Council Agenda
Enclosure 5
British Cardiovascular Society Working Group for Women’s Heart Health
Annual Report 2007
Chair: Jane Flint
Membership: Alex Callaghan (BHF)
Bernie Downey (BACR)
Ghada Mikhail (Her at Heart)
Janet McComb (HRUK)
Vahini Naidoo (Women’s Heart Alliance, BNCS)
Michaela Nuttall (BANCC)
Carol Reilly (HCP UK, Cardiac Networks)
Lip Bun Tan (Maternal Cardiovascular Disease)
Fiona Walker (RCOG 51st Study Group)
Our Working Group has brought together the several enthusiastic faculties presenting work on cardiovascular and other heart disease in women during the last eighteen months, along with particularly supportive affiliated groups, to summarise 12 Key British Recommendations on prevention and management. Approved by Council in March, a joint affiliated groups’ session under the auspices of BANCC, with HCP UK, BACR, and BHF sponsorship, is being held during the ASC on 6th June to explore implementation. A full document is in preparation, and acknowledgement will be made of all significant contributions.
The Recommendations cover awareness and education on gender-specific issues in cardiovascular disease, particular risk assessment in women including those of reproductive age, referral for appropriate investigation of symptoms where heart disease cannot be excluded, and diversity impact assessment of care pathways, with development of individualised care plans.
A national registry of all cardiac patients is recommended. Women should be proportionately represented in clinical trials, and gender-specific research encouraged where necessary. The RCOG 51st Study Group recommendations on management of pregnancy in women with heart disease will be recognised. Gender-sensitive cardiac prevention and rehabilitation with counselling on psychosocial issues should be reflected in commissioning statements reviewed in all Cardiac Networks to optimise services or women with heart disease and reduce any remaining inequalities with regard to age, disability, ethnicity, or gender.
The European Heart Health Charter and British Cardiovascular Society Working Group Recommendations for Women’s Heart Health
Jane Flint BSc MD FRCP
Chair of Working Group
The launch of the European Heart Health Charter is timely for the UK where we are reflecting on the achievements of our National Service Framework for Coronary Heart Disease, the significant areas of inequality of services which remain, and the now more joined-up drive to prevent as much overall cardiovascular disease as possible. Our British Cardiovascular Society’s Working Group for Women’s Heart Health welcomes this contextual document emphasising the higher percentage of women (55% of all fatal deaths) than men (43% of all fatal deaths) and the higher mortality among those of lower socio-economic position from cardiovascular disease across Europe.
Consultation with our patients and public about women’s heart health and rehabilitation advises that awareness, education, prevention and rehabilitation are now the highest items on their agenda, reflecting Articles 12 to 15 of the European Charter. Although we have made an impact in the UK with implementation of our NSF, there is much still to do with cardiac rehabilitation and stroke services. The high level EU Council Conclusion 2004 and Luxemberg declaration 2005 on promoting cardiovascular healthcare emphasise the importance of acting at both population and individual level within a community to identify individuals at high risk. Our primary care CVD Risk Registers now exceed our actual CVD Registers but we have no room for complacency, and article 18 of the Charter reminds us to review the extent of implementation, a lesson we might take on board with cardiac rehabilitation and preventive services particularly. Article 11 encourages heart health alliances which we have constituted within our Working Group for Women’s Heart Health with British Cardiovascular Society Affiliated Groups BANCC, BACR, HCP UK; British Heart Foundation, Cardiac Network Patient and Carer Partnerships, Her at Heart, PCTs, RCOG, and Women’s Heart Alliance to make recommendations.
The 12 Key BCS Working Group Recommendations for Women’s Heart Health follow a care pathway approach, emphasising life course (Charter Article 6) starting in utero with appropriate care of pregnant women, earlier diagnosis, appropriate management, rehabilitation and prevention (Article 7). European Charter Article 8: “There is a need to be sensitive to gender-specific aspects of cardiovascular health and disease” is our raison d’etre, and we recommend diversity impact assessment of care pathways, with development of individualised care plans. Our further response to Articles 9 and 10 on national policy is to recommend a national registry of all cardiac patients extending our CCAD associated databases, and facilitating further audit. Addressing Article 16 on research including “the cardiovascular vulnerability of women” we demand that women should be proportionately represented in clinical trials, and gender-specific research encouraged where women show an increased MACE rate. As our brief includes all heart disease, the RCOG 51st Study Group Consensus Statement on management of pregnancy in women with heart disease is recognised. As well as the main risk factors, which relate to lifestyle, eating habits and physical activity, the factors of obesity, diabetes mellitus, excess alcohol consumption and psychosocial stress are also given emphasis in Articles 3 and 4, as we recommend are reflected in women’s best risk assessment process. Our NSFs, NICE, HCC, Equality and Smoking legislation all support Article 5 on national policy. Article 2 of the Charter recommends signatories to promote and support measures giving priority to lifestyle orientated interventions that will considerably help reduce the burden of cardiovascular disease. Our Working Group has stated that gender-sensitive cardiac prevention and rehabilitation with counselling on psychosocial issues should be reflected in commissioning statements reviewed in all Cardiac Networks to optimise services for women with heart disease and reduce any remaining inequalities with regard to age, disability, ethnicity or gender.
The European Charter reflects on how economic development is impaired in countries with high rates of CVD, production losses due to CVD mortality and morbidity cost the EU over €35 billion, 21% of total cost of those diseases. Our financial case for expanding services further should allow recognition of the longer-term cost:benefit analysis for so doing.
EJF 12 May 2007
British Cardiovascular Society Working Group Key Recommendations for Women’s Heart Health
1. Raise awareness of gender-specific issues in cardiovascular and heart disease through educational activities among health professionals, patients and public, facilitated by committed BCS affiliated groups – BACR, BANCC, BNCS, HCP UK and member cardiac patient associations, PCCS; British Heart Foundation, Cardiac Network Patient and Carer Partnerships, Her at Heart, PCTs, RCOG, Women’s Heart Alliance.
2. The risk assessment process should be tailored for women, in particular reflecting the risks associated with diabetes, obesity, ageing, smoking history, lack of exercise, but also extended in preventive advice to younger women including those of reproductive age to influence favourably the health of the next generation.
3. Women with suspected heart disease, or presenting with symptoms where heart
disease cannot be excluded, should be offered support, counselling, risk assessment and timely referral for specialist investigation by a Cardiologist regardless of age, disability or ethnicity.
4. All clinical guidelines and integrated care pathways for patients with cardiac conditions should be reviewed using a Diversity Impact Assessment Tool to ensure fair and equitable access to services, facilities, information and staff, and individualised care plans evolved.
5. Diagnostic methods should be used which are evidence-based and cost-effective, such as myocardial perfusion scintigraphy in diagnosis and risk assessment of coronary heart disease and echocardiography in heart failure.
6. A national registry of all cardiac patients should evolve from current PCT held registers, MINAP and CCAD linked databases including the primary PCI dataset, and pregnancy data in women with heart disease, adequate fields facilitating audit with gender analysis.
7. Treatments should be improved by stimulating gender-specific research into medications and interventions where gender specific issues of efficacy, tolerance, bleeding risk, torsades, heart failure, and increased MACE (major adverse cardiac events) rate exist in particular conditions and where there is a history of maternal cardiovascular disease.
8. Women should be appropriately represented in clinical trials, recruitment and retention issues addressed, gender analysis should be considered in the design and analysis of studies, and research presentation attracted in national BCS ASC sessions.
9. All women of reproductive age with congenital or acquired heart disease should have access to specialised multidisciplinary preconception counselling, and once pregnant, clinical assessment by the specialist high risk obstetric team, both including a Cardiologist, followed up by appropriate DGH or tertiary care according to individual management plan within a network of care.
10. Health Economy plans for Cardiac Rehabilitation should link with Cardiac Network Strategy to provide gender-sensitive, menu-driven rehabilitation services defined in individual care plans promoting longer term attendance and patient empowerment.
11. Counselling of women with heart disease should be gender-sensitive; psycho-social considerations including appropriate self-prioritisation should be afforded appropriate individual relevance.
12. Commissioning statements should be reviewed in all Cardiac Networks to optimise services for women with heart disease and reduce any remaining inequalities with regard to age, disability, ethnicity or gender.
EJF/Draft 3 Mar 2007
1.1 A Working Group of the British Cardiovascular Society has been brought together representing the Faculties promoting awareness of, and education about cardiovascular disease in women. European and World calls for action demand that every nation responds to summarise their approach to the issue, and this report presents the progress, Key Recommendations based upon evidence, and strategy for implementation within the UK.
1.2 Affiliated Groups of the Society, in particular the British Association for Nurses in Cardiac Care (BANCC), the British Association for Cardiac Rehabilitation (BACR), the British Nuclear Cardiology Society (BNCS) and Heart Care Partnership UK (HCP UK) have all highlighted relevant issues during their proceedings for health professionals and patients within the last decade. The British Heart Foundation (BHF) has campaigned recurrently in the public arena.
1.3 Recent Faculties constituting ‘Her at Heart’, the Women’s Heart Alliance, and the 51st Study Group of the Royal College of Obstetricians and Gynaecologists (RCOG), supported by a group concerned to see further research on maternal cardiovascular disease, have focussed on the need for Recommendations.
1.4 The emerging 12 Key Recommendations reflect current NHS standards of practice evolved within our National Service Framework for Coronary Heart Disease, Arrhythmias and Grown Up Congenital Heart Disease, NICE guidance affecting patients with heart disease, and comply with the national priority to reduce inequalities in healthcare and the 2006 Equality Act. Their launch with the European Heart Health Charter adds value to both documents.
1.5 A referenced summary of essential evidence is presented in each section to back up each recommendation, epidemiological issues of relevance raised to guide future direction and underpin the required approach by professional, patient/carer and lay groups across the whole community.
1.6 WHO statistics show that not only is cardiovascular disease (CVD) the leading cause of mortality, but more women than men die from this cause. Paradoxically, there is a serious misperception inverting the actual 36% UK CVD and 4% UK breast cancer mortalities in women.
1.7 Women and even their professional carers do not know that the greatest health threat to women is heart disease, women are less likely to receive aggressive management for both heart disease and stroke than men, and there is a significant evidence gap regarding efficacy of treatment and intervention compared to what is known in men.
1.8 Younger women have a lower prevalence than men of cardiovascular disease, and
although death rates have been falling since the late 1970s, the fall has been slower in the 35-44 age group and compared to men. Ethnic minority women fare particularly badly and are less aware of their risk.
1.9 Recommendation 1. calls for a wide educational campaign across society, inclusion
within the training syllabus for all health professionals, and giving empowerment to patient/carer and lay groups to spread awareness, the concept of risk and potential for prevention – a major priority among the patient/carer and lay groups consulted.
1.10 School curricula in Science, PSHE, and Psychology should include reference to
gender-specific health problems including heart disease, and a guide to healthy living, with the concept of what may eg cardiovascular disease, and may not be prevented eg congenital heart disease. Assessment of understanding may be made from Key Stage 3 onwards.
1.11 Medical school, postgraduate courses, and training programmes for allied health professionals should extend knowledge beyond just heart disease in pregnancy to include cardiovascular and congenital heart disease, arrhythmias with predominant female incidence of both supraventricular tachycardia and torsades de point, and heart failure from all causes including cardiomyopathy. The need for further research may be usefully emphasised in these fora (see Sections 7, 8).
1.12 Both patients and professionals should reach out to community organisations, eg Women’s Institutes, Suroptomist International, targeting female but also general audiences to raise general awareness of true cardiovascular risk and possibilities for prevention (see also Section 2). Cardiac Network Patient and Carer Partnerships and PCTs provide an ideal inroad, and may facilitate education regarding expected care pathways (see Sections 3, 4, 5, 7, 9, 10, 11)
1.13 The British Cardiovascular Society, its affiliated groups, the British Heart Foundation, RCP, RCOG, Her at Heart and Women’s Heart Alliance should work in partnership to spread appropriate educational materials. Internationally accepted guidelines should be disseminated (see Section 2).
2.1 The UK cardiovascular disease (CVD) mortality in 2004 stood at 36% for women as
compared with 37% for men. The prevalence and incidence of CVD in both men and women have been shown to increase with age. Pre-menopausal women are known to have a lower risk of developing CVD largely because of the protective effects of oestrogens. In younger women, therefore, the prevalence of coronary heart disease (CHD) is lower in women compared to men. In the older age group, however, this gender difference narrows. In the UK, death rates from CHD have been falling since the late 1970s with a slower fall in younger age groups, and a faster rate in those aged 55 years and above. Between 1994 and 2004, there was a 56% fall in death rate in women aged 55-64 years (compared to a 49% fall in men), and a 20% fall in those aged 35-44 years (compared to a 30% fall in men). South Asians living in the UK are known to have a higher premature death rate from CHD. The rate is 46% higher for men and 51% higher for women.