Commissioning guides
Published 01 May 2012

Services for the prevention of cardiovascular disease

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg45

3 Assessing service levels for cardiovascular disease prevention

Commissioners and their partners should examine local need for cardiovascular disease prevention, identify gaps in service provision, plan sufficient capacity and develop accessible and inclusive services. A local needs and assets assessment for the prevention of cardiovascular disease should include:

  • the number of people who are diagnosed with cardiovascular disease (see section 3.1)

  • the number of people with modifiable and fixed risk factors (see section 3.2)

  • existing practice, community assets and optimal local practice (see section 3.3).

3.1 Prevalence of cardiovascular disease

Defining the prevalence of cardiovascular disease is complex because there are different definitions of the disease and its component conditions are often comorbid. The prevalence of cardiovascular disease has been estimated here using the Public Health Observatory 'Modelled estimate of prevalence of CVD in England'. In this model a person is defined as having cardiovascular disease if they have had diagnosed angina, myocardial infarction (heart attack), transient ischaemic attack or stroke.

Using the above model, the indicative benchmark rate for the number of people with cardiovascular disease is 11,730 per 100,000 population aged 16 years or over. It is therefore estimated that 4.9 million people aged 16 or over in England have cardiovascular disease, which is 11.73% of the population[7].

The Public Health Observatory model covers both local authority and primary care trust levels. The model takes into account age, gender, ethnicity, smoking status and deprivation. Commissioners should explore local prevalence and incidence of cardiovascular disease and use information on modifiable and non-modifiable risk factors to consider how local rates may be reduced by implementing a cardiovascular disease prevention programme.

3.1.1 Hospital episode statistics

It is estimated that there were around 1.4 million hospital episodes for cardiovascular disease in 2010/11[8]. Of these, around 60% were for people younger than 75 and more than 50% of admissions were as an emergency.

Cardiovascular disease is a major cause of premature death, with a quarter of deaths being before the age of 75[9]. A high number of hospital episodes for diseases of the circulatory system, including those that result in death, involve a long length of stay[10]. Reducing the number of cardiovascular events by preventing cardiovascular disease could reduce premature mortality from cardiovascular disease and cardiovascular disease-related hospital admissions, and also reduce length of stay.

It should be noted that a proportion of all hospital activity for cardiovascular disease will be from non-modifiable, or fixed, causes, which may not be influenced by preventing modifiable cardiovascular disease risk factors.

3.2 Epidemiology of cardiovascular disease risk factors

The risk of a future cardiovascular disease event can be calculated using modifiable and fixed risk factors, and people at greater risk can be identified. For example:

  • cardiovascular disease predominantly affects people older than 50 and risk increases significantly with age[11]

  • cardiovascular disease is strongly associated with low income and social deprivation

  • the lifetime burden is greater in women because of their longevity and their increased risk of stroke over the age of 75[12]

  • South Asian men are more likely to develop cardiovascular disease at a younger age

  • family history of premature coronary heart disease identifies a possible genetic predisposition[11].

There is strong evidence that a multifactorial approach that addresses a range of modifiable cardiovascular disease risk factors will yield the most benefit to commissioners and have the greatest impact on population outcomes[11].

The Interheart study identified nine modifiable risk factors for myocardial infarction (see table 2)[13]. These nine risk factors are used here as a proxy for modifiable cardiovascular disease risk, as they were in NICE public health guidance 25 on the prevention of cardiovascular disease.

The modifiable risk factors and the proportion of the population with each risk factor are shown in table 2. The table includes NICE-recommended interventions to reduce risk. Further information about each modifiable risk factor is provided later in this section.

Table 2 Nine modifiable risk factors for myocardial infarction in adults (aged 16 or over)

Population attributable risk[a]

Risk factor

Measure and Source

England prevalence

Interventions to reduce risk

63.4%

Abdominal obesity

Raised waist circumference[b]

40%

Dietary and weight management interventions, physical activity services (section 4.3)

Medical interventions (section 4.4)

44.6%

Abnormal lipids (cholesterol)

Cholesterol level above 5.0 mmol/litre[c]

 34.5%

Dietary interventions (section 4.1 and 4.3)

Medical interventions (section 4.4)

38.9%

Psychosocial factors[d]

'High' GHQ12 score of 4 or more [b]

15%

Not applicable[d]

38.4%

Regular physical activity

Proportion of population not meeting exercise guidelines[b]

66%

Encourage modifications to physical environment and physically active travel (section 4.1)

Physical activity services (section 4.3)

29.3%

Smoking or tobacco use

Current smokers [b]

20%

Population-wide smoking cessation approaches including illicit tobacco control (section 4.1)

Smoking cessation services (section 4.3)

Medical interventions (section 4.4)

21.9%

High blood pressure (hypertension)

High blood pressure [b]

 30.2%

Behaviour change and lifestyle interventions (section 4.3)

Medical interventions (section 4.4)

18.7%

Alcohol consumption: drinking over recommended levels at least 1 day a week

Excess alcohol consumption [b]

34%

Behaviour change and lifestyle interventions (section 4.3)

15.0%

Diabetes

Diagnosed and undiagnosed diabetes [e]

 7.3%

Behaviour change and lifestyle interventions (section 4.3)

Services for people with type II diabetes

12.4%

Diet, including food high in fat, salt and sugar

Not consuming five portions of fruit or vegetables daily[b] 

74%

Strategies to reduce population-wide salt intake (section 4.1)

[a] Population attributable risk of acute myocardial infarction associated with risk factor in western Europe population after adjustment for smoking, age and gender.

[b] The NHS Information Centre for Health and Social Care (2011) Health survey for England 2010. Leeds: The NHS Information Centre.

[c] Derived from a sample of GP practice systems, IMS disease analyser, 2011 (see section 3.2.1)

[d] There is uncertain evidence about the link between psychosocial stress and modifiable cardiovascular disease risk, and a lack of evidence that interventions to reduce psychosocial stress can reduce individual risk.

[e] The Public Health Observatory (2011) Diabetes prevalence model for England. Leeds: The Public Health Observatory.

The Interheart study demonstrated that these nine measureable and potentially modifiable risk factors account for more than 90% of the population attributable risk (PAR)[14] of an initial acute myocardial infarction. The effect of these risk factors is consistent in men and women, and according to age and ethnic group. The effect of the risk factors is higher in younger men and women, indicating that most premature myocardial infarction is preventable[15]. An alternative to PAR is odds ratio[16] to rank the modifiable risk factors. This, along with relative risk reduction is examined further in the commissioning and benchmarking tool.

3.2.1 Number of people with a risk factor for cardiovascular disease

An individual can have more than one risk factor for cardiovascular disease. Attempting to quantify the proportion of the population with at least one risk factor is complex. We have used primary care data from the IMS disease analyser[17] to estimate the overall number of people with a risk factor. For this estimate we considered people aged 18 or over who have at least one of the following risk factors:

  • abnormal lipids (cholesterol above 5.0 mmol/litre)

  • smoking or tobacco use

  • obesity

  • high blood pressure (hypertension)

  • diabetes

Five factors were selected rather than the nine used elsewhere in this guide because data for these factors were more reliable[18].

It is estimated that around 23.5 million people[19] in England aged 18 or over have at least one of the five listed risk factors for cardiovascular disease. That is 57.1% of the adult population, or 57,100 people per 100,000 population aged over 18.

This increases to around 80% of the population aged 55 or over, and around 84% of the population aged 65 or over.

3.2.2 Obesity and abdominal obesity

The Interheart study[13] identified that body-mass index is related to risk of myocardial infarction, but this relationship was weaker than that of abdominal obesity (raised waist circumference). The 2010 Health Survey for England reported that 40% of adults have raised waist circumference[20]. This figure is nearly double that reported in 1993, which was 23% of the adult population.

The 2010 Health Survey for England also reported that 26.1% of the adult population (aged 16 or over) were obese (BMI 30 or more), and 36.7% were overweight (BMI 25–30). The prevalence of obesity in adults rose from 13% of men in 1993 to 26.2% in 2010, and from 16% of women in 1993 to 26.1% in 2010. The rate of increase of obesity for both genders has gradually reduced since 2001, although the trend is still upwards. Prescribing for obesity and rates of bariatric surgery have been increasing significantly[21]. Rising rates of overweight and obesity are likely to have a significant impact on population-level cardiovascular disease risk in the future[22],[23].

3.2.3 Abnormal lipids: high cholesterol

Abnormal lipids, measured by testing blood cholesterol, are a key modifiable risk factor for cardiovascular disease. Blood cholesterol can be reduced by dietary change, physical activity and medical interventions. Data from IMS disease analyser shows that the prevalence of cholesterol levels above 5.0 mmol/litre in the adult population has decreased significantly in recent years[24], and was 34.5% of the population in 2011.

3.2.4 Psychosocial stress

There is uncertain evidence about the link between psychosocial stress and cardiovascular disease risk, and a lack of evidence that interventions to reduce psychosocial stress can reduce an individual's risk of cardiovascular disease.

Living a stressful life can cause people to adopt habits such as smoking and poor diet, which in turn are risk factors for cardiovascular disease[25]. The Interheart study found that exposure to psychosocial stressors is associated with increased risk of acute myocardial infarction.

3.2.5 Physical activity levels

Increased physical activity can lower the risk of cardiovascular disease. Trend data from the Health Survey for England in figure 3 show the percentage of adults at each activity level (16 years or over).The number of people meeting recommendations[26] for exercise has been increasing in recent years; however, two-thirds of adults still do not meet the recommendations.

Figure 3 Adult trend: meeting recommendations for exercise

3.2.6 Smoking and tobacco use

Smoking is among the most significant modifiable risk factors for cardiovascular disease. Although rates of smoking have been declining in recent decades, in 2010 around 20% of adults aged 16 years or over in England were current smokers[27]. This is equivalent to 8.7 million adults in England, or 21,200 per 100,000 adults.

Smoking rates are much higher in some social groups, including those with the lowest incomes, and these groups suffer the highest burden of smoking-related illness and death. Smoking is the single biggest cause of inequalities in death rates between the richest and poorest communities[28]. There is a strong association between smoking and mental health disorders. Overall smoking prevalence among psychiatric patients is two to three times higher than among the general population[29].

The type of tobacco consumed varies between ethnic groups, with water pipes and smokeless tobacco more commonly used in Middle Eastern and Asian populations[30].

3.2.7 High blood pressure (hypertension)

Hypertension is a major risk factor for cardiovascular disease. Untreated hypertension is usually associated with a progressive rise in blood pressure. The vascular and renal damage that this may cause can culminate in a treatment-resistant state. The 2010 Health Survey for England reported that 30.2% of adults aged 16 or over had high blood pressure. Of these, 19.6% reported that the condition was untreated or uncontrolled. 2009/10 QOF data showed that 13.4% of the population has diagnosed hypertension.

The NHS Information Centre report Statistics on obesity, physical activity and diet: England, 2010 reported that overweight or obese adults aged 16 or over were more likely to have high blood pressure than those in the normal weight range. Other risk factors for raised blood pressure include high salt intake, lack of physical activity and excess alcohol intake.

3.2.8 Alcohol

Excessive alcohol consumption is linked to an increased risk of cardiovascular disease (see table 2). The Health Survey for England reported that 41% of men and 28% of women (34% overall) drank more than the recommended levels on at least 1 day in the week prior to the survey[31].

Using the AUDIT criteria, the Adult Psychiatric Morbidity Survey (APMS)[32] found that hazardous and harmful drinking[33] is common in England:

  • The rate of hazardous drinking is around 24.2% or 24,200 per 100,000 of the population aged 16 and over.

  • The rate of harmful drinking is around 3.8% or 3,800 per 100,000 of the population aged 16 and over. Two-thirds of harmful drinkers show signs of alcohol dependence.

3.2.9 Diabetes

Being diagnosed with, or being at risk of, diabetes is a risk factor for cardiovascular disease. QOF data for 2010/11 showed that 5.5% of the population aged 17 and over in England have diagnosed type I or II diabetes mellitus. The Public Health Observatory Diabetes Prevalence Model for England estimates the number of people aged 16 or over who have diabetes (diagnosed and undiagnosed) adjusted for age, gender, ethnic group and deprivation. This model estimates that 7.3% of people in England have diabetes.

Type II diabetes is the more common type and around 90% of people with diabetes have this type. Type II diabetes is often linked with being overweight or obese. It usually appears in people aged 40 or over. However, in South Asian and African-Caribbean populations it often appears in people aged 25 or over[34].

It should be noted that although type I diabetes is non-modifiable it should still be well managed in order to prevent complications from developing.

3.2.10 Diet

A diet high in saturated fat is linked to raised cholesterol, which is a key risk factor for cardiovascular disease. The 2011 National Diet and Nutrition Survey reported that mean saturated fat intakes for all age groups exceed the recommended fat level of no more than 11% of food energy. The mean saturated fat intake for adults aged 19 to 64 was 12.8% of food energy. However, mean intakes of trans-fatty acids provided 0.7–0.9% of food energy for all age groups, which was within the recommendation of no more than 2% of food energy.

The 2010 Health Survey for England reported that just 26% of adults aged 16 or over consumed five portions of fruit or vegetables daily. A diet rich in fruit and vegetables confers protective effects against the development of cardiovascular disease and certain cancers. A meta-analysis of 13 cohort studies found that intakes of more than five portions of fruit and vegetables a day were associated with a 17% reduction in coronary heart disease risk, and intakes of 3–5 portions per day were associated with a more modest decrease in coronary heart disease risk (7% reduction)[35].

NICE public health guidance 25 states that high levels of salt in the diet are linked with high blood pressure. This can lead to stroke and coronary heart disease. It recommends a reduction in salt intake among the population, aiming for a maximum intake of 6 g per day per adult by 2015 and 3 g by 2025. The 2008 Urinary Sodium Survey assessed salt intakes in the general adult population in the UK. The survey showed a reduction in the UK's average daily salt consumption from 9.5 g to 8.6 g since the National Nutrition and Diet Survey (NDNS) in 2000/01.

3.2.11 Deprivation and cardiovascular disease

There are strong links between deprivation and cardiovascular disease.

NICE public health guidance 15 on reducing the rate of premature mortality from cardiovascular disease and other smoking-related diseases focuses on primary care practitioners undertaking outreach work or 'proactive case finding' to identify adults who are at higher risk and disadvantaged.

The Care Quality Commission publication 'Closing the gap' states that modifiable cardiovascular disease risk factors are less likely to be diagnosed in people living in more deprived areas, which may result in poorer access to treatment. The National Service Framework for Coronary Heart Disease found that there are inequalities in the effects of heart disease, for example prevalence is almost three times higher among unskilled men than among professional men.

3.3 Current and optimal local practice

Barton et al's 2011 study on the effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations looked at a programme of cardiovascular disease prevention across England and Wales. The report concludes that reducing cardiovascular disease events by just 1% a year would deliver savings to the health service of at least £30 million a year compared with no additional intervention. It would also be likely to have cost savings for social care. In addition:

  • Reducing mean cholesterol concentrations or blood pressure levels in the population by 5% would result in annual savings of £80 million to £100 million. Improvements at this level have been demonstrated by studies in Finland and the USA[36],[37].

  • Actions to reduce dietary salt intake by 3 g a day (current mean intake approximately 8.5 g a day[38]) would prevent approximately 30,000 cardiovascular events, with savings of at least £40 million a year[39].

  • Actions to reduce intake of industrial trans-fatty acid by approximately 0.5% of total energy content might gain around 570,000 life years and generate NHS savings of at least £230 million a year[34].

Furthermore there is evidence that smoking cessation would deliver significant savings to the health service:

  • In 2010 there were around 157,000 cardiovascular deaths in England[40]. A reduction in smoking prevalence of 5% would lead to around 3800 fewer smoking-attributable deaths per year[41].

  • In 2010/11 there were approximately 83,000 emergency hospital admissions[42] attributable to cerebrovascular diseases in adults aged 35 years or over[36]. A reduction in smoking prevalence of 5% would lead to around 2400 fewer hospital admissions per year[37] .

Other studies have shown that a population approach can have a significant impact on cardiovascular disease, and small differences can have a large effect. A recent study[43] showed that adopting four additional healthy lifestyle behaviours was associated with a fourfold difference in mortality, equivalent to 14 years in chronological age.

3.4 Conclusion

Based on the epidemiological data and other information outlined above:

  • Around 4.9 million adults in England have diagnosed cardiovascular disease; that is 11,730 per 100,000 population aged 16 or over.

  • Around 23.5 million people in England aged 18 or over have at least one risk factor for cardiovascular disease; that is 57.1% of the adult population.

  • Tackling the risk factors of cardiovascular disease has been shown to reduce the future incidence of cardiovascular events.

  • Reducing cardiovascular events by just 1% would result in cost savings to the health and social care systems.

Commissioners should use their local needs assessment to determine optimum levels for local service provision. Commissioners should note that the benchmark rates do not represent NICE's view of desirable, or maximum or minimum, service levels.

Commissioners should use this benchmark and local data to facilitate local discussion on optimum service levels. There is considerable variation in the number of people with cardiovascular disease. This is influenced by the population risk factor profile as well as the social, economic and demographic profile of the local population, so commissioners are encouraged to consider local assumptions

Use the prevention of cardiovascular disease commissioning and benchmarking tool to determine the level of service that might be needed locally and to calculate the cost of commissioning the service using the indicative benchmark and/or your own local data.



[7] Applied to mid-2010 Office for National Statistics population estimates for England.

[8] This is estimated from Hospital Episode Statistics (HES), which show that there were 1.4 million finished consultant episodes for 'all diseases of the cardiovascular system'. Cardiovascular disease is defined here as 'all ICD-10 codes in Chapter IX – Diseases of the circulatory system (I00–I99)' (from the 2012/13 NHS outcomes framework technical appendix). An inpatient or daycase episode is where the patient has completed a period of care under a consultant/midwife/consultant nurse and is either transferred to another consultant/midwife/consultant nurse or discharged.

[9] Death registrations in England and Wales, selected data tables 2010, Office for National Statistics (ONS); London 2011

[10] This is examined further in the NICE guide for commissioners on end of life care for adults.

[12] Seshadri S, Beiser A, Kelly-Hayes M et al. (2006) The lifetime risk of stroke: estimates from the Framingham Study. Stroke 37: 345–50.

[13] Yusuf S, Hawken S, Ounpuu S, et al (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study., Canada L8L 2X2. Lancet 364: 937–52.

[14] PAR is the portion of the incidence of a disease in the population (exposed and non-exposed) that is due to exposure. It is the incidence of a disease in the population that would be eliminated if exposure were eliminated.

[15] Yusuf S, Hawken S, Ounpuu S, et al. (2004) Young men defined as aged 55 or under and young women defined as 65 or under. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Ontario, Canada L8L 2X2. Lancet 364: 937–52.

[16] The odds ratio is a way of comparing whether the probability of a certain event is the same for two groups. An odds ratio of 1 implies that the event is equally likely in both groups. An odds ratio greater than one implies that the event is more likely in the first group. An odds ratio less than one implies that the event is less likely in the first group.

[17] The IMS disease analyser collects data from a sample of around 100 GP practice systems, with about 2.7 million patient records. The sample includes practices from England, Wales, Scotland and Northern Ireland and has a representative UK sample by age and sex. The database holds significant clinical events relating to any period in a patient's life that has been summarised into computer records by the practice. As in any observational database, data entered by panel doctors may be incomplete.

[18] Reliable risk factors encompass factors with more complete data coverage, giving a more reliable measure of prevalence. The reliable risk factors are abnormal lipids (cholesterol above 5.0 mmol/litre), smoking or tobacco use, obesity, high blood pressure (hypertension) and diabetes.

[19] Applied to mid-2010 Office for National Statistics population estimates for England.

[20] Raised waist circumference is taken to be greater than 102 cm in men and greater than 88 cm in women.

[21] The NHS Information Centre for Health and Social Care (2010) Statistics on obesity, physical activity and diet: England, 2010. Leeds: NHS Information Centre.

[22] Franco M, Ordunez P, Caballero B et al. (2007) Impact of energy intake, physical activity, and population-wide weight loss on cardiovascular disease and diabetes mortality in Cuba, 1980–2005. American Journal of Epidemiology 166: 1374–80

[23] Zatonski A, Willet W (2005) Changes in dietary fat and declining coronary heart disease in Poland: population based study. BMJ 331: 187–8

[24] The NHS Information Centre for Health and Social care (2008) Health survey for England 2006, volume 1: cardiovascular disease and risk factors in adults. Leeds: The NHS Information Centre.

[25] Bosma H, Peter R, Siegrist J et al (1998) Two alternative job stress models and the risk of coronary heart disease. American Journal of Public Health 88: 68–74.

[26] Meets recommendations: 30 minutes or more of moderate or vigorous activity on at least 5 days a week.

[27] The NHS Information Centre for Health and Social Care (2011) Health survey for England 2010. Leeds: The NHS Information Centre.

[28] Department of Health (2011) Healthy lives, healthy people: a tobacco control plan for England. London: Department of Health.

[29] Action on Smoking and Health (2011) Smoking and mental health factsheet. London: Action on Smoking and Health.

[30] Action on Smoking and Health (2011) Tobacco and ethnic minorities factsheet. London: Action on Smoking and Health.

[31] The recommended levels are 3 units of alcohol for women and 4 units of alcohol for men.

[32] The NHS Information Centre for Health and Social Care (2008) Adult Psychiatric Morbidity Survey, 2007 Leeds: The NHS Information Centre.

[33] Babor, Higgins-Biddle, Saunders. The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care, World Health Organization AUDIT, Second Edition. General Department of Mental Health and Substance Dependence

[34] Diabetes in the UK 2010: Key statistics on diabetes. Diabetes UK, London. 2010

[35] He FJ, Nowson CA, Lucas M, MacGregor GA (2007) Increased consumption of fruit and vegetables is related to reduced risk of coronary heart disease: meta-analysis of cohort studies. Journal of Human Hypertension 21: 717–28.

[36] Laatikainen T, Critchley J, Vartiainen E et al (2005) Explaining the decline in CHD mortality in Finland between 1982 and 1997. American Journal of Epidemiology 162: 764–73.

[37] Winkleby MA, Taylor CB, Jatulis D et al. (1996) The long term effects of cardiovascular disease prevention trial: the Stanford five–city project. American Journal of Public Health 86: 1773–9.

[38] Food standards agency, Joint Health Surveys Unit, urinary sodium survey 2008, London.

[40] Primary diagnosis of ICD-10 I60-I69, HESONLINE.

[41] The Health and Social Care Information Centre (2011) Statistics on smoking: England, The Health and Social Care Information Centre: Leeds.

[42] Hospital Episode Statistics 2010/11, emergency admissions for people aged 35 years or older with a primary diagnosis of (I60-I69) in England.

[43] K.Khaw, N.Wareham, S.Bingham et al. (2008) Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study. Cambridge.