Improving the quality of care of people with and at risk of cardiovascular diseases

UCL research on the quality and outcomes of care of people with or at risk of cardiovascular diseases has informed guidelines and clinical management in a number of areas.

Coronary heart disease is the UK's single biggest killer, accounting for around 73,000 deaths each year. Under the leadership of Professor Harry Hemingway (UCL Institute of Epidemiology & Health Care), researchers have worked since the mid-1990s to improve our understanding both of why and how cardiovascular diseases occur and then progress, and of the quality and outcomes of care for people with or at risk of developing these diseases.

The findings of their research have directly informed national and international public health policy and healthcare across a number of areas relating to the treatment of cardiovascular disease, with important effects on the healthcare and health of both the UK and international populations. Their work has, moreover, also generated vital funding streams to support further work in this field, leading to the establishment of the £5.3m National Institute of Cardiovascular Outcomes Research and of the Farr Institute of Health Informatics Research, funded to a total of £9.3m.

The idea that ethnic minorities and women describe angina differently from white men is a myth - a dangerous one, since it may lead to unequal access to care. We show this myth should be busted. - Professor Harry Hemingway

The impacts of the research on health and healthcare have been achieved particularly via its use to develop influential national and international clinical guidelines. Key national guidance informed by the UCL work includes the National Institute for Health and Clinical Excellence (NICE) guidelines on Chest pain of recent onset, which draw especially on insights relating to the use of exercise electrocardiography (ECG) to diagnose stable angina. Published in 2010, these guidelines prompted a very significant change in the diagnostic pathways for patients suspected of having this condition, citing Professor Hemingway's research in recommending a move away from the decades-old reliance on exercise ECG (treadmill) in assessing all such patients. The implementation of this bold recommendation has already catalysed significant reductions in the use of ECG testing, and increases in the use of computerised tomographic (CT) angiography, with no negative impact on diagnostic capacity.

As well as addressing the use of new imaging methods to help diagnose patients with suspected angina, the 2010 guidelines drew on the UCL research to advise against defining anginal chest pain differently, either in men and women or in different ethnic groups. Supposed differences between these demographics had previously been used to attempt to justify differences in the rates at which procedures were used to treat them. As such this, the first unequivocal statement to clinicians that typical anginal pain does not differ by sex and ethnicity, supports fairer - as well as more effective - patient treatment.

New is not always better than old, but in the case of diagnosing angina it seems that we can do better with CT than the decades-old exercise ECG. - Professor Harry Hemingway

Research conducted by Professor Hemingway's group further underpinned recommendations in the 2011 NICE guidelines on Management of stable angina on revascularisation - the restoration of blood circulation to an organ - for patients with angina. The research particularly underpinned recommendations about how patients and healthcare providers should arrive at a decision about which of the two principal modes of revascularisation - coronary artery bypass graft and percutaneous coronary intervention - to use. Those recommendations include advice based on research findings both about the cost efficiency of both procedures and about the relative survival rates of each for patients with specific medical needs. Reviews conducted by the UCL team have also contributed to recommendations in European guidance on the need to assess psychosocial factors, including depression, in people with myocardial infarction - more commonly known as heart attack. The European Society of Cardiology's most recent (2012) guidelines directly cite the UCL work in support identifying depression as a specific risk factor, providing the strongest recommendations to date that clinicians might assess psychosocial factors alongside behavioural and biological considerations.