develop a painful ache in their legs when they walk, which usually disappears after a few minutes’ rest. The medical term for this is “intermittent claudication”. The risk of developing PAD increases with age. It is estimated that around one in every five people over the age of 60 are affected by the condition to some degree. Men tend to develop the condition more often than women. Smoking is the most significant risk factor for PAD as well as diabetes, high blood pressure and high cholesterol. Exercising regularly and stopping smoking can ease the symptoms of PAD and reduce the chances of the condition getting worse. If applicable, treating the underlying conditions of high blood pressure, high cholesterol and diabetes and surgery can improve blood flow in the legs. Whilst not immediately life-threatening, the process of atherosclerosis can lead to serious and potentially fatal problems such as heart attack and stroke. There is also the risk that leg tissue will begin to die (gangrene) and in severe cases this can lead to amputation of the lower leg.

Within a systematic review examining global prevalence estimates and risk factors for peripheral arterial disease, it states that about 10–20% of people with peripheral artery disease have intermittent claudication, another 50% have atypical leg symptoms, and those without exertional leg pain have poor mobility compared with individuals without peripheral artery disease. Patients with and without leg ischaemic symptoms have roughly a three-fold increase in risk of mortality and major cardiovascular events (heart attack and stroke) compared with those without peripheral artery disease.

The Hull Picture

Cardiovascular Disease

Local analysis of the QOF data has been completed for 2021/22 with the prevalence calculated for each GP practice and Primary Care Network group.

Practices have been divided into five approximately equal-sized groups (based on total list size) based on the average deprivation score of their patients (Index of Multiple Deprivation 2019). Each practice – except Delta Healthcare – is also within a Primary Care Network. The prevalence of diagnosed disease based on the Quality and Outcomes Framework is presented for each practice, deprivation group and PCN in the following Excel file.

The Office for Health Improvement & Disparities’ Fingertips gives the percentage of deaths with an underlying cause of cardiovascular disease by age. The percentage of cardiovascular disease deaths is higher in Hull compared to England for the majority of age groups for 2020.

For all ages, the percentage of CVD deaths has been reasonably similar to England, although for 2020 the percentage was slightly higher in Hull.

Among those aged 85+ years, the percentage of CVD deaths has shown some year-on-year variability in Hull, but has been reasonably similar to England, although for 2020 the percentage increased in Hull compared to a decrease nationally resulting in the percentage in Hull being higher than England.

For those aged 75-84 years, the percentage of CVD deaths has been reasonably similar to England over time.

Among those aged 65-74 years, the percentage of CVD deaths has shown some year-on-year variability in Hull, but has been reasonably similar to England. For 2020, the percentage increased in Hull compare to a decrease nationally resulting in the percentage in Hull being higher than England.

Among those aged under 65 years, the percentage of CVD deaths has shown some year-on-year variability in Hull, but has been reasonably similar to England until 2017. The percentage in Hull has been slightly higher than England for 2018, 2019 and 2020.

The Projecting Older People Population Information Service (POPPI) provide current estimates and future projections at local authority level of the number of people with cardiovascular disease.

They use estimates for the prevalence of cardiovascular disease for different age groups for men and women separately, and apply those prevalence estimates to Hull’s population. It is likely that this will represent an underestimate for Hull due to Hull’s high levels of deprivation.

They estimate that there are over 12,000 residents of Hull who are living with cardiovascular disease, but due to the ageing population this is anticipated to increase to around 16,000 by 2040.

Gender	Age	2020	2025	2030	2035	2040
Males	65-74	3,774	3,774	4,148	4,284	4,012
Males	75+	3,066	3,612	3,948	4,326	4,830
Females	65-74	2,415	2,499	2,751	2,814	2,604
Females	75+	3,201	3,498	3,696	4,059	4,521
Persons	Total 65+	12,456	13,383	14,543	15,483	15,967

Coronary Heart Disease

The Office for Health Improvement & Disparities’ Fingertips gives the percentage of patients registered with Hull GPs who are diagnosed with coronary heart disease (CHD). In 2020/21, there were 10,730 patients registered with Hull GPs who had been diagnosed with CHD. The percentage was higher in Hull compared to England (3.5% versus 3.0%).

From the national Quality and Outcomes Framework datasets, in 2021/22, there were 10,643 patients registered with Hull GPs diagnosed with CHD which was higher than England (3.5% versus 3.0%).

The prevalence of CHD among patients registered with Hull GPs has decreased over time although the decrease in Hull has been slightly lower than the decrease nationally.

From the local analysis of the national Quality and Outcomes Framework datasets, there was a statistically significant association between average age of the practice patients and the prevalence of diagnosed CHD across the 32 practices in Hull for 2021/22. If the practices were divided into six approximately equal sized groups based on average age of patients (with each sixth having approximately one-sixth of the total registered patients in Hull) then the prevalence increased from 2.0% for the practices serving the youngest practice patients to 4.5% for the practices serving the oldest practice patients. For every increase in the average age of the patients of 10 years, the prevalence of CHD increased by 2.4 percentage points. Further analysis of diagnosed disease by the average age of practice patients is within the file above and within Local Analysis of Quality and Outcomes Framework Data.

There was no statistically significant association between the prevalence of diagnosed CHD and the average deprivation score of registered patients (using the Index of Multiple Deprivation 2019) across the 32 practices.

The directly standardised hospital admission rate for CHD in Hull for 2020/21 is similar to England. The rate is given as the number of admissions per 100,000 population (in the European Standard Population).

The admission rate for CHD has been decreasing for Hull. The recent admission rate is less than half the rate of Hull’s peak rate in 2011/12. It is not surprising that the number of admissi0ns fell between 2019/20 and 2020/21 as this might have been anticipated due to the COVID-19 pandemic, however, the rate of the decrease in Hull was similar to the decrease over the previous year (between 2018/19 and 2019/20).

The directly standardised mortality rate for CHD is significantly higher than England among those aged under 75 years for 2017-19 being two-thirds (66%) higher than England. The rate is given as the number of deaths per 100,000 population (in the European Standard Population).

There was a relatively steep decrease in the CHD under 75 mortality rate in Hull between 2003-05 and 2010-12, but since then the mortality rate has remained relatively constant, although there has been a slight increase between 2016-18 and 2017-19.

Stroke

Fingertips gives the percentage of patients registered with Hull GPs who have been diagnosed as having had a stroke or transient ischaemic attack (TIA). In 2020/21, there were 4,752 patients registered with Hull GPs who had had a stroke or TIA. The prevalence was slightly lower in Hull than England (1.6% versus 1.8%).

From the national Quality and Outcomes Framework datasets, in 2021/22, there were 4,766 patients registered with Hull GPs diagnosed with stroke or transient ischaemic attack which was lower than England (1.6% versus 1.8%).

The percentage of patients in Hull who have been diagnosed as having had a stroke or transient ischaemic attack has remained relatively static in Hull at 1.6%. The rate has also remained relatively unchanged in England, but has increased slightly across Humber, Coast and Vale in the last three years.

From the local analysis, there was a statistically significant association between average age of the practice patients and the prevalence of diagnosed stroke and transient ischaemic attack across the 32 practices in Hull for 2021/22. The prevalence was 0.9% among practices serving the youngest patients compared to 2.0% among practices serving the oldest patients. For every increase in the average age of the patients of 10 years, the prevalence of stroke and transient ischaemic attack increased by 0.99 percentage points. Further analysis of diagnosed disease by the average age of practice patients is within the file above and within Local Analysis of Quality and Outcomes Framework Data.

There was no statistically significant association between the prevalence of diagnosed stroke and transient ischaemic attack and the average deprivation score of registered patients across the 32 practices.

The number of admissions are also given as recorded by the Sentinel Stroke National Audit Programme.

The number of stroke admissions has varied between 360 and 443 per year between 2013/14 and 2020/21.

The directly standardised mortality rate for stroke is substantially higher than England for both deaths occurring under 75 years and 75+ years for 2017-19 being two-thirds (66%) higher for those aged under 75 years and around half as much as England again (48% higher) for those aged 75+ years. The mortality rate is given as the number of deaths per 100,000 population (in the European Standard Population).

There was a relatively sharp fall in the under 75s stroke mortality rate between 2004-06 and 2011-13 from 32.4 deaths per 100,000 population to a low of 17.7 per 100,000 population, but since then the mortality rate has increased to 20.7 per 100,000 population in 2017-19. At the same time, the mortality rate across England and Humber, Coast and Vale have both consistently decreased. Thus the inequalities gap between Hull and England has increased over time for stroke mortality among under 75s.

For those aged 75+ years, the mortality rate in Hull was slightly higher than England but not significantly higher between 2004-06 and 2010-12, but since then the mortality rate in England has decreased compared to an overall increase in Hull although the mortality rate has decreased in the last three years. Since 2010-12, the stroke mortality rate for those aged 75+ years has been statistically significantly higher than England.

The Projecting Adult Needs and Service Information (PANSI) provides current estimates and future projections at local authority level of the number of people with different health needs. The prevalence for different age groups and for males and females estimated from different surveys and research has been applied to current population estimates and population projections to provide estimates for each local authority.

The estimates do not take into account deprivation, and due to Hull’s high levels of deprivation, the incidence of stroke is higher than England. However, it is difficult to say how different the prevalence of stroke will be in Hull because more people in Hull who have a stroke will die from their stroke.

They estimate that there are around 450 residents of Hull aged 18-64 years who are living with a long-standing health condition caused by a stroke.

Gender	Age	2020	2025	2030	2035	2040
Males	18-44	0	0	0	0	0
Males	45-64	246	236	225	222	226
Males	Total 18-64	246	236	225	222	226
Females	18-44	50	50	50	50	49
Females	45-64	154	145	139	138	138
Females	Total 18-64	204	195	189	187	187

Atrial Fibrillation

In 2020/21, there were 5,215 patients registered with Hull GPs who had been diagnosed with atrial fibrillation which was lower than England (1.7% versus 2.0%).

From the national Quality and Outcomes Framework datasets, in 2021/22, there were 5,394 patients registered with Hull GPs diagnosed with atrial fibrillation which was lower than England (1.8% versus 2.1%).

The prevalence of atrial fibrillation has been gradually increasing in Hull in line with increases across England and for Humber, Coast and Vale. However, the percentage diagnosed with atrial fibrillation in Hull has been consistently lower than both England and for the Humber, Coast and Vale.

From the local analysis, there was a statistically significant association between average age of the practice patients and the prevalence of diagnosed atrial fibrillation across the 32 practices in Hull for 2021/22. The prevalence was 1.0% among practices serving the youngest patients compared to 2.5% among practices serving the oldest patients. For every increase in the average age of the patients of 10 years, the prevalence of atrial fibrillation increased by 1.3 percentage points. Further analysis of diagnosed disease by the average age of practice patients is within the file above and within Local Analysis of Quality and Outcomes Framework Data.

There was no statistically significant association between the prevalence of diagnosed atrial fibrillation and the average deprivation score of registered patients across the 32 practices.

It is estimated that under three-quarters (73%) of people with atrial fibrillation have been diagnosed for 2018/19 compared to eight in ten for England.

Heart Failure

In 2020/21, there were 2,360 patients registered with Hull GPs who were diagnosed with heart failure representing 0.8% of Hull’s registered population which was slightly lower than England (0.9%).

From the national Quality and Outcomes Framework datasets, in 2021/22, there were 2,511 patients registered with Hull GPs diagnosed with heart failure which was lower than England (0.8% versus 1.0%).

The prevalence of heart failure has increased gradually in Hull over time following similar increases in England and across the Humber, Coast and Vale, although the percentage in Hull has been consistently lower than both these geographical areas since 2017/18.

From the local analysis, there was a statistically significant association between average age of the practice patients and the prevalence of diagnosed heart failure across the 32 practices in Hull for 2021/22. The prevalence was 0.5% among practices serving the youngest patients compared to 1.1% among practices serving the oldest patients. For every increase in the average age of the patients of 10 years, the prevalence of heart failure increased by 0.54 percentage points. Further analysis of diagnosed disease by the average age of practice patients is within the file above and within Local Analysis of Quality and Outcomes Framework Data.

There was no statistically significant association between the prevalence of diagnosed heart failure and the average deprivation score of registered patients across the 32 practices.

The directly standardised hospital admission rate for heart failure in Hull for 2020/21 is statistically significantly higher than England. The rate is given as the number of admissions per 100,000 population (in the European Standard Population).

The admission rate for heart failure was significantly lower than England between 2006/07 and 2010/11, but has been increasing since then and is currently increasing at a more rapid rate compared to England. It is possible that part of this increase could be better case diagnosis and recording of heart failure. In 2019/20, the admission rate was 49% higher in Hull compared to England. There has been a drastic fall in the admission rate between 2019/20 and 2020/21 and this presumably is due to the COVID-19 pandemic. This recent fall was considerably greater in Hull than for England, but the admission rate for heart failure in Hull is still significantly higher than England for the latest year 2020/21.