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Advancing a prevention agenda for cardiovascular care in Ireland

By Priscilla Lynch - 19th Mar 2023

cardiovascular care

A new report by the National Institute for Prevention and Cardiovascular Health (NIPC) and the National CVD Prevention Council (NIPC and the Irish Heart Foundation) has identified significant gaps in Ireland’s cardiovascular healthcare services.

The report outlines that cardiovascular disease (CVD) kills nearly 9,000 in people in Ireland every year, despite an estimated 80 per cent of premature CVD being preventable. Long waiting times for hospital-based services are a recognised issue in Ireland as a major barrier to effective prevention and treatment. It has been reported that waiting times for diagnostic services, such as echo and angiography, can exceed a year in some public hospitals. Even before the Covid-19 pandemic, waiting times for a first consultation with a cardiologist were as long as 14 months. Conversely, people with private insurance are often able to access diagnostic services rapidly – within a few days – driving inequalities in healthcare access and outcomes.

While Ireland has made good progress in CVD prevention and management, notes the report, the most recent national CVD strategy, which expired in 2019, has not been evaluated and is yet to be replaced. This means there is currently no overall national approach to preventing and managing this set of conditions. Furthermore, while many aspects of CVD care are being addressed through the National Clinical Heart and Stroke Programmes in the acute, community and primary care settings, there is a lack of a national co-ordinated multidisciplinary approach.

Commenting at the launch of the report earlier this month, Dr Angie Brown, Medical Director of the Irish Heart Foundation, said: “We face a groundswell of rising CVD risk factors from population ageing, obesity, to new environmental threats from climate change. These challenges will result in a growing burden of disease and pressure on our healthcare system. To avoid this, we must identify any gaps in CVD prevention and management and ensure all patients requiring services to treat CVD should have access to timely, preventive care through the development of an annually reviewed national strategy that supports our healthcare system whilst saving lives.”

Key findings

While there is a myriad of gaps in how the Irish healthcare system detects signs of CVD, notable issues outlined in the report include Ireland having the lowest rate of detection of high blood pressure in Western Europe. This is particularly worrying when considering that in 75 per cent of those that had a heart attack between 2017-2020, the heart attack was the first manifestation of CVD.

Likewise, more than 1,200 people that suffered an ischaemic stroke in 2020 were found to also have atrial fibrillation (AF). However, AF was not identified in 40 per cent of patients until they suffered the stroke. In 2015, HIQA published a health technology assessment of opportunistic AF screening in primary care, which concluded that opportunistic screening of men and women aged 65 and over in primary care, via pulse check followed by electrocardiogram, was likely to be cost-effective. Pulse checks are now included in the HSE’s Chronic Disease Management Programme (CDMP), so AF is likely to be detected more frequently as part of this programme. However, most people aged under 70 years are ineligible for the CDMP, so alternative strategies are needed to ensure more cases of AF are detected and treated before they cause a stroke, the report states.

As well as Ireland having the lowest hypertension detection rate in Western Europe, there is no specific case-finding approach for familial hypercholesterolaemia, a genetic condition which causes dangerously high cholesterol levels from birth, and an important cause of premature cardiovascular death, the report points out. FH affects around 20,000 people in Ireland, but only a very small proportion of cases have been identified. FH is not addressed in the CDMP, and detection is sporadic and generally depends on opportunistic identification of high cholesterol or awareness of family history of premature CVD death. For lipid disorders more broadly, there are very limited specialist resources (eg lipid clinics) across the country and GPs may need more support to manage lipids in primary care.

Prof Bill McEvoy, NIPC’s Research and Medical Director, commented: “The report recommends a screening programme for FH…. FH affects around one-in-200-to-250 people in Ireland, however, the majority of this goes undetected. Childhood FH screening programmes are commonplace throughout Europe.”

The report notes that Slovenia introduced an FH screening programme in 1995, making it the first country to implement such an initiative nationwide. Cholesterol levels are assessed during scheduled visits to primary care paediatricians, and children found to have elevated cholesterol are referred to a dedicated lipid clinic for genetic testing.  The programme has been identified as an EU Public Health Best Practice example for FH screening by the European Commission, alongside similar initiatives in the Czech Republic, Italy, the Netherlands, Norway, Spain, and the UK.

Initiating or escalating prevention in the acute setting

The report also details issues in the treatment and discharge of patients following the detection of CVD. These issues include long waiting times in public hospitals and the lack of tailored discharge plans for patients.

Data from Sweden show that, in the year following a heart attack, nearly one-in-five people die from a cardiovascular cause or experience a repeat heart attack or stroke. Similarly, data from Norway suggest that nearly one-in-five people will be readmitted to hospital within 90 days of discharge following an ischaemic stroke and that two-in-five will be readmitted within a year. Readmission rates in Europe for acute heart failure are over 40 per cent within one year of discharge.

For people who have been hospitalised with CVD, standardised prevention of repeat events and hospitalisations should clearly be a priority, yet many lack access to vital services in Ireland.

In hospitals, initiation of preventive services is inconsistent across regions and often falls short of national targets, and dedicated heart failure units are unequally distributed across the country, the report points out.

In addition, while access to cardiac rehabilitation is paramount to the recovery of those post-cardiac events, it has significantly declined in Ireland. A 2017 study previously identified that there was national capacity to meet only 39 per cent of the need for cardiac rehabilitation while in 2021 there was a waiting list of more than 2,800 people, with 40 per cent waiting at least three months following hospital discharge to access a programme.

The report also outlines the requirement for investment in data collection and analysis to inform the strategy, the need to expand the role of nurses and allied health professionals, and to increase access and care to disadvantaged groups. Dr Brown added that the implementation of electronic health records is a critically-important key to integration of services required for effective prevention in clinical practice.

Next steps

In response to the urgent needs identified by the report, NIPC and the National CVD Prevention Council are calling on the Government to develop a national strategy to tackle CVD.

Prof McEvoy said: “We know that there is real ambition to transform the Irish healthcare system. With Ireland’s ageing population, making the prioritisation of CVD prevention part of that transformation is more important than ever. The lack of a national strategy for what is society’s greatest killer is a significant and worrying gap. CVD is a preventable disease, yet it kills nearly 9,000 people per year. We have previously demonstrated national leadership in the space through lasting actions such as the smoking ban; we now need to recognise that more needs to be done to tackle CVD.”

The full report can be accessed at: https://nipc.ie/national-prevention-
council-report-2023/
.

Key clinical recommendations from the report

Boost biomarker usage by ensuring direct GP access and adequately resourcing laboratories

  • As part of the Enhanced Community Care initiative, GPs in Ireland can now order NT-proBNP testing for people who: Are enrolled in the CDMP with diagnosed type 2 diabetes; ischaemic heart disease or AF; or have suspected new or worsening heart failure. This is a welcome development, which should help to detect possible heart failure in people with certain risk factors and which may also improve efficiencies by avoiding unnecessary referrals for echo among people with normal NT-proBNP levels. It is crucial that this plan is fully implemented and resourced in the long-term to support early detection of heart failure and reduce avoidable hospitalisations.

Increase access to echo for people who need it

  • Following preliminary investigations, such as electrocardiogram or NT-proBNP testing, people requiring echo must be able to access the service rapidly to support timely diagnosis of heart failure or valvular heart disease and to help reduce healthcare inequalities. Plans to provide echo in community ambulatory hubs are very welcome, but this must be supported by greater investment in an adequately trained workforce, including cardiac physiologists and cardiologists with a special interest in imaging.

Support detection and management of heart valve disease in primary care through existing programmes

  • A heart murmur, indicating possible heart valve disease, can quickly and easily be detected with a stethoscope check in primary care. Stethoscope checks should be performed opportunistically during GP visits, along with the other opportunistic checks included in the CDMP.
  • People who have heart valve disease, but are not yet suitable candidates for surgery, require routine monitoring and care. This should be provided in the community care hubs or primary care by expanding the CDMP to include heart valve disease, with specialist support where needed.

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