Associate Feature: Heart problems
The transformation of Scotland from sick man of Europe to world leader on public health has been dramatic.
Rates of heart attack and coronary heart disease have all fallen in the last two decades, smoking rates are down and the once-unthinkable has happened: other countries have started to see Scotland as a example to learn from.
But there are worrying signs that Scotland’s success is faltering and even going into reverse.
Deaths from heart and circulatory diseases are on the up. Last year, they were at their highest since 2008.
Data from National Records of Scotland, analysed by BHF Scotland, suggests that there have been around 2,700 excess deaths from cardiovascular disease (CVD) in Scotland since the onset of the Covid-19 pandemic. These are deaths over and above the number scientists would expect. The number of excess deaths from cardiovascular disease in Scotland has grown with each subsequent year of the pandemic.
In the background there are worrying long-term trends at work, including rising levels of obesity, but the pandemic has had a major impact. The disruption to medical services has made detection and management of heart conditions much more difficult.
Jonathan Roden, policy and public affairs manager at BHF Scotland, says: “The pandemic meant that people who had high-risk conditions like high blood pressure, high cholesterol or atrial fibrillation haven’t had them detected or managed, which is unfortunately contributing to the loss of lives.”
The number of people waiting for a cardiology appointment was similar in December 2020 as December 2019, but since 2020 the list has more than doubled, from 9,588 in December 2020 to 20,776 in March 2023. The number of people waiting more than 16 weeks has grown from 3,228 to 7,928.
World renowned cardiologist and medical researcher Professor Nick Mills is warning that much more investment is needed to turn the recent Heart Disease Action Plan into reality, so that patients get the timely diagnosis and treatment they need.
Mills, BHF Chair of Cardiology at the University of Edinburgh and a consultant cardiologist, sees the delays up close. “We’d got to a point [before the pandemic] where the delivery of care for patients with acute cardiac conditions as well as chronic cardiac conditions was excellent, but Covid disrupted traditional models of care. The way primary and secondary care communicated with each other changed, the priority and focus changed, and that had a detrimental effect on the way that we deliver cardiac care in Scotland.
“I’ve certainly observed, not just locally but across the country, that waiting times for procedures that we never had any concerns about before have lengthened substantially. These are basic diagnostic tests that people are waiting longer for.
“Before, I had never really felt that this was impacting on how I was able to do my job effectively for patients, but in the last year or so following Covid it has become much more noticeable.”
There are also ongoing concerns that the virus itself could be causing an increase in levels of cardiovascular disease. A study based on nearly 160,000 people published in January in the journal of the European Society of Cardiology indicated that Covid-19 is associated with higher risks of cardiovascular disease and death in the short and long term.
Mills cautions that the study is already out of date as scientists’ understanding of the impact of Covid on cardiovascular health has developed dramatically over the last two years and continues to change. He says: “Initially what was clear was that people who had underlying heart disease were at higher risk of dying during a Covid illness. As the pandemic has evolved and with mass vaccination, we’re not seeing that any more.” It has helped that the virus has become less virulent.
But the longer-term, lasting impacts of the disease on cardiovascular health remain “very uncertain”.
Prof Mills is seeing the virus delaying cardiovascular patients getting treatment in a surprising way right now, however. He says: “Many people who actually have symptoms of heart disease – chest pain, breathlessness, palpitations – are getting drawn into thinking that they have some form of long Covid or the consequences of Covid, rather than being investigated for treatable conditions that are common.
“I have seen many patients in my clinic who have been referred to me with [suspected] long Covid who have actually got coronary disease but because they happened to have Covid last year, someone’s been distracted into thinking this has been the cause of their symptoms.
“In my view the biggest challenge here is just getting people to the right speciality and the right investigations. That has been my experience, that people have been misdiagnosed.”
Heart and circulatory diseases encompass all diseases of the heart and circulation, including conditions that are inherited or that a person is born with, and those that develop later, such as coronary heart disease, atrial fibrillation, heart failure, stroke and vascular dementia. An estimated 700,000 people in Scotland live with heart and circulatory diseases. They cause nearly three in ten deaths, which is over 18,000 deaths each year or 50 per day.
Coronary heart disease remains the single biggest killer in Scotland.
Roden says: “It’s deeply troubling to see so many people lose their lives to heart and circulatory diseases. It drives home the priority that needs to be placed by the Scottish Government on heart disease to tackle this rising figure.
“We know issues exist around increasing waiting lists for things like diagnostic tests. There isn’t the investment to address this in the long term. It isn’t there compared to investment to tackle other major conditions.”
A Heart Disease Action Plan was published by the Scottish Government in 2021 and was welcomed by campaigners as it encompassed many of their priorities, but funding remains the main roadblock to progress.
Roden says: “The Heart Disease Action Plan has resulted in positive progress, and is ambitious in its scope, but with increasing deaths from heart disease, we really need to see it supported by investment to create the changes needed to tackle the increasing burden.
“The Heart Disease Action Plan was launched with £2.2m in 2021, which was labelled initial funding.
“Comparing that to other strategies, cancer was allocated £117m and type 2 diabetes £42m, so the scale isn’t comparable.”
The £2m is being spent on issues such as improving data, but that in itself won’t reduce heart disease deaths, Roden adds. “What this will do is reveal issues that need to be addressed, like where the workforce gaps are, rather than solve them.
“The figures we’re seeing in deaths and heart disease suggest a need for much more urgency.”
Mills is similarly concerned. He says: “We published a research paper supported by the BHF a couple of years ago where we looked at trends over the last 25 years in outcomes for patients with heart attacks and strokes. It was remarkable the improvement in outcomes we observed over that 25-year period. Right at the very end it plateaued and the improvements stopped.
“We looked at the Scottish Health Survey in parallel over that period and tried to define what the major changes in lifestyle and practice were over that period and how they linked with the improved outcomes. The major changes we saw were blood pressure falling, cholesterol falling, smoking rates plummeting over all age groups and that was driving those improvements in care.
“But what we started to see towards the end of that 25-year period was an increase in the proportion of the population that were obese and an increase in the proportion of the population that were developing diabetes, and of course they have long-term impacts on cardiovascular health. As they increase across society, the 10- and 20-year consequences of that are accelerated cardiovascular disease and we will certainly see that increase if it isn’t kept in check.
“Our ability not just to deliver acute care but have the time in the health service to work with people on their risk factors and try and change some of those trends is really difficult when you’ve got a healthcare system that is at full stretch.
“I’d worry that in five years’ time we’re going to be reporting the first sustained increases in adverse outcomes from cardiovascular disease unless we actively manage this situation.
“So I think investment in the Heart Disease Action Plan is critical from the Scottish Government because the signs are there that things are going to get worse.
“It’s really a capacity issue. I think people have been working for many years beyond their means to try and sustain things and I’m just not sure that they’re willing to do that any more.”
The Scottish Burden of Disease study published by Public Health Scotland estimated that cardiovascular diseases will see the biggest increase of any group of diseases by 2043, with a 34 per cent increase in ill-health caused.
This month, the Cross-Party Group on Heart and Circulatory Diseases will begin an inquiry into the Heart Disease Action Plan to look at how it has been implemented.
Roden is worried about the gap between aspiration and funding.
He says: “The grief and suffering caused by heart and circulatory diseases profoundly affect every community in Scotland.
“Ministers have set out ambitious plans to tackle it, but with services under more pressure than ever, more investment is crucial to prevent increasing deaths from these diseases.”
This article is sponsored by British Heart Foundation Scotland