Mortality

In 2012, for the first time since the middle of the 20th century,9 CVD went from being the main cause of death to the second cause of death in the UK. Twenty-eight per cent of deaths were caused by CVD in 2012, and 29% were caused by cancer. When analysed by sex, however, CVD was still a larger cause of death than cancer for women, but this was no longer the case for men (figure 1).

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Figure 1

Deaths by cause and sex, UK. This figure compiles data from the four countries of the UK. In Northern Ireland, the data for lung cancer only includes International Classification of Diseases-10 code C34. Adapted from England and Wales, Office for National Statistics (2014) Deaths registered by cause, sex and age. http://www.statistics.gov.uk (accessed January 2014); Scotland, National Records of Scotland (2014) Deaths, by sex, age and cause. http://www.gro-scotland.gov.uk (accessed January 2014); Northern Ireland, Statistics and Research Agency (2014) Registrar General Annual Report. NISRA: Belfast.

The main causes of CVD death are CHD and stroke. In 2012, 46% of CVD deaths were from CHD and 26% were from stroke. Overall, CHD was responsible for 16% of all male deaths and 10% of all female deaths, a total of just under 73 500 deaths. Around 41 000 deaths were from stroke, making up 6% and 9% of total deaths in men and women, respectively (figure 1).

In this review, we treat deaths before the age of 75 as premature. More than one quarter of premature deaths in men and around 18% of premature deaths in women were from CVD in 2012 (see online supplementary tables). In total that year, there were nearly 42 000 premature deaths from CVD in the UK. CHD by itself was the most common single cause of premature death in the UK in men, responsible for about 15% of premature male deaths in 2012. In women, CHD caused around 8% of premature deaths.

Regional variations in mortality

Age-standardised CVD mortality rates by local authority showed a clear trend for higher CVD rates in Scotland and the North of England and lower CVD rates in the South of England. Glasgow City had the highest CVD mortality rate for both premature mortality (144/100 000 population) and mortality at all ages (400/100 000 population). Half of all the local authorities with the 10 highest CVD mortality rates in the UK were in Scotland, four were in the North of England and one was in Wales (table 1). Age-standardised CVD mortality rates were highest in Scotland in 2012 at 347/100 000 population and lowest in the South West of England at 269/100 000 population (see online supplementary data).

Prevalence

We obtained prevalence data by age through the CPRD GOLD database. Obtaining data from this database is prolonged and expensive; therefore, it was not possible to provide data for conditions within other ICD10 subchapters. Throughout the UK, prevalence of MI in men was almost three times greater than for women in 2013. Applying country-specific and age-specific population estimates, obtained from the national statistics agencies, to prevalence data from the CPRD GOLD database suggests that >915 000 people in the UK have suffered an MI and >1.3 million are living with angina. Consequently, if we combine estimates for MI and angina, we find that almost 2.3 million people in the UK are living with some form of CHD. Applying prevalence figures for heart failure to population estimates suggests that there are >308 000 men and 250 000 women in the UK living with heart failure. Using the same method, we estimate that 1.1 million people are living with atrial fibrillation in the UK (table 2).

Regional variations in prevalence

Estimates of the number of people in the UK who have CVD, derived from the CPRD GOLD database, are broadly supported by results from the QOF. QOF data suggest that in 2012/2013 there were around 2.3 million people suffering from CHD, 1.2 million people suffering from stroke, around 1 million from atrial fibrillation and just over 480 000 from heart failure. QOF only measures certain cardiovascular conditions; therefore, prevalence data are not available for all ICD10 chapters.

Comparing between regions in England, those in the North had a higher prevalence for CVD than the those in the South, with the highest prevalence reported in the North East for all diseases described here (4.5% for CHD, 2.1% for stroke). London had the lowest prevalence for all (2.1% for CHD, 1.0% for stroke). For CHD, the North East, North West and Yorkshire and The Humber all had a prevalence of 4% or higher. Among UK countries, England had the lowest prevalence for all cardiovascular conditions (3.4% for CHD, 1.7% for stroke) except hypertension (13.6%), for which Northern Ireland was lowest (12.9%). Scotland had the highest prevalence for CHD (4.3%), stroke (2.1%) and peripheral arterial disease (0.9%), while Wales had the highest for hypertension (15.5%), heart failure (0.9%) and atrial fibrillation (1.8%). It should be noted that these rates have not been adjusted to account for differences in the age structure of populations (table 3).

Inpatient episodes

In the UK, there were >1.6 million episodes related to CVD in NHS hospitals, accounting for 10.1% of all inpatient episodes among men and 6.3% among women. The proportion of inpatient episodes attributed to CHD was almost twice as high among men as among women, accounting for 3.5% of all inpatient episodes in men and 1.5% in women in the UK. Stroke accounted for around 1.1% of inpatient episodes in women and 1.2% in men in the UK. As a proportion of all conditions, stroke accounts for about 1.1% of all hospital episodes in the UK (table 4).

The highest proportion of inpatient episodes for all CVD were in Scotland (12.4% of men and 8.6% of women). The lowest proportion of CVD inpatient episodes were in Northern Ireland for men (8.0%) and in England for women (6.1%) (figure 2). Northern Ireland had the lowest proportion of inpatient episodes for stroke (0.5% for both men and women), and Scotland had the highest proportion (1.7% for men and 1.6% for women).

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Figure 2

Percentage of all inpatient episodes for selected cardiovascular conditions, by sex and country of the UK, 2012/2013. Adapted from Department of Health (2013). Hospital Episode Statistics 2012/2013. http://www.hesonline.nhs.uk (accessed January 2014); Information Services Division Scotland (2015) Main diagnosis discharges from hospital 2012/2013. Personal correspondence; NHS Wales Informatics Service (2013). The Patient Episode Database for Wales—2012/2013. http://www.infoandstats.wales.nhs.uk (accessed January 2014); Hospital Information Branch (2012). Northern Ireland Episode Based Acute Inpatient and Day Case Activity Data (2012/2013) http://www.dhsspsni.gov.uk (accessed January 2014). Personal correspondence. CVD, cardiovascular disease; IHD.

Prescriptions

Prescription data is not available for the UK as a whole; therefore, we present England data here (table 5) and data for the other UK countries in online supplementary tables. The rapid increase in the number of prescriptions for the treatment and prevention of CVD began in the late 1980s. In 2013, >300 million prescriptions were dispensed for CVD in England, more than six times as many as issued in 1981, and an increase of 2.2% from the number of prescriptions in 2012. Since 1990, the number of prescriptions dispensed for antiplatelet drugs has increased steadily; there are now >38 million prescriptions for antiplatelet drugs in England every year. The increase in the number of prescriptions of lipid-lowering drugs was slow until the late 1990s, but since then has been very rapid, with the number of prescriptions for lipid-lowering drugs now more than six times higher than in 2000. HSE data show that 16% of men and 12% of women report being prescribed lipid-lowering medicines. Also, 14% of men and 15% of women reported being prescribed antihypertensives specifically for hypertension (figure 3).

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Figure 3

Percentage of individuals aged 16 and over taking cardiovascular-related prescriptions, by sex, England 2012–2013. Medicines are included in the ‘Anti-hypertensive medicines’ category only if they were specifically prescribed for hypertension. Adapted from Joint Health Surveys Unit. Health Survey for England 2013. London: Health and Social Care Information Centre 2014.

Operations

The total number of operations carried out to treat CHD is increasing in the UK. The number of PCIs carried out in the UK in 2012 was more than two times higher than a decade earlier; >90 000 procedures were carried out in 2012 in the UK. The number of CABGs reached a peak in the late 1990s/early 2000s. CABGs have become less common due to the more widespread use of less-invasive procedures such as PCIs. Just under 17 000 CABGs were carried out in the UK in 2012 (figure 4) and >6000 carotid endarterectomies in 2011/2012 (see online supplementary tables).

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Figure 4

Number of coronary artery bypass operations and percutaneous coronary interventions per year, UK 1980 to 2012. Operations performed in NHS hospitals and selected private hospitals are included. Adapted from British Cardiovascular Intervention Society (2013). BCIS Audit returns. Personal communication; The Society for Cardiothoracic Surgery in Great Britain and Ireland (2014). http://bluebook.scts.org/#ActivityRates (accessed in March 2014).

costs of CVD

Cost data are not available for the UK as a whole; therefore, we present England data here. More than £6.8 billion was spent on treating CVD within the NHS in England in 2012/2013. The highest expenditure was on secondary care with £4373 million spent on secondary care for CVD in England. Within secondary care, emergency admissions had the greatest expenditure. Within primary care, the second highest setting for expenditure, the majority of costs were due to prescribing (£1387.5 million). Economic cost data for Wales, Scotland and Northern Ireland come from different sources (see online supplementary tables) and so may not be comparable. In 2012/2013 in Wales, a total of £442.3 million was spent on CVD, in Northern Ireland, £393 million was spent and in Scotland it is estimated that >£750 million was spent on treatment of CVD (figure 5).

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Figure 5

Percentage of National Health Service (NHS) expenditure on cardiovascular disease by care setting, England 2012/2013. Expenditure data included are taken from the 2012–2013 programme budgeting returns. Programme budgeting returns are based on a subset of primary care trust (PCT) accounts data and represent a subset of overall NHS expenditure data. Estimates of expenditure are calculated using price paid for specific activities and services purchased from healthcare providers. PCTs follow standard guidance, procedures and mappings when calculating programme budgeting data. Adapted from NHS England—Analytical services—Programme Budgeting Team (2014) 2012/2013 Programme Budgeting Benchmarking Tool. http://www.england.nhs.uk/resources/resources-for-ccgs/prog-budgeting/ (accessed February 2014).

Summary and discussion

Although CVD is no longer the biggest cause of death overall in the UK, it is still the largest cause of death for women. Overall figures also mask substantial regional inequalities in mortality from CVD, with the highest CVD death rates occurring in Scotland and the North of England. Improved survival also means that there is a high prevalence of CVD conditions such as MI and angina; again, prevalence is higher in the North of England. There are also a large number of hospitalisations and operations resulting from CVD, which are in conjunction with an increase in the number of prescriptions dispensed for CVD conditions.

Cancer has overtaken CVD to become the main cause of death in a number of European countries, for example, in Belgium, Denmark and France,2 indicating that the UK is one of many countries undergoing this change. The decrease in mortality from CVD in the UK is partially due to improved case fatality rates after MIs over the last decade and partially due to a decline in incidence.3 Although the data we present here shows large increases in treatment over the past decade, Unal et al10 estimated that between 1981 and 2000, 58% of the decline in deaths from CHD was due to improvements in risk factors, such as smoking, and 48% was due to treatments.

Accurate incidence data is difficult to obtain, but conditions such as MI can be measured using HES or general practice data linked to mortality, or through disease registries such as the Myocardial Ischaemia National Audit Project. These sources provide information on both new cases presenting to the health service and on those who die before reaching hospital. We have not presented incidence data in this review, but there is published evidence that the incidence of some CVDs is declining over time. Measured using HES linked to mortality, the incidence of MI has declined in many developed countries, including England, since the 1970s.3 ,11 ,12 Measured using general practice data, between 1999 and 2008, the incidence of stroke in the UK dropped by 30%.13 However, it has been demonstrated that only using one source of incidence data can underestimate MI by 25–50%.14

Despite the substantial shift towards PCIs in the past years, CABG procedures remain as one of the main surgical treatments for certain more complex conditions.15 For example, it is recommended that CABGs remain as the standard revascularisation care for patients with complex coronary lesions or severe left main coronary disease. Where patients are eligible for both CABG and PCI, the National Institute for Health and Care Excellence reports that although CABG is still effective it is not cost-effective when compared with PCI and so the latter procedure should be performed.16

While we aimed to use high-quality nationally representative data sources, all have their limitations. Mortality and HES cover the entire population; however, data from the CPRD database came from about 9% of the population. It is possible therefore that CPRD data are not nationally representative; however, the fact that QOF prevalence data (which covers virtually all general practices) supports CPRD prevalence estimates lends some credibility to the representativeness of the CPRD database.