Associate Feature: On a mission to save lives
It shouldn’t be down to chance whether someone is discovered to be at high risk of heart attack.
But all too often it is. In Scotland, there’s no guarantee that risk factors like high blood pressure, high cholesterol and atrial fibrillation (AF) will be picked up.
Sometimes these conditions are identified during visits to the GP or hospital, but all too frequently, they are not identified at all and the result of that failure can be deadly.
It’s estimated that more than a million people in Scotland are living with at least one of these conditions and as many as a third of them don’t know they have it. Among those who are aware, many are not getting the most effective treatment.
BHF Scotland believes that this situation must be tackled urgently. This is especially important given that progress in cutting heart disease deaths has stalled. By 2043, the burden of cardiovascular disease is projected to rise by 34 per cent compared to 2019, more than for any other category of illness, according to a Public Health Scotland study published in November. This will mostly affect the over 65s and is linked to the ageing of the population.
Overall, the disease burden from all causes is forecast to increase 21 per cent.
Public Health Scotland notes in its report that “preventative activity, alongside early intervention and improved treatments, would all need to be acted upon for these forecasts not to become a reality”.
With the support of world-leading cardiologists, BHF Scotland is now calling on the Scottish Government to make the detection and treatment of high-risk conditions a national mission, backed by financial investment, and to increase funding for heart disease services through the recently published Heart Disease Action Plan.
Jonathan Roden of BHF Scotland says: “As a nation, we have made great progress in tackling heart and circulatory disease, but we know that there is much more we can do to reduce the impact of heart disease on the health of Scotland.
“We’ve known for many years that high blood pressure, high cholesterol and atrial fibrillation – an irregular heartbeat that is often very fast – are major risk factors for heart attack as well as stroke, kidney disease, diabetes and other health problems.
“Yet it has been estimated that hundreds of thousands of people don’t know they are living with these conditions.
“It is not a simple task to find, treat and monitor people who are at risk, but with the overall number of heart attack deaths set to rise in Scotland and increasing pressures on our NHS, there is an urgent need for it to be done.
“Making the detection and treatment of these conditions a national mission would focus minds, attention and money on tackling key risk factors for heart disease in a way that is not happening now and help to save thousands of lives from heart disease.”
Dave Newby, BHF Duke of Edinburgh Chair of Cardiology at the BHF Centre of Research Excellence, University of Edinburgh, says extrapolating from the data of trials suggests that the impact of tackling these conditions could be very substantial: “If you did something like lower blood pressure by, say, 10 millilitres on average across the population you’d have a huge impact in terms of reducing the number of strokes and heart attacks. The same could also be said to a degree on cholesterol.
“All of those three conditions in theory should benefit if they are detected and treated properly.”
Dr David Murdoch, consultant cardiologist at Queen Elizabeth University Hospital in Glasgow, describes the national mission plan as “laudable”, adding that lessons learned so far from trials should be taken into account.
The Heart Disease Action Plan already lists ‘minimising preventable heart disease by improving the detection, diagnosis and management of risk factor conditions’ as a top priority. The key difference with making it a national mission, believes Dr Murdoch, would be money.
“Although those things are our priorities, they are not backed by funding,” he says.
The five-year Keep Well prevention programme, launched in 2006 to target hard-to-reach groups with health checks (predominantly for heart disease), was funded to the tune of £50m. “That kind of money doesn’t come with the Heart Disease Action Plan,” says Dr Murdoch.
He points to previous trials designed to identify people with heart disease risk factors, not just in Scotland but in Denmark, Canada and elsewhere. He believes that sustaining prevention efforts over the long term, not just for the few years typical of such initiatives, is key. He also believes the national mission should sit alongside efforts backed by legislation to tackle things like excessive drinking and obesity.
If you did something like lower blood pressure by, say, 10 millilitres on average across the population you’d have a huge impact in terms of reducing the number of strokes and heart attacks (Prof Dave Newby, cardiologist)
One of the greatest challenges involved in preventing heart disease and heart attacks is engaging with hard-to-reach groups, particularly those from deprived backgrounds, who are at higher risk of preventable ill-health.
Making the detection of these risk factors a high-profile, government-backed national mission could help. Prof Newby says: “This campaign is good on two levels. One is in reinforcing the message: let’s get back to basics here, this is important stuff. Number two is engaging with the public in trying to be part of the solution in terms of their health.”
Does the Scottish Government place enough emphasis on the detection and treatment of high blood pressure, high cholesterol and AF?
“Probably not, no,” says Prof Newby. “It’s probably in the ‘boring’ box because we’ve known about this and have been doing it for years.
“That I think is where this is coming from – it’s an attempt to re-engage institutionally but also on an individual level. It’s saying ‘these things are important, let’s not forget about them’.”
There is no single cause of high blood pressure. Lifestyle factors like being overweight, not getting enough exercise and consuming too much salt can affect blood pressure, as can age and genetic factors. High cholesterol too is linked to lifestyle factors like diet and can run in families.
“I always sit down with my patients and talk to them about lifestyle changes,” says Prof Newby, but adds that drugs tend to be much more effective at lowering blood pressure and cholesterol.
BHF Scotland does not envisage formal screening programmes being set up, but would like to see innovative approaches taken to finding people who have these conditions. In some countries, for instance, automated health check kiosks in workplaces or supermarkets can perform blood pressure, heart rate, weight and other checks in minutes. Pharmacies and mobile testing vans on town high streets are other potential sites where people could get tested for high blood pressure or cholesterol.
Technology already plays a role in the monitoring of people with these conditions and that could be greatly expanded, BHF Scotland believes.
Dr Murdoch agrees: “Self-monitoring is the way forward, for people to take responsibility for it themselves.” Patients can already take their own blood pressure, put the results into an app and connect with health professionals about it online, on an ongoing basis. Some people buy their own monitors but there are calls for them to be provided to people in deprived areas by the NHS.
It will take time and money to improve detection and treatment of these key conditions, but how can the case be made for funding now, when the NHS is under such dire pressure?
Spending up front on averting heart disease and heart attacks can save lives, reduce suffering and save money further down the line.
Prof Newby says: “Prevention is better than cure but the floodgates are open. We’re still trying to get control of that, let alone trying to drop the sea level as it were.
“But ultimately you need to do both. It’s about making decisions about what you can invest in as a health board and nationally.”
Any effort to improve the detection and treatment of these risk factors will take time to show results. Dr Murdoch believes the slated new community treatment centres being established around Scotland could be useful in making it happen.
There is nothing new in the idea that identifying and treating these three conditions could reduce deaths. But in spite of that knowledge, hundreds of thousands of people are still walking around unaware that they are at high risk. BHF Scotland wants those people to have lots of opportunities to discover their condition, whether it’s during a trip to the shops, when they pop into the chemist or while visiting the GP or practice nurse about something unrelated. They want those affected to be well-monitored over a long period of time, and have access to advice as and when they need it. Galvanising government policy-makers, researchers, doctors, nurses and other NHS workers to come together and find a sustainable way of making this happen in every health board area in Scotland, is the aim of the proposed national mission.
“We have come so far as a nation in tackling the rate of heart attacks but progress has stalled,” says Roden. “By detecting and tackling the risk factors that contribute so much to heart disease, we can save lives and improve the outlook for hundreds of thousands of people.
“The opportunity could hardly be greater.”
This article is sponsored by BHF Scotland.