The burden of coronary heart disease (CHD) is higher in the UK than in many other countries. More than 110,000 people die from CHD in England every year, of whom 41,000 are aged under 75 years. About 300,000 people in the UK have heart attacks every year and over 1.4 million suffer from angina. CHD accounts for about 3% of all hospital admissions in England. Angina, heart attack and stroke are all more common amongst those in manual social classes. There are also ethnic variations, for people born in the Indian sub-continent, the death rate from heart disease is 38% higher for men and 43% higher for women than rates for the country as a whole.

The National Service Framework (NSF) for Coronary Heart Disease sets out the standards and services that should be available throughout England. It recognises the importance of prevention and primary care as well as the contribution of the more specialised services. The NSF establishes 12 standards for the prevention, diagnosis and treatment of CHD. In order to deliver these standards a variety of measures are included in the NSF, for example:

• local delivery plans reflected in Health Improvement Programmes and long term service agreements
  
  
• PCG/Ts, NHS trusts and health authorities forming local networks of cardiac care and agreeing referral criteria and care pathways.

Milestones have been identified for each standard that are intended to foster a process of continuous improvement. Examples of milestones and goals for primary care include:

• by April 2002 a protocol describing the systematic assessment, treatment and follow-up of people with CHD has been agreed locally and is used to provide structured care to people with CHD
  
  
• by April 2003 clinical audit data, no more than 12 months old, are available that describe the use of relevant effective interventions in angina and heart failure.
  

People with established cardiovascular disease and others at high risk of a future cardiovascular event should be identified and offered advice and treatment. Two recent MeReC Bulletins1,2 describe in detail the approach to cardiovascular risk assessment and the risk assessment tools recommended in the NSF for CHD. Risk assessment tools should not be used for people with pre-existing cardiovascular disease. The Joint British Societies Coronary Risk Prediction charts can also be found at the back of the current BNF.

Supporting smokers who wish to stop is an immediate priority. Bupropion (amfebutamone) and nicotine replacement therapy products (NRT) are now available on NHS prescription. The Committee on Safety of Medicines has recently alerted prescribers to the modified dosage and safety precautions for bupropion to minimise the risk of adverse effects and reduce the risk of seizures3. Prescribing of bupropion has increased gradually since its introduction in summer 2000, reaching 114,000 prescriptions for the quarter to December 2000 costing £4.5 million. NICE will publish an appraisal of NRT and bupropion later this year. From April 2001 nurse prescribers have also been able to prescribe NRT.

The NSF for CHD recommends interventions for people with diagnosed CHD including:

• advice about how to stop smoking (including NRT)
• information about other modifiable risk factors
• advice and treatment to maintain blood pressure below 140/85 mmHg
• low dose aspirin (75mg daily)
• statins and dietary advice to lower serum cholesterol concentrations to either less than 5mmol/l or by 30% (whichever is greater)
• ACE inhibitors for people who also have left ventricular dysfunction
• beta-blockers for people who have also had a myocardial infarction
• warfarin or aspirin for people over 60 years old who also have atrial fibrillation
• meticulous control of blood pressure and blood glucose in people who also have diabetes.

A NICE Clinical Guideline4 makes recommendations for patients who have experienced a myocardial infarction (MI) and has the aim of decreasing subsequent premature mortality. Patients with prior MI who do not have heart failure should be offered long-term treatment firstly with a beta-blocker and an antiplatelet drug (aspirin) and then with a statin and an ACE inhibitor. Calcium-channel blockers, nitrates and potassium-channel activators have no effect on premature mortality making their role the management of symptoms and risk factors (principally hypertension). Patients with prior MI and heart failure should be offered long term treatment with an ACE inhibitor and then a beta-blocker. Beta-blocker treatment should be started at low doses and should be slowly increased. In addition these patients should be treated with an antiplatelet drug. Those patients who have moderate or severe heart failure should also be treated with spironolactone.

Prescribing of cardiovascular drugs reached 34.0 million prescriptions (£329.8 million) for the quarter to December 2000. Prescribing of lipid-regulating drugs, antiplatelet drugs and renin-angiotensin system drugs (Chart 1) has shown the greatest increase. Not surprisingly cost has also risen (Chart 2): more is now spent on lipid-regulating drugs and renin-angiotensin system drugs than any other cardiovascular drugs. The following prescribing data are given for the quarter to December 2000 unless otherwise indicated.

References

1. Anonymous. Assessing cardiovascular risk (part 1). MeReC Bulletin 2000; 11: 25-28
   
2. Anonymous. Assessing cardiovascular risk (part 2). MeReC Bulletin 2000; 11: 29-32
   
3. A Breckenridge. CMO's Urgent Communication CEM/CMO/2001/07. May 2001
   
4. Clinical Guideline A Prophylaxis for patients who have experienced a myocardial infarction. National Institute for Clinical Excellence, April 2001
   
5. B Pitt et al. The effects of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999; 341: 709-717
   
   
6. C Mulrow & R Jackson. What are the effects of drug treatment in primary hypertension? Primary Prevention, Clinical Evidence Issue 4, BMJ Publishing Group, Dec 2000: 66-69