Cardiovascular Disease

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

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).

Headlines

• Cardiovascular disease (also called circulatory 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.
• Just under one-fifth of all deaths are due to cardiovascular disease in Hull (23.4%) with 668 deaths in total which were registered during 2020. The percentage in Hull is slightly higher than England (21.8%).
• The premature (under 75 years) mortality rates from cardiovascular disease and from cardiovascular diseases considered to be preventable are statistically significantly higher in Hull compared to England, and are the highest in the region. Whilst mortality rates declined sharply in Hull from 176 to 102 deaths per 100,000 population between 2001-03 and 2011-13, the mortality rate has gradually increased since then to 120 deaths per 100,000 population for 2021-23. There were on average 258 deaths a year in Hull among those aged under 75 years where the underlying cause is cardiovascular disease that were registered during 2021-23. Just over four in ten of these premature deaths are from causes considered to be preventable.
• It is anticipated that the number of people aged 65+ years with cardiovascular disease in Hull will increase by around 23% in the next 20 years due to the ageing population.
• The prevalence of diagnosed coronary heart disease in 2023/24 in Hull is 10% higher in Hull compared to England (3.3% versus 3.0%), hospital admissions were 22% higher than England in 2023/24, but premature mortality rates for 2020-22 are 61% higher. The discrepancies suggest that there might be higher rates of undiagnosed CHD in Hull and/or it is less well managed among patients in Hull. There are 10,538 (3.4%) patients registered with Hull GPs who have been diagnosed with CHD in 2022/23, 1,095 hospital admissions in 2022/23, and around 140 premature (under 75 years) deaths from CHD each year (registered during 2020-22). The premature CHD mortality rate had decreased sharply earlier in the decade but has remained relatively unchanged between 2010-12 and 2019-21 with a small increase between 2019-21 and 2020-22.
• There were 4,987 (1.6%) patients diagnosed with stroke or a transient ischaemic attack (‘mini’ stroke) in 2023/24 among those registered with Hull GPs which was lower than England (1.9%) likely associated with Hull’s younger population. There were 425 hospital admissions for stroke among Hull patients in 2022/23, and an average of 40 premature deaths from stroke per year during 2020-22. Hospital admission rates and premature deaths from stroke are both statistically significantly higher in Hull compared to England, with hospital admission rates 15% higher and mortality rates around 50% higher in Hull. The premature stroke mortality rate had decreased sharply earlier in the decade but has remained relatively unchanged between 2007-09 and 2020-22
• In 2023/24, among patients registered with Hull GPs, 5,486 (1.7%) were diagnosed with atrial fibrillation and 2,579 (0.8%) were diagnosed with heart failure. Compared to England, fewer people in Hull were diagnosed with atrial fibrillation (2.2%) and heart failure (1.1%). There were 46,681 (14.8%) Hull patients had diagnosed hypertension (high blood pressure) which was the same as for England (14.8%) and 2,320 (0.7%) Hull patients were diagnosed with peripheral arterial disease which was higher than England (0.6%). 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 between 2014/15 and 2019/20, but the percentage has fallen in 2020/21 and 2021/22 likely due to the COVID-19 pandemic, but the percentage only increased marginally in 2022/23 to 86.6%.
• Perhaps unsurprisingly, practices whose patients had a higher average age tended to have a higher prevalence of diagnosed cardiovascular disease.
• Hull’s population tends to be younger than England, so in some cases, it is not surprising if the prevalence is lower than England. However, to counter this, the increased levels of deprivation in Hull increases the risk of cardiovascular disease. Thus there is generally a mixed picture in relation to diagnosed prevalence when comparing Hull with England. However, it is likely that more people in Hull have undiagnosed cardiovascular disease. Furthermore, despite generally comparable rates of diagnosed disease, admission rates and mortality rates for cardiovascular disease are generally much higher in Hull which highlights the inequalities present.

The Population Affected – Why Is It Important?

All Cardiovascular Disease

Cardiovascular disease (CVD) is also known as circulatory disease. It 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 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

Some information is available on cardiovascular disease as a whole, such as hospital admission and mortality data. However, the majority of the information available and presented below is for specific cardiovascular diseases.

Number of People with Cardiovascular Disease

A Local Analysis of the Quality and Outcomes Framework Data (see Quality and Outcomes Framework in the Glossary for more information) has been completed for 2023/24. The diagnosed prevalence and screening measures are presented for the 28 practices in Hull, each Primary Care Network in Hull and for five deprivation and age groups, as well as for comparator geographical areas. As the file includes a number of indicators related to cardiovascular disease, the file is also included below. This includes diagnosed prevalence for coronary heart disease, stroke and transient ischaemic attack, atrial fibrillation, heart failure, left ventricular systolic dysfunction, hypertension (high blood pressure) and peripheral arterial disease as well as the percentage of the population aged 45+ years who have had their blood pressure measured within the last five years.

Further information from the Quality and Outcomes Framework, such as trends over time, are presented below for each specific cardiovascular disease.

Percentage of Deaths From Cardiovascular Disease

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.

Premature Mortality Rates From Cardiovascular Disease

The premature mortality rates from cardiovascular disease in Hull are significantly higher than England and are the highest in the region for 2021-23 for men and among the highest for women.

The premature mortality rates from cardiovascular disease in Hull are also the highest in the region for men and among the highest for women for deaths registered during 2021-23.

The premature mortality rate from cardiovascular disease in Hull decreased relatively sharply between 2001-03 to 2011-13 falling from 176 to 101 deaths per 100,000 population. However, since then the mortality has increased slightly from 102 to 108 deaths per 100,000 population between 2011-13 and 2018-20 with a slightly greater increase in the 2-3 years with the latest mortality rate being 120 per 100,000 population. The last time the mortality rate was this high in Hull was for 2009-11.

In contrast, whilst the mortality rate for the region and England also showed a decrease between 2001-03 to 2011-13, but in contrast to Hull, that increase continued albeit at a reduced rate of decrease beyond 2011-13. The premature mortality rate from cardiovascular disease also increased for the region and England in the last 2-3 years.

As a result, the inequalities gap between Hull and England has increased since 2011-13.

For the latest three year period 2021-23, there were 774 deaths registered among Hull residents aged under 75 years from cardiovascular disease which is an average of 258 deaths per year.

The trend over time for males is similar with a relatively sharp decrease in the premature mortality rate from cardiovascular disease between 2001-03 and 2011-13 from 248 to 145 deaths per 100,000 population followed by a gradual increase to 151 deaths per 100,000 population prior to the pandemic in 2017-19, with a slightly greater increase in the last 2-3 years to 169 deaths per 100,000 population for 2021-23.

Again, in contrast, the mortality rate for the region and England declined the whole period prior to the pandemic.

The premature mortality rate for 2021-23 is similar to what it was for 2009-11 in Hull.

Among men, there were 544 premature deaths from cardiovascular disease over the three year period 2021-23 which equates to an average of 181 per year.

Seven in ten of all the premature deaths from cardiovascular disease in Hull were among men.

A reasonably similar pattern in the trends over time occurred for Hull women, although there were slight differences. The mortality rate decreased between 2004-06 and 2011-13 from 110 to 61 deaths per 100,000 population, then increased to a peak of 72 death per 100,000 population for 2014-16. The mortality rate then declined to a low of 60 per 100,000 population in 2017-19 but has increased since the pandemic with 71 deaths per 100,000 population for 2021-23. Again, for the region and for England, the premature deaths from cardiovascular disease has reduced for almost 20 years, and has only increased very marginally in the 2-3 years.

Among women living in Hull, there were 230 premature deaths from cardiovascular disease over the three year period 2021-23 which equates to an average of 77 per year.

Three in ten of all the premature deaths from cardiovascular disease in Hull were among women.

The trend in the premature mortality rate from cardiovascular diseases considered to be preventable follows a similar pattern to that for premature mortality rate from cardiovascular disease.

There were 321 deaths from cardiovascular disease among Hull residents prior to the age of 75 years which were considered to be preventable over the three year period 2021-23. This represents 41% of all premature cardiovascular disease deaths.

A similar pattern is also evident among men, and there were 234 male premature deaths from cardiovascular diseases considered to be preventable over the three year period 2021-23 which equates to an average of 78 deaths per year, and is 43% of all premature cardiovascular disease deaths among men.

A similar pattern is also evident among women for cardiovascular diseases considered to be preventable as was observed for all premature cardiovascular disease deaths among women. There were 86 female premature deaths from cardiovascular diseases considered to be preventable over the three year period 2021-23 which equates to an average of 29 deaths per year, and is 37% of all premature cardiovascular disease deaths among women.

Estimated Number of People in the Future Who Will Have Cardiovascular Disease

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	2023	2025	2030	2035	2040
Males	65-74	3,706	3,774	4,148	4,284	4,012
Males	75+	3,444	3,612	3,948	4,326	4,830
Females	65-74	2,436	2,499	2,751	2,814	2,604
Females	75+	3,399	3,498	3,696	4,059	4,521
Persons	Total 65+	12,985	13,383	14,543	15,483	15,967

Coronary Heart Disease

Number of People with 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). The sub Integrated Care Board areas which include Hull are within the Humber and North Yorkshire Integrated Care Board. In Fingertips, the sub-ICB area referenced by 03F relates to Hull (see Integrated Care Board for the codes relating to the other local sub-ICB areas).

In 2023/24, there were 10,314 patients registered with Hull GPs who had been diagnosed with CHD. The percentage was higher in Hull compared to England (3.3% versus 3.0%).

The prevalence of CHD among patients registered with Hull GPs has been steadily and gradually decreasing since 2014/15. The prevalence for England has also decreased over the same time period, but at a much slower rate of change.

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 28 practices in Hull for 2023/24. If the practices were divided into five approximately equal sized groups based on average age of patients (with each fifth having approximately one-fifth of the total registered patients in Hull) then the prevalence increased from 1.8% for the practices serving the youngest practice patients to 4.2% 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 2.6 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 28 practices.

Hospital Admissions for Coronary Heart Disease

The directly standardised hospital admission rate for CHD for 2023/24 is 18% higher in Hull compared than 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 quite variable in Hull since 2003/04. The rate remained relatively unchanged between 20004/05 and 2006/07 at just over 800 admissions per 100,000 population, but decreased to 645 admissions per 100,000 population for 2008/09 before increasing sharply to 946 admissions per 100,000 population for 2011/12. The admission rate did then fall sharply to to 600 admissions per 100,000 population for 2014/15. The rate increased slightly for 2015/16, but remained just over 600 admissions per 100,000 population until 2017/18 when there was a further decrease to 578 admissions per 100,000 population for 2018/19. So whilst there have been quite a sharp increase and decrease between 2008/09 and 2014/15, there has been a general decrease over the entire period between 2003/04 and 2018/19.

There was a sharp decrease in the admission rate in Hull between 2018/19 and 2020/21 which will – at least in part – be due to the COVID-19 pandemic. The admission rate for most non-COVID-19 conditions and diseases did decrease, but in most cases, this occurred between 2019/20 and 2020/21. It is possible that there was a reduction in March 2020 which could have influenced the reduction between 2018/19 and 2019/20, but it is also possible that there was a reduction that was not influenced by the pandemic as there has been reductions over the previous 2-3 years prior to this. There has been an increase in the admission rate for CHD between 2020/21 and 2023/24, and it is possible that this is associated with a reduction during the pandemic and care and treatment has been delayed.

For the latest year 2023/24, there were 1,070 admissions for CHD among Hull residents.

Deaths from Coronary Heart Disease

The directly standardised mortality rate for CHD (or ischaemic heart disease which is another name for CHD) is significantly higher than England among those aged under 75 years for 2021-23 being 77% higher in Hull compared to England.

The rate is given as the number of deaths per 100,000 population (in the European Standard Population).

The inequalities gap between Hull and England is similar for males and females. There are differences between males and females when comparing against the other local authorities in the region. The premature CHD mortality rate for Hull men is the highest in the region and considerably higher than the next highest local authority, and whilst the mortality rate for Hull women is among the highest in the region, it is not the highest.

There was a relatively sharp decrease in the premature CHD mortality rate in Hull between 2001-03 and 2010-12 with the mortality rate almost halving from 117 to 63 deaths per 100,000 population. However, since 2010-12 the mortality rate has changed little in Hull with a slight decrease to just under 60 deaths per 100,000 population in recent years, although the rate has increased to 73 deaths per 100,000 population for 2021-23.

Over the three year period 2021-23, there were 472 deaths among Hull residents aged under 75 years from CHD giving an average of 157 such deaths per year.

The change over time was similar for men with a relatively large decrease in the premature CHD mortality rate between 2001-03 and 2010-12 with the mortality rate decreasing from 176 to 95 deaths per 100,000 population. This was followed by little change in the mortality rate between 2011-13 and 2019-21 with the mortality rate remaining between 86 and 94 deaths per 100,000 population. There has been an increase in the last two years to 112 deaths per 100,000 population for 2021-23.

Among men, over the three year period 2021-23, there were 361 deaths among Hull residents aged under 75 years from CHD giving an average of 120 deaths per year.

Among women in Hull, there was also a relatively sharp reduction in the premature CHD mortality rate between 2001-03 and 2010-12 from 61.4 to 31.2 deaths per 100,000 population. The mortality rate did reduce slightly between 2010-12 and 2019-20 to 26.0 deaths per 100,000 population, but has increased to 34.1 deaths per 100,000 population for deaths registered during 2021-23.

Among women, over the three year period 2021-23, there were 111deaths among Hull residents aged under 75 years from CHD giving an average of 37 deaths per year.

Stroke

Number of People who have had a Stroke or Transient Ischaemic Attack (Mini 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) with Hull (03F) included within the Humber and North Yorkshire Integrated Care Board.

In 2023/24, there were 4,987 patients registered with Hull GPs who had had a stroke or TIA. The prevalence was slightly lower in Hull than England (1.6% versus 1.9%).

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% although the absolute numbers in Hull have increased in the last few years. The rate has also remained relatively unchanged in England and across the local Integrated Care Board, albeit both at a higher rate compared to Hull, although there has been a slight increase for England in the last year.

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 28 practices in Hull for 2023/24. 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 1.1 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 28 practices.

Hospital Admissions for Stroke

The directly standardised admission rate for stroke is marginally higher than England for 2023/24.

The rate is given as the number of admissions per 100,000 population (in the European Standard Population).

Between 2012/13 and 2021/22, the admission rate for stroke has been reasonably similar to England with between 160 and 187 admissions per 100,000 population (the rate in 2016/17 at 189 per 100,000 population was slightly higher and statistically significantly higher than England). Whilst the rate increased to 194 admissions per 100,000 population for 2022/23, the rate has decreased to 175 admissions per 100,000 population for 2023/24.

For the latest financial year 2023/24, there were 390 admissions among Hull residents where the primary reason for admission was stroke.

Deaths from Stroke

The directly standardised mortality rate for stroke is substantially higher than England for both deaths occurring under 75 years and 75+ years for 2021-23 being 38% higher for under 75s, and 31% higher among those aged 75+ years. The mortality rate from stroke is among the highest in the region.

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 34.2 deaths per 100,000 population to a low of 17.6 per 100,000 population, but the mortality rate increased to 21.0 deaths per 100,000 population for 2014-16 and has remained around 20 deaths per 100,000 population until 2019-21, with a decrease in the last two years to 18 deaths per 100,000 population for 2021-23.

Throughout the entire period 2001-03 to 2020-22, the premature mortality rate from stroke has been statistically significantly higher in Hull compared to England, although with the reduction in Hull in the last couple of years, the inequalities gap between Hull and England has narrowed slightly.

There were 112 deaths among Hull residents who are aged under the age of 75 years during the three year period 2021-23 equating to an average of 37 deaths per year.

The trends over the time in the premature mortality from stroke followed a similar pattern for males with a decrease from 40.7 to 22.5 deaths per 100,000 population between 2001-03 and 2011-13 with the mortality rate remaining relatively unchanged until 2016-18 when it increased slightly to around 25 deaths per 100,000 population until 2019-21. However, there has been a slight decrease in the last two years with the mortality rate with 21.0 deaths per 100,000 population for 2021-23.

Among men, there were 67 deaths among Hull residents who are aged under the age of 75 years during the three year period 2021-23 equating to an average of 22 deaths per year.

Six in ten of all the premature deaths due to stroke were among men.

The premature mortality rate among Hull women was just under 30 deaths per 100,000 population between 2001-03 and 2004-06, but fell sharply to a low of 12.9 deaths per 100,000 population for 2011-13 before increasing to 18.8 deaths per 100,000 population in 2014-16. The mortality has reduced since then falling to 13.9 deaths per 100,000 population for 2021-23.

Among women, there were 45 deaths among Hull residents who are aged under the age of 75 years during the three year period 2020-22 equating to an average of 15 deaths per year.

Four in ten of all the premature deaths due to stroke were among women.

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 decreasing from 1,002 to 721 deaths per 100,000 population in line with the decrease for England. However, whilst the mortality rate continued to decline at a similar rate in England, the mortality rate increased in Hull to 787 deaths per 100,000 population for 2012-14 and remained just under 800 deaths per 100,000 population until 2015-17 before reducing to 549 deaths per 100,00 population for 2021-23. Whilst the latest mortality rate in Hull is considerably lower than it was in 2001-03, the mortality rate has been statistically significantly higher than England since 2011-13.

Whilst the inequalities gap between Hull and England has reduced from its high of 5-9 years ago, the current inequalities gap is wider now than it was in 2001-03.

Among those aged 75+ years, there were 291 deaths among Hull residents from stroke during the three year period 2021-23 equating to 97 deaths per year.

Estimated Number of People in the Future Who Will Have Had a Stroke

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 440 residents of Hull aged 18-64 years who are living with a long-standing health condition caused by a stroke.

Gender	Age	2023	2025	2030	2035	2040
Males	18-44	0	0	0	0	0
Males	45-64	242	236	225	222	226
Males	Total 18-64	242	236	225	222	226
Females	18-44	50	50	50	50	49
Females	45-64	148	145	139	138	138
Females	Total 18-64	197	195	189	187	187

Atrial Fibrillation

In 2023/24, there were 5,482 patients registered with Hull GPs (03F) who had been diagnosed with atrial fibrillation which was lower than England (1.7% versus 2.2%).

The prevalence of atrial fibrillation has been gradually increasing in Hull in line with increases across England and for Humber and North Yorkshire Integrated Care Board. However, the percentage diagnosed with atrial fibrillation in Hull has been consistently lower than both England and for the local Integrated Care Board. Furthermore, the diagnosed prevalence has increased in England and for the local Integrated Care Board in the 3-4 years but there has been no real change in Hull.

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 28 practices in Hull for 2023/24. The prevalence was 0.9% among practices serving the youngest patients compared to 2.4% 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 1.5 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 28 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

Number of People with Heart Failure

In 2023/24, there were 2,579 patients registered with Hull GPs (03F) who were diagnosed with heart failure representing 0.8% of Hull’s registered population which was lower than England (1.1%).

The prevalence of heart failure has increased gradually in Hull over time following similar increases in England and across the Humber and North Yorkshire Integrated Care Board until 2019/20 prior to the pandemic. The numbers fell for 2020/21, but have increased subsequently in Hull although the percentage has remained relatively unchanged. In contrast, the prevalence has increased since 2019/20 for both England the the local Integrated Care Board.

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 28 practices in Hull for 2023/24. The prevalence was 0.4% among practices serving the youngest patients compared to 1.0% 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 0.6 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 28 practices.

Hospital Admissions for Heart Failure

The directly standardised hospital admission rate for heart failure in Hull for 2023/24 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 presumably 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 was still significantly higher than England for 2023/24.

During 2023/24, there were 440 emergency and elective admissions for heart failure among Hull residents.

Deaths from Heart Failure

Information is also given on the percentage of deaths from heart failure which occur at home or at the deceased usual residence. The percentage in Hull is considerably lower than England for the two-year period 2022-23 (37% versus 60%).

Just over half of all heart failure deaths in Hull occurred at home or their usual place of residence for 2012-13, but this has decreased to 39% in 2015-16 and remained just over 40% until 2018-19. The percentage increased for 2019-20 and 2020-21, but this could be associated with the pandemic with fewer people being admitted to hospital and thus dying in hospital, but the percentage returned to just over 40% for 2021-22, although has decreased further to a new low of 37% for 2022-23.

A significantly lower percentage of people with heart failure die at home or their usual place of residence in Hull compared to England. Many factors could influence this which might include patient choice, family support mechanisms and facilities at home (for example, making room for medical equipment or having a downstairs toilet in the home etc).

Hypertension

Number of People with Hypertension

In 2023/24, there were 46,681 patients registered with Hull GPs (03F) who were diagnosed with hypertension (high blood pressure) representing 14.8% of Hull’s registered population which is the same as for England. The recorded prevalence in Hull is considerably lower than the average for the Humber and North Yorkshire Integrated Care Board, although the population across the local Integrated Care Board will be slightly older on average compared to Hull which could partly explain the difference.

The prevalence of hypertension in Hull has remained relatively unchanged in the three years prior to the COVID-19 pandemic, but decreased for 2020/21 and 2021/22, although the numbers have increased in the last two years to a new high prevalence of 14.8% for Hull for 2023/24. The change in prevalence over time for Hull has been very similar to that of England, and whilst the pattern of change has also been similar to the local Integrated Care Board, the prevalence in Hull has been consistently lower.

From the local analysis, there was a statistically significant association between average age of the practice patients and the prevalence of diagnosed hypertension across the 28 practices in Hull for 2023/24. The prevalence was 9.3% among practices serving the youngest patients compared to 17.9% among practices serving the oldest patients. For every increase in the average age of the patients of 10 years, the prevalence of hypertension increased by 9.3 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 hypertension and the average deprivation score of registered patients across the 29 practices.

Number of People who have had Blood Pressure Measured in Last Five Years

A slightly high percentage of patients aged 45+ years registered with Hull GPs (03F) had had their blood pressure measured in the last five years in 2022/23 compared to England (86.6% versus 86.0%) with a total of 107,579 patients aged 45+ years having their blood pressure measured in the last five years.

Between 2014/15 and 2019/20, the percentage fell very slightly over time, but despite the decrease, nine in ten have had their blood pressure measured in the last five years over these years. However, the percentage fell to a low of 86.2% for 2021/22 which could be associated with the COVID-19 pandemic. The percentage has increased slightly in 2022/23 although it is considerably lower than it was in 2014/15 (91.5%). It is possible that time is in even shorter supply now which has resulted in fewer patients having their blood pressure measured opportunistically during routine primary care appointments.

Peripheral Arterial Disease

In 2023/24, there were 2,320 patients registered with Hull GPs (03F) who were diagnosed with peripheral arterial disease (PAD) representing 0.7% of the patient population in Hull which is slightly higher than for England (0.6%).

The prevalence of PAD has increased slightly in Hull from 0.6% to 0.8% between 2017/18 and 2020/21, but decreased between 2020/21 and 2021/22, although the numbers have increased to a similar level for 2023/24 but the prevalence is marginally lower than it was for 2020/21. Since 2017/18, the prevalence in Hull has been consistently higher than for England.

From the local analysis, there was a statistically significant association between average age of the practice patients and the prevalence of diagnosed PAD across the 28 practices in Hull for 2023/24. The prevalence was 0.5% among practices serving the youngest patients compared to 0.9% among practices serving the oldest patients. For every increase in the average age of the patients of 10 years, the prevalence of PAD increased by 0.3 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 a statistically significant association between average deprivation score of registered patients (based on the Index of Multiple Deprivation 2019) and the prevalence of diagnosed PAD across the 28 practices in Hull for 2023/24. The prevalence was 0.5% among practices serving the patients living in the least deprived areas of Hull compared to 0.8% among practices serving the patients living in the least deprived areas of Hull. For every increase in the deprivation score of 10 units, the prevalence of PAD increased by 0.1 percentage points. Further analysis of diagnosed disease by the average deprivation score of practice patients is given within Local Analysis of Quality and Outcomes Framework Data.

Strategic Need and Service Provision

All Cardiovascular Disease

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change.

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend, and those who have already been diagnosed with a cardiovascular disease should attend their annual reviews so that they get the best on-going treatment for their condition in order to minimise the likelihood of a further cardiovascular event.

The local NHS Hull Clinical Commissioning Group’s Cardiovascular Disease Outcomes Strategy details local on-going programmes and work areas to reduce CVD and its effects in relation to integrated care, prevention and risk management, improving acute care, improving and enhancing case finding in primary care, better identification of very high risk families and individuals, and better early management and secondary prevention in the community.

The Yorkshire and Humber Familial Hypercholesterolaemia Service was launched in 2017 which identifies people with familial hypercholesterolaemia and then offering cascade testing of relatives of the index case to identify other family members affected. Once identified, with familial hypercholesterolaemia statin treatment, the risk of having a cardiac event can be reduced to the level of risk in the general population.

Practices should be supported in terms of case finding with regard to cardiovascular diseases. Where a patient has one cardiovascular condition, clinicians should proactively seek to assess the risk and diagnose other cardiovascular conditions with a standard cardiovascular assessment undertaken to examine the existence of and/or risk of hypertension, familial hypercholesterolaemia, coronary heart disease, stroke, peripheral arterial disease, type 2 diabetes, and kidney disease.

Coronary Heart Disease

People need to know that stopping smoking has immediate health benefits, with heart rate and blood pressure dropping within 20 minutes, excess risk of coronary heart disease reducing to half that of a continuing smoker’s after one year, and risk of coronary heart disease reducing to that of a non-smoker’s after 15 years.

Cardiac rehabilitation is a structured set of services that enables people with CHD to have the best possible help (physical, psychological and social) to preserve or resume their optimal functioning in society. Cardiac rehabilitation also supports patients’ return to work, improves their functional capacity and physical activity status, perceived quality of life and supports the development of self-management skills. It is proven to be cost effective, with a lower cost per QALY (Quality Adjusted Life Years), compared with all other cardiology treatments. The benefits of a menu driven approach, with a choice of setting and individually identified patient goals are increasingly recognised. This service should be available to all, and all people who would benefit should be encouraged to participate in a cardiac rehabilitation programme.

Stroke

Work should continue to ensure that people realise that stroke is a medical emergency, and people with symptoms of a stroke or a transient ischaemic attack seek medical help immediately.

There is a need to work with partners to ensure that services are integrated, high quality and accessible in ways that offer people appropriate choices. Also working with partners to promote self-care, reablement or mutual support in community settings so this is viewed as the norm and reduce reliance on residential or home care. 

The intention is to reduce mortality and levels of dependency following an acute stroke, reduce length of stay of stroke patients in bed-based services, reduce re-admission rates, facilitate earlier hospital discharge home to usual place of residence with the necessary support or into stroke community rehabilitation units, to increase numbers of patients supported to maximise their ability and independence in their own home, improve stroke survivor experience, improve detection and management of psychological issues in stroke survivors and ensure routine use of assessment tools to systematically assess patients at six months. National clinical guidelines for stroke are available which detail how to achieve these outcomes.

Heart Failure

Testing for Brain Natriuretic Peptide (BNP and NT Pro-BNP) can act as a cost effective pre-screening tool to ensure only those patients deemed at higher risk of heart failure are referred on for specialist assessment with echocardiography. Practices have access to BNP testing for patients with suspected heart failure, and across the region could help save over £200,000 and means valuable resources are used effectively.

A diuretic is a medicine which increases the amount of water that passes out of the kidneys. Whilst they are often used to treat heart failure, they are also used to treat other conditions such as certain liver and kidney disorders, and sometimes hypertension. Patients without heart failure who are taking loop diuretics (one type of diuretics) should be assessed to ensure they do not have heart failure through BNP testing.

Patients with heart failure require specialist heart failure assessment followed by systematic care with medication and rehabilitation once their condition is stable. Hull CCG commissions a tele-health service which include tele-monitoring provision for patients with heart failure. Rehabilitation should include education, lifestyle advice, physical activity and self-management advice. Cardiac rehabilitation should be available to all people with heart failure who would benefit, and people who would benefit should be encouraged to participate.

Furthermore, as the prognosis of heart failure is poor, appropriate palliative care and end of life care should be provided where necessary.

Atrial Fibrillation

Opportunities should be taken to identify people with undiagnosed atrial fibrillation through pulse checking and/or use of blood pressure monitors which can detect irregular pulse.

Appropriate treatment should be given, for example, anti-coagulation, for patients newly diagnosed with atrial fibrillation to reduce the likelihood of having a stroke.

Hypertension

Opportunistic approaches should be taken to detect those with undiagnosed hypertension including the use of 24 hour blood pressure monitoring devices.

There is a need to increase the number of patients achieving blood pressure targets.  Achieving blood pressure targets for patients, particularly those with diabetes and hypertension, shows that serious events such as fatal and non-fatal strokes are significantly reduced. This further reduces unplanned hospital admissions, reducing NHS costs. Patients who are not achieving the nationally recognised blood pressure target should be referred to the correct healthcare professional for review and treatment.

Resources

The Office for Health Improvement & Disparities’ Fingertips: https://fingertips.phe.org.uk/

NHS Digital. Quality and Outcomes Framework. https://qof.digital.nhs.uk/

Projecting Adult Needs and Service Information (PANSI). www.pansi.org.uk

Projecting Older People Population Information (POPPI). www.poppi.org.uk

Department of Health, Cardiovascular disease outcomes strategy.  Improving outcomes for people with or at risk of cardiovascular disease. 2013, Department of Health: London.

National Institute for Health and Care Excellence, Clinical Guidance 71.  Identification and management of familial hypercholesterolaemia. www.nice.org.uk. 2008, National Institute for Health and Care Excellence: London.

NHS. Coronary heart disease.  www.nhs.uk. 2014, NHS Choices: London.

Newton, J.N., et al., Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 2015. 386(10010): p. 2257-2274.

NHS. Stroke.  www.nhs.uk. 2013, NHS Choices: London.

NHS. Transient ischaemic attack (TIA).  www.nhs.uk. 2014, NHS Choices: London.

Medline Plus, Stroke.  US National Library of Medicine National Institutes of Health: Bethesda, USA, 2014

Department of Health, National Stroke Strategy.  www.dh.gov.uk. 2007, Department of Health: London.

O’Donnell, M.J., et al., Risk factors for ischaemic and intracerebral haemorrhagic stoke in 22 countries (the INTERSTROKE study): a case-control study. Lancet, 2010. 376(9735): p. 112-123.

National Institute for Health and Care Excellence, Clinical guideline 108:  Chronic heart failure.  Management of chronic heart failure in adults in primary and secondary care.  www.nice.org.uk. 2010, National Institute for Health and Care Excellence: London.

NHS. Atrial fibrillation.  www.nhs.uk. 2013, NHS Choices: London.

National Institute for Health and Care Excellence, Clinical Guideline 180 Atrial fibrillation: the management of atrial fibrillation.  www.nice.org.uk. 2014, National Institute for Health and Care Excellence: London.

Doncaster Primary Care Trust, User Guides for QOF Benchmarking Tool, 2008.

Office for National Statistics, Prescribing of specific types of drugs for patients with atrial fibrillation by age, sex and calendar year: 1994-98.  www.ons.gov.uk. 2005, Office for National Statistics: London.

NHS. High blood pressure (hypertension).  www.nhs.uk. 2014, NHS Choices: London.

National Institute for Health and Care Excellence, Clinical guideline 127: Hypertension.  Clinical management of primary hypertension in adults.  www.nice.org.uk. 2011, National Institute for Health and Care Excellence: London.

NHS. Peripheral arterial disease (PAD).  www.nhs.uk. 2014, NHS Choices: London.

Fowkes, F.G.R., et al., Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet, 2013. 382: p. 1329-1340.

Stoffers, H.E.J.H., et al., The prevalence of asymptomatic and unrecognized peripheral arterial occulsive disease. International Journal of Epidemiology, 1996. 25: p. 282-290.

Hirsch, A.T., et al., Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA, 2001. 286: p. 1317-1324.

McDermott, M.M., et al., Asymtomatic peripheral arterial disease is independently associated with impaired lower extremity functioning: the women’s health and aging study. Circulation, 2000. 101: p. 1007-1012.

Pande, R.L., et al., Secondary prevention and mortality in peripheral artery disease: National Health and Nutrition Examination Study, 1999 to 2004. Circulation, 2011. 124: p. 17-23.

Smith, G.D., M.J. Shipley, and G. Rose, Intermittent claudication, heart disease risk factors, and mortality.  The Whitehall Study. Circulation, 1990. 82: p. 1925-1931.

Fowkes, F.G., et al., Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA, 2008. 300: p. 197-208.

American Cancer Society, When smokers quit what are the benefits over time?  www.cancer.org. 2014, American Cancer Society: Atlanta.

National Institute for Health and Care Excellence, Cardiac rehabilitation services.  Guide for commissioners. 2013, National Institute for Health and Care Excellence: London.

Surgeon General of the US Public Health Service, How tobacco smoke causes disease, 2010.

International Agency for Research on Cancer, IARC Handbooks of Cancer Prevention: Tobacco control: reversal of risk after quitting smoking.  www.iarc.fr/ 2007, World Health Organisation: Lyon.

The National Collaborating Centre for Chronic Conditions on behalf of National Institute for Health and Care Excellence, Clinical guideline 68:  Stroke.  National clinical guidelines for diagnosis and initial management of acute stroke and transient ischaemic attack.  www.nice.org.uk. 2008, Royal College of Physicians: London.

Royal College of Physicians, National clinical guidelines for stroke.  Prepared by the Intercollegiate Stroke Working Party.  Fourth edition.  www.rcplondon.ac.uk. 2012, Royal College of Physicians: London.

NHS Yorkshire and the Humber. Delivering Healthy Ambitions Better for Less.  Heart failure, 2015.

Updates

This page was last updated / checked on 28 May 2025.

This page is due to be updated / checked in November 2025.