Cardiovascular disorders
Updated July 2006
- Angina
- Acute heart failure
- Chronic heart failure
- Complete heart block
- Coronary artery disease
- Hypertension
- Myocardial infarction
All deaths, by cause and sex, 2004, England, Wales, Scotland, Northern Ireland and United Kingdom [1]
| England | Wales | Scotland | N. Ireland | UK | ||
| All causes | Men |
229,099 | 15,323 | 26,775 | 6,935 | 278,132 |
| Women |
251,618 | 16,994 | 29,412 | 7,419 | 305,443 | |
| total | 480,717 | 32,317 | 56,187 | 14,354 | 583,575 | |
| All heart disease | Men |
58,563 | 4,010 | 6,809 | 1,804 | 71,186 |
| Women |
54,381 | 3,941 | 6,483 | 1,709 | 66,514 | |
| total | 112,944 | 7,951 | 13,292 | 3,513 | 137,700 | |
| Rheumatic heart disease | Men |
302 | 26 | 31 | 8 | 367 |
| Women |
787 | 61 | 104 | 26 | 978 | |
| total | 1,089 | 87 | 135 | 34 | 1,345 | |
| Hypertensive disease | Men |
1,398 | 93 | 123 | 35 | 1,649 |
| Women |
1,838 | 141 | 193 | 46 | 2,218 | |
| total | 3,236 | 234 | 316 | 81 | 3,867 | |
| Coronary heart disease | Men |
47,905 | 3,312 | 5,814 | 1,524 | 58,555 |
| Women |
38,265 | 2,807 | 4,964 | 1,251 | 47,287 | |
| total | 86,170 | 6,119 | 10,778 | 2,775 | 105,842 | |
| Other heart disease including heart failure | Men |
8,958 | 579 | 841 | 237 | 10,615 |
| Women |
13,491 | 932 | 1,222 | 386 | 16,031 | |
| total | 22,449 | 1,511 | 2,063 | 623 | 26,646 | |
| Stroke | Men |
18,940 | 1,195 | 2,294 | 541 | 22,970 |
| Women |
30,621 | 2,112 | 3,861 | 894 | 37,488 | |
| total | 49,561 | 3,307 | 6,155 | 1,435 | 60,458 | |
| Other diseases of the circulatory system | Men |
7,769 | 485 | 658 | 171 | 9,083 |
| Women |
7,779 | 474 | 732 | 153 | 9,138 | |
| total | 15,548 | 959 | 1,390 | 324 | 18,221 |
References:
[1] Allender S et al (2006) Coronary heart disease statistics. London: British Heart Foundation.
[2] Lawlor D A et al (2003) Geographical variation in cardiovascular disease, risk factors, and their control in older women: British Women's Heart and Health Study. Journal of Epidemiology and Community Health 57:134-140.
Angina
Pain in the chest, usually brought on by exertion and relieved by rest.
Angina is chest pain that originates in the heart muscle during physical activity and is quickly relieved by rest. The pain is due to an inadequate supply of blood to the heart muscle. Angina affects both sexes but is less common in women under 60 because the hormone oestrogen protects against it. This protection gradually disappears when levels of oestrogen drop after the menopause. It sometimes runs in families and the risk factors include smoking, a high-fat diet, lack of exercise, and excess weight.
The most common cause of angina is coronary artery disease, a narrowing of the arteries that supply the heart muscle, this narrowing is usually the result of fatty deposits building up on the inside of the artery walls. The blood flow through the arteries may be sufficient for the heart while it is at rest but becomes inadequate during exertion. If the supply of oxygen-rich blood is insufficient, the heart muscle is starved of oxygen and toxic substances build up in the heart muscle, causing a constrictive, cramp-like pain. People who have a high blood cholesterol level, persistently high blood pressure (see hypertension) or diabetes mellitus have an increased risk of developing atherosclerosis and angina.
The chest pain of angina varies from mild to severe. It usually starts during exertion and is relieved after a short rest.
The symptoms of angina are:
- a dull, heavy, constricting sensation in the centre of the chest
- a discomfort that spreads into the throat and down one or both arms, more often on the left arm
The treatment of angina depends on its severity. Drugs are used to relieve acute episodes of pain and also to reduce the number and severity of attacks. Lifestyle changes can prevent worsening of angina as can increasing the level of exercise that can be achieved without experiencing pain.
For mild angina, the outlook is good provided that sensible lifestyle changes are made and treatment recommendations followed. People often have no further symptoms once treatment has started, and many are able to live a normal life apart from some restrictions on exercise.
Acute heart failure
Sudden deterioration in the pumping action of the heart, usually leading to accumulation of fluid in the lungs.
Heart failure is the term used when the heart’s ability to pump efficiently is reduced. The condition is more common in people over the age of 65. In acute heart failure, the condition develops suddenly, often due to a severe heart attack. In most cases, only the left side of the heart is affected. Acute heart failure may develop in people with complete heart block, or people with chronic heart failure if the weakened heart is put under strain.
The symptoms of acute heart failure usually develop rapidly and include:
- severe shortness of breath
- wheezing
- cough with pink, frothy sputum
- pale skin and sweating
Chronic heart failure
Long-standing inefficient pumping action of the heart, leading to poor circulation of blood and accumulation of fluid in tissues.
Chronic heart failure is one of the commonest reasons for elderly people to consult their GP or to be admitted to hospital.
In chronic heart failure, the heart is unable to pump blood around the body effectively, leading to a gradual build-up of fluid in the lungs and body tissues. Chronic heart failure is a common progressive condition that may be so mild at first that symptoms go unnoticed. Although the term chronic heart failure appears to imply a life-threatening disorder, it can often be treated, and people with mild chronic heart failure can live for many years. However, the condition may limit physical activity. More severe heart failure carries a prognosis worse than many cancers.
It should be emphasised that heart failure is a syndrome, not a diagnosis, and most patients require some assessment to delineate the underlying cause. In 8 out of 10 cases, chronic heart failure is caused by coronary artery disease in which the blood supply to the heart muscle is reduced. It is more common in those aged over 65.
The symptoms of chronic heart failure develop gradually, are often vague, and may include:
- tiredness
- shortness of breath that is worse during exertion or when lying flat
- loss of appetite
- nausea
- swelling of the feet and ankles
- in some cases, confusion
Acute heart failure needs immediate hospital treatment. Mild or moderate chronic heart failure may be helped by regular gentle exercise, such as walking. It is important to stop smoking and to lose any excess weight to avoid putting unnecessary strain on the heart. Salty foods should also be avoided to discourage fluid retention.
There is now a substantial body of evidence to show that certain medications, and particularly ACE inhibitors and B blockers, improve mortality rates and reduce hospital admissions. Increasingly these drugs are being shown to be effective in the elderly.
Complete heart block
Complete failure of the system that conducts electrical impulses from the upper to the lower heart chambers.
Complete heart block, is when damage to the heart’s conductive tissue prevents electrical impulses from the atria (the upper chambers) from reaching the ventricles (the lower chambers), so that the ventricles cannot contract normally. Heart muscle contracts automatically in the absence of a regulating signal. In a complete heart block, the ventricles contract at about 40 beats per minute instead of the usual 60 to 80 beats per minute. The tissue damage that causes complete heart block becomes more likely in older people and is linked with coronary artery disease for which lifestyle factors such as smoking, high-fat diet, lack of exercise and excess weight increase the risk.
The symptoms may come on gradually or suddenly and typically include:
- palpitations (awareness of an irregular heartbeat)
- light-headedness and loss of consciousness if the heart stops beating
- shortness of breath
- chest pain
Coronary artery disease
Narrowing of the coronary arteries that supply the heart muscle with blood leading to heart damage.
The coronary arteries, which branch from the main artery in the body, the aorta, supply the heart muscle with oxygen-rich blood. In coronary artery disease (CAD), also known as coronary heart disease, one or more of the coronary arteries is narrowed, blood flow through the arteries is restricted, which leads to damage of the heart muscle. Heart disorders, including heart attacks, and the chest pain of angina are usually caused by CAD.
Coronary artery disease is usually due to atherosclerosis, a condition in which fatty deposits accumulate on the inside of the artery walls. These deposits narrow the arteries and restrict blood flow. If a blood clot forms or lodges in the narrowed area of an artery, the vessel can become completely blocked. High blood cholesterol levels increase the risk of CAD caused by atherosclerosis. CAD is also linked to smoking, obesity, lack of exercise, diabetes mellitus and high blood pressure.
In the early stages of CAD, there are frequently no symptoms. In the later stages, the first symptom is usually either pain in the chest on exertion, a condition known as angina, or a heart attack. Some people with CAD develop an abnormality of the heart rhythm (arrhythmia) which may cause palpitations (awareness of heartbeats), light-headedness, and sometimes, loss of consciousness. Some severe forms of arrhythmia can cause the heart to stop pumping completely, which accounts for most of the sudden deaths from CAD. In older people, CAD may lead to chronic heart failure.
CAD is usually diagnosed only when a person develops symptoms of the disease such as chest pain, or heart attack. Treatment falls into three categories: lifestyle changes to reduce the risk of CAD becoming worse, drug treatments to improve the function of the heart and help to relieve symptoms, and surgical procedures, such as coronary angioplasty that improve the blood supply to the heart muscle.
Coronary artery disease affects people in middle to old age and is more easily prevented than treated. The chance of developing the disease can be reduced by following a healthy lifestyle. For an individual with CAD, the outlook depends on the number of blood vessels involved and how extensively the heart muscle is damaged when the condition is diagnosed.
Hypertension
Persistent high blood pressure that may damage the arteries and the heart. Until fairly recently treating hypertension was not felt to be necessary or effective in the elderly. This is no longer the case.
This condition puts strain on the heart and arteries, resulting in damage to delicate tissues. If it is left untreated, hypertension may eventually affect the eyes and kidneys. The higher the blood pressure, the greater the risk that complications such as heart attacks, myocardial infarction, coronary artery disease, and stroke, will develop. It is more common with increasing age and slightly more common in males.
Blood pressure is expressed as two values given in units of millimetres of mercury (mmHg). The blood pressure of a resting, healthy young adult should not be more than 120/80 mmHg. In general, a person is considered to have hypertension when his or her blood pressure is persistently higher than 140/90 mmHg, even at rest.
Hypertension does not usually cause symptoms, but if the blood pressure is high enough it may cause:
- headaches
- dizziness
- blurred vision
Hypertension can be diagnosed by measuring blood pressure. This should be done routinely at least every two years after the age of 18. If the value is more than 140/90 mm Hg this should be re-checked after a short interval to confirm the reading. Some individuals become anxious when visiting the doctor, which may cause a temporary rise in blood pressure, referred to as white coat hypertension. Therefore, a diagnosis of hypertension is usually not made unless there is elevated blood pressure on three separate occasions.
Hypertension cannot usually be cured but can be controlled with treatment. In mild hypertension, changing lifestyle is often the most effective way of lowering blood pressure. Salt and alcohol consumption should be reduced and smoking stopped altogether. Body weight should be within the ideal range, within the Body Mass Index (BMI) range of 18.5 to 24.9.[1]
The prognosis depends on the degree and duration of the elevated blood pressure. For most people, lifestyle changes and drug treatment can control blood pressure and reduce the risk of complications. These measures usually need to be maintained for life. Long-standing, severe hypertension carries the greatest risk of complications.
There is now a large body of evidence to show that successful treatment of hypertension prevents vascular events such as stroke, myocardial infarction, renal impairment, heart failure and possibly dementia. This evidence base now includes substantial numbers of elderly patients. However, as with any treatment, the balance of risks versus benefits needs to be carefully weighed, particularly in the very frail elderly.
References:
[1] World Health Organization, Press release: Obesity, high blood pressure, high cholesterol, alcohol and tobacco: The World Health Organization’s response
Myocardial infarction
Loss of blood supply to part of the heart muscle due to a blockage in a coronary artery, commonly known as a heart attack.
Heart attack or ‘coronary’ are common terms for the disorder myocardial infarction, which means, literally, death of part of the heart muscle following a blockage in its blood supply. Myocardial infarction is one of the major causes of death in developed countries such as the UK.
If a coronary artery is narrowed by a fatty deposit, the fibrous cover of the deposit may rupture, triggering the formation of a blood clot. If this clot blocks the artery, blood flow to an area of heart muscle stops, causing a myocardial infarction.
A family history of coronary artery disease (CAD) is indicative of an increased risk of having a heart attack, especially if one or more members of the family developed CAD or had a heart attack under the age of 55. The risk is also increased if there is raised blood pressure or cardiovascular problems as a result of diabetes mellitus.
The symptoms of a heart attack usually develop suddenly and may include:
- Indigestion-like symptoms, although this is not as common
- heavy, crushing pain in the centre of the chest that may spread up to the neck and into the arms, especially the left arm
- pallor and sweating
- shortness of breath
- nausea and, sometimes, vomiting
- anxiety, sometimes accompanied by a fear of dying
- restlessness
- an Inferior Myocardial Infarction (40%) leads to upper abdominal pain, just below the sternum
- there are also cases of silent myocardial infarctions in the elderly with symptoms including undue and increasing tiredness over a few weeks, leading to increasing debility
The immediate aims of treatment for myocardial infarction are to relieve pain and restore the blood supply to the heart muscle to minimise the amount of damage and prevent further complications. These aims are best achieved by immediate admission to an intensive or coronary care unit where heart rhythm and vital clinical signs can be monitored continuously.
Unless contraindicated, thrombolysis ("clot busting drugs") is a key treatment of patients with myocardial infarction who present early enough (usually within 12 hours of onset of chest pain). Although complications of thrombolysis (mainly haemorrhagic stroke) are commoner in the elderly, there is some evidence to suggest that they may potentially benefit more from this treatment than younger patients.
During recuperation it is important for patients to follow advice about how soon to return to normal activities. It is common for patients to experience some mild depression during this period. Many hospitals offer ongoing cardiac rehabilitation programmes after discharge from hospital to help people regain their confidence and share their experiences.
The prognosis is good if there was no previous myocardial infarction, the treatment was prompt, and there were no complications. After two weeks, the risk of another heart attack is considerably reduced, and there is a good chance of living for another 10 years at least. The outlook is better if smoking is stopped, alcohol intake is reduced, exercise is undertaken, and the patient adheres to a healthy diet. If there was a previous heart attack, the outlook depends on the amount of heart muscle that was damaged and whether there are additional complications. However, many people who have surgery or angioplasty live for 10 years or more.
Further information:
- BBC - Heart Disease
- British Cardiac Patients Association
- British Cardiovascular Society
- British Heart Foundation
- British Hypertension Society
- Department of Health – Coronary heart disease, includes the National Service Framework
- European Society of Cardiology
- Heart, peer reviewed journal for health professionals and researchers in all areas of cardiology
- Heart Research UK
- Heart UK
- Hearts for Life
- High Blood Pressure Foundation
- MEDLINEplus Medical Encyclopaedia
- NHS National Library for Health – Cardiovascular diseases specialist library
- National Heart Forum
- NHS Direct Online
- Women’s Heart Foundation
- World Health Organisation – Cardiovascular diseases
- World Heart Federation
For all vascular disease (angina, myocardial infarction, ischaemic or hypertensive heart failure, stroke and peripheral vascular) and probably also in those with hypertension or diabetes there is increasing evidence that aggressive treatment of vascular risk factors (smoking, hypertension, high cholesterol) can prevent first or recurrent vascular events. Lifestyle modification (smoking cessation, alcohol moderation, dietary changes, exercise) in conjunction with drug treatment (e.g. aspirin, cholesterol lowering drugs, ACE inhibitors, B blockers) should be considered for patients of all ages, including the elderly, with vascular risk factors or those who have had a vascular event.