Heart disease: action plan

4. Priority 1: Prevention - tackling risk factors:

We will minimise preventable heart disease and stroke by improving the detection, diagnosis and management of risk factors.

Many people in Scotland live with cardiovascular risk factors such as high blood pressure or high cholesterol which place them at increased risk of heart disease or stroke.

Atrial fibrillation (AF), the most commonly diagnosed type of arrhythmia (or irregular heart rhythm), is associated with an up to fivefold increased risk of stroke.

Actions on other risk factors such as obesity, smoking and alcohol consumption are covered in other Scottish Government policy commitments. Though not addressed specifically by this plan, this does not diminish the importance of such measures and this plan should be viewed as complementary to the measures set out in Raising Scotland's Tobacco-Free Generation: Tobacco Control Action Plan 2018; A Healthier Future: Scotland's Diet & Healthy Weight Delivery Plan 2018; A More Active Scotland: Scotland's Physical Activity Delivery Plan 2018; Alcohol Framework 2018: Preventing Harm and Cleaner Air for Scotland: The Road to a Healthier Future.

Similarly, this priority does not specifically address diabetes, although it is a key risk factor for heart disease. The Diabetes Improvement Plan specifies key actions on diabetes and we will work collaboratively across these two plans to ensure alignment.

Often, high blood pressure, high cholesterol and atrial fibrillation may not have any symptoms. This means that people may not realise that they are at an increased risk of heart disease or stroke. Furthermore, once diagnosed, many people with these conditions may not be treated to optimal levels.

For example, it is estimated that as many as 610,000 adults in Scotland don't know they have high blood pressure. Lowering blood pressure significantly reduces the risk of heart and circulatory disease and death^[18]. Despite this it is estimated that only 27% of adults with high blood pressure in Scotland have their blood pressure treated and controlled to below the SIGN recommended threshold of 140/90mmHg^[19].

It is therefore vital to ensure appropriate detection, diagnosis and optimal management of these risk factor conditions to reduce cardiovascular disease in Scotland. Work in this area must be mindful of health inequalities and actively consider how to provide care and self-management support in a way that actively addresses such inequalities, and reaches people from communities that are particularly underserved by current models. A robust lived experience structure will play a key role in this regard.

Furthermore, we will work to support the principle identified within the Women's Health Plan that opportunities for optimisation of cardiovascular health and risk reduction should be taken across the women's lifespan. Of particular relevance to our priority on tackling risk factors is the identification and management of hypertensive disorders within pregnancy.

4.1 Models of community care

Examples from other countries have shown that community models of detection, diagnosis and management of high blood pressure are effective.

For example, in Canada, the Cardiovascular Health Awareness Programme introduced community based cardiovascular health promotion and chronic disease management activities through partnership with primary care, community pharmacists, third sector organisations, community groups and locally trained volunteers acting as peer health educators. The programme was linked with a 9% reduction in hospital admissions at population level for stroke, heart attack and heart failure among working age people (under 65), compared to communities that did not implement the programme^[20]. Similar models could be developed in Scotland with close collaboration with key delivery partners including the third sector and community pharmacy.

Community models of care provide an opportunity to consider ways to reach those who may be less likely to engage with healthcare, and we must ensure that we are listening to lived experience and co-producing models in a way that identifies local solutions to local challenges, in order to address health inequalities.

4.2 Tele monitoring

Innovative ways to support diagnosis and support self-management of these conditions is also important. For example, self-monitoring is an increasingly common part of blood pressure management and can increase adherence to lifestyle changes or medication.

Self-monitoring of blood pressure is most effective when combined with support from a health care professional^[21]. This can be supported through tele monitoring. Scale-Up BP is part of the Technology Enabled Care (TEC) programme funded by Scottish Government. People with suspected high blood pressure are given a validated blood pressure monitor and are prompted regularly to check their blood pressure at home and then asked to text back the readings through a text messaging system. The system informs them immediately if their blood pressure is on target or to contact a doctor or nurse if it is worryingly high.

Such models of care can support with diagnosis, and with longer term self-management and therefore it is important that any efforts to reshape detection, diagnosis and self-management should build on the work of this programme, including considering how such an approach can support a range of health care services. The Covid-19 pandemic has highlighted the importance and potential of tele monitoring for supporting people with a variety of long term conditions. It is important that we continue to support and expand tele-monitoring for high blood pressure and also work to include other risk factor or cardiac conditions within such models of care.

Another area where we have supported remote monitoring is in the development of a Heart Failure Remote Health Pathway. A collaborative approach has been undertaken by clinicians, digital technicians, patients and third sector organisations to develop a remote monitoring pathway specifically for people with newly diagnosed heart failure or unstable symptoms. This enables clinicians to remotely monitor a patient's blood pressure, heart rate, bodyweight (in some cases oxygen saturation) and answers to a number of health-related questions.

4.3 Measuring improvement

It is estimated that only 27% of adults with high blood pressure in Scotland have their blood pressure treated and controlled to below the SIGN recommended threshold of 140/90mmHg^[22]. This is based on data from the Scottish Health Survey and so there is scope to more accurately understand the treatment of people with blood pressure across Scotland and to support us in understanding variation and supporting improvement.

Familial hypercholesterolaemia (FH) is a specific inherited condition characterised by raised blood cholesterol levels and increased risk of early atherosclerosis, heart attack and stroke^[23]. Early treatment with lipid-lowering drugs is very important for people with FH.

Because it is an inherited condition, parents, siblings and children of people with an FH gene mutation possess a 50% chance of having the faulty gene and NICE guidelines recommend a cascade testing system to support identification of FH^[24].

Across Scotland there are variations in the models for the diagnosis and management of FH. There is also significant variation in access to testing. A more standardised approach in line with the national pathways vision identified within Priority 2 and improved data collection and identification of quality indicators in line with Priority 4 would help to understand variation and outcomes in order to drive forward positive changes in the delivery of care for people with FH across Scotland.

A similar lack of data collection and national understanding of variation is present for AF. To date, we have sought to address this through improving access to information about AF through SPIRE (Scottish Primary Care Information Resource). It is a service which allows information to be requested from GP practice records and collected centrally to produce statistics for Scotland as a whole. SPIRE also provides a platform for practices to see information about their patients, through a report on certain conditions. One of the reports in development is for AF. It focuses on identifying people documented as having a diagnosis of AF within their patient record, and determines if that person has received appropriate treatment, based on their risk score.

This information supports GP cluster-level learning, but we should also extract it at national level. This will enable baseline measurement of the current rate of appropriate anticoagulation, and enable an ambitious Scotland wide target for improvement to be set. This tool could also be used to support GP clusters to drive improvements in the management of high blood pressure and high cholesterol, including FH.

An important aspect of being able to measure improvement is the agreement of indicators that identify whether the patient journey is optimal. Development of indicators, as identified in Priority 4, should also include indicators relevant to the conditions highlighted within this chapter.

4.4 Actions

1. We will collaborate with partners to implement a community-based awareness, prevention and detection programme for high blood pressure and high cholesterol across Scotland, which is person-centred and co-designed.

2. We will develop indicators and improve data collection for all three conditions (high blood pressure, high cholesterol, and atrial fibrillation), by developing the SPIRE reports to include high blood pressure and high cholesterol (including FH). This will support local quality improvement within primary care and data should also be made available at regional and national level to identify unwarranted variation.

3. We will support and invest in the use of proven technology to support detection, tele-monitoring and the provision of tailored support for people with heart disease or cardiac risk factors.