Cardiovascular disease is one of the leading causes or morbidity and mortality in the Hampshire and Isle of Wight Integrated Care System (ICS) and is a key priority for Hampshire and Isle of Wight Integrated Care Board (ICB). 

Prevention of cardiovascular disease and the reduction of healthcare inequalities for people living with cardiovascular disease is therefore a key area of focus for GP practices and Primary Care Network (PCN) teams.

The aim of this website page is to signpost healthcare professionals to key information and resources to support the delivery of CVD prevention work in Hampshire and Isle of Wight.

How do I find my data?
The Cardiovascular Disease Prevention Audit (CVDPREVENT) is a national primary care audit that automatically extracts data from GP clinical systems and provides clear data and insights into our population: CVDPREVENT

In Hampshire and Isle of Wight we are fortunate to have this data presented in an alternative format making finding your data even easier. You can access this here: HIOW CVDPREVENT | Tableau Public

If you would like to discuss your data, or need some support in understanding it, please speak to a member of the medicines optimisation team.

The ‘Healthy Hearts’ section of our website also contains some useful resources for patients and healthcare professionals: Healthy Hearts :: NHS Hampshire and Isle of Wight (icb.nhs.uk)

The Wessex Health Innovation Network (HIN) hosts a variety of helpful resources including educational videos, publications and links to national programmes: CVD - Cardiovascular Disease | Health Innovation Wessex

NHS England information on the national CVD plan: NHS England » Cardiovascular disease (CVD)

NHS Benchmarking have created a useful infographic to show the results of the annual CVD Prevent report CVDP annual audit report and also a patient and public report CVDPREVENT March 2022
 

Anticoagulation therapy is a critical component of preventing and managing thromboembolic conditions in England, particularly in patients with Atrial Fibrillation (AF), Venous Thromboembolism (VTE), and those at high risk of stroke. 

With AF affecting over 1.5 million people in England and increasing the risk of stroke fivefold, the effective use of anticoagulation is essential to reducing preventable deaths and disability.

Despite the availability of highly effective therapies, including direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs), significant gaps remain in anticoagulation coverage. National audits reveal that up to one-third of eligible patients with AF remain untreated, leaving them at a higher risk of life-threatening strokes. 

Primary care teams are at the forefront of improving anticoagulation management. This involves identifying patients at risk, initiating appropriate therapy based on clinical guidelines, and conducting regular monitoring to ensure safety and efficacy. 

Tools such as CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk, ORBIT Bleeding Risk Score for Atrial Fibrillation, HAS-BLED Score for Major Bleeding Risk, enable clinicians to balance the benefits of stroke prevention with the risks of bleeding, ensuring a personalized approach to care.

Through a collaborative effort across primary and secondary care, alongside effective use of anticoagulation pathways and patient education, we can optimize treatment outcomes and significantly reduce the burden of thromboembolic disease in England.

For further information and support tools please check the following resources: 

PrescQIPP resources: (will require PrescQIPP log in) 

Atrial Fibrillation (AF) is the most common cardiac arrhythmia, affecting approximately 1.5 million people in England.  and can lead to serious health conditions. 

It significantly increases the risk of stroke, with AF-related strokes often being more severe and associated with higher mortality and long-term disability compared to non-AF strokes. Despite its prevalence and impact, AF frequently goes undiagnosed, with an estimated 270,000 people in England living with undetected AF.

The NHS Long Term Plan prioritizes improving AF detection and management as part of a broader strategy to prevent cardiovascular disease and reduce health inequalities.

AF is more common in older people, with prevalence increasing to over 10% for those over 80. The risk of stroke increases with age and other health conditions like high blood pressure or diabetes. 

Primary care teams play a pivotal role in case finding, diagnosis, and management. Opportunistic pulse checks during routine consultations and the use of validated devices for detecting irregular heart rhythms can help identify undiagnosed cases. 

Once diagnosed, managing AF requires a structured approach, including stroke risk assessment using tools such as CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk, initiation of anticoagulation therapy where appropriate, NHS England » Commissioning recommendations for national procurement for direct-acting oral anticoagulant(s) (DOACs) and symptom control strategies.

Integrated care pathways, collaboration with secondary care, and patient education are essential for optimizing AF outcomes. By focusing on early diagnosis and evidence-based management, clinicians can reduce the risk of AF-related complications and improve quality of life for patients.
 

Chronic kidney disease (CKD) is a common condition affecting around 9% of people globally. The prevalence is expected to continue to increase due to an ageing population and a higher incidence of diseases such as type 2 diabetes and hypertension.

CKD can lead to complications including acute kidney injury, hypertension, dyslipidaemia, cardiovascular disease and end-stage kidney disease.

The management of patients with CKD is another important role for primary care healthcare professionals.

For more information, please visit the following resources:

Identification of people at high risk of FH is a key priority of the NHS England national cardiovascular disease (CVD) programme and the NHS long term plan.

Health Innovation Wessex, PRIMIS and NHS Hampshire and Isle of Wight conducted a collaborative project to identify patients at high risk of FH, and to refer them onto the Wessex Genetics Service so that these patients could be found and treated to avoid future cardiac related events. You can read about this here: FAMCAT Case study Final 12-7-24.pdf (healthinnovationwessex.org.uk)

To find out more about how you can find patients at high risk of FH in your practice population please see here: Familial Hypercholesterolaemia (healthinnovationwessex.org.uk)

Overview | Familial hypercholesterolaemia: identification and management | Guidance | NICE
 

CVD is strongly associated with health inequalities in England. People in the most deprived areas are almost four times more likely to die prematurely from CVD than those in the least deprived areas.

High risk conditions include atrial fibrillation, high blood pressure and raised cholesterol

  • Black and other non- white ethnicities are less likely to receive the recommended treatment of anticoagulation
  • Black ethnic groups are likely to have poorly controlled blood pressure
  • Females are less likely than males to be prescribed lipid lowering therapies and are less likely to achieve optimal management

Use data insights to identify worsening inequality gaps in and devise interventions to level up and close these gaps – contact the medicines optimisation team if you would like some support in understanding your data.

For more information, please visit the following resources:

The prevalence of heart failure in the UK is estimated to be around:

  • 1 in 35 people 65–74 years of age.
  • 1 in 15 people 75–84 years of age.
  • Just over 1 in 7 people 85 years of age or older

A holistic approach to the management of patients with heart failure is vitally important, and primary care colleagues (including pharmacy teams) are increasingly involved in this. 

If you would like to know more about the management of chronic heart failure, you may find the following resources useful:

Hypertension, or high blood pressure, is one of the leading preventable causes of cardiovascular disease and mortality in England. Affecting nearly 13.5 million adults, it is often referred to as the "silent killer" due to its asymptomatic nature and significant contribution to stroke, heart disease, and kidney failure. Despite its prevalence, over 4 million people remain undiagnosed, highlighting the need for improved detection and management.

GP’s and Primary care teams play a central role in tackling hypertension as part of the NHS Long Term Plan, which aims to prevent 150,000 heart attacks, strokes, and dementia cases by 2030. 

Through integrated care pathways, primary care teams, community pharmacists, and secondary care specialists play a vital role in detecting, diagnosing, and managing hypertension. 

Effective management starts with identifying individuals at risk, leveraging regular health checks, and promoting opportunistic screening during routine consultations.

Emphasizing early intervention, lifestyle changes, and adherence to evidence-based treatments can significantly reduce complications and improve patient outcomes.

For more information about hypertension, its diagnosis, management, monitoring and to support with NHS Long Term Plan 2024/25 priorities and operational planning guidance please visit the following resources: 

Lipid management is a cornerstone of cardiovascular disease (CVD) prevention in England, where heart disease and stroke remain leading causes of morbidity and mortality. Elevated cholesterol levels, particularly low-density lipoprotein cholesterol (LDL-C), significantly contribute to atherosclerosis and cardiovascular risk. 

It is estimated that over 6 million adults in England live with high cholesterol, with many unaware of their condition or untreated, leaving them at increased risk of heart attacks and strokes.

As part of the NHS Long Term Plan 2024/25 priorities and operational planning guidance, lipid management has been identified as a critical area for intervention to reduce the burden of CVD. 

The ambition is to prevent 150,000 heart attacks, strokes, and cases of vascular dementia by 2030. 

Primary care and integrated care teams play a pivotal role in achieving this goal through systematic identification of patients at risk, lipid profiling, and targeted interventions.

Effective lipid management encompasses lifestyle modification, including diet, exercise, and smoking cessation, alongside pharmacological treatments. 

National frameworks, including the NICE lipid modification guidelines, provide evidence-based pathways to support clinicians in optimising care.

By focusing on high-risk populations, such as those with familial hypercholesterolemia (FH), diabetes, or established CVD, utilising tools like QRISK3 for risk stratification, clinicians can deliver proactive and personalized care, reducing the burden of CVD and improving outcomes for patients.

For more information about Lipid Management please visit the following resources: 

  • An active lifestyle lowers the risk of both depression and early death by 30% and reduces the risk of major illness by up to 50%.
  • In the United Kingdom, physical inactivity is the fourth greatest cause of ill health with negative impacts on health, social and economic outcomes for individuals and communities. It is responsible for 1 in 6 UK deaths, which is equivalent to smoking. Importantly, up to 40% of long-term conditions could be prevented if everyone met the UK Chief Medical Officer’s physical activity recommendations.
  • One person dies of physical inactivity every 15 minutes – that is more than cigarette smoking – causing 1 in 6 deaths in the UK
  • Healthcare professionals have always been considered well placed to provide physical activity advice to patients. 25% of patients would be more active if advised by a healthcare professional. 
  • The benefits of physical activity outweigh the risks. Physical activity is safe, even for people living with symptoms from multiple medical conditions. 

Energise Me is working across Hampshire and the Isle of Wight to tackle the things that prevent active lifestyles, and healthcare professionals play a key role in this mission to support our communities to move more. Contact aimee.cadman@energiseme.org to hear the support and training opportunities available for you to improve your knowledge and confidence in supporting others to be physically active. 

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