Convenient cardiac care

With coronary heart disease being the UK’s single biggest cause of premature death, new technology is being introduced throughout England to tackle the issue. And there’s a role for pharmacy teams in all four home nations, too

The ‘NHS Long Term Plan’, published in January 2019, aimed to reduce the number of heart attacks and strokes by 150,000, as well as promising that patients would benefit from cutting-edge therapies and techniques. But not much progress has been made. During the pandemic, the waiting times for cardiac diagnosis and treatments have escalated, rather than reduced.

According to the British Heart Foundation’s ‘The Tip of the Iceberg’ briefing in May 2021, there were 5,800 more deaths than would be expected (excess deaths) from conditions including heart attack and stroke in England during the first year of the pandemic, despite the NHS working harder than ever. Around 131,000 (28 per cent) fewer heart procedures and operations were performed in England during the first year of the pandemic, and there has been a 180-fold increase in the number of people waiting more than a year for heart procedures, including surgery. GP referrals to specialist heart doctors in England fell by nearly a third in 2020.

As part of the plan to combat this, in May 2021, NHS England announced the roll-out of HeartFlow – a test that involves safe, revolutionary 3D heart scans to diagnose and treat around 100,000 patients with suspected heart disease, five times faster than normal. According to NHS England, around 100,000 people are eligible to use HeartFlow over the next three years, with more than 35,000 people set to benefit each year. But will this new technology help to cut the reported backlog of care and aid NHS recovery from the disruption caused by the pandemic?

Heart disease diagnosis

According to the British Heart Foundation, there are currently 1.9 million people living with coronary heart disease (CHD) in England. Coronary heart disease is one of the country’s leading causes of death and the single biggest cause of premature death. It develops when the arteries leading to the heart narrow, reducing blood flow, or become blocked. This can cause chest pain and heart attacks. When someone has stable chest pain, the main initial test is currently a computed tomography (CT) coronary angiography – also known as an angiogram or cardiac catheterisation – which is an invasive and time-consuming procedure.

“Historically, investigations for coronary heart disease involved one or another form of stress testing as the first port of call,” says Dr Campbell Rogers, executive vice president and chief medical officer at HeartFlow. “But results from these tests often proved inconclusive and required further invasive angiograms to help clinicians make a diagnosis. These invasive procedures come with a certain amount of risk and prove, in retrospect, to have been unnecessary for many patients found to have no obstructive coronary heart disease.”

In February 2021, the National Institute for Health and Care Excellence (NICE) ‘Impact Cardiovascular Disease Management’ report recommended HeartFlow analysis as one of several non-invasive tests to improve the speed and accuracy of cardiovascular disease diagnosis. While the number of people having HeartFlow analysis has increased in recent years, the NHS Accelerated Access Collaborative estimates that less than 20 per cent of eligible people currently have these tests. NICE estimates that around 89,300 people with stable, recent-onset chest pain who are offered an angiogram as part of its chest pain pathway will be eligible for HeartFlow instead.

“It is good to see wider access and roll-out of technology that can more accurately assess the severity of coronary disease by a CT scan across the NHS,” says Professor Nilesh Samani, British Heart Foundation medical director. “This will benefit patients and the NHS by preventing unnecessary admissions for angiograms and quickly providing information that allows patients to be put on the best treatment pathway for their condition. This is particularly important at a time when we are dealing with the challenges that Covid-19 has caused to the delivery of normal care to patients with heart and circulatory diseases.”

How does HeartFlow work?

HeartFlow turns a regular, quick and easy CT scan of the heart into a 3D image of the patient’s coronary arteries using mathematical algorithms and input from highly trained analysts. Doctors can then establish, blood vessel by blood vessel, both the extent of an artery’s narrowing and the impact that the narrowing has on blood flow to the heart. This means that they can better understand the severity of the disease. Using HeartFlow, doctors can diagnose life-threating coronary heart disease in just 20 minutes.

By identifying which patients need treatment and which do not, doctors can limit unnecessary invasive testing, reduce healthcare system costs and improve patient quality of life.

Treatments for heart disease, depending on its severity, include surgery, medication or having a stent fitted. For less serious cases, patients may be given tips on healthy lifestyle changes to adopt or cholesterol-lowering medication, meaning the risk is quickly resolved before it becomes life-threatening.

“HeartFlow is unique in using already collected data to enable doctors to visualise where a problem might be and help them target any treatment without further tests on the patient,” says a NICE spokesperson. “Traditionally, treatments, which might include stents or heart bypass operations, might have been applied to any blockage that was identified. HeartFlow allows doctors to target treatments on the specific area causing problems. HeartFlow can also help rule out where heart disease may not be present without further testing and uncertainty for the patient.”

In April 2021, NICE released an updated review that found HeartFlow reduces false positives by as much as 50 per cent and reduces the need for diagnostic angiograms. By adopting this technology, the NHS in England could potentially save a minimum of £9.4 million by 2022 by avoiding invasive investigation and treatment. “Using HeartFlow, a good proportion of patients will have non-invasive tests such as an ECG and then a CT scan and can get a definitive diagnosis without any further tests,” says a NICE spokesperson. “One of the biggest advantages is that it helps avoid having a coronary angiogram and the associated follow-up appointments. It often gets a patient an early definitive diagnosis and it is common – in up to 80 per cent of patients – that there isn’t any further testing needed. Based on the current evidence, and assuming there is access to appropriate CT coronary angiography facilities, using HeartFlow may lead to cost savings of £391 per patient.”

Heart health

Dr Derek Connolly, consultant interventional cardiologist at Sandwell and West Birmingham NHS Trust, says there’s a long road ahead to get back to normal pre-pandemic services, but technologies such as HeartFlow will certainly help. 

“Sending a CT scan for a HeartFlow analysis doesn’t require patients to come back to the hospital for any further scans and can lead to them getting a diagnosis and treatment plan in a matter of hours,” he says. “Not only does it cut the time to diagnosis, but it means we can prioritise time in the catheterisation lab for those who need it most. What’s more, being able to reduce the number of hospital visits for patients is a key consideration during the pandemic.”

Early diagnosis of heart disease is essential to prevent heart attacks and stroke, so it’s important that healthcare professionals and patients recognise red flag symptoms. “Waiting too long can have long-term health impacts,” says Dr Connolly. “If a customer comes into the pharmacy complaining of chest pain or tightness, unusual heart palpitations and breathlessness – especially when not doing strenuous activity – always urge them to seek further medical advice from their doctor. Some of the lesser-known symptoms of coronary heart disease include nausea and pain in the neck or jaw, particularly in women. It is worth being aware of these symptoms when giving medical advice to customers.”

There are many ways to reduce the risk of heart disease, and pharmacies are well-placed to offer lifestyle advice. “Diet and physical activity are particularly important,” says Dr Connolly. “Cutting down on salty foods whilst upping fibrous foods will certainly help. In addition to eating the recommended portions of fruit and veg a day, exercise will strengthen the heart and help it work more efficiently. Importantly, the combination of diet and exercise will help people maintain a healthy weight, which in turn significantly reduces the chances of developing high blood pressure and heart disease.”

Additional benefits for heart health

According to recent research published in the medical journal The Lancet, blood pressure-lowering medicines can prevent serious cardiovascular conditions such as strokes, heart failure and heart attacks in adults with normal blood pressure. The study, part-funded by the British Heart Foundation, found the beneficial effects of treatment were similar regardless of the starting blood pressure level, in people who had a previous heart attack or stroke as well as in those who had never developed heart disease.

The University of Oxford researchers studied 344,716 adults from 48 randomised trials. For every 5mmHg reduction in systolic blood pressure, the risk of developing major cardiovascular disease fell by around 10 per cent. Stroke and heart failure risk dropped by 13 per cent, coronary heart disease by eight per cent and death from cardiovascular disease by five per cent. The researchers recommend that when doctors discuss blood pressure medication with patients, they should emphasise its importance in reducing their overall heart disease risk, rather than just lowering their blood pressure.

Professor Nilesh Samani, British Heart Foundation medical director, says that this study stresses the importance of good blood pressure control. “The benefits of lowering blood pressure are there whether you have pre-existing heart disease or not,” he says, “and this study shows that lowering blood pressure – even if it is in the normal range – is associated with fewer heart attacks and strokes. This doesn’t mean we should treat everyone with blood pressure-lowering drugs. If someone already has a low risk of heart disease, a 10 per cent reduction in their blood pressure may only carry a small direct benefit. Ultimately, the decision to treat blood pressure and the target level to aim for is something that requires a conversation between the patient and the doctor. It’s also important to remember that blood pressure can be improved by means other than medication, such as exercise and losing weight.”