Discuss the division of resources with regards to the prevention and treatment of CHDs:

Rosie Waldron 12 WMS

Although the rate of death from coronary heart disease in the UK continues to fall significantly each year, only Finland and Ireland have a higher death rate from CHD among developed countries. Being the nation’s biggest killer it is unsurprising that millions of pounds are spent each year on the treatment and prevention of CHD. In this essay I aim to discuss and evaluate how resources should be divided with regards to the prevention and treatment of CHD and the various conditions associated with it.

CHD is the disease of the two coronary arteries supplying the heart muscles with oxygenated blood and nutrients. CHD causes damage to these arteries by blocking the lumen of the vessels with plaques which leads to irreversible damage to the heart as the oxygen supply to the heart becomes either blocked or reduced casing the heart tissue becomes oxygen starved. The consequence of this is that part of the heart becomes deprived of oxygen and therefore dies unless an interconnecting blood vessel can take over the supply.

If there is only a small blockage and the oxygen supply is reduced, the heart muscle is forced to respire anaerobically, therefore producing a painful build up of lactic acid. This is known as angina, and is the most common form of CHD and affects and an estimated 2 million people currently in the UK. Angina is largely a chronic condition, this causes a huge burden on the NHS as its treatment is ongoing and large amounts of money must be constantly spent on treating the condition.

The NHS spends millions of pounds on treating CHD every year; this is made up of everything from expensive drugs to treat angina through to hospital stays for by-pass operations. Added to this are the millions of pounds lost to the economy from people taking time off work through ill health. Currently the majority of our country’s resources are being spent on the treatment of CHDs with a small amount being afforded to prevention methods. This is largely due to the fact that the medical service and operations are not only lifesaving and essential but hugely expensive (one heart transplant is estimated to cost the NHS over 200 000 pounds) whereas education and anti-smoking and healthy eating campaigns do not bare an immediate effect on the number of lives saved.

Operations are obviously hugely expensive, the medical equipment and maintenance and safety procedures alone account for vast sums of money, not to mention the high wages of the surgeon and medical teams. The drugs and anesthetic prescribed is also expensive and can be ongoing. With thanks to the BBC website I have compiled a list and brief description of the major operative procedures used to treat or cure CHDs, I must also mention the research being done into the use of stem cells to ‘grow’ heart for use in transplants:

Heart Transplants- With organs such as the heart, transplantation is used only if the alternative to early death. Close matching organs are therefore sometimes difficult due to the urgency of obtaining the donor heart. The demand for donor hearts is very high, with an estimated 400 people per million needing a heart or heart/lung transplant.

The surgical process of heart transplantation is relatively straight forward as the heart is a simple organ. The major medical problem is that of the body rejecting the heart, although immuno-suppressant drugs curb the rejection of the heart, few recipients of a transplanted heart live longer than 5 years after the operation. This is longer than the recipient of the heart would have lived without the surgery and there is a much improved quality of life and relief from pain, fatigue and breathlessness. The Immuno-suppressive treatment also could lead to infections such as pneumonia and the growth of tumours, damage to bones and body organs occurring very easily as the immune system is not working to full standards. These drugs must be taken for the rest of the person's life.

Due to the problems however, few heart transplants are carried out, there is also a great shortage of suitable donor hearts. The use of artificial hearts and xenographs from animals such as pigs are being researched into to for future heart transplantation methods. Transplants are also very costly to the NHS and donors may not always be available.

A better method may be to repair the heart with bypass operations - an autograft, if areas of the coronary artery have become blocked with atheromatous plaques. A vein from the leg is grafted on to the heart to bypass the blocked coronary artery. As the tissue comes from the same patient there is no need for immuno-suppressive drugs as the tissue is already genetically matched.

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An angioplasty may also be carried out which is the mechanical widening of the lumen of an artery affected by atheromatous plaques. A deflated balloon is attached to a fine catheter and inserted into the partially blocked artery. When inflated it stretches the lumen, widening it enough to increase the flow of blood and reduce the risk of a thrombus forming.

Although these surgical methods can alleviate the symptoms of CVD, after surgery the patient must also be willing to take care of their health with a good diet, stop smoking if a smoker and gentle exercise to experience the benefits of their operation. If not the whole operation was pointless as they will damage their 'fixed' body once again and be in no better health physically.

A surprisingly large amount of money is spent every year on drugs and treatment procedures for CHD and conditions associated with CHDs. I have aquired the following information on these drugs and treatment programs and although they have little relevance to the title of this essay the drugs used and how they work is relevant to the topic of CHD and the amount of treatment procedures described is a bearing on the number and cost of the treatment processes which must be occurring nationwide:

A large range of drugs exist to treat and control the symptoms of coronary heart disease or risk factors, such as angina or high blood pressure. Most drugs fall into a handful of types which act in similar ways, so if one particular drug doesn't suit you, your doctor will usually be able to prescribe a different one.

The following are the main categories of heart drugs. For specific information on a medication you have been prescribed, contact your doctor or pharmacist.

ACE angiotensin converting enzyme-inhibitors

These are used to treat heart failure and lower blood pressure. They work by blocking the activity of a hormone, angiotensin II, which narrows the blood vessels, improving blood flow and decreasing the amount of work your heart has to do.

Angiotensin II receptor antagonists

These are used to lower your blood pressure by limiting angiotensin, a hormone produced by the body which regulates blood pressure.

Anti-arrhythmic drugs

These drugs control the rhythm of your heart. Their effectiveness depend on keeping exactly the right amount in your bloodstream - so it is important to take them exactly as instructed.

Anticoagulants

These are used to inhibit blood clotting. They work by preventing fibrin (a protein involved in clotting) from forming. They are also used to treat deep vein thromboses (clots in the legs), and to prevent these from travelling to the lungs where they may cause a pulmonary embolism (blood clot on the lungs). They can be taken either orally (by mouth) or given by injection.

Aspirin and anti-platelets (blood thinning drugs)

These are drugs which prevent blood clotting by reducing the stickiness of blood cells called platelets that are involved in clotting. They are used to reduce the risk heart attacks or heart diseases, for angina and to prevent blood clotting following bypass surgery and other procedures.

Beta blockers

These are used to prevent angina and lower high blood pressure. They work by blocking the effects of stress hormones, which make your heart beat faster and more forcefully. They may be used to lower your risk of a subsequent heart attack if you have already had one, and/or help control abnormal heart rhythms (arrhythmias).

Calcium channel blockers or calcium antagonists

These are used to treat angina and/or to reduce high blood pressure. They work by reducing the amount of calcium entering the muscle cells in your arteries which are needed for their action. This in turn relaxes and widens your arteries, increasing the blood flow to your heart, reducing the heart's workload and lowering your blood pressure.

Lipid lowering drugs

These drugs lower levels of blood fats or lipids. They may work by raising levels of good HDL cholesterol and/or lower circulating amounts of LDL cholesterol. The main type are 'statins,' a group of cholesterol lowering drugs that can inhibit the action of an enzyme involved in cholesterol synthesis to lower LDL cholesterol levels. They are intended to be used in alongside lifestyle measures to lower your cholesterol level, such as increasing physical activity giving up smoking and eating a diet low in fat with at least 5 portions of fruit and vegetables a day.

Diuretics ('water tablets')

These work on your kidneys to increase excretion of water in the urine. They are useful for treating heart failure, which causes an excess of water to accumulate in your tissues and to reduce blood pressure.

Nitrates

These relax the muscles in the walls of your blood vessels, so reducing the workload of your heart's left ventricle (one of the four chambers of the heart). They are used to treat angina and may be prescribed as sublingual tablets which you dissolve under your tongue, as an aerosol spray which you spray under your tongue, as tablets, or as skin patches.

Potassium channel activators

These act to relax the walls of your coronary arteries and improve blood flow. They are used to alleviate angina.

Thrombolytic drugs - 'clot busters'

This group of drugs can dramatically reduce your risk of dying of a heart attack, and can help minimise the damage of a heart attack. They work by breaking up clots, restoring blood flow through the narrowed artery, and reducing damage to the heart muscle.

One of the most recent breakthroughs in CHD is the increasingly common use of statins and other cholesterol lowering drugs. Prescriptions of these drugs went up by nearly a third between 2000 and 2001, with over one million prescriptions dispensed in England every month. Cholesterol lowering drugs alone saw the NHS drug treatment bill rise by 22% and now cost the NHS more than any other class of drug with over £440 million spent in 2001 (an increase of £113 million since 2000).

There has also been an increase in the number of treatments taking place which will also add extra burden on the NHS budget. Revascularisation procedures have more than doubled in the past 10 years and the number of angioplasties has risen by nearly 40% in the past year to 39,000.

Many of these treatment programs are ongoing and are relatively common which means they cost the NHS millions of pounds a year, and, the more effective they are, the longer the sufferer survives so the more drugs and therefore money is needed. The number of people at risk could become an increasing burden upon the NHS, creating a strong argument for the need of more money to be spent on preventative measures.

There are two types of prevention; primary prevention and secondary prevention. Primary prevention is the use of healthy lifestyle education, preventative drugs or procedures before the patient has exhibited any signs of suffering from a CHD. This form of treatment can include the aforementioned statins and other cholesterol and lipid lowering drugs, these are at a cost to the NHS and are usually prescribed to those in high risk groups.

Secondary prevention is the use of preventative drugs or procedures and/or a lifestyle change after a patient has had a CHD or expressed symptoms. Although strictly this could be classed as treatment as it is directly treating symptoms, usually it is before the patient has developed a major CHD and is often prescribed as a result of rise in blood pressure or similar symptoms. Also statins are often prescribed after the patient has finished treatment, eg. After a heart by-pass or transplant.

The cost of statins and other cholesterol and lipid lowering drugs has already been mentioned in this essay but I felt it important to stress that they can be used both as a treatment and a preventative measure. In other words they are used to ensure that patients at high risk do not go on to develop CHDs and that patients who have a CHD do not deteriorate, and in some cases it has managed not only to control but also reverse symptoms.

Antioxidant vitamins and health foods with cholesterol lowering agents eg benecol and flora active are also recommended by doctors as a preventative measure, and often people buy these products without advice from their doctor. They are widely available and although they are more expensive, cholesterol lowering foods are becoming more popular due to advertising and health consciousness amongst many people today.

The main issue that I will be discussing with regard to prevention is the resources being used to educate the public, especially the younger generation with regards to diet, smoking and exercise. This is the most sensible route to follow if we want to reduce the number of CHD in the UK and will also save the NHS millions of pounds in the long run.

CHD is a long-term degenerative disease and people must be made aware of the complications of an unhealthy lifestyle early to try and educate them towards a healthy lifestyle. It has long been considered that CHD is a self-inflicted disease because the lifestyle led by sufferers has influenced the onset of the disease. The main risk factors that can lead to CHD are as follows:

Diet- A diet that is high in saturated fats causes a rise in blood cholesterol. In countries such as Japan where CVD is relatively rare, lower fat intakes and lower blood cholesterol are found than is typical of people in Britain. The amount of blood cholesterol is influenced mainly by the amount of saturated fats in the diet rather than the amount of cholesterol. This increases the deposition of cholesterol in the arteries leading to the formation of atheromatous plaques which are the underlying cause of CVD.

Hypertension- Hypertension, or high blood pressure, is associated with stress, smoking, obesity, excessive alcohol consumption and lack of exercise. Long term hypertension places an extra strain on the heart and cardiovascular system making it work harder, speeds up the development of atheromatous plaques and increases the chances of suffering from angina, myocardial infarction or stroke. Hypertension may lead to heart failure, which occurs when heart muscles weaken and are unable to pump properly. A blood pressure of 170/100 increases the chance of dying from CHD twofold compared to that of men with a normal blood pressure of 120/80.

Smoking- Smoking cigarettes has both a harmful effect on the respiratory system as the cardiovascular system. Carbon Monoxide and nicotine are both toxic to the endothelium of arteries and therefore make the penetration of cholesterol plaques easier causing atheromatous plaques. Carbon monoxide reacts irreversibly with haemoglobin to form carboxy-haemoglobin. This decreases the volume of oxygen carried in the blood and will therefore induce angina attacks.

Nicotine causes a higher concentration of fibrinogen which stimulates the clotting of platelets thus increasing the chance of developing a thrombus in an artery as the platelets are stimulated to stick to the surface of the endothelium. Nicotine also increases blood pressure and heart rate, but also constricts the blood vessels. This increases the chances of thrombosis especially stokes if the carotid arteries are effected as well as putting the heart under extra strain..

Physical Exercise- A lack of exercise will lead to a weak heart with a low cardiac output as the heart muscle is rarely exercised. Like any other muscle, exercise will increase the strength of the heart muscle and will enable a larger stroke volume to occur, therefore the heart doesn't need to beat as fast to pump as much blood around the body. Lack of exercise will increase the risk of CHD because the heart is working much harder to pump blood around the body, therefore is being put under extra strain as with hypertension.

Gender- Men are twice as likely to suffer from CVD than women. Testosterone has a harmful effect on the cardiovascular system and pre-menopausal women produce oestrogen which protects against CHD. Post menopausal women tend to have an increase in blood fat levels, so the risk of developing CHD increases, but treatment with hormone replacement therapy will protect the body again from CHD. Although men cannot help their gender, to lower their risk they should make extra considerations about diet, exercise and smoking.

Stress- Leading a stressful lifestyle may increase the risk of heart attacks and angina attacks. Stressful lifestyles are also often coupled with lack of exercise (sedentary jobs in offices), smoking, excessive alcohol intake and poor diet.

Genetic factors- Heart disease has an inherited component, the more close relatives you have who develop heart disease, the more likely you are to suffer too. The main reasons that CVD runs in families is that it has a genetic component - such as certain genes that may increase the risk of developing atheromatous plaques. The second reason is that families share a common environment such as diet and being in an environment with smoke from cigarettes.

It is obvious that some of these factors are unpreventable, however that makes it all the more important for people to be educated so those already at risk can make sure that they do not put any extra strain on their heart and are extra-conscious about other factors eg diet and exercise.

The fact that although the government invests huge amounts of money into the treatment of CHD the UK remains to have one of the worst death rates due to CHD amongst the developed countries has not gone unnoticed by the government. Recently (October 2003) a 40million pound strategy to reduce the number of deaths from CHD and strokes has been unveiled. Cash will also be used to reduce waiting times for potentially life-saving angiography and angioplasty procedures in the next two years. The British Medical Association (BMA) welcomed the strategy but stressed that it had to be backed up by proper staff training and recruitment.

The Minister Jack McConnell has said: "Improving the shameful health record, to create a society fit for the challenges of the 21 century, is one of the key issues facing us as a nation.

"It demands the high level of investment and reform we are making in the NHS to enhance patients' treatment, improve services and support the efforts of NHS staff.

"It is simply unacceptable to invest record amounts of money and still have one of the worst health records in Western Europe.

"Britain's first heart disease and stroke strategy will cut the number of people dying from two of our 'big three' killers."

Key features of the new strategy include:

The creation of locally managed clinical networks for CHD and stroke in each every NHS Board area by 2004
The creation of national databases for CHD and stroke to provide detailed information about the care patients are receiving from their GPs
A commitment to create additional specialist stroke units to treat 5000 more patients a year
A commitment to prevent 200 fewer deaths and provide support to 300 more patients returning home after stroke.

Talks between ministers and NHS chiefs will soon take place to implement training for existing and new medical staff to support the strategy.

Conclusion: The fact that deaths from coronary heart disease are continuing to fall is good news and can be partly attributed to the resources and skill committed to CHD in the UK today. However, the fact that we have one of the highest death rates in the western world is shocking. While we can expect more people to survive the condition in the future, we need to consider the growing burden on the NHS to provide treatment and care for those living with CHD.

We need to tackle the underlying causes of CHD in the UK - in particular lifestyle factors such as physical inactivity - if we are to improve the heart health of the nation. one of the major problems in reducing the prevalence of CHD is people's continued complacency about major risk factors such as smoking, physical inactivity and obesity. Despite increasing knowledge about the dangers of certain risk factors, the message that CHD is largely preventable is clearly not getting through:

Smoking levels remain static in the UK - 29% of men and 25% of women still smoke.
Around 40% of men and women have raised blood pressure - despite recent evidence from the World Health Organisation (WHO) that it is the second most important cause of death and disability in developed countries - exceeded only by tobacco.
Only 13% of men and 15% of women eat the recommended 5 portions of fruit and veg a day. While the consumption of fruit has risen four fold since the 1940s, vegetable consumption has declined.
Physical inactivity is still a major problem - only just over a third (37%) of men and a quarter of women (25%) take the recommended 30 minutes of exercise five times a week.
The proportion of adults who are overweight continues to rise - particularly in men. Obesity rates in men have tripled in the since the mid 1980s - with men now as likely to be obese as women.
In the last ten years, the number of women drinking more than the weekly recommended levels of alcohol has risen by over 50% but remained stable in men.

We need to put increasing pressure on people in the UK to take responsibility for their own health. The major risk factors, such as smoking and obesity, are now well documented - and yet the number of people ignoring these warnings continues to rise. We need to accept that as a nation we are putting our hearts at risk - and identify ways to put people 'on alert' - to reduce the needless suffering from heart disease in the UK today.