Burden of CVD Still High in UK Despite Prevention Efforts Over 20 Years

The incidence of cardiovascular disease has decreased in the United Kingdom over the past two decades, but the overall burden has remained high, according to new registry data.

Specifically, rates of coronary artery disease and stroke have come down, but there’s been an uptick in diagnoses of cardiac arrhythmias, valve disease, and thromboembolic disease. Also, the researchers note a discrepancy regarding age wherein the declines in CVD were largely seen in people older than 60 years.

A variety of prevention efforts targeted at cardiovascular disease have been designed to increase awareness and improve treatment, yet it remains a top killer, blamed for 27% of deaths globally even though its burden varies around the world and, in many regions, by race and ethnicity

“Cardiovascular disease prevention has been, I think, one of the major successes of public health over the past 50 years,” lead author Nathalie Conrad, PhD (University of Glasgow, Scotland; KU Leuven, Belgium; and University of Oxford, England), told TCTMD. “But on the other hand, it has slowed down really for the past 15 years. And it has slowed down for different reasons. Some risk factors for cardiovascular disease are well known and have been increasing, especially obesity and diabetes. But also, we see other cardiovascular diseases picking up. From our study we see that we need to investigate more how this will impact mortality.”

The data also highlight several disparities about who has benefited from worldwide prevention initiatives, not only by age but also socioeconomic status, Conrad said. “The question is: what do we do about that? How do we tackle this? Moving on, I think that would be a big challenge for cardiovascular disease prevention.”

To TCTMD, Gregory A. Roth, MD, MPH (University of Washington, Seattle), said the study demonstrates how as patients are living longer, their disease burden has shifted.

“One theory is that heart block and aortic stenosis are conditions that reflect the improved survival of people who were previously dying at younger ages due to coronary disease,” he said. “As we do a better job of treating coronary disease, we're unmasking these other components of the structure of the heart that fail at the oldest ages. This is important because it helps us think about what kind of healthcare we're going to have to prepare to be able to deliver over the next 30 years as the population continues to age.”

CVD Patients Down, Diagnoses Stable

For the study, Conrad and colleagues looked at data from more than 22 million UK-based individuals in the GOLD and AURUM datasets of Clinical Practice Research Datalink between January 2000 and June 2019, equating to more than 146 million patient-years of follow-up.

CVD was comprised of ACS, aortic aneurysm, aortic stenosis, atrial fibrillation or flutter, chronic ischemic heart disease, heart failure (HF), PAD, second- or third-degree heart block, stroke (ischemic, hemorrhagic, and unspecified), and venous thromboembolism (deep vein thrombosis or pulmonary embolism). They identified 2,906,770 new diagnoses of CVD among 1,650,052 patients (mean age 70.5 years; 47.6% women).

The burden has gone down for the older individuals, but for the younger ones, it has been pretty flat over the past 20 years. Nathalie Conrad

Overall, the number of patients diagnosed with CVD declined by 20% over the study period. The specific age- and sex-adjusted incidence rate ratios for ACS (0.70), chronic ischemic heart disease (0.67), and stroke (0.75) reflected an approximately 30% decrease over time. PAD also decreased (0.89), but not by as much. Notably, upticks were seen in the incidence of cardiac arrhythmias including atrial fibrillation (AF)/flutter (1.36) and heart block (2.22) as well as valve disease, including aortic aneurysm (1.38) and aortic stenosis (2.42), and venous thromboembolism (1.28). The incidence of heart failure remained stable throughout the study (1.05).

This resulted in a relatively stable total number of new CVD diagnoses over the study period.

In analyses stratified by age, only those older than 60 years saw decreases in chronic ischemic heart disease, ACS, and stroke. Those aged 60 and younger had relatively stable rates of these diseases. Most diseases were diagnosed at older ages with a median age of diagnosis between 65 and 80, but venous thromboembolism generally occurred in younger patients with a median age at diagnosis of 45 years. The researchers noted that patients with diagnoses occurring before age 60 more often had lower socioeconomic status and a higher prevalence of several risk factors.

While the age-adjusted incidence of total CVD was higher in men than in women (1.46), the only differences seen among the individual diseases was for aortic aneurysm, which was more likely in men (3.49). Interestingly, despite their being more women in the older age groups, the crude incidence of CVD was similar for men and women (1,069 vs 1,176 per 100,000 patient-years)

Lastly, the data showed a socioeconomic gradient where the incidence of CVD was greater for those in the most- versus least-deprived subgroups for almost every CVD investigated, most notably for PAD (1.98), ACS (1.55), and HF (1.50). These gradients did not decrease over time, but rather increased specifically for aortic aneurysms, AF, HF, and aortic stenosis.

Conrad said she was surprised not to see more differences between men and women, but even more unexpected was the lack of progress made in younger patients. “We've done a lot of work in cardiovascular disease prevention, and of course, we know it's largely focused on people aged 60 plus because they are at highest risk of cardiovascular disease,” she said.

The data indicate that “the burden has gone down for the older individuals, but for the younger ones, it has been pretty flat over the past 20 years,” Conrad added. “That means that the younger ones haven't benefited as much from cardiovascular disease prevention as the older generation.” This should highlight some future priorities for the field of CVD prevention, she said.

Mostly ‘Good News’

Nick Curzen, PhD (University Hospital Southampton, England), who was not involved in the study, told TCTMD his sees the findings as primarily positive.

“It confirms that the incidence of atherosclerotic conditions is going down, which is a fantastic thing, and it demonstrates that the pickup of other cardiovascular disease entities is going up,” he said. “Now whilst that may initially sound bad, I'm sure that it relates to an improved ability of the healthcare system to pick up conditions such as aortic stenosis and atrial fibrillation. And that, of course, is a very good thing for those people.”

As we do a better job of treating coronary disease, we're unmasking these other components of the structure of the heart that fail at the oldest ages. Gregory A. Roth

Consumer tools such as smartwatches have increased the detection of AF for the better, Curzen said. “When this first started happening a few years ago, I think most physicians were relatively skeptical about whether the device really had detected an arrhythmia, particularly AF, but when a new patient comes to see me and they say ‘My phone's detected a rhythm abnormality called atrial fibrillation,’ I now normally assume that it's true.”

While this would signal an increase in diagnoses on paper, Curzen said this also now means these patients receive earlier access to treatment. And while this overall burden might “stress an already stressed system even more,” this must be interpreted positively, he added.

Pascal Meier, MD (Royal Brompton Hospital, London, England), agreed that the study results are mostly “good news.” However, he said, the fact that the benefits of prevention initiatives aren’t being seen among younger patients means “we start the prevention too late and should start earlier.”

Roth also pointed to the complication of treating patients with multiple diseases and how these varying conditions can overlap and affect each other, especially since few randomized trials focus on this population, which usually skews older. “We're going to have to get better at managing patients who accumulate more conditions all at once,” he said. “Our goal needs to be longer life with better quality of life. . . . The results of this study really point for us to focus on healthy aging and the preservation of health, not just the elimination of diseases that kill us suddenly.”

Regarding the nuances observed by gender and socioeconomic status, Curzen said these “concerning” findings still lack complete explanations. For sex specifically, it could be that women are presenting differently than men or that they’re not “being given access to the same investigation and diagnosis management pathways,” he said.

Moreover, the fact that there were socioeconomic differences observed within a national health system means this is likely a “more pronounced” problem in regions without one, Meier added.

Nevertheless, “it really highlights for me that where we should be going in cardiovascular disease now is early detection of disease and that must be our holy grail,” Curzen stressed. “We want to get to a position where we don't wait until someone has a heart attack or a stroke; we want to be able to detect people at risk of these conditions and prevent them from happening.”