Leading heart health charity, the British Heart Foundation (BHF), has published a report highlighting the impact of deprivation, gender and ethnicity on cardiovascular disease (CVD) care. The number of people dying from cardiovascular (heart and circulatory) disease in the UK each year has almost halved since BHF began funding research and campaigning for better heart health in the 1960s. Despite this apparent progress, CVD remains the world’s biggest killer. ‘Bridging Hearts: Addressing inequalities in cardiovascular health and care’ is BHF’s first report on health inequalities, which the charity believes are contributing to the growing crisis in cardiovascular health in the UK. BHF found that CVD and the factors that drive it are more concentrated in poorer communities and affect women and people from certain ethnic backgrounds disproportionately. The difference is starkly illustrated by the fact that those in the poorest areas in England can expect to live for 20 fewer years in good health than those in the richest areas, with CVD being the single largest contributor to the gap in overall life expectancy. How does deprivation increase the risk of cardiovascular disease (CVD)? British Heart Foundation’s Bridging Hearts report finds that in every UK nation, people who are most deprived are at greater risk of dying prematurely from heart disease. The charity says that this is not inevitable, but is ‘the result of policy failure and inaction on the wider determinants of poor health, in the face of clear evidence’. People living in the most deprived communities in the UK have more risk factors for CVD, such as higher rate of obesity, which increases CVD risk factors such as atherosclerosis, high blood pressure and cholesterol, and type 2 diabetes. BHF comments that obesity rates may be driven by higher prices and inaccessibility of healthier foods and drinks, which means the most deprived 20% of the population would need to spend half their disposable income on food to meet the government’s dietary recommendations. Meanwhile there is a lack of effective NHS weight-loss services in many areas, due to restricted budgets. Smoking is another CVD risk factor affecting life expectancy, but is also more prevalent in deprived areas. As around 70% of the CVD burden in the UK is caused by modifiable risk factors, such as obesity and smoking, which are more prevalent in deprived communities, BHF believes that action to address them could reduce the inequalities in cardiovascular outcomes and early death rates. However, BHF points out that cuts to the Public Health Grant paid by the government to English local authorities for public health services, including weight management and smoking, have disproportionately affected deprived areas in England. People in deprived areas are more likely to have heart and circulatory diseases, such as high blood pressure and high cholesterol. Despite their greater need for treatment, at every step along the cardiac pathway they have less access to healthcare that could help them manage and treat their condition. Even after diagnosis, they are less able to manage their condition and adhere to medical treatment plans (such as taking statins for high cholesterol), or to access monitoring and management of their risk factors by GPs, who are disproportionately fewer, busier and poorly funded in deprived areas. Poor GP management of CVD risk factors, such as blood pressure, means patients from deprived areas tend to access care in a worse state of health. BHF points out that the rate of urgent and emergency admissions for acute CVD conditions is much higher in England’s most deprived areas, but could be avoided with better primary care. In addition, 40% of the UK’s most deprived communities have no registered defibrillators, which can be life-saving during a cardiac arrest. In 2023, BHF’s new Community Defibrillator Programme began identifying areas where access to public defibrillators is limited and, so far, has funded 300 defibrillators to fill the gaps. BHF found that after cardiac events, patients from deprived areas are less likely to access and finish cardiac rehabilitation (CR) which can help them recover, reduce the need for hospital readmission, and return to as full a life as possible. They are more likely to die young from cardiovascular disease (CVD) and to die within a year of having cardiac surgery. In 2022/23 the rate of people dying early from CVD in the UK was at its highest in more than a decade, with the early death rate from CVD in England’s most deprived areas 2.5 times higher than in the most affluent areas. How does being male or female affect CVD risk factors and the CVD care that patients receive? BHF’s report highlights that biological sex and gender ideals affect people’s CVD risks and the medical care that they receive. Men and women both experience higher risks of CVD at certain stages in their lives, whereas gender stereotyping contributes to the ‘persistent myth’ that CVD is a man’s disease, leaving patients and clinicians dangerously unaware of the risk to women of cardiovascular conditions. BHF’s report finds that more men live with and die from CVD, but women face significant barriers to receiving timely, effective care and are often misdiagnosed as a result of clinical bias and inadequate treatment and management of cardiovascular disease in women. In the UK, 7.6 million people live with CVD. Around 4 million of these are men and 3.6 million are women. Two-thirds of coronary heart disease patients in England are men, and male patients account for nearly two-thirds of all heart attack admissions each year. These statistics have contributed to a perception (which BHF calls a ‘myth’) that heart disease is not a significant health risk for women. BHF says this leaves women under-aware, under-diagnosed and under-treated, and significantly more likely to be misdiagnosed, receive lower quality treatment and have a worse prognosis than men. BHF points out that coronary heart disease kills more than twice as many women in the UK as breast cancer each year and is the leading cause of death in women worldwide. In the UK, more men live with, and die early from, CVD than women. This is due to a combination of factors, including men’s lower levels of the hormone oestrogen (which helps to control cholesterol and reduce the risk of atherosclerosis), and that men are more likely to accumulate visceral fat (a risk factor for CVD), eat poorly and smoke, but are less likely to attend NHS health checks or visit their GP. This means they are less likely to receive help with reducing their CVD risk factors such as obesity, smoking or high blood pressure. Women’s cardiovascular risk is affected by life-stage factors which do not affect men. These include early menarche, polycystic ovary syndrome, oral contraceptive medication, pregnancy complications such as pre-eclampsia, menopause-related reduction in oestrogen, or post-menopausal Takotsubo cardiomyopathy (a type of heart failure). However, BHF found that their increased CVD risk from these biological events is not reflected in their healthcare. Women are also affected differently by common risk factors for CVD for both men and women. This means that although fewer women than men smoke, smoking is more harmful for women’s cardiovascular health, and female smokers have a 25% greater risk of developing coronary heart disease than male smokers. Women with high blood pressure have poorer CVD outcomes than men, and some (but not all) studies about diabetes have found a greater CVD risk in women with diabetes than men. BHF found that, despite these greater risks, women are less likely than men to have their CVD risk factors effectively managed, women with established CVD are less likely to have their cholesterol levels properly treated, and fewer women with CVD receive prescriptions for lipid-lowering therapy. BHF warned that lack of awareness leads to under-diagnosis and inadequate treatment, and that the misperception of CVD as a man’s disease has been a significant barrier to women receiving timely and effective cardiac care. This has led women to be less aware of their cardiovascular risk and less empowered to act upon it. Research has found that women wait longer than men before contacting medical services and are less likely to call an ambulance for themselves. This is reflected in a greater risk of 30-day mortality (death) for women, demonstrating the risks of delaying time-critical care. The misperception that CVD is a man’s disease has also resulted in unconscious bias during clinical decision-making and care, leaving women inadequately treated for cardiovascular conditions. BHF noted that research had found that women in England or Wales were 50% more likely than men to receive the wrong initial diagnosis for heart attack. The report also found that misdiagnoses were driven by bias within the clinical guidelines, such as where diagnostic tests failed to account for different possible presentations of symptoms between men and women. Even when symptoms presented similarly, BHF-funded researchers found that women in England and Wales were less likely to receive the care that complies with national guidelines. This has led to women experiencing higher mortality rates than men after a heart attack, with an estimated 8,200 women’s lives needlessly lost to heart attack in England and Wales over a ten-year period, because they did not receive the same standard of care as men. BHF found that women are 59% less likely to access coronary artery bypass surgery and 24% more likely to die within one year. Women with long-term CVD were also significantly less likely to be referred to cardiac rehabilitation (CR) programmes by clinicians, or to achieve the same outcomes. Clinical under-awareness and bias, and the harm that it causes, are exacerbated by the fact that cardiovascular clinical trials tend to under-represent women. How does a person’s ethnicity increase their risk of CVD? BHF found clear evidence that there are differences in cardiovascular risk and mortality between different ethnic groups in the UK, but warned that the link between ethnicity and CVD is ‘complex and nuanced, with as many differences existing within “minority groups” in terms of cardiovascular health as there are between White and non-White groups’. Studies suggested higher rates of CVD and CVD risk factors, such as high blood pressure and stroke, particularly in South Asian and Black ethnic groups compared to White ethnic groups, with access to CVD-related care being more limited for Black ethnic groups. In relation to CVD healthcare, British Heart Foundation found that different ethnic groups have varying access to care. In primary (GP) care, people from Black and Mixed ethnic groups are also less likely to be prescribed medication, receive consistent monitoring or achieve treatment targets. Asians are more likely to be prescribed lipid-lowering therapies and receive adequate cholesterol treatment than other ethnic groups, and are more likely than other ethnic groups (except White) to have their blood pressure adequately treated. In hospital, Black people are less likely to undergo cardiac surgery, but those who do have an increased risk of death or readmission after surgery. If you or a family member have suffered severe injury as a result of medical negligence or have been contacted by HSSIB/MNSI or NHS Resolution you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.
