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Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
Incidence and prevalence
- Coronary heart disease (CHD) is the most common cause of death (and premature death) in the UK.
- 1 in 5 men and 1 in 7 women die from CHD.
- There are 80,000 deaths from CHD in the UK each year.
- Death rates from CHD are highest in Scotland, and the North of England, and lowest in the South of England.
- Death from CHD is more likely during winter and this increased winter mortality increases with increasing age.
- In recent years, CHD death rates have been falling more slowly in younger age groups and fastest in those aged 55 and over. There is some evidence that these rates are beginning to level off in younger age groups.
- Death rates from all heart attacks and heart attacks that are immediately fatal have declined, with around a 50% decrease in men and women since 2002.
- Premature death rates from heart attacks have declined, with a 58% reduction between 2002 and 2010.
- Despite the decline in death rates from cardiovascular disease (CVD) in the UK, rates are still relatively high compared to other Western European countries.In Western Europe, only Ireland, Germany, Sweden and Luxembourg had a higher death rate than the UK in the same year.
- The overall incidence of myocardial infarction in England in 2010 was 154 per 100,000 in men and 34 per 100,000 in women.
- The overall incidence of myocardial infarction in Scotland in 2009 was 255 per 100,000 in men and 113 per 100,000 in women.
- The overall incidence of angina in the UK in 2011 was 38 per 100,000 in men and 21 per 100,000 in women.
- The prevalence is higher in lower socio-economic groups.
- Although mortality from CHD is falling, morbidity appears to be rising.
The aetiology of CHD is multifactorial. It is the result of interaction between genetic, lifestyle and environmental factors. Poor diet and other lifestyle factors are estimated to account for about one-third of all deaths from CVD in England.
- CHD increases with age.
- Traditionally, CHD has been considered a disease of men. However, CHD is the leading cause of death both in men and women.
- It is responsible for a third of all deaths in women worldwide and half of all deaths in women over the age of 50 years in developing countries.
- In England and Wales there is a positive correlation between deaths from circulatory diseases and levels of deprivation.
- There is a marked difference in prevalence of CHD between and within communities.
- Men and women living in the West of Scotland are nearly six times more likely to die prematurely from CHD than men and women living in the South West of England.
- Within London, people living in Tower Hamlets have a three times increased risk of dying prematurely from CHD compared with those in Kensington and Chelsea.
- The difference in CHD rates in different socio-economic groups is related to many factors, including diet, smoking, exercise, and alcohol.
- Mortality from CHD is 60% higher in smokers.
- Regular exposure to passive smoking increases CHD risk by up to 25-30%.
- World Health Organization (WHO) research estimates that over 20% of CVD is due to smoking.
There are national, regional, socio-economic and ethnic differences in nutrition.
- A WHO report in 2003 stated that a diet high in fat (particularly saturated fat), sodium and sugar and low in complex carbohydrates, fruit and vegetables increases the risk of CVD.
- It has been recommended that the percentage food energy derived from fat should be 35%, with 11% from saturated fat. However, there is currently some debate regarding the validity of current advice regarding a low-fat diet.
- Trans fatty acids reduce high-density lipoprotein (HDL) and increase low-density lipoprotein (LDL) cholesterol and can increase CHD risk. A meta-analysis showed that a 2% increase in the energy intake from trans fatty acids increased CHD incidence by 23%.
- Eating oily fish rich in omega-3 fatty acids has been shown to reduce CHD mortality.
- Increased intake in dietary fibre also appears to reduce risk.
- A healthy diet is essential, irrespective of the individual risk of CVD.
- Physical activity reduces the risk of CHD.
- The 2002 World Health Report estimated that over 20% of CHD in developed countries was due to physical inactivity.
- Recommended physical activity levels are 30 minutes of moderate physical activity on five or more days per week.
- Over one third of UK adults are estimated to be inactive (exercising for less than one occasion of 30 minutes per week).
- 1 to 2 units of alcohol per day reduce the risk of CHD. Alcohol increases HDL cholesterol and reduces thrombotic risk. Higher levels of consumption increase risks from other causes.
- The World Health Report in 2002 estimated that 2% of CHD in men in developed countries is due to excessive alcohol consumption.
- Men should drink no more than 3 to 4 units on any one day and women no more than 2 to 3 units.
- Work stress, lack of social support, depression, anxiety and personality (particularly hostility) can all increase CHD risk.
- For adults aged 40 to 69 years, each 20 mm Hg rise in usual systolic blood pressure or 10 mm Hg rise in diastolic blood pressure doubles the risk of death from CHD.
- The INTERHEART study showed that 22% of heart attacks in Western Europe were due to a history of high blood pressure and those with hypertension had almost twice the risk of a heart attack.
- CHD risk is related to cholesterol levels.
- The INTERHEART study suggested that 45% of heart attacks in Western Europe are due to abnormal blood lipids.
- People with low levels of HDL cholesterol have an increased risk of CHD and a worse prognosis after a myocardial infarction.
- In the UK, it is suggested that the target cholesterol is <4 mmol/L for people with diabetes or established CVD or for people at high risk of developing CVD. People with HDL cholesterol <1 mmol/L should also be considered for treatment.
Overweight and obesity
- Obesity is an independent risk factor for CHD. It is also a risk factor for hypertension, hyperlipidaemia, diabetes and impaired glucose tolerance.
- Central or abdominal obesity is most significant. Those with central obesity have over twice the risk of heart attack.
- Men with type 2 diabetes have a 2 to 4 times greater annual risk of CHD; women have a 3 to 5 times greater risk.
- Around 6% of men and 5% of women in England have diagnosed diabetes. The prevalence is increasing.
- South Asian people living in the UK (people from India, Pakistan, Bangladesh and Sri Lanka) have a higher premature death rate from CHD (46% higher for men; 51% higher for women).
- Hypotheses for this include migration, disadvantaged socio-economic status, 'proatherogenic diet', lack of exercise, high levels of homocysteine and lipoprotein(a) (Lp(a)), endothelial dysfunction and enhanced plaque and systemic inflammation.
- The premature death rate from CHD in West African people and people from the Caribbean is much lower (half the rate compared with the general population for men and two thirds of the rate for women).
- First-degree relatives of patients with premature myocardial infarction have double the risk themselves.
- Premature CHD is that before age 55 years in men and 60 years in women.
- More than one third of admissions for premature myocardial infarction could be prevented by screening and treating first-degree relatives.
- Genetic predisposition and shared lifestyle are likely to contribute.
- Several regions of the human genome have been shown to be associated with either CHD or hypertension.
- It has been considered that elevated levels of homocysteine are an independent risk factor for CHD, likely due to oxidative damage to the endothelium, platelet activation and thrombus formation.
- However, there is no evidence to suggest that homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination should be used for preventing cardiovascular events.
- In 2009, CVD cost the healthcare system in the UK around £8.7 billion and the cost to the UK economy was £19 billion.
- The cost per capita for cardiovascular disease in the UK is lower than the European Union average.
Further reading and references
Coronary Heart Disease Statistics 2012; British Heart Foundation
Nichols M, Townsend N, Scarborough P, et al; Cardiovascular disease in Europe: epidemiological update. Eur Heart J. 2013 Oct34(39):3028-34. doi: 10.1093/eurheartj/eht356. Epub 2013 Sep 7.
Levy LB; Dietary strategies, policy and cardiovascular disease risk reduction in England. Proc Nutr Soc. 2013 Nov72(4):386-9. doi: 10.1017/S0029665113001328. Epub 2013 Jul 10.
Mikhail GW; Coronary heart disease in women. BMJ. 2005 Sep 3331(7515):467-8.
Pilote L, Dasgupta K, Guru V, et al; A comprehensive view of sex-specific issues related to cardiovascular disease. CMAJ. 2007 Mar 13176(6):S1-44.
Hawkins NM, Scholes S, Bajekal M, et al; The UK National Health Service: delivering equitable treatment across the spectrum of coronary disease. Circ Cardiovasc Qual Outcomes. 2013 Mar 16(2):208-16. doi: 10.1161/CIRCOUTCOMES.111.000058. Epub 2013 Mar 12.
Doll R, Peto R, Boreham J, et al; Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ. 2004 Jun 26328(7455):1519. Epub 2004 Jun 22.
Anthony D, George P, Eaton CB; Cardiac risk factors: environmental, sociodemographic, and behavioral cardiovascular risk factors. FP Essent. 2014 Jun421:16-20.
Guilbert JJ; The world health report 2002 - reducing risks, promoting healthy life. Educ Health (Abingdon). 2003 Jul16(2):230.
Diet, nutrition and the prevention of chronic diseases; Report of a Joint AHO/FAO Expert Consultation, World Health Organization, 2003
Mozaffarian D, Katan MB, Ascherio A, et al; Trans fatty acids and cardiovascular disease. N Engl J Med. 2006 Apr 13354(15):1601-13.
Bays HE, Tighe AP, Sadovsky R, et al; Prescription omega-3 fatty acids and their lipid effects: physiologic mechanisms of action and clinical implications. Expert Rev Cardiovasc Ther. 2008 Mar6(3):391-409.
Whayne TF Jr, Maulik N; Nutrition and the healthy heart with an exercise boost. Can J Physiol Pharmacol. 2012 Aug90(8):967-76. doi: 10.1139/y2012-074. Epub 2012 Jul 19.
Palmefors H, DuttaRoy S, Rundqvist B, et al; The effect of physical activity or exercise on key biomarkers in atherosclerosis - A systematic review. Atherosclerosis. 2014 Jul235(1):150-161. doi: 10.1016/j.atherosclerosis.2014.04.026. Epub 2014 May 1.
Global recommendations on physical activity for health; World Health Organization
Safe Alcohol Consumption; A Comparison of Nutrition and Your Health: Dietary Guidelines for Americans and Sensible Drinking International Center for Alcohol Policies.
Yusuf S, Hawken S, Ounpuu S, et al; Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004 Sep 11-17364(9438):937-52.
Kuppuswamy VC, Gupta S; Excess coronary heart disease in South Asians in the United Kingdom. BMJ. 2005 May 28330(7502):1223-4.
Chow CK, Pell AC, Walker A, et al; Families of patients with premature coronary heart disease: an obvious but neglected target for primary prevention. BMJ. 2007 Sep 8335(7618):481-5.
Marti-Carvajal AJ, Sola I, Lathyris D, et al; Homocysteine-lowering interventions for preventing cardiovascular events. Cochrane Database Syst Rev. 2013 Jan 311:CD006612. doi: 10.1002/14651858.CD006612.pub3.
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