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Coronary Heart Disease (CHD)
September 2014
Coronary Heart Disease (CHD) affects the blood supply to the heart. It occurs when a fatty substance builds
up on the wall of an artery, reducing the amount of blood, and thus oxygen, that is able to reach the heart. In
severe cases, a narrowed artery becomes blocked, causing a heart attack.
Similar to the national picture, CHD is one of the biggest killers in Islington causing around 159 deaths each
year, many are premature deaths (under 75 years) and potentially avoidable. Premature death and disability
from CHD is also a major driver of health inequality in Islington, the difference in health status between socioeconomic groups. The major risk factors for CHD are lifestyle factors such as smoking, and obesity and
physical inactivity.
Facts and figures
3,854
287
63%
people diagnosed with CHD in
Islington 2012/13
emergency hospital admissions
per year for CHD 2012/13
of people with CHD in Islington
3,780
159
People from Asian ethnic groups
people with undiagnosed CHD
in Islington 2012/13
deaths per year from CHD in
Islington 2008-10
are men
2012
are twice as likely to be
diagnosed with CHD as black
people in Islington 2011/12
Issues for Islington

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CHD is a major cause of early and potentially preventable death in Islington
Only half of the people in Islington living with CHD have been diagnosed with the condition
Early diagnosis is crucial as it allows people to access treatment early enough to reduce the impact of the
disease on their health, as well as reducing the number of early deaths.
Programmes and services
Key programmes in Islington focus on early identification and management of CHD to prevent further illness
and death in people who have the disease, as well as population interventions to reduce CHD risk factors
such as smoking, poor diet and lack of exercise.
These programmes include: NHS Health Checks Programme; Cardiac Rehabilitation Services; specialist
secondary care interventions including revascularisation procedures; Stop Smoking Services; Weight
Management Services, Exercise on Referral and the Hearty Lives Programme.
Measures for reducing inequalities
The ‘wider determinants of health’ are the social, economic and environmental conditions which influence the
health of individuals and populations. Building upon the existing work of Islington Council, Islington CCG and
other partners, the recent transition of Public Health into local government provides an opportunity to
consider what more can be done locally to reduce health inequalities by tackling the wider determinants of
health.
Alongside a focus on influencing the determinants of health, we are working to better target our services
aimed at preventing and managing long term conditions. To reduce health inequalities we work to improve
access and increase uptake for people in different age, ethnic, geographical and gender groups who may be
missing out.
 evidencehub.islington.gov.uk
Population groups
Men are at higher risk of developing CHD until women reach a post-menopausal age, at which time their risk
is similar to that of men in the same age group. People who smoke, are physically inactive or have a diet low
in fruit and vegetables and high in fat and salt are also at higher risk of developing CHD. Certain ethnic
groups, such as people of Asian and Irish backgrounds, are also at higher risk of developing CHD.
At risk groups

Men are at higher risk of
developing CHD

The risk of developing CHD
increases with age

People from Asian and Irish
ethnic groups
What are the risk factors for CHD?
Lifestyle factors such as smoking, an unhealthy diet and physical inactivity and their consequences
(becoming overweight or obese, having high cholesterol, high blood pressure and diabetes) are the major risk
factors for CHD. They not only increase the likelihood of getting the disease, but also contribute to the
progression of the disease.
Age

The risk of developing CHD increases with age, as fatty tissue builds up in the arteries over time due to
genetic conditions and lifestyle factors.
Smoking

Smoking is the primary cause of heart disease. Smoking damages the lining of the arteries, and smokers
are twice as likely to have a heart attack compared to people who have never smoked.
Unhealthy eating

Salt and fat consumption are important key risk factors for CHD, as diets which are high in saturated fat
raise the level of cholesterol in the blood, and high cholesterol is a cause of CHD. A diet high in salt is
associated with high blood pressure.
Physical inactivity

Regular activity, and in particular aerobic activity, is related to a lower incidence of CHD and its risk factors
in particular obesity, diabetes and high blood pressure.
Overweight and obesity

Obesity increases the risk of premature death as it causes diabetes, high blood pressure and high cholesterol, which are all major risk factors for CHD.
Clinical Risk Factors
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High blood pressure (hypertension) is a major risk factor for CHD. It can be caused by physical inactivity,
drinking too much alcohol, eating a diet high in salt and being overweight or obese
Having too much harmful cholesterol in the blood increases the risk of CHD. A common cause of high
blood cholesterol is the consumption of saturated fat
Diabetes tends to worsen the effect of other risk factors for CHD such as smoking, high blood pressure
and obesity.
Deprivation

High levels of deprivation are associated with higher CHD mortality. Deprivation is a mediator for many
other risk factors, such as smoking.
 evidencehub.islington.gov.uk
THE ISLINGTON PICTURE
Using surveys and data from GP practices we are able to learn more about the people living with CHD. This
information helps ensure that the appropriate treatments are available and suggests that there are many
people who do not know they have the disease. Increasing the numbers of diagnoses is important so that
people with CHD can access treatment early in order to reduce the impact on their health and the possibility
of early death.
Expected
prevalence
Diagnosed
prevalence
Estimated numbers
undiagnosed
Numbers
diagnosed
3.6%
1.7%
4,300
3,800
Who has CHD?
Diagnosed CHD prevalence by age, sex,
deprivation and ethnicity, Islington 2012
12%
higher prevalence of CHD in the most deprived
areas and 15% lower prevalence in the least
deprived areas compared to the Islington average,
adjust for age 2012
Most
Least
deprived deprived
Deprivation quintile
Islington average
0
50
100
Indirectly standardised ratio
150
22%
of people with CHD are from BME groups. This is
significantly lower than the percentage of people
from BME groups living in Islington (28%) 2012
What other long term conditions (LTCs) do people with CHD have?
Of people diagnosed with CHD, 27% have another
diagnosed LTC, 27% have two diagnosed LTCs and
32% of people with CHD are living with three or more
other LTCs.2012
Of people diagnosed with CHD, 61% also have
high blood pressure, 33% have diabetes, 20%
have chronic kidney disease (CKD) and 16%
have heart failure.2012
The large numbers of people with more than one long term condition reflects the shared risk factors common
to CHD and other Long-Term Conditions (LTCs) such as diabetes and heart failure.
 evidencehub.islington.gov.uk
Prevalence
Expected and recorded prevalence of CHD by GP practice, Islington's registered
population, aged 16+, 2012
In Islington GP practices,
prevalence of diagnosed
CHD ranges from 1.2% to
3.4%.
In most practices, the
recorded prevalence is
significantly lower than
expected.
Managing the disease
Percentage of people with CHD with uncontrolled cholesterol and uncontrolled high blood pressure
Cholesterol
11%
of people
with
uncontrolled
cholesterol
are not on a
statin
2012/13
High blood pressure
Uncontrolled
Controlled
Not recorded
76%
of the small
number of
people with
uncontrolled
high blood
pressure are not
on antihypertensives
Diagnosing CHD early is important in ensuring that potentially fatal events such as heart attacks can be
prevented. Early diagnosis also helps primary care professionals work with patients to control key risk factors
such as high blood pressure and cholesterol by prescribing medications such as statins,
anti-hypertensive drugs, and medication to prevent blood clots such as aspirin and beta-blockers. Early
diagnosis also offers an opportunity to reduce disease progression and / or disease severity.
Deaths from CHD
Cardiovascular
disease (CVD) is
the leading cause
of death.
Most CVD deaths
are due to CHD
(58%).
 evidencehub.islington.gov.uk
What do local people think?
Understanding peoples’ views and experiences of CHD and its treatments is important to future prevention
and management, and Islington is working to gather this information, for example research on local attitudes
to the NHS Health Checks Programme found that of the 304 participants, three-quarters would attend a
check if it was offered to them. In general, women were more likely to attend a health check than men, and
GP surgeries and community centers were the preferred location. The most common reason survey
participants gave for attending such a check was to improve their health.
What works?
Primary prevention and evidence-based interventions can dramatically reduce the risk of CHD.
North Karelia in Finland had the highest CVD rates in Europe 25 years ago but through rigorous
implementation of public health and individual patient level interventions CVD mortality has reduced by 50 per
cent. Analysis of CHD trends in Ireland indicates that over a 15-year period, primary prevention achieved a
two-fold larger reduction in CHD deaths than secondary prevention (management of established disease).
Primary prevention
in the general
Case finding and
early diagnosis
Secondary
prevention
Interventions to reduce the prevalence of CVD risk factors in the general
population, including smoking cessation, increasing physical activity and
healthy eating and controlling blood pressure and cholesterol.
Addressing the physical health needs of people with poor mental health is
particularly important, as research has shown that there is a high prevalence of heart disease in people with poor mental health.
Identification and assessment of patients at risk of heart disease and
management of key risk factors through appropriate advice on smoking,
diet, physical activity as well as appropriate medication, for example
through the national NHS Health Checks Programme.
Management of CHD in primary and secondary care for people with
established disease to prevent deterioration and the occurrence of acute
cardiac events such as heart attacks.
Treatment may include monitoring and control of risk factors through lifestyle advice and medication, cardiac rehabilitation and revascularisations
procedures to restore the blood flow through blocked coronary arteries.
Future need
Estimated projections of CHD prevalence are not available. While the estimated prevalence of CHD each
year has remained relatively static (and therefore the proportion of people living with CHD is not
expected to increase significantly), population projections for Islington suggest an increase in the population
over time, and therefore we can expect the number of people living with CHD to increase.
 evidencehub.islington.gov.uk
Targets and outcomes
There is a national target for the delivery of the NHS Health Checks programme and a number of targets
relating to CHD in the Quality Outcomes Framework (QOF) for general practice.
Document or
strategy that target
is taken from
Target
To offer an NHS Health Check to 20% of the eligible population
every year
There are seven QOF indicators for the prevention of CHD
including:

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

NHS Health Check
programme standards:
a framework for quality
improvement, 2014
Quality and Outcomes
Framework 2014-15
Deadline for
target
April 2015
April 2015
In whom the last blood pressure reading (measured in the
preceding 15 months) was 150/90 or less (53-93%)
Whose last measured total cholesterol (measured in the
preceding 15 months) was 5mmol/l or less (45-85%)
In whom it was recorded in the preceding 15 months that
aspirin, an alternative anti-platelet therapy, or an
anti-coagulant was being taken (56-96%)
Who have had influenza immunisation in the preceding
1 September to 31 March
With a history of myocardial infarction currently treated with
an ACE inhibitor (or ARB if ACE intolerant), aspirin or an
alternative antiplatelet therapy, beta-blocker and statin (60100%)
National and local strategies
As a major cause of premature death, CHD is a local and national priority.
NATIONAL STRATEGIES
LOCAL STRATEGIES
National Service Framework for CHD, 2000-2012
Health and Wellbeing Strategy, 2013-2016
The National Service Framework for Coronary Heart
Disease (NSF CHD), published in March 2000, set
out a strategy to modernise CHD services over ten
years. It details 12 standards (for improved
prevention, diagnosis, treatment and rehabilitation)
and goals to secure fair access to high quality
services. A revised national strategy is currently in
development.
One of the three key priorities which have been
identified by Islington’s Health and Wellbeing Board is
improving the management of long-term conditions,
which includes cardiovascular disease.
Closing the Gap: Tackling Health Inequalities in
Islington, 2010-2030
Islington’s Health Inequalities strategy highlights the
need to reduce early deaths due to CHD and includes
recommendations for reducing the gap between
recorded and expected prevalence for CHD. It also
recommends ways to tackle major risk factors for
cardiovascular disease, such as smoking, and
promotes healthy eating and physical activity.
NHS Health Check Programme
The NHS health-check programme is a national
cardiovascular screening programme which aims to
prevent coronary heart disease, diabetes and chronic
kidney disease. It includes finding people with
undiagnosed high blood pressure, so that the
condition can be treated.
Islington is responsible for the local implementation
of this national programme and due to local need
offers a check to anyone aged 35-74.
 evidencehub.islington.gov.uk
What is being done locally?
Primary prevention
There are a number of services in Islington focused on improving healthy lifestyles and health behaviours and
helping to prevent the development of long term conditions such as CHD. The services include:
 Weight Management Services for people aged 18+ with a body mass index (BMI) >30 (or >27.5 for
south Asian people)

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Exercise on Referral services for people at high risk of cardiovascular disease or individuals with
diagnosed long-term conditions
Stop Smoking Services are available in GP practices, as well as pharmacies and community locations
and are available to anyone living, working or studying in Islington who smokes
Alcohol Screening & Advice is available to all residents via primary care providers and
dontbottleitup.org.uk an alcohol self-help website provided by Islington Public Health. Structured expert
support is also available from Islington Community Alcohol Service
Hearty Lives Islington is a £100,000 three year Project funded by the British Heart Foundation (BHF).
The project aims to impact on health inequalities in the borough by tackling areas relating to heart health.
There are three strands; healthy catering commitment, workplace health and community engagement
Broad programmes of work in collaboration with multiple stakeholders to encourage increased levels of
physical activity and healthy eating in the population.
Case finding and early diagnosis

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NHS Health Checks programme: The programme is designed to prevent heart disease, stroke, diabetes
and kidney disease by identifying and treating people at high risk through targeting 35-74 year olds.
During the Health Check individuals are also offered lifestyle advice. Between 1st April 2013 and 1st June
2014 39,319 checks have been delivered in Islington in general practices, pharmacies and outreach
community centres. Health checks have been proved to be effective for case-finding CHD; between April
2011 and March 2012 51 new diagnoses of CHD and Myocardial Infarction (MI) were made following a
health check
Closing the prevalence gap: This programme involves GP practices identifying those people on their
practice register who are at greater risk of certain conditions including HBP, a major risk factor for CHD.
Individuals found to have previously undiagnosed conditions will be followed up and managed in primary
care and referred to lifestyle services as appropriate.
Cardiac Rehabilitation
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Cardiac rehabilitation consists of four phases and is suitable for the majority of people with acute coronary
syndromes, post vascularisation, newly diagnosed angina, heart failure, established stable angina and
valve and other cardiac surgery. In Islington, phases I-III are offered by two local hospitals (The
Whittington and UCLH), and phase IV is available from Aquaterra Leisure. Phase IV is the final stage of
cardiac rehabilitation and involves an extended exercise programme to help maintain physical activity and
lifestyle changes for the long term
Evidence suggests that people who receive cardiac rehabilitation have a 26% relative reduction in cardiac
mortality over the following five years. In 2013/14, 68 referrals were received by the cardiac rehabilitation
service, an increase on the 63 referrals received in 2012/13. All referrals met the criteria for Phase IV
cardiac rehabilitation and 62 individuals started the programme. However, there was a 27% drop-out rate
with only 44 individuals completing the course
There has however been a significant drop in the number of referrals to the cardiac rehabilitation service
in the past two years. Considerable work is required to raise awareness among health professionals and
the public of the availability of this service and its benefits to meet the annual target of 115 referrals.
 evidencehub.islington.gov.uk
Further information
Further information on this topic can be found at the following locations:
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British Heart Foundation, 0300 330 3311 www.bhf.org.uk
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Hearty Lives http://www.islington.gov.uk/islington/news-events/council-news/Pages/hearty-lives.aspx

Coronary Heart Disease: national service framework for coronary heart disease—modern standards
and service models. Department of Health, 2000 www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_4094275

The NHS Health Checks Programme www.healthcheck.nhs.uk
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NHS Islington (2012) Annual Public Health Report 2012: One too many? http://www.islington.gov.uk/
publicrecords/library/Public-health/Quality-and-performance/Reporting/2012-2013/(2012-11-14)-APHR2012-Full-report.pdf
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NHS Islington/Islington Council (2010) Closing the Gap. Tackling Health Inequalities in Islington 20102030 www.islington.gov.uk/publicrecords/library/Democracy/Quality-and-performance/Reporting/20112012/(2012-03-03)-NHS-Islington.pdf
Contact information:
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Weight Management: www.aquaterra.org/activities/aquaterra-rebalance-weight-management
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Alcohol Screening & Advice: www.dontbottleitup.org.uk or call 0808 800 0019
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Stop Smoking Services: www.smokefreeislington.nhs.uk/ or call 0800 093 9030
About the Evidence Hub
The Evidence Hub is a partnership between the local NHS and Islington Council that brings together
information held across different organisations into one accessible place. It provides access to evidence,
intelligence and data on the current and anticipated needs of the Islington population and is designed to be
used by a broad range of audiences including practitioners, researchers, commissioners, policy makers,
Councillors, students and the general public.
This profile has been produced by Polly Reynolds, Assistant Public Health Strategist and signed off by Liz
Brutus, Assistant Director of Public Health.
For more information contact [email protected] or call 020 7527 8086.
© Islington Public Health
 evidencehub.islington.gov.uk