Improving outcomes in cardiovascular care—time to refocus on the hidden determinants of health?

The technological and pharmacological advances in cardiovascular care have contributed to improved patient outcomes, but the burden of disease remains significant. This has recently been confirmed by the World Heart Federation (WHF), demonstrating that more than half a billion people globally are affected by cardiovascular disease.1 Moreover, global cardiovascular disease-related mortality increased from 12.1 million in 1990 to 20.5 million in 2021. Interestingly, these mortality rates declined in high income countries, compared with low- and middle-income countries that contribute to ∼80% of all cardiovascular death. The media report ‘the miracle drug’ or ‘major scientific breakthrough’ from a promising clinical trial, but often, no dramatic change is seen in practice. It is now acknowledged that other factors play an important role in maintaining health, and these are known as the social determinants of health. The well-known determinants are individual life-style factors and social and community networks as outlined by Dahlgren and Whitehead2 30 years ago.1 Covid-19 has highlighted the huge disparities in equity and access to healthcare, and the impact of this inequality is evident across healthcare, regardless of location.3 These disparities have refocused attention on determinants that previously were not the focus with an emphasis on health-related quality of life.4,5 With growing inequality in society, we are now beginning to appreciate the importance and impact of income, geographical location and social status, education and literacy levels as well as patients’ personal health practices and coping skills, and how these contribute to the global burden of cardiovascular disease. In this issue of the European Journal of Cardiovascular Nursing, Jennings et al.6 highlight the importance of illness perceptions and health literacy. In their review of 3408 participants in EUROASPIRE V, as well as reporting the prevalence of cardiovascular risk factors (38% were obese, 60% physically inactive, and 41% hypertensive), illness perceptions that were deemed threatening were evident. These illness perceptions were markedly greater in those with lower income and lower education levels, and participants had higher rates of anxiety and depression. As often is the case, those with lower levels of education also have poorer health, and this translated to poorer rating in health-related quality of life. It is clear from this paper that our cardiac rehabilitation programmes need to take these factors into consideration and suggests that assessment of health literacy should become a key part of patient assessment, especially when considering cardiac rehabilitation. The importance of socio-economic status was also highlighted by Garcia-Mayor et al.7 who analysed how socio-economic status affected weight status through health-related lifestyles. Although the WHF recommends that country’s health expenditure should be at least 5% (as a percentage of GDP), this might not be achievable, and many studies have shown that those who live in areas of higher levels of socio-economic deprivation often have poor diets (i.e. high in saturated fats and processed foods as well as low intake of fresh food), lower levels of physical activity, higher rates of smoking, and precarious employment and living conditions. It is not surprising that this latent class analysis confirms the association between obesity and socioeconomic status as poverty is a strong driver of health. The complexity of health and the social, environmental, and economic inequalities all merge and often present as obesity. This undoubtedly makes the healthcare professionals’ job of educating, advising, and empowering patients with cardiovascular disease to modify their lifestyle, if their circumstances do not allow them to make the positive changes. How can we encourage a patient with a recent cardiac event to change their lifestyle when they are living in poor housing, working on a low paid zero-hours contract, with a poor social support system, and local food outlets are primarily affordable take-away foods? This is where policy and public health play a key role. Although as cardiovascular healthcare professionals, most of us are not in a position to change public policy, we can play a role in providing education and advice to our patients and their families and guide them in achieving a better lifestyle. However, often, the burden on caregivers and family members is not explored in those with long-term conditions. Thodi et al.8 undertook a nurse-led educational intervention in patients who had recently been hospitalized with heart failure examining the impact on their caregivers. Their study observed that it is possible to reduce caregiver burden and feelings of guilt by using home visits and telephone sessions along with usual care. Patients and caregivers require education in order to be able to improve their self-management, and this study provides a good overview on the impact on caregivers—an often under-reported aspect of management of chronic conditions. Nurses, of course, play an important role in cardiovascular disease, and nurse-led services are common, albeit with a paucity of evidence supporting the role. Driscoll et al.9 have specifically examined the heart failure nurse practitioner (HF-NP) model in heart failure, and via a retrospective two-group comparative design, they demonstrated the benefits of an inpatient HF-NP service in a cohort of 408 patients compared with usual care, with a lower risk of 12-month rehospitalization and emergency department presentations. The study also improved referrals for home visits highlighting the need for patient management within their home environment. There is no doubt that the levels of social, economic, and environmental inequality damage our health and negatively affect our wellbeing. Sir Michael Marmot has set up the Institute of Health Equity with the aim of ensuring we have a fair society and healthy lives.9 His most sobering thought is that ‘Most of our choices are constrained by the conditions in which we are born, grow, live, work and age.’10 As healthcare professionals, it is perhaps useful to keep this in mind when we are interacting and working with our patients and their families. The authors received no financial support for the research, authorship and/or publication of this article. No original data are used for this editorial.