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					        NEW ZEALAND HEALTH S TRATEGY




                DHB TOOLKIT


    Cardiovascular Disease
To reduce the incidence of cardiovascular disease



                       2003




                 Edition 2: February 2003
Contents

Contents .......................................................................................................................... 2
Executive summary ......................................................................................................... 4

Introduction ...................................................................................................................... 5
     Linkages ................................................................................................................... 5

1.     Cardiovascular disease, risk assessment and management .................................... 6
       Burden of cardiovascular disease in New Zealand ................................................... 6
       Cardiovascular risk factors ....................................................................................... 7
       Cardiovascular assessment and risk management .................................................. 8
       Primary prevention of cardiovascular disease .......................................................... 9
       Secondary prevention of cardiovascular disease ................................................... 11
       Cardiac rehabilitation.............................................................................................. 12
       Secondary prevention of ischaemic stroke ............................................................. 12
       Tools available for District Health Boards ............................................................... 14
       Tools under development ....................................................................................... 14
       Tools for future development .................................................................................. 15

2.     Management of acute coronary syndromes ........................................................... 16
       Acute coronary syndromes in New Zealand ........................................................... 16
       Acute pre-hospital care .......................................................................................... 16
       Hospital care .......................................................................................................... 17
       Tools available for District Health Boards ............................................................... 18
       Tools under development ....................................................................................... 18
       Tools for future development .................................................................................. 18
3.     Heart failure............................................................................................................ 19
       Heart failure in New Zealand .................................................................................. 19
       Management of heart failure .................................................................................. 19
       Tools available for District Health Boards ............................................................... 20
4.     Rheumatic heart disease ........................................................................................ 21
       Rheumatic fever and heart disease in New Zealand .............................................. 21
       Tools available for District Health Boards ............................................................... 22
5.     Stroke services ....................................................................................................... 23
       Burden of stroke in New Zealand ........................................................................... 23
       Stroke care in New Zealand ................................................................................... 23
       Access to and quality of stroke services ................................................................. 24
       Organised stroke care ............................................................................................ 25
       Tools available for District Health Boards ............................................................... 26
       Tools under development ....................................................................................... 26
       Tools for future development .................................................................................. 26
6.     Cardiovascular disease and Maori ......................................................................... 27
       Tools available for District Health Boards ............................................................... 27

New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                                                      2
      Tools under development ....................................................................................... 30
      Tools for future development .................................................................................. 30

7.    Cardiovascular disease and Pacific peoples .......................................................... 31
      Tools available for District Health Boards ............................................................... 31
      Tools under development ....................................................................................... 32
      Tools for future development .................................................................................. 32
References .................................................................................................................... 33
    APPENDIX 1: Indicators ......................................................................................... 37
    APPENDIX 2: Definitions ....................................................................................... 43




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                                                   3
Executive summary
Cardiovascular disease is the leading cause of death in New Zealand, accounting for 41 percent of
all deaths in 1999, thus it has a large impact on the delivery of health services. Of the
cardiovascular diseases, coronary artery disease is the major cause of death, followed by stroke,
which is the greatest cause of disability in older people.
The burden of cardiovascular disease is greatest among Maori and Pacific peoples, as the
following evidence indicates.
•   Mortality from all cardiovascular diseases is higher among Maori than the general population.
    Coronary heart disease is the leading single cause of death for Maori.
•   Maori have the highest rate of hospital admissions for heart failure (nearly three times that of
    Europeans/others).
•   Pacific peoples have the highest mortality rate for cerebrovascular disease and the highest
    hospital discharge rate for stroke.
•   The chance of being dependent at 12 months post stroke is three times higher among Maori
    and Pacific peoples than among Europeans who have a stroke.
•   Maori and Pacific peoples have the highest discharge rates for both rheumatic fever and
    rheumatic heart disease.
One of the 13 population health objectives of the New Zealand Health Strategy is to reduce the
incidence and disease impact of cardiovascular disease in New Zealand.
In addressing this priority a Cardiovascular Expert Advisory Group was established to assist the
Ministry of Health to identify those cardiovascular areas that would have the greatest population
impact. Following a review of the evidence, an action plan was developed, which includes the
following priority areas:
•   cardiovascular risk screening and management
•   acute coronary syndromes
•   secondary prevention
•   cardiac rehabilitation
•   organised stroke care
•   cardiovascular disease and Maori
•   cardiovascular disease and Pacific peoples.
The Cardiovascular Action Plan is currently being implemented over three years. Its main work
includes:
•   development of New Zealand cardiovascular cardiac and stroke guidelines for DHB
    providers
•   development of national service specifications for cardiac and stroke services
•   addressing inequalities, particularly for Maori and Pacific peoples. (Additional work on
    Reducing Inequalities in Health and a Reducing Inequalities Toolkit are available from the
    Ministry of Health.)
•   consumer education
•   addressing workforce issues.
This toolkit provides evidence on each of the cardiovascular priority areas and information on
cardiovascular tools currently available, tools under development and tools for future
development.

New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       4
Introduction
The New Zealand Health Strategy has identified 13 priority areas for population health. District
Health Boards (DHBs) will be required to report annually on progress towards each of these
priority areas. This toolkit provides information and resources to assist DHBs to achieve the
objective of reducing the incidence and impact of cardiovascular disease in their communities.
The toolkit was developed by the Clinical Services Directorate within the Ministry of Health in
conjunction with a Cardiovascular Expert Advisory Group composed of clinicians, District
Health Boards New Zealand (DHBNZ), consumers, Maori and Pacific peoples. As there were no
existing cardiovascular strategies, the advisory group assisted the Ministry to produce a
Cardiovascular Action Plan aimed at addressing those cardiovascular areas that would have the
greatest population impact.
The action plan was developed following a review of the evidence. It includes the following
priority areas in which strategic work is currently being carried out:
•   cardiovascular risk screening and management
•   acute coronary syndromes
•   secondary prevention
•   cardiac rehabilitation
•   organised stroke care
•   cardiovascular disease and Maori
•   cardiovascular disease and Pacific peoples.
To assist DHBs this toolkit provides:
•   evidence and information on each of the cardiovascular priority areas
•   information on current cardiovascular tools that can be utilised by DHBs
•   information on cardiovascular tools currently under development and tools for future
    development.
Information is also provided on heart failure and rheumatic heart disease.

Links
This toolkit should be read in conjunction with the following Ministry of Health toolkits:
• Tobacco http://www.newhealth.govt.nz/toolkits/tobaccocontrol.htm
• Improve nutrition http://www.newhealth.govt.nz/toolkits/nutrition.htm
• Obesity http://www.newhealth.govt.nz/toolkits/obesity.htm
• Physical activity http://www.newhealth.govt.nz/toolkits/physicalactivity.htm
• Diabetes http://www.newhealth.govt.nz/toolkits/diabetes.htm




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                      5
1. Cardiovascular disease, risk assessment
   and management

Key points
•   Cardiovascular disease is the leading cause of mortality in New Zealand. It accounted for 41
    percent of all deaths in 1999.
•   Maori have the highest rates of mortality for all categories of cardiovascular disease.
•   The major modifiable risk factors for cardiovascular disease are smoking, hypertension, high
    serum cholesterol, diabetes, obesity, exercise and diet. Those at highest absolute risk derive
    the most benefit from treatment.
•   Although there are no national systematic cardiovascular screening programmes, tools are
    available for cardiovascular risk assessment by providers. There are also effective primary
    and secondary interventions for reducing and managing cardiovascular risk.
•   National strategic work includes the development of New Zealand guidelines for risk
    assessment and for primary and secondary prevention of cardiovascular disease. It also
    includes modelling work to investigate the costs and benefits of screening populations for
    different levels of cardiovascular risk.
•   DHBs should identify the cardiovascular burden within their population, particularly for
    Maori and Pacific peoples, and determine service provision within their DHBs in preparation
    for the development of national service specifications for stroke and cardiac services.

Burden of cardiovascular disease in New Zealand
Cardiovascular diseases are diseases affecting the heart and circulatory system. They include
ischaemic heart disease, rheumatic heart disease, cerebrovascular disease and other forms of
vascular and heart disease. Cardiovascular disease is the leading cause of death in New Zealand,
accounting for 41 percent of all deaths in 1999. It is also the leading cause of years lost to
premature mortality, accounting for 33 percent of life years lost between 45 and 64 years of age
(Hay 2001).
Although coronary artery disease is declining in New Zealand (Ministry of Health 1998), it still
results in the highest number of deaths of cardiovascular disease-related deaths (91 per 100,000).
It is the second leading cause of death following cancer. Coronary heart disease accounted for 23
percent of all deaths in 1999, of which just over 52 percent were attributable to myocardial
infarction. Eighty-five percent of coronary heart disease deaths occur in those over 65 years (Hay
2001).
Stroke is the third leading cause of death in New Zealand (33 per 100,000). It accounted for 10
percent of all deaths in 1999, of which most occurred in those over 65 years (Hay 2001).
Mortality from all cardiovascular diseases is higher among Maori than the general population.
Coronary heart disease is the leading single cause of death for Maori. Maori men are 1.8 times
more likely to die from coronary heart disease than non-Maori males (221 per 100,000 compared
to 122 per 100,000). Maori women are 1.8 times more likely to die from coronary heart disease
than non-Maori women (97 per 100,000 compared to 55 per 100,000) (Hay 2001). The coronary
heart disease mortality rate for Maori aged under 65 years is almost three times higher than that
of non-Maori in this age group. Death rates from cerebrovascular disease are 1.2 times higher in
Maori than in non-Maori, and from hypertensive disease they are five times higher (Hay 2001).


New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                      6
Mortality rates from coronary heart disease for Pacific peoples are lower than rates for Maori
(199 per 100,000 compared to 267 per 100,000 in 1999) but higher than European/others (158 per
100,000). Mortality rates for cerebrovascular disease are higher for Pacific peoples (115 per
100,000) than for Maori (82 per 100,000) and others (64 per 100,000) (1999 figures) (Ministry of
Health 2002a).
Mortality rates for coronary heart disease are higher among those in lower socioeconomic classes
(Kawachi et al 1991).
The cost of cardiovascular disease in New Zealand is considerable. In the early 1990s the cost of
coronary artery disease was estimated at between $306 million and $467 million ($179 million in
direct costs). Hospital costs for stroke have been estimated at $58 million; the cost of stroke to the
country as a whole has been estimated at $154 million a year. Cardiovascular drugs alone cost in
excess of $100 million and contribute to over 20 percent of Pharmac expenditure (Pharmac
2001).

Cardiovascular risk factors
There is abundant evidence that the following factors increase cardiovascular risk.

Cigarette smoking
Cigarette smoking is associated with a two- to three-fold increase in coronary artery disease,
stroke and peripheral vascular disease (Levy et al 1990). It is also thought to be the single most
preventable cause of heart disease. Population prevalence of smoking is estimated at around 25
percent (Ministry of Health 2002b). The prevalence of smoking for Maori is much higher, at 44
percent for Maori men and 51 percent for Maori women (Ministry of Health 2002b). Refer to
Tobacco Facts 2002 for more information.

Hypertension
Hypertension is a major risk factor for coronary artery disease and is the most important risk
factor for stroke. It has been estimated that among those aged 15 years and over, nearly 22
percent of males and 18.2 percent of females have high blood pressure (Ministry of Health
1999b).

Cholesterol
The association between cholesterol level and risk of developing cardiovascular disease has been
found to be continuous and graded. That is, the risk of cardiovascular disease mortality increases
with rising cholesterol levels.

Diabetes
Diabetes is a major risk factor for coronary artery disease, stroke and peripheral vascular disease
(Eastman and Keen 1997). It is associated with a two- to three-fold increased risk in coronary
artery disease in men and a four- to five-fold increase in premenopausal women (Fuller et al
1980; Rosengren et al 1989). There is a five-fold increase in heart failure among diabetics
(Yudkin and Hendra 1992). It is the leading cause of death in type 1 and type 2 diabetics (SIGN
1997). Refer to the diabetes toolkit for further information.

Obesity
People who are obese (ie, with a body mass index (BMI) of 30 or greater) are two to three times
more likely to develop coronary heart disease than those who are not obese (Agencies for
Nutrition Action 2001). Mortality from cardiovascular disease begins to increase with a BMI
above 25. The 1997 National Nutrition Survey estimated that 17 percent of New Zealanders are


New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                         7
now obese (ie, have a BMI greater than 30) compared to 11 percent in 1989 (Ministry of Health
1999a).

Physical activity
People who are sedentary are 1.9 times more likely to die from coronary artery disease than
active people, irrespective of other factors (Berlin and Colditz 1990). A similar finding is
produced by other systematic reviews and studies (Eaton 1992; Sherman et al 1999). Physical
activity can also reduce the risk of stroke (Gillum et al 1996). The New Zealand Nutrition survey
identified that over one third of New Zealanders (40 percent) are physically inactive.

Absolute risk and cumulative effect of risk factors
It is widely accepted that a person’s risk of cardiovascular disease is determined by the
synergistic effect of all the cardiovascular risk factors. The Framingham study (Jackson 1996)
identified that a cumulative effect of risk in the presence of two or more risk factors results in a
higher absolute risk of cardiovascular disease.
Figure 1 demonstrates the cardiovascular risk over an eight-year period for 40-year-old men with
the same four systolic blood pressure groups but with different numbers of risk factors. There is
nearly a 20-fold difference in cardiovascular risk between the first and last groups. Those at
highest absolute risk can be expected to receive the greatest benefit from treatment. It is
important to note that in this study physical activity and obesity are considered to have an effect
through the other risk factors (NHS Centre for Reviews and Dissemination 1998).

Figure 1:        CVD risk in 40-year-old men by SBP and other risk factors, Framingham, USA
               Risk of CVD risk in 40 year old men by SBP
                and other risk factors, Framingham, USA
                                                                      700
  CVD risk
  per 1000
  in 8 years
                                                         459


                                                326

                                   210


                        46


     SBP       105 ----189 105 ----189 105 ----189 105 ----189   105 ----189 mmHg
     high chol.    -          +            +          +             +
     gluc intol.   -           -           +          +             +
     cigarettes    -           -           -          +             +
     LVH           -           -           -          -             +


Source: R Jackson (1999). Reproduced with permission.


Cardiovascular assessment and risk management
The Cardiovascular Expert Advisory Group has identified cardiovascular risk assessment and
management as a national priority area. Cardiovascular risk is managed through both:
• primary prevention, defined as ‘the long term management of people at increased risk but
   with no evidence of cardiovascular disease’ (BMJ Publishing Group 2000)
• secondary prevention, defined as ‘the long-term management of people who have existing
   cardiovascular disease, have had a cardiovascular event, have had a cardiovascular surgical
   procedure and are at risk of a cardiovascular event’ (BMJ Publishing Group 2000).

New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                          8
There are currently no national systematic risk assessment and management screening
programmes for the primary and secondary prevention of cardiovascular disease. In part, they are
absent because of international debate over the level of risk at which cardiovascular risk
screening and treatment should occur given scarce national resources. Some individual provider
groups (eg, First Health and Procare) offer cardiovascular risk programmes.
Assessment and treatment of cardiovascular risk are an important part of the roles of primary and
secondary providers. Current guidance for providers on the level of risk at which patients should
be treated is based on an absolute risk assessment used in the hypertension and lipid guidelines.
References for these publications are included later in this section.

Primary prevention of cardiovascular disease
Assessment of risk for the primary prevention of cardiovascular disease is the role of primary
care providers. Interventions are directed at modifying cardiovascular risk factors to reduce the
absolute risk of cardiovascular disease. Effective primary prevention interventions include:
• quitting smoking
•   reducing high blood pressure
•   improving lipid profiles
•   more intensive control of diabetes
•   changing lifestyle factors (dietary patterns, reducing weight and increasing physical activity).

Cigarette smoking
Effective measures to decrease smoking in the population are outlined in the tobacco control
toolkit. Interventions include population media strategies, Quitline, the provision of health
professional advice (particularly by doctors) and the use of nicotine replacement therapy.

Hypertension
Interventions to lower blood pressure include salt reduction, weight loss, exercise and
antihypertensive drug therapy. Another is a dietary pattern high in fruits and vegetables, whole
grain cereals, low-fat dairy products, fish (especially oily fish), chicken and lean meat.
From rigorous meta-analyses of randomised trials of antihypertensive medications (chiefly
diuretics or beta-blockers), data have demonstrated a consistent reduction in mean
systolic/diastolic blood pressure (Collins et al 2000). The estimated reduction in the risk of
having a cardiovascular event over five years is 2–3 percent for each 1 mm Hg drop in systolic
blood pressure (Mulrow et al 1997).
The treatment and management of hypertension are outlined in the Guidelines for the
Management of Mildly Raised Blood Pressure in New Zealand, developed in 1995 by the New
Zealand Guidelines Group.

Cholesterol lowering
Interventions to lower blood cholesterol include dietary advice, the use of plant sterols, weight
loss, exercise and cholesterol-lowering drug therapy. However, one type of cholesterol-lowering
drug (statins) has the most significant effect.
A recent meta-analysis of the five major statin trials reported reductions of total cholesterol by 20
percent, low density lipids (LDL) by 28 percent and triglycerides by 13 percent, along with an
increase in high density lipids (HDL) by 5 percent. After an average of five years treatment, the
risk of coronary heart disease mortality was reduced by 31 percent, cardiovascular deaths by 27
percent and all-cause mortality by 21 percent. It has been demonstrated that the risk reduction is
similar for men, women, older people and the middle aged (LaRosa et al 1999).

New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       9
In 2000 lipid modifying agents resulted in the highest expenditure ($36.6 million) of the drugs in
the pharmaceutical schedule (Pharmac 2001). This cost could be far greater if more eligible
people took up statins. Currently approximately 50 percent of 160,000 patients who are eligible
for statins are receiving them. In interpreting this level of access, it should be noted that
approximately 45,000 people are receiving alternative lipid lowering drugs, mainly fibrates
(Pharmac 2001).
The lipid guidelines developed by the National Heart Foundation are the current guide to the
management of lipid lowering. These guidelines are currently being updated and are being
incorporated into a New Zealand guideline on the assessment and management of cardiovascular
risk (see section below on tools under development). Coinciding with this work is a review by
Pharmac of the eligibility criteria for statins due to a decrease in their price.

Diabetes
As stated above, men with diabetes are two to three times more likely to die from coronary heart
disease and premenopausal women with diabetes are four to five times more likely to die from
coronary heart disease. The prospective diabetes study in the United Kingdom found that the
ECG readings of 15 percent of men and 23 percent of women indicated myocardial ischaemia at
diagnosis of diabetes (Morrish et al 1991). It is therefore suggested that it is important that all
diabetics are assessed and treated for cardiovascular risk (SIGN 1997).
The Scottish Intercollegiate Guidelines Network has developed guidelines for the management of
diabetic cardiovascular disease (SIGN 1997). These guidelines recommend that diabetics should
be assessed for cardiovascular risk factors yearly and that glycaemic control to reduce
cardiovascular risk should be optimised. As for other people at cardiovascular risk, they also
recommend reduction of smoking, weight management, lipid reduction and changes to lifestyle.
The management of diabetic cardiovascular disease is included in the guideline currently being
developed for the assessment and management of cardiovascular risk.

Lifestyle factors
Reduction in weight has been shown to reduce blood pressure. From 76 randomised controlled
trials (RCTs) evaluating the effect of weight loss on blood pressure, an analysis demonstrated that
a 10 kg weight loss in hypertensive patients was associated with an average reduction of 7 mm
Hg systolic and 3 mm Hg diastolic blood pressure compared with controls. Reduction in weight
can also reduce lipid levels (National Heart, Lung and Blood Institute 1998).
A meta-analysis has shown that physical activity alone (aerobic exercise) independent of caloric
reduction through diet results in a modest weight loss of 3 kg in men and 1.4 kg in women
(World Health Organization 1990). Diet and physical activity together produce a greater weight
loss than either therapy alone. Over nine months to two years, a combination of diet and physical
activity resulted in weight loss approximately 1.5 to 3 kg greater than diet alone (National Heart,
Lung and Blood Institute 1998).
Primary care providers need to be able to provide advice on weight maintenance, nutrition and
physical activity.
Information on obesity, physical activity and nutrition is available from the Ministry of Health
toolkits. Other information on nutrition and physical activity for providers is available through
the National Heart Foundation of New Zealand. Information on physical activity and green
prescriptions is also available for providers through the Hillary Commission. The Hillary
Commission (2001) identified that general practitioners write about 4,000 green prescriptions a
year, with the most common prescription being walking.



New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       10
Secondary prevention of cardiovascular disease
Assessment of risk for the secondary prevention of cardiovascular disease is the role of primary
and secondary care providers. Interventions are directed at modifying cardiovascular risk to
reduce the risk of further events or death. As in primary prevention, interventions include quitting
smoking (the CVD risk becoming that of a non-smoker within two to five years; LaRosa et al
1999), reducing high blood pressure, lowering lipid levels, controlling diabetes more intensively
and modifying lifestyle. Other interventions are additional drug therapy, revascularisation and
cardiac rehabilitation.

Drug therapy
In those with established coronary heart disease, there is substantial evidence of benefit
(ie, reduction in coronary artery disease morbidity and mortality) with the use of aspirin, beta-
blockers, ACE inhibitors and lipid modifying drugs (BMJ Publishing Group 2000; Koudstaal
2000).
•   Aspirin is an antiplatelet therapy effective in reducing mortality in people who are having or
    have had myocardial infarction and in preventing an initial or subsequent stroke (BMJ
    Publishing Group 2000).
•   Beta-blockers have an effect on beta receptors that decrease cardiac work and myocardial
    oxygen demand. Beta-blockers reduce the risk of all-cause mortality, coronary mortality,
    recurrent non-fatal myocardial infarction and sudden death in people after myocardial
    infarction (BMJ Publishing Group 2000).
•   ACE inhibitors can reduce rates of death and hospitalisation for people who have a recurrent
    non-fatal myocardial infarction and who have left ventricular dysfunction. The effect in
    people who have had a myocardial infarction but no left ventricular dysfunction has not been
    properly evaluated (BMJ Publishing Group 2000)
•   Statins can reduce the need for revascularisation (either angioplasty or coronary artery bypass
    surgery) by as much as 37 percent (BMJ Publishing Group 2000). In a recent study, only 32
    percent of patients who had had a previous heart attack were on a lipid-lowering agent (Ellis
    1998).

Revascularisation
Revascularisation procedures include angioplasty (PTCA) and coronary artery bypass graft
(CABG).
Randomised controlled trials up to the mid-1980s have found that, compared with medical
treatment, coronary artery bypass surgery causes a greater risk of death in the first year but
reduced risk of death at 5 and 10 years. Greatest benefit occurred in people with more severe
disease. Intracoronary stents have been found to be superior in the long term compared to PTCA
(BMJ Publishing Group 2000). The issue of medical treatment versus revascularisation is subject
to ongoing research and debate.
Revascularisation procedures are prioritised using referral guidelines for specialist assessment,
access criteria for first specialist assessment and clinical priority access criteria (CPAC) for
access to procedures or surgery. These guidelines and criteria have been developed by clinicians
since 1997 and take into account both the ability to benefit from revascularisation procedures and
the need of patients requiring these procedures. Final prioritisation decisions by clinicians take
into account both the CPAC score at which procedures are carried out and the funding threshold
of hospitals. Such decisions are reported on quarterly by hospitals.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       11
Cardiac rehabilitation
Cardiac rehabilitation is a multidisciplinary approach that aims to modify cardiac risk through
lifestyle change, to improve functional capacity and self-confidence and to reduce psychological
distress. Rehabilitation programmes usually include exercise training, risk factor modification,
education (including diet) and counselling. In the past, cardiac rehabilitation has been chiefly
prescribed for patients following a heart attack but it is now recognised that people with all forms
of cardiovascular disease may well benefit from this approach.
Randomised controlled secondary prevention trials of exercise-based cardiac rehabilitation
following myocardial infarction have shown a reduction in total mortality and cardiovascular
mortality by 20 to 25 percent (O’Connor et al 1989; Oldridge et al 1988). Cardiac rehabilitation
has also been shown to produce significant direct cost saving through reduced hospital
admissions, hospital costs, disability benefits and support services, while improving quality and
duration of life.
Currently 37 centres in New Zealand offer phase 1 and 2 cardiac rehabilitation. The provision of
cardiac rehabilitation varies considerably across the country. There is variation in facilities,
equipment, format of the service, duration of the programmes and the number of sessions offered.
In a recent audit of a large institution, the National Heart Foundation identified that 56 percent of
those eligible for cardiac rehabilitation do not attend, and of those who do attend only 19 percent
actually complete the programme. Reasons for non-attendance could include lack of referral from
health professionals and lack of knowledge of cardiac rehabilitation services by patients (Parks et
al 2000).
A New Zealand guideline for cardiac rehabilitation has recently been completed by the National
Heart Foundation and the New Zealand Guidelines Group. This guideline provides
comprehensive information on the management of the rehabilitation of cardiac patients,
information on audit of cardiac rehabilitation services and a set of performance indicators. It is
intended that the cardiac rehabilitation guideline will inform future development of National
cardiac service specifications. A copy of the guideline can be viewed on the New Zealand
Guidelines Group website.

Secondary prevention of ischaemic stroke
Secondary prevention of stroke should commence in the first week following a stroke.
Interventions are directed at modifying risk factors to reduce the risk of further strokes and
cardiovascular events. A clear patient management plan involving both the patient and caregivers
is essential. It is also important that there is effective co-ordination among hospital, primary care
and other providers to ensure that the plan is implemented.
Interventions to prevent further strokes can include reduction of blood pressure, quitting smoking,
treatment of dyslipidaemia, antiplatelet treatment, carotid endarterectomy, treatment of atrial
fibrillation and other comorbidities.

Reduction of blood pressure
Hypertension is the most important reversible risk factor for stroke. It is recommended that
hypertension is treated after a patient has had a stroke or a transient ischaemic attack (TIA) and
should follow standard guidelines. It is important, however, that blood pressure treatment is not
commenced until one to two weeks after a stroke. Lowering blood pressure in the first few days
after stroke reduces cerebral blood flow and may increase the size of the cerebral infarct (Stroke
Foundation of New Zealand 1996).




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                      12
Quitting smoking
The risk of stroke is increased in cigarette smokers by about 50 percent. It is important that the
patient management plan identifies suitable strategies for assisting the patient to give up smoking
(Stroke Foundation of New Zealand 1996).

Treatment of dyslipidaemia
The evidence that cholesterol-lowering drugs reduce the risk of further strokes is as yet
incomplete. Randomised control trials have found that statins reduce the occurrence of strokes in
people with coronary heart disease, but it is uncertain whether cholesterol-lowering drugs reduce
the risk of recurrent stroke in patients with symptomatic cerebrovascular disease (BMJ Publishing
Group 2000). Randomised control trials are ongoing to address this issue (BMJ Publishing Group
2000).
In the meantime the Stroke Foundation guidelines recommend managing dyslipidaemia according
to the standard lipid guidelines developed by the National Heart Foundation of New Zealand in
1996.

Antiplatelet treatment
Aspirin reduces the risk of further serious vascular events by about 25 percent. In an overview of
randomised controlled trials, low doses (<150 mg/day) and high doses (>325 mg/day) of aspirin
were effective in reducing the risk of recurrent vascular events (stroke, myocardial infarction or
vascular death). Although the optimal dose is uncertain, doses of 325 mg/day or lower are safe,
effective and cheap. A combination of aspirin and dipyridamole is a safe and effective alternative
to aspirin alone (BMJ Publishing Group 2000; Stroke Foundation of New Zealand 1996).
Clopidogrel is another effective antiplatelet treatment that can be used instead of aspirin,
particularly for people who cannot tolerate aspirin. It is currently not subsidised in New Zealand
but is under review by Pharmac.
Before commencing aspirin or other antiplatelet treatment it is important that patients have an
early CT scan to exclude a haemorrhagic stroke (Stroke Foundation of New Zealand 1996)

Carotid endarterectomy
Carotid endarterectomy is recommended only for patients who have severe stenosis (>70 percent)
of the symptomatic carotid artery. To be eligible for this procedure, patients should have little or
no functional problems as a result of their stroke or TIA. Carotid endarterectomies should be
performed by a vascular surgeon who has a history of low rates of perioperative complications
(perioperative stroke or death in the first month after carotid endarterectomy for symptomatic
carotid stenosis of <6 percent) (BMJ Publishing Group 2000; Stroke Foundation of New Zealand
1996).

Carotid angioplasty
Carotid angioplasty is not currently recommended in the secondary prevention of stroke except in
the setting of a clinical trial (BMJ Publishing Group 2000).

Treatment of atrial fibrillation
Non-valvular atrial fibrillation is a common cause of ischaemic stroke. Warfarin is the preferred
treatment, reducing the risk of recurrent stroke in people with atrial fibrillation. This treatment is
complex and requires rigorous monitoring. The target international normalised ratio (INR) should
be 2.0 to 3.0.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                      13
If warfarin cannot be administered safely to people with atrial fibrillation, then aspirin is
recommended. However, aspirin is not as effective as warfarin (Stroke Foundation of New
Zealand 1996, BMJ Publishing Group 2000).
For patients with a recent ischaemic stroke who do not have severe symptomatic carotid stenosis
or atrial fibrillation, anticoagulation does not reduce the risk of recurrent stroke or death.

Rheumatic valvular heart disease
The efficacy of warfarin in patients with rheumatic valvular heart disease with or without atrial
fibrillation has not been assessed in randomised control trials. However, anecdotal experience
clearly shows that anticoagulation reduces the risk of further cardioembolic events.

Artificial heart valves
Warfarin is usually given to people with bioprosthetic heart valves for three to six months unless
the patient has atrial fibrillation, in which case it is continued indefinitely. If the patient has
mechanical heart valves, warfarin and an antiplatelet agent should be given indefinitely.

Secondary prevention in people who had a stroke following myocardial infarction
The Stroke Foundation guidelines recommend the use of heparin and warfarin to reduce the risk
of recurrent cerebral emboli in patients who have had a cerebral infarct following a myocardial
infarction.

Tools available for District Health Boards
Five-year trends for key cardiovascular data to assist with needs analysis and DHB planning are
included with this toolkit in electronic form here. The following tools are available elsewhere.
• Guidelines for the Management of Mildly Raised Blood Pressure in New Zealand 1995,
    available at http://www.nzgg.org.nz.
• The Lipid Guidelines are available from the National Heart Foundation of New Zealand; they
    are also published in the New Zealand Medical Journal vol 109, 1996. The Heart Foundation
    website is: http://www.heartfoundation.org.nz.
• The New Zealand Cardiac rehabilitation guidelines available at http://www.nzgg.org.nz.
• The National Heart Foundation produces pamphlets and guidelines for consumers and
    providers on cardiovascular risk, nutrition, cardiac rehabilitation and exercise for people with
    heart disease. Educational material is also available for the public.
    http://www.heartfoundation.org.nz.
• Absolute risk assessment tables are included in New Ethicals catalogue and the
    pharmaceutical schedule.
• Referral guidelines, access criteria for specialist assessment and CPAC tools for cardiac
    catheterisation, PTCA and CABG are all available from Elective Services.
•   The Stroke Foundation’s (1996) Life after Stroke: New Zealand guidelines for best practice
    in rehabilitation after stroke (currently being updated).

Tools under development
The following guidelines are currently under development and will be available from 31 June
2003. The CVD toolkit will be amended to include these guidelines once they are completed.
       The assessment and management of cardiovascular risk.
       The use of medications after cardiovascular disease.


New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       14
      Life after Stroke: New Zealand guidelines for best practice in rehabilitation after stroke
       currently being updated and should be available from June 2003.

Tools for future development
   Guidelines for the management of atrial fibrillation.
      National service specification for cardiac services.
      Consumer education resources.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       15
2. Management of acute coronary syndromes

Key points
•   Acute coronary syndromes include patients with unstable angina or acute myocardial
    infarction.
•   A British study identified that 45 percent of those who have a myocardial infarction die
    within 30 days of myocardial infarction.
•   Evidence indicates that in reducing morbidity and mortality in patients with acute coronary
    syndromes, it is important to have effective acute pre-hospital care (particularly for those in
    rural areas) and effective hospital assessment and management.



Acute coronary syndromes in New Zealand
Acute coronary syndromes include those patients who have:
• unstable angina, a syndrome that incorporates rest angina, new onset or crescendo effort
   angina, post-infarct angina, or angina after angioplasty or coronary bypass surgery
• acute myocardial infarction.
The diagnosis of both these conditions is not clearcut. It is important to undertake an ECG and a
number of blood tests (eg, to test the level of troponins) for a correct diagnosis and to establish
early whether the person has had a myocardial infarction.
New Zealand data shows that in 2000/2001, 7,338 people were admitted to hospital with a
myocardial infarction and approximately 573 people died of a myocardial infarction during their
stay in hospital. 1999 NZ mortality data shows that Maori and Pacific peoples are more likely to
die from a myocardial infarction within 30 days than Europeans/others. Thirty-day standardised
mortality rates for Maori and Pacific peoples were 211.6 and 135.6 per 1,000 discharges
respectively compared to 121.5 per 1,000 discharges for Europeans/others (Ministry of Health
2002a).
The above data does not include those people who die from myocardial infarction before they
reach hospital. A two-year community- and hospital-based study examined case fatality outside
hospital from acute coronary events in three British health districts. Its sample comprised 3,523
men and women under 75 years of age, including people who died before they reached hospital.
The study found that 45 percent of people (1,589) who had an acute coronary event had died
within 30 days of the event. Of the fatal events, 74 percent happened outside hospital; the
likelihood of a fatal event occurring outside hospital was greater for people under 55 years (91
percent) than for those aged 65–74 years (70 percent) (Norris et al 1998).
In reducing morbidity and mortality of patients with acute coronary syndrome it is important that
acute pre-hospital and hospital care is effectively set up to systematically assess and manage
these patients.

Acute pre-hospital care
Normally all patients who have had chest pain for longer than 10 minutes that is not relieved by
sublingual nitrates should be considered a medical emergency. They should be transferred to a
hospital for urgent assessment (National Heart Foundation of Australia 2000).



New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                     16
Those who live in rural areas or more than an hour from a hospital may experience delays in
access to emergency services and treatment. The longer that treatment is delayed, the greater the
risk of myocardial damage (Williams 1997). Early treatment with thrombolysis for eligible
patients has been identified as important in reducing morbidity and mortality from myocardial
infarction. It has been shown that thrombolytic treatment given within four hours after the onset
of pain produces the best results (Cannon 2000). Several observational studies have shown that
decreases in mortality of 30–48 percent occur when thrombolytic therapy is given within one
hour of the onset of chest pain. The reduction in mortality decreases to 20–25 percent when given
after three hours (Fibrinolytic Therapy Trialists’ Collaborative Group 1994). Randomised control
trials of pre-hospital thrombolysis have shown an overall reduction in mortality of 17 percent (16
lives saved per 1,000 patients receiving pre-hospital thrombolysis) (European Myocardial
Infarction Project Group 1993). Before giving thrombolysis, it is important that an ECG is carried
out to confirm the diagnosis of myocardial infarction.
Delays to receiving thrombolysis may occur because patients who have a myocardial infarction
may delay seeking treatment or because access to ambulance services and the general practitioner
is reduced. Further delays may occur once the patient has arrived in hospital. A New Zealand
study in 1995 found that most of the delay before administration of thrombolysis occurred in the
community (median 2.5 hours) (Porter et al 1995). This finding may arise partly because some
people are not aware that they are having a heart attack. It has been estimated that around 30
percent of heart attacks are unrecognised, particularly in women, the elderly, post-operative
patients, diabetics or others with chronic disease states (Fowles 1995).
The NHS Service Framework for coronary heart disease states that people thought to be suffering
a heart attack should, if indicated, receive aspirin and should be given thrombolysis within 60
minutes of calling for help. Achieving this timeframe would involve equipping and training
community health professionals, ambulance or paramedical staff and rural general practitioners.
New Zealand and Canadian recommendations suggest a ‘door-to-needle’ delay of no more than
30 minutes after the arrival at hospital (Cox 1997; Porter et al 1995).
Guidelines for the delivery of thrombolysis by general practitioners in New Zealand have been
completed by the Cardiac Society and are currently undergoing the New Zealand Guideline
Group endorsement process. These will be added to the toolkit when available.

Hospital care
Once the patient with unstable angina or myocardial infarction has been admitted to hospital, it is
important to have a systematic process for assessing and managing these patients to ensure that
patients receive the appropriate care.
In a study of patients with chest pain presenting to emergency departments by Lee, Rouan and
Weisberg (1987) showed that almost two thirds of these patients are admitted, but only about 15
percent are proven to have a myocardial infarction. Of those discharged, 1 to 5 percent have a
myocardial infarction, which can result in up to 16 percent mortality (Jesse 1997).
A new test is available in New Zealand that can identify the level of cardiac troponins. This
measure indicates the level of myocardial damage and assists in enabling a more accurate
diagnosis of unstable angina or myocardial infarction. In addition to other kinds of tests (eg,
ECG), and other blood tests, it can more accurately classify patients with chest pain into
categories of low, intermediate or high risk. It is suggested that those who are considered low
risk, with normal cardiac troponins and ECG, could be discharged with a follow-up outpatient
appointment whereas intermediate and high-risk patients who have an increaseded level of
cardiac troponins would be admitted to hospital for investigation and appropriate treatment.
Guidelines developed by the National Heart Foundation of Australia (2000) for unstable angina
indicate that a structured chest pain service would enable better assessment, diagnosis and

New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                     17
management of patients with chest pain. A number of structured chest pain units have been
established in Australia and other countries.
A structured chest pain assessment service has been shown to reduce discharge of those with a
‘missed infarction’ from 4.5 to 0.4 percent, and to reduce hospital admissions from 57 percent to
47 percent (Graff et al 1997; Roberts et al 1997). A study of 773 consecutive patients presenting
with acute chest pain concluded that a policy of early discharge of low-risk patients (without
elevated troponin levels) was relatively safe. After patients with normal troponin levels at
baseline and at least six hours later were discharged from the emergency department, their 30-day
event rates for death or myocardial infarction were 1.1 percent for cardiac troponin T (cTnT) and
0.3 percent for cardiac troponin I (cTnI) (Hamm et al 1997). Intermediate and high-risk patients
would stay in hospital for more intensive management.
There is debate around the appropriate treatment of unstable angina and acute myocardial
infarction. This debate is mainly around acute medical care and acute revascularisation. A study
of 2,457 patients showed that early revascularisation for eligible patients (PTCA or CABG) can
reduce subsequent death and myocardial infarction by 22 percent and subsequent hospitalisation
by 45 to 50 percent. It also reduces the overall length of stay (National Heart Foundation of
Australia 2000).
Although it may appear that acute revascularisation brings benefits, introducing this treatment
nationally would incur a significant cost as revascularisation costs far more than acute medical
care. If its nationwide introduction was to be considered, a comprehensive cost–benefit analysis
would need to be conducted. DHBs would need to consider this analysis in relation to current
services and the overall prioritisation of services.

Tools available for District Health Boards
Cardiovascular trend data are included here with this toolkit in electronic format for DHB needs
analysis.

Tools under development
   Guidelines for pre-hospital administration of thrombolytic therapy by New Zealand
      General Practitioners available from New Zealand Guidelines Group.
      Guidelines for the management of acute coronary syndromes currently being developed
       by the New Zealand Cardiac Society.


Tools for future development
   National service specification for cardiac services.
      Consumer education resources.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                  18
3. Heart failure

Key points
•   Hospital admissions for heart failure are increasing.
•   Maori have the highest rate of hospital admissions, at nearly three times that of non-Maori
    and higher for those under 65 years of age. Pacific peoples also have high hospital admission
    rates, at just over twice the rates of others.
•   Many hospital admissions for heart failure have been found to be preventable.
•   There is good evidence for the effectiveness of heart failure treatment.



Heart failure in New Zealand
Heart failure occurs mainly as a result of coronary heart disease, but can also result from
rheumatic heart disease, hypertension, cardiomyopathy and other cardiac diseases. It is a
significant personal and public health problem and is increasing in prevalence. About two-thirds
of all patients with heart failure die within five years of diagnosis and mortality rates increase
with age. Doughty (1995) identified that of an average of 850 deaths caused by heart failure, two-
thirds occurred in patients over 75 years of age. Only 5 percent of deaths occurred in patients
younger than 45 years of age.
International literature shows growing hospital admission rates for heart failure and a high level
of readmissions. In a New Zealand study of hospital discharge data from 1988 to 1991, more than
200 hospital admissions per 100,000 individuals involved a primary or secondary diagnosis of
heart failure (Doughty 1995). About 40 percent of these admissions were readmissions in the
same year. Many admissions have been found to be preventable. Poor compliance with prescribed
drugs is an important cause of hospital readmission.
Maori have the highest hospital admissions for heart failure. Standardised discharge rates for
congestive heart failure in 2000/2001 were nearly three times those of Europeans/others (30.4 per
10,000 population compared to 11.9 per 10,000 population) (Ministry of Health 2002a), and are
four or more times higher for Maori under the age of 65 years (Westbrooke et al 2001). Pacific
peoples have a lower discharge rate for heart failure than Maori but have more than twice the
discharge rate of Europeans/others (24.4 per 10,000 compared to 11.9 per 10,000) (Ministry of
Health 2002a). The high discharge rates for heart failure for both Maori and Pacific peoples are
likely to reflect the higher incidence of cardiovascular disease and diabetes in these populations.
They may also reflect delays in access to primary care services and in detection and treatment of
disease.
It has been estimated that hospital admissions in New Zealand for heart failure in 1990 cost $48.7
million (Carr 1999). Hospital admissions for heart failure grew by 5.8% from 1996/97 to
1999/2000 (5,098 discharges to 5,394), but then decreased by 4.5% from 1999/00 to 2000/01
(5,394 discharges to 5,153) (Ministry of Health 2002a)

Management of heart failure
Heart failure is one of the few areas of medical treatment where there is good evidence for the
effectiveness of treatment and clear evidence that early and consistent treatment prolongs life. It
is important that patients are diagnosed accurately and managed appropriately to improve quality
of life and to prevent unnecessary hospital admissions.


New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                    19
The National Heart Foundation of New Zealand (2001) has written guidelines for the
management of heart failure. The management of heart failure should include education and
counselling of the person and their family members about the lifestyle changes required (eg,
quitting smoking, reducing salt in diet, reducing or abstaining from alcohol, and the need for
exercise, effective drug therapy and cardiac rehabilitation).
Effective drugs include ACE inhibitors, diuretics and beta-blockers. ACE inhibitors are the only
drugs that have been shown to improve survival, symptoms, the amount of left ventricular fluid,
and a decrease in hospitalisation. Diuretics provide relief of symptoms of pulmonary and
systemic venous congestion. There are no data regarding the effects of diuretics on mortality. A
meta-analysis of 18 published clinical trials of beta-blockers showed a 41 percent reduction in the
risk of hospitalisation and a 32 percent reduction of all-cause mortality in patients with mild to
moderate heart failure (Lechat et al 1998). Other effective drugs are Spironolactone for severe
heart failure (NYHA classification II or IV), Digoxin for patients with heart failure who are in
atrial fibrillation, and aspirin for patients with underlying coronary artery disease or concomitant
peripheral vascular or cerebrovascular disease (National Heart Foundation of New Zealand
2001).
The management of heart failure is an important role of the primary care provider. Effective links
between primary and secondary providers are needed in both managing heart failure and
preventing hospital admissions.

Tools available for District Health Boards
• A guideline for the management of heart failure: a health professionals guide is available
  from the National Heart Foundation of New Zealand.
• The National Heart Foundation has produced pamphlets and information for people coping
  with heart failure. The Heart Foundation website is: http://www.heartfoundation.org.nz.
  Pamphlets are also produced by pharmaceutical companies.
• A video made by Maori for Maori people with, or at risk of, heart failure was launched on
  March 2001. This video is available through Te Hotu Manawa Maori.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                    20
4. Rheumatic heart disease

Key points
•   Rheumatic fever is preventable. However, if it is not diagnosed and treated appropriately, it
    can lead to rheumatic heart disease, chronic disability and premature death.
•   Although rheumatic fever has declined substantially in New Zealand since the 1970s, the
    rates remain unacceptably high for Maori and Pacific peoples.
•   There are effective primary and secondary strategies for the prevention of rheumatic heart
    disease.

Rheumatic fever and heart disease in New Zealand
Rheumatic fever is one of the most important preventable communicable diseases affecting
children in New Zealand. Rheumatic fever results from a group A streptococcal throat infection.
Risk factors for the development of the disease include age, ethnicity, poverty and overcrowding.
Mortality from rheumatic fever is rare but repeated infections can cause rheumatic heart disease
and lead to chronic disease (eg, heart failure), disability and premature death. Although acute
rheumatic fever has declined substantially since the 1970s, New Zealand still has unacceptably
high rates compared to other developed countries.
For those under 30 years with rheumatic fever in New Zealand, the annual age-standardised
hospitalisation rate in 2000/01 was 8 per 100,000 (138 cases per year). Pacific peoples have the
highest hospitalisation rate for rheumatic fever, over nine times that of non-Pacific/non-Maori (24
per 100,000, 54 cases, compared to 1 per 100,000). The Maori hospitalisation rate is just over five
times that of Europeans/others (13 per 100,000, 72 cases) (Ministry of Health 2002a).
Just over 31 percent of Pacific peoples (17 cases) and 21 percent of Maori (15 cases) who had
developed rheumatic fever in New Zealand were readmitted to hospital for rheumatic fever
during 2000/2001. It is therefore not surprising that Maori and Pacific peoples are more likely to
develop rheumatic heart disease. Hospitalisation rates in 2000/01 for rheumatic heart disease in
both Maori and Pacific peoples were three times the rate for Europeans/others (27 and 27 per
100,000 compared to 1 per 100,000) (Ministry of Health 2002a).
Primary prevention of rheumatic fever and rheumatic heart disease is achieved through early
identification by primary care providers, by adequate antibiotic treatment and improvements to
socio-economic determinants of health such as reducing overcrowding. This strategy requires
parents to take their children to the doctor when they have a sore throat. It is particularly
important that Maori and Pacific peoples are aware of the importance of early diagnosis and
treatment.
For the secondary prevention of rheumatic fever (prevention of recurrence), patients with acute
rheumatic fever should receive monthly benzathine penicillin for 10 years or until their 21st
birthday. A rheumatic fever register can facilitate a secondary prophylaxis programme and such a
programme has been established in a number of DHBs eg, Auckland and Rotorua. There is
evidence that register-based programmes can be more effective than general practitioners or
hospital outpatient services in maintaining client contact and preventing recurrent ARF episodes
but further research is required in this area (New Zealand Public Health Report 2001). Treatment
of rheumatic heart disease often involves surgery to replace the mitral valves due to the
development of mitral stenosis or mitral regurgitation. Delays in treatment for rheumatic heart
disease can lead to the development of heart failure.



New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       21
Tools available for District Health Boards
   Five-year trend data on hospital discharge and readmission rates for rheumatic fever, by
      DHB, are supplied electronically with this toolkit here. Trend information on hospital
      discharges for rheumatic heart disease, by DHB, is also supplied.
      Referral guidelines, access criteria to specialists and clinical priority access criteria for
       mitral stenosis and mitral regurgitation can be obtained from Elective Services.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                          22
5. Stroke services

Key points
•   Stroke is the third leading cause of death in New Zealand and the greatest cause of disability
    in older people.
•   Access to and quality of stroke services vary across New Zealand.
•   Evidence indicates that organised stroke care reduces disability, mortality and long-term
    institutional care.
•   Pacific peoples have the highest mortality rate for cerebrovascular disease and the highest
    hospital discharge rate for stroke.



Burden of stroke in New Zealand
Stroke has been defined by the World Health Organization as:
     ‘rapidly developing symptoms and/or signs of focal, and at times global, loss of cerebral
     function, with symptoms lasting more than 24 hours or leading to death with no
     apparent cause other than that of vascular origin. This diagnosis includes subarachnoid
     haemorrhage that is estimated at around 5 percent of all strokes’ (WHO 1988).
Stroke is an important cause of premature death and disability. It is the third leading cause of
death in New Zealand, following cancer and coronary heart disease. It is the most important cause
of disability in older people. Each year stroke accounts for approximately 1 in 12 of all deaths in
men and 1 in 8 of all deaths in women. About 7,000 New Zealanders have a stroke every year,
many of whom are left with a chronic disability. The average age of stroke is 56 years for Maori,
60 years for Pacific peoples and 73 years for Pakeha (Stroke Foundation of New Zealand 1996).
In 2000/2001 there were 7,041 discharges of people with stroke aged over 55 years, representing
a standardised discharge rate of 88.0 per 10,000 population. Pacific peoples had the highest
hospital discharge rate of 153.1 per 10,000 compared to Maori and Europeans/others (91.5 per
10,000 and 86.5 per 10,000, respectively). Readmission rates for stroke in 2000/2001 were higher
for Maori than for Europeans/others (11.5 percent compared to 10.2 percent). The chance of
being dependent at 12 months post stroke is three times higher for Maori and Pacific peoples than
for Europeans who have a stroke (McNaughton 2002).
The costs of stroke are heavy not only to the health system but also to community services and
family. Stroke has been estimated to cost the taxpayer approximately $58 million per year for
hospital charges. Its total quantifiable cost to the country has been estimated at up to $154 million
per year (Stroke Foundation of New Zealand 2000).
It is therefore a priority that stroke services are delivered in an effective and organised manner.

Stroke care in New Zealand
After a stroke, people use a wide range of personal health and disability support services,
including:
• primary health care services
• hospital emergency departments
• neurological and neurosurgical departments


New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                         23
•   medical wards
•   geriatric and rehabilitation services
•   allied health professionals (public and private)
•   home nursing
•   home help services
•   various community-based and voluntary services.
Services that are frequently required on a long-term basis include outpatient services, home-based
rehabilitation services, home help and community support networks.
When a person has a stroke it should be regarded as a medical emergency. Immediate transfer to
hospital for assessment, diagnosis and treatment is extremely important. Essential investigations
include blood tests, ECG and CT scan. A number of other investigations may also be undertaken
depending on the type of stroke. It is important that secondary prevention treatment is initiated to
prevent further strokes and complications.
The rehabilitation process for people with stroke is also crucial. It should be started early to
minimise disability and prevent future strokes. It involves six major areas of focus (Gresham et al
1997):
1. Preventing, recognising and managing co-morbid illness and medical complications.
2   Training for maximum independence.
3. Facilitating maximum psychosocial coping and adaptation by patient and family.
4. Preventing secondary disability by promoting resumption of home, family, recreational and
   vocational activities.
5. Enhancing quality of life in view of residual disability.
6. Preventing recurrent stroke and other vascular conditions, such as myocardial infarction, that
   are more frequent in patients with stroke.
To attain these goals, rehabilitation interventions should assist the patient in achieving the
greatest possible return to functional independence, helping them to compensate for disabilities
by learning new ways to perform tasks. Achieving this goal requires a team of stroke
rehabilitation specialists, including rehabilitation nurses, physicians, physiotherapists,
occupational therapists, speech language therapists, social workers and psychologists. It also
requires ongoing care and support in the community.
The treatment and management of stroke are detailed in the 1996 Stroke Foundation of New
Zealand guidelines, which are currently being updated.

Access to and quality of stroke services
Access to a full range of stroke services varies throughout New Zealand, and can be particularly
problematic in rural areas (Barber et al 2002). Around 70 percent of stroke cases are admitted to
hospital; this figure excludes people who have had a TIA, the great majority of whom are not
admitted. Thus approximately 30 percent of stroke cases (as well as TIAs) are not accessing
hospital services and may not be having their risk factors managed appropriately. This lack of
appropriate management is likely to result in costs caused by recurrent strokes and complications,
which may have been prevented (McNaughton 2001).
The quality and type of care given to stroke patients in New Zealand also vary significantly. A
survey of 293 physicians in 1999 asked for their opinion on the management of acute ischaemic
stroke in New Zealand (Ardern-Holmes et al 1999). Among the common deficiencies identified
were:


New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                      24
•   a lack of physicians with a special responsibility for stroke
•   use of aspirin and heparin before intracerebral haemorrhage had been excluded with a CT
    scan
•   use of heparin despite lack of evidence from randomised trials that it is beneficial
•   lowering of blood pressure after ischaemic stroke differing from the guidelines
•   a lack of stroke units and lack of recognition of the value of stroke units and stroke teams.
These problems have persisted despite publication of comprehensive guidelines for the
management of stroke developed by the Stroke Foundation of New Zealand in 1996. A survey of
acute stroke services confirmed the lack of organised stroke services at that time (Barber et al
2002).

Organised stroke care
The Cardiovascular Expert Advisory Group has recommended that organised stroke services be
developed to improve the care of stroke patients in New Zealand.
Organised stroke care requires that stroke patients are managed effectively through all stages of
their care. To this end there must be effective co-ordination among primary care, acute care,
rehabilitation services and community services. An overall management plan needs to incorporate
early identification of stroke, implementation of suitable therapies, referrals to other services
(including rehabilitation) and organised follow-up. An efficient interface between health and
community sectors is essential, as a smooth transition for the patient from the hospital to
community care has the benefit of ensuring that the value of organised hospital care is not lost at
discharge.
To be effective, stroke care requires an organised multidisciplinary team that is knowledgeable
and enthusiastic about treating stroke. This team should be composed of neurologists, emergency
physicians and nurses, radiologists, pharmacists and stroke rehabilitation staff. Experienced staff
in stroke care result in better detection, treatment and early rehabilitation of patients, thus
reducing mortality and morbidity (Gresham et al 1997; Rosenberg and Popelka 2000).
An abundance of evidence supports the development of organised stroke services. Studies show
that well-organised, co-ordinated management of stroke care can reduce disability, mortality and
long-term institutional care (Stroke Unit Trialists Collaboration 2000). These benefits are likely
to be the result of improved recognition and ongoing treatment (including rehabilitation) of stroke
patients, the multidisciplinary make-up of the stroke team, and the experience of staff dedicated
to stroke management (Collins et al 2000).
The Cochrane review on organised inpatient (stroke unit) care reported that stroke patients who
receive organised inpatient care by multidisciplinary stroke teams are more likely to be alive,
independent and living at home one year after the stroke. The apparent benefits were independent
of patient age, sex, stroke severity and types of stroke unit organisation. Also, there was no
indication that organised stroke unit care lengthened hospital stay. In those managed stroke units
the chance of dying was reduced by 18 percent, the chance of dying or requiring long-term
institutional care by 25 percent and the chance of dying or remaining physically dependent by 29
percent (Stroke Unit Trialists Collaboration 1997).
Introducing organised stroke care may have some cost implications, particularly in rural areas.
However, it will not be known how significant these implications will be until additional analysis
and modelling are completed. In some cases the development of organised stroke services may
require only a reorganisation of services within the community, so that services are delivered in a
co-ordinated manner by a multidisciplinary stroke care team. Stroke Foundation guidelines will
also need to be introduced in all centres, to ensure best practice in the care of people who have
had a stroke. As part of the national strategic work the Ministry of Health will work with DHBs

New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       25
to review stroke services and identify possible options for implementing an effective, organised
stroke care service.

Tools available for District Health Boards
Five-year stroke trend data by DHB are included with this toolkit to assist with needs analysis.
The following resources are all available from the Stroke Foundation of New Zealand. Only two
of the publications are available from the Stroke Foundation of New Zealand website (see
below):
•   Life after Stroke: New Zealand guidelines for best practice in rehabilitation after stroke.
    1996.
•   Life After Stroke: a guide for people with a stroke and their families, an information resource
    book written for people with stroke and their families/whanau.
•   Understanding Stroke: for patients, families and the community, available from
    http://www.stroke.org.nz.
•   Preventing Stroke, available from http://www.stroke.org.nz.
•   Stroke and Stress.
•   A series of full colour A2 colour posters on preventing and understanding stroke complete
    with graphics.
•   Life after Stroke diary, to record the personalised stroke experience and rehabilitation process.
•   A series of four education videos about stroke produced by the Stroke Foundation - Video I
    Understanding a Stroke, Video II Rehabilitation Following a Stroke, Video III Returning to
    the Community, Video IV Life After Stroke for Caregivers.
•   Stroke self-assessment chart for patients to assess their risk of having a stroke.

Tools under development
•   Life after Stroke: New Zealand guidelines for best practice in rehabilitation after stroke
    currently being updated and should be available from August 2003.
•   National service specification for organised stroke services.
•   National guidelines for the assessment and management of cardiovascular risk.
•   National guidelines on the use of medications after cardiovascular disease.



Tools for future development
•   Consumer education resources for Maori, Pacific peoples and other cultures.
•   National guidelines for the management of atrial fibrillation.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                      26
6. Cardiovascular disease and Maori
Mortality from all cardiovascular diseases is higher among Maori than among the general
population. Maori are also highly represented among the most deprived people in New Zealand.
Under the Treaty of Waitangi and the New Zealand Health Strategy, DHBs have a key role in
improving cardiovascular outcomes for Maori and to this end they should work in partnership
with Maori.
This section summarises some of the key data on cardiovascular disease for Maori. It provides
information on current tools available including recommendations for District Health Boards
from the Maori Cardiovascular Advisory Group who have been assisting with national
cardiovascular strategic work.

Key data
•   Coronary heart disease is the leading single cause of death for Maori. Maori men are 1.8
    times more likely to die from coronary heart disease than non-Maori males (221 per 100,000
    compared to 122 per 100,000). Maori women are 1.8 times more likely to die from coronary
    heart disease than non-Maori women (97 per 100,000 compared to 55 per 100,000) (Hay
    2001).
•   The coronary heart disease mortality rate for Maori under 65 years of age is almost three
    times higher than that for non-Maori in the same age group (Hay 2001).
•   The 30-day case fatality rate for myocardial infarction in 1999 was 211.6 per 1,000
    discharges for Maori compared to 135.6 per 1,000 for Pacific peoples and 121.5 per 1,000 for
    Europeans/others (Ministry of Health 2002a).
•   The prevalence of smoking among Maori is much higher than Europeans/others, at 45 percent
    for Maori men and 53 percent for Maori women (as compared to 22%, for male and female)
    (Hay 2001).
•   Maori are less likely to access PTCA and coronary artery bypass surgery than non-Maori
    (Health Funding Authority 1998).
•   Maori have the highest rate of hospital admissions for heart failure. Discharge rates for heart
    failure in 2000/2001 were nearly three times that of non-Maori (30.4 per 10,000 compared to
    11.9 per 10,000) (Ministry of Health 2002a), and are four or more times higher for Maori
    under the age of 65 years (Westbrooke et al 2001).
•   Discharge rates for Maori for rheumatic heart disease are more than twice that of
    Europeans/others (Ministry of Health 2002a).
•   Death rates from cerebrovascular disease are 1.2 times higher in Maori than non-Maori. From
    hypertensive disease death rates are five times higher (Hay 2001).
•   The average age of stroke is 56 years for Maori, 60 years for Pacific peoples and 73 years for
    Pakeha (Stroke Foundation of New Zealand 1996).
•   The chance of being dependent at 12 months post stroke is three times higher among Maori
    and Pacific peoples than among Europeans who have a stroke (Stroke Foundation of New
    Zealand 2000).

Tools available for District Health Boards
Information on cardiovascular tools is also provided in the other sections. Specific tools for Maori
include:



New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                    27
•   five-year trend data on mortality, hospital discharges and procedures by ethnicity and District
    Health Board, available electronically with this toolkit here.
•   a video made by Maori for Maori people with heart failure or at risk of heart failure, available
    through Te Hotu Manawa Maori
•   Cardiac rehabilitation guidelines has a section providing specific guidance for Maori people
    available from http://www.nzgg.org.nz/library/gl_complete/Cardiac_Rehab/index.cfm.


A Maori Cardiovascular Action plan developed by the Maori Advisory group funded by the
Ministry of Health has made some specific recommendations for District Health Boards in the
following areas:
Treaty of Waitangi-based policy decision-making
    1. Inclusion of the Treaty of Waitangi and whakatataka in policy development and
         documentation, including action plan and guideline aims and objectives. These may
         include legislative requirements.
    2.   Policy aims and objectives that recognise the social and economic determinants of
         cardiovascular health.
    3.   Policy aims that translate into operational outputs specifically seeking to improve
         Maori cardiovascular health and remove disparities in cardiovascular outcomes
         between Maori and non-Maori.
    4.   Maori cardiovascular health gains recognised as priority in all service planning and
         provision documentation including strategic goals and objectives.
    5.   Early and ongoing consultation with key Maori stakeholders.
    6.   Health impact assessments to consider possible impact of policy options for Maori
         cardiovascular health.

Complete and consistent collection of ethnicity data
    1. Implementation of standardised ethnicity data collection methodology across all
       health datasets using self-identification questionnaire as in the 2001 Census.
    2. Implementation of staff training for this purpose.
    3. Regular audits undertaken to assess level of accuracy achieved.
    4. Audits aligned to corrective action that is time-bound, monitored and tied to
       accountability at managerial/fiscal level.
    5. All access and utilisation reports to include analysis by ethnicity.
    6. Critique of ethnicity data inaccuracies including implications for validity of reports.

Cardiovascular health needs assessment
    1. Cardiovascular health needs assessments and surveys conducted to identify level of
       unmet Maori health need, and gaps in data.
    2. Comprehensive assessment will include:
       • current demographic information about the service area that describes population
          size, ethnic composition, age and gender structure/trends and socioeconomic
          profile
       • current epidemiological information about the service area that describes
          cardiovascular disease mortality and morbidity
       • estimation of disease prevalence by ethnicity
       • description of the range of cardiovascular health services available to people in the
          area


New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                    28
        •   identification of the Maori providers and any service agreements with these
            providers
        • service access and utilisation data.
   3.   Key issues and local service priorities identified in partnership with Maori
        stakeholders, including consultation with iwi, Maori providers and consumers.
   4.   Service access barriers identified and action plans developed in consultation with
        Maori stakeholders.
   5.   In order to meet DHBs responsibility to ensure equitable distribution of cardiac
        procedures for Maori. calculate the expected number of first specialist visits and
        cardiac interventions (PTCA and CABG) for Maori based on prevalence of cardiac
        disease in Maori within the DHB.
   6.   Implementation of Maori proposals for improvement of service.

Development of Maori health services
Development, maintenance and promotion with adequate and ongoing resourcing.

Development of Maori workforce
Short term
   1. Benchmark audit to measure: number of Maori in service (specialists, registrars, CCU
        level ¾ nurses, cardiac rehabilitation nurses/staff, community health workers):
        identification of priority areas for development of Maori cardiovascular workforce;
        expenditure analysis of current and required resource investment.
   2. Identification of Maori providers and level of cardiovascular expertise and skill mix.

Medium term
  3. Maori workforce development plan including affirmative action policies and
     proactive career planning (recruitment, advancement and retention).
     • Selection process.
     • Targeted training programmes.
     • Scholarships.
     • Supervision and mentoring.
     • Release time for conferences/hui/wananga/te reo.
     • Annual review of plan and targets.


Non-Maori workforce development
   1. Service-wide education and recognition of the Treaty of Waitangi.
   2. Service-wide education and recognition of the wider social and economic
      determinants of cardiovascular health.
   3. Benchmark needs/expenditure analysis for training activities.
   4. Utilisation of approved training programmes and resources.
   5. Training induction/orientation for all new staff.
   6. Community placements with Maori providers.
   7. Evaluation process for training.
   8. Documentation of staff attendance with annual review of targets.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                29
Advanced Service Development: New models of service delivery and care

   1. Models of care based on ambulatory service delivery such as marae- and community-
      based clinics.
   2. Service delivery based on integrated models of care such as specialist Maori provider
      case review clinics.
   3. Pilot research projects to investigate proposed new models of service delivery and
      care.

A set of clinical indicators have also been developed by the Maori Cardiovascular Advisory
Group. These indicators are currently being considered by the guideline groups developing
national CVD guidelines. Once these indicators are finalised they will be added to the CVD
toolkit.



Tools under development
  • All cardiac and stroke guidelines currently under development have a section on specific
      issues for Maori (please see other sections of the toolkit).
   •   The national service specification for organised stroke services that is currently being
       developed has a section on service requirements for Maori.


Tools for future development
  • It is intended that cardiovascular consumer resources will be developed for Maori
      people.
   •   The national service specification for cardiac services yet to be developed will have a
       section on service requirements for Maori.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                     30
7. Cardiovascular disease and Pacific
   peoples
The effect of cardiovascular disease on Pacific peoples has been covered in each of the previous
sections. Of particular note is that Pacific peoples have the highest mortality rate for
cerebrovascular disease, whereas Maori people have the highest mortality rate for coronary artery
disease.
This section summarises some of the key data on cardiovascular disease in Pacific peoples and
provides information on the overall national strategic direction and the role of DHBs in meeting
the needs of Pacific peoples with cardiovascular disease.

Key data
•   Mortality rates for cerebrovascular disease are higher for Pacific peoples (15.1 per 10,000
    discharges) than for Maori and Europeans/others (8.1 per 10,000, 6.7 per 10,000,
    respectively) (Ministry of Health 2002a).
•   Pacific peoples have the highest hospital discharge rate for stroke at 153.1 per 10,000,
    compared to 91.5 per 10,000 for Maori and 86.5 per 10,000 for Europeans/others (Ministry of
    Health 2002a).
•   The average age of stroke for Pacific peoples is 60 years, compared to 56 years for Maori and
    73 years for Europeans/others (Stroke Foundation of New Zealand 1996).
•   The chance of being dependent at 12 months post stroke is three times higher among Maori
    and Pacific peoples than among Europeans who have a stroke (Stroke Foundation of New
    Zealand 2000).
•   Pacific peoples have the highest hospitalisation rates for rheumatic fever: 2.4 per 10,000
    population compared to 1.3 per 10,000 for Maori and 0.1 per 10,000 for Europeans/others
    (Ministry of Health 2002a).
•   For both Maori and Pacific peoples in 2000/2001, hospitalisation rates for rheumatic heart
    disease were three times the rate of Europeans/others (2.7 and 2.7 per 10,000 population
    compared to 1.0 per 10,000) (Ministry of Health 2002a).
•   The mortality rate from coronary heart disease for Pacific peoples is 164.6 per 100,000,
    which is lower than that for Maori (217.9 per 100,000) but higher than that for
    Europeans/others (144.3 per 100,000) (Ministry of Health 2002a).
•   The hospital discharge rate for heart failure is 24.4 per 10,000 for Pacific peoples, which is
    also lower than that for Maori (30.4 per 10,000) but more than twice that of Europeans/others
    (11.9 per 10,000) (Ministry of Health 2002a).


Tools available for District Health Boards
   Five-year trend data on mortality, hospital discharge, procedures by ethnicity and DHB is
      provided here electronically with this toolkit.
  • Cardiac rehabilitation guidelines have a component for Pacific peoples. These are
      available from http://www.nzgg.org.nz/library/gl_complete/Cardiac_Rehab/index.cfm.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                     31
Tools under development
  • All cardiovascular guidelines currently under development have a component for Pacific
      peoples.
    •   The service specification for organised stroke services that is currently being developed
        has a section on service requirements for Pacific peoples.
    •   A Pacific working party has been formed specifically to develop a cardiovascular action
        plan to address issues of improving cardiovascular outcomes for Pacific peoples that are
        not covered under the other national cardiovascular work in progress. Once this plan has
        been developed relevant information for District Health Boards will be made available.


Tools for future development
  • The development of a national service specification for cardiac services will have a
      section on specific service requirements for Pacific peoples.
  • It is intended that cardiovascular consumer resources will be developed for Pacific
      peoples.


.




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       32
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New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                    36
APPENDIX 1: Indicators


The Ministry of Health has developed accountability indicators for District Health Boards
relating to the priority areas of the New Zealand Health Strategy. The Ministry of Health will be
working with DHBs to look at appropriate indicators in the light of national cardiovascular
strategic work and this toolkit.
This appendix lists a number of possible indicators associated with this toolkit although it should
be noted that only indicators CAR-03 and CAR-05 and are included in current accountability
agreements.


Coronary artery disease
CAR-01         Standardised discharge rates for ischaemic heart disease
NUMERATOR (DATA SOURCE: MINISTRY OF HEALTH)
The number of unique individuals discharged from hospital with any diagnosis ICD10 code in the
range I20–I25, during the reporting period.
DENOMINATOR (DATA SOURCE: MINISTRY OF HEALTH)
The expected number of unique individuals discharged from hospital for ischaemic heart disease
(with expectations calculated from national rates, standardising (indirectly) for
age/socioeconomic deprivation differences) during the reporting period.

CAR-02         Standardised discharge rates for acute myocardial infarction
NUMERATOR (DATA SOURCE: MINISTRY OF HEALTH)
The number of unique individuals discharged from hospital with a principal diagnosis ICD10
code in the range I21–I22, during the reporting period.
DENOMINATOR (DATA SOURCE: MINISTRY OF HEALTH)
The expected number of unique individuals discharged from hospital for acute myocardial
infarction (with expectations calculated from national rates, standardising (indirectly) for
age/socioeconomic deprivation differences) during the reporting period.


 Indicator                 Standardised discharge rates for ischaemic heart disease
 National target
 Indicator type            Primary outcome
 Accountability status     Explanatory indicator
 Interpretation issues     Can compare inter-DHB variation, no ideal rate identified
 Population breakdown      Total population, and Maori/Pacific peoples/other
 Methodology               Ethnicity standardisation will be undertaken for total population breakdown.
                           These data will be generated centrally and forwarded to DHBs




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                             37
 Indicator                           Standardised discharge rates for acute myocardial infarction
 National target
 Indicator type                      Primary outcome
 Accountability status               Explanatory indicator
 Interpretation issues               Can compare inter-DHB variation, no ideal rate identified
 Population breakdown                Total population, and Maori/Pacific peoples/other
 Methodology                         Ethnicity standardisation will be undertaken for total population breakdown.
                                     These data will be generated centrally and forwarded to DHBs


Revascularisation
Rationale
Angioplasty and coronary artery bypass grafting are revascularisation procedures for people with
severe angina and coronary artery disease.
Surgical interventions may save lives and are important in improving the quality of life through
relieving pain and functional limitations.

CAR-03      Number of people with certainty who have been waiting for more than
six months for a coronary artery bypass graft
DEFINITION (DATA SOURCE: DISTRI CT HEALTH BOARD)
The number of people who waited more than six months for a coronary artery bypass graft, after
being given certainty of treatment, during the reporting period.

CAR-04               Actual financially sustainable threshold for coronary artery bypass graft
D E F I N I TI O N ( D A T A S O U R C E : D I S T R I C T H E A L T H B O A R D )
The tenth percentile of CPAC scores for patients receiving a coronary artery bypass graft, during
the reporting period.

CAR-05      Number of people with certainty who have been waiting for more than
six months for an angioplasty
D E F I N I TI O N    ( D A T A S O U R C E : D I S T R I C T H E A L T H B O AR D )
The number of people who waited more than six months for an angioplasty, after being given
certainty of treatment, during the reporting period.

CAR-06               Actual financially sustainable threshold for angioplasty
D E F I N I TI O N    ( D A T A S O U R C E : D I S T R I C T H E A L T H B O AR D )
The tenth percentile of CPAC scores for patients receiving an angioplasty during the reporting
period




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                                       38
 Indicator                        Number of people with certainty who have been waiting for more than
                                  6 months for a coronary artery bypass graft
 National target
 Indicator type                   Access and coverage
 Accountability status            Accountability indicator
 Interpretation issues
 Population breakdown             Total population, and Maori/Pacific peoples/other
 Methodology


 Indicator                        Actual financially sustainable threshold for coronary artery bypass grafts
 National target
 Indicator type                   Access and coverage
 Accountability status            Explanatory indicator
 Interpretation issues
 Population breakdown             Total population, and Maori/Pacific peoples/other
 Methodology


 Indicator                        Number of people with certainty who have been waiting for more than
                                  six months for an angioplasty
 National target
 Indicator type                   Access and coverage
 Accountability status            Accountability indicator
 Interpretation issues
 Population breakdown             Total population, and Maori/Pacific peoples/other
 Methodology


 Indicator                        Actual financially sustainable threshold for angioplasty
 National target
 Indicator type                   Access and coverage
 Accountability status            Explanatory indicator
 Interpretation issues
 Population breakdown             Total population, and Maori/Pacific peoples/other
 Methodology



Stroke
CAR-07           Standardised discharge rates for stroke in people 55 and over
N U M E R A T O R ( D A T A S O U R C E : M I N I S TR Y O F H E A L T H )
The number of unique individuals, aged 55 years and over, discharged from hospital with a
principal diagnosis ICD10 code in the range I60–I67, or G45, during the reporting period.
DENOMINATOR (DATA SOURCE: MINISTRY OF HEALTH)




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                              39
The expected number of unique individuals, aged 55 years and over, discharged from hospital for
stroke (with expectations calculated from national rates, standardising (indirectly) for
age/socioeconomic deprivation differences) during the reporting period.

CAR-08         Repeat admissions for stroke in people aged 55 and over
NUMERATOR (DATA SOURCE: MINISTRY OF HEALTH)
The number of unique individuals, aged 55 years and over, discharged from hospital with a
principal diagnosis ICD10 code in the range I60–I67, or G45 who have previously, within the last
six months, been discharged with a principal diagnosis ICD10 code in the range I60–I67, or G45,
during the reporting period.
DENOMINATOR (DATA SOURCE: MINISTRY OF HEALTH)
The number of unique individuals, aged 55 years and over, discharged from hospital with a
principal diagnosis ICD10 code in the range I60–I67, or G45, during the reporting period.

 Indicator                 Standardised discharge rates for stroke in people aged 55 and over
 National target
 Indicator type            Primary outcome
 Accountability status     Explanatory indicator
 Interpretation issues     Can compare inter-DHB variation, no ideal rate identified
 Population breakdown      Total population, and Maori/Pacific peoples/other
 Methodology               Ethnicity standardisation will be undertaken for total population breakdown.
                           These data will be generated centrally and forwarded to DHBs




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                             40
 Indicator                  Repeat admissions for stroke in people aged 55 and over
 National target
 Indicator type             Primary outcome
 Accountability status      Accountability indicator
 Interpretation issues
 Population breakdown       Total population, and Maori/Pacific peoples/other
 Methodology                Ethnicity standardisation will be undertaken for total population breakdown.
                            These data will be generated centrally and forwarded to DHBs



Rheumatic heart disease
Rationale
Acute rheumatic fever can lead to the development of rheumatic heart disease, particularly if
there are repeat episodes of rheumatic fever. Rheumatic heart disease is largely preventable.
Primary prevention includes health promotion and education on the management of sore throats
in children. It is important that there is early recognition and treatment of sore throats caused by
the streptococcal bacteria particularly in the high-risk population, such as Maori and Pacific
peoples.
There is conflicting evidence, however, on the extent to which the first attack of rheumatic fever
can be avoided by treatment of sore throats. While school-based or community interventions
aimed at reducing the prevalence of streptococcal upper respiratory tract infections may be
effective at reducing the incidence of acute rheumatic fever, there is no evidence that the general
practice treatment of streptococcal throat infection has any effect on the incidence of primary
attacks of acute rheumatic fever.
Once a person has had rheumatic fever, however, it is possible to prevent further attacks of the
disease. Secondary prevention of rheumatic fever includes the provision of antibiotic prophylaxis
in those who have had rheumatic fever. This intervention is important in avoiding subsequent
attacks of rheumatic fever that are likely to lead to the development of rheumatic heart disease.
The indicator for repeat rheumatic fever is particularly important in providing information on the
effectiveness of secondary prevention.

CAR-09         Standardised discharge rates for acute rheumatic fever in people
under 30
NUMERATOR (DATA SOURCE: MINIST RY OF HEALTH)
The number of unique individuals, aged under 30 years, discharged from hospital with a principal
diagnosis ICD10 code in the range I00–I02, during the reporting period.
DENOMINATOR (DATA SOURCE: MINISTRY OF HEALTH)
The expected number of unique individuals, aged under 30 years, discharged from hospital for
acute rheumatic fever (with expectations calculated from national rates, standardising (indirectly)
for age/socioeconomic deprivation differences) during the reporting period.

CAR-10         Repeat admissions for acute rheumatic fever in people under 30
NUMERATOR (DATA SOURCE: MINIST RY OF HEALTH)
The number of unique individuals, aged under 30 years, discharged from hospital with a principal
diagnosis ICD10 code in the range I00–I02 who have previously been discharged with a principal
diagnosis ICD10 code in the range I00–I02, during the reporting period.



New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                              41
DENOMINATOR (DATA SOURCE: MINISTRY OF HEALTH)
The number of unique individuals, aged under 30 years, discharged from hospital with a principal
diagnosis ICD10 code in the range I00–I02, during the reporting period.

CAR-11         Standardised discharge rates for chronic rheumatic hear t disease
NUMERATOR (DATA SOURCE: MINISTRY OF HEALTH)
The number of unique individuals discharged from hospital with a principal diagnosis ICD10
code in the range I05–I09, during the reporting period.
DENOMINATOR (DATA SOURCE: MINISTRY OF HEALTH)
The expected number of unique individuals discharged from hospital for chronic rheumatic heart
disease (with expectations calculated from national rates, standardising (indirectly) for
age/socioeconomic deprivation differences) during the reporting period.

 Indicator                 Standardised discharge rates for acute rheumatic fever in people under 30
 National target
 Indicator type            Primary outcome
 Accountability status     Explanatory indicator
 Interpretation issues     Can compare inter-DHB variation, no ideal rate identified
 Population breakdown      Total population, and Maori/Pacific peoples/other
 Methodology               Ethnicity standardisation will be undertaken for total population breakdown.
                           These data will be generated centrally and forwarded to DHBs


 Indicator                 Repeat admissions for acute rheumatic fever in people under 30
 National target
 Indicator type            Primary outcome
 Accountability status     Accountability indicator
 Interpretation issues
 Population breakdown      Total population, and Maori/Pacific peoples/other
 Methodology               These data will be generated centrally and forwarded to DHBs


 Indicator                 Standardised discharge rates for chronic rheumatic heart disease
 National target
 Indicator type            Primary outcome
 Accountability status     Explanatory indicator
 Interpretation issues     Can compare inter-DHB variation, no ideal rate identified
 Population breakdown      Total population, and Maori/Pacific peoples/other
 Methodology               Ethnicity standardisation will be undertaken for total population breakdown.
                           These data will be generated centrally and forwarded to DHBs




New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                             42
APPENDIX 2: Definitions


Acute myocardial infarction: also called a heart attack; results from permanent damage to an
area of the heart muscle. This damage is incurred when the blood supply to the area of the heart is
interrupted because of narrowed or blocked blood vessels. In the majority of cases this narrowing
or blocking is due to coronary artery disease.
Angina: discomfort in the chest caused by an inadequate supply of blood to the heart muscles.
Angioplasty: surgery whereby a balloon is inflated inside a blocked artery to open it up. Stents
are frequently used with angioplasty procedures to prevent renarrowing. Also known as
percutaneous transluminal coronary angioplasty (PTCA), coronary artery balloon dilation or
balloon angioplasty.
ACE (angiotensin converting enzyme) inhibitors: a type of drug used for blood pressure
control and heart failure. ACE inhibitors and vasodilators expand blood vessels and decrease
resistance, allowing blood to flow more easily and making the heart's work easier or more
efficient.
Atheroma: fatty material that can build up within the walls of the arteries.
Atherosclerosis: hardening and thickening of the walls of the arteries as a result of deposits of
atheroma on their inner lining. This build-up of atheroma may slow down or stop blood flow.
Beta-blockers: drugs that block the action of the hormone adrenaline, which makes the heart beat
faster and more vigorously thereby relieving stress to the heart muscle. Beta-blockers are often
used to slow the heart rate, lower blood pressure, prevent angina attacks, prevent irregular
heartbeats and reduce the risk of heart attacks in people who have already had one.
Blood pressure: a measure of the force of the blood being pushed by the heart through the
arteries. This pressure is created when the heart beats, forcing blood around the body, and also by
the elastic resistance of the arteries themselves. The pressure is measured on a blood pressure
gauge in millimetres of mercury (mm Hg).
Body mass index (BMI): a formula to assess body weight in relation to height. Weight in
kilograms is divided by height in meters squared (kg/m2). In the West a person is considered
overweight when his/her BMI is above 25, obese when it is above 30 and severely obese when it
is above 35.
Calcium channel blocker: a drug used to treat angina and to lower blood pressure.
Cardiomyopathy: a serious disease in which the heart muscle becomes inflamed and does not
work as well as it should. There may be multiple causes including viral infections.
Cerebrovascular disease: damage to the blood vessels in the brain, which may result in a stroke.
Cholesterol: a waxy, fat-like substance used by the body to build cell walls. It is either produced
in the liver or absorbed from the animal fats we eat. Cholesterol is carried in the bloodstream by
particles called lipoproteins. Although there are several kinds, the ones to be most concerned
about are low-density lipoprotein (LDL) and high-density lipoprotein (HDL). Cholesterol is an
important part of a healthy body because it is used to form cell membranes, some hormones and
other needed tissues. But a high level of cholesterol in the blood – hypercholesterolemia – is a
major risk factor for coronary heart disease, which leads to a heart attack.
Coronary artery: blood vessels that deliver oxygenated blood to the muscle of the heart.
Coronary artery bypass graft (CABG): surgery to re-route, or ‘bypass’ blood around clogged
arteries and improve the supply of blood and oxygen to the heart. During bypass surgery,

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surgeons take a blood vessel from another part of the body and construct a detour around the
blocked part of the coronary artery. Blood can then use this new path to once again flow freely to
the heart muscle.
Coronary artery disease: begins when atheroma is deposited within a coronary artery. This can
result in coronary attacks (commonly called heart attacks). Also called ischaemic heart disease or
coronary heart disease.
Diastolic blood pressure: the pressure between heartbeats (the pressure when the last sound is
heard).
Diuretics: an antihypertensive drug used to treat heart failure and lower high blood pressure.
Diuretics rid the body of excess fluids and salt (sodium).
Electrocardiogram (ECG): a test using electrodes placed on the chest, arms and legs to record
the rhythm and electrical activity of the heart.
Heart failure: occurs when the heart muscles become overworked from the strain of pushing
blood through narrow, hard blood vessels.
Heparin: an anticoagulant that delays the clotting (coagulation) of blood. When a blood vessel is
plugged by a clot and an anticoagulant is given, the drug tends to prevent new clots from forming
or the existing clot from enlarging. An anticoagulant does not dissolve an existing blood clot.
Another common anticoagulant is warfarin.
High-density lipoprotein (HDL): cholesterol is carried in the bloodstream by lipoproteins.
HDL recovers cholesterol from cells, vessel walls and other lipoproteins and thus tends to prevent
or reverse the build-up of plaque in the arteries. That is why HDL cholesterol is considered
‘good’ or ‘protective’.
Hypertension: persistently elevated blood pressure; also called high blood pressure.
Ischaemia: a usually temporary shortage of oxygen in a part of the body. It can occur when an
artery bringing blood to that part, such as the heart, is narrowed by spasm or disease.
Ischaemic heart disease: includes heart attack and related heart problems caused by narrowed
coronary arteries and thus less blood and oxygen reaching the heart. Also called coronary artery
disease and coronary heart disease.
Left ventricle: large, muscular chamber of the heart that pumps blood out to the body.
Lipoprotein: a particle composed of protein and lipids that transports the lipids in the
bloodstream and lymph system. Lipoproteins are of varying size and density and contain different
amounts of lipids and proteins.
Low-density lipids (LDL): carries most of the cholesterol from the liver to the cells. If there is
an excess of cholesterol or it cannot be properly delivered to the cells, LDL cholesterol tends to
accumulate in the vessel walls. Together with other substances it can form plaque, a thick, hard
deposit that can clog those arteries. This condition is known as atherosclerosis. For this reason
LDL cholesterol is often called ‘bad’ cholesterol. Lower levels of LDL cholesterol reflect a lower
risk of heart disease.
Mitral stenosis: a stenotic heart valve cannot open completely, so blood is pumped through a
smaller-than-normal opening.
Mitral valve: the mitral valve is the heart valve between the left atrium and left ventricle.
Peripheral vascular disease: diseases of blood vessels outside the heart and brain. It is often a
narrowing of the vessels that carry blood to leg and arm muscles.


New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       44
Plant sterols: micronutrients found in fruits and vegetables.
Revascularisation: the procedure by which a blocked vessel can be either dilated (angioplasty)
or bypassed (coronary artery bypass surgery).
Rheumatic heart disease: a condition in which the heart valves are damaged by a disease
process that begins with a strep throat from streptococcal infection. If it is not treated, the
streptococcal infection can develop into acute rheumatic fever.
Stable angina: occurs when individuals experience angina on a regular basis and can be given
medication to treat it.
Statin: a class of drug that lowers cholesterol.
Stent: a wire mesh tube used to prop open an artery. A stent may be used as an alternative to – or
in combination with – angioplasty. Certain features of the artery blockage make it suitable for
using a stent, such as the size of the artery and location of the blockage.
Stroke: occurs when a blood vessel bringing oxygen and nutrients to the brain bursts or is
clogged by a blood clot or some other particle. Because of this rupture or blockage, part of the
brain does not get the blood flow it needs. Deprived of oxygen, nerve cells in the affected area of
the brain cannot function.
Systolic blood pressure: the pressure of the blood flow when the heart beats (the pressure when
the first sound is heard).
Thrombolysis: the breaking up of a blood clot. Thrombolysis involves injecting a clot-dissolving
agent, such as streptokinase, reteplase or tissue plasminogen activator (TPA), to dissolve a clot in
a coronary artery and restore some blood flow.
Thrombosis: formation or presence of a blood clot inside a blood vessel or cavity of the heart.
Transient ischaemic attack (TIA): ‘mini-strokes’ that produces stroke-like symptoms but no
lasting damage. TIAs occur when a blood clot temporarily clogs an artery, and part of the brain
does not get the blood it needs. The symptoms occur rapidly and last a relatively short time.
Unlike stroke, when a TIA is over, there is no injury to the brain. TIAs are strong predictors of
stroke.
Triglyceride: the chemical form in which most fat exists in food as well as in the body. They are
also present in blood plasma and, in association with cholesterol, form the plasma lipids.
Triglycerides in plasma are derived from fats eaten in foods or made in the body from other
energy sources like carbohydrates. Calories ingested in a meal and not used immediately by
tissues are converted to triglycerides and transported to fat cells to be stored. Hormones regulate
the release of triglycerides from fat tissue so they meet the body's needs for energy between
meals.
Troponin: cardiac muscle proteins that control the interactions between actin and myosin, which
contracts or squeezes the heart muscle. Troponins specific to heart muscle have been found,
allowing the development of blood tests (assays) that can detect heart muscle injury with great
sensitivity and specificity. Normally the level of troponin in the blood is very low. It increases
substantially within several hours (on average four to six hours) of muscle damage. It peaks at 10
to 24 hours and can be detected for a week or more thereafter. Several studies have identified a
measurable relationship between cardiac troponin levels and long-term outcome after an episode
of chest discomfort. They suggest that these tests may be particularly useful to evaluate levels of
risk. In other words, it is possible that the results of a troponin test could be used to identify
people at either low risk or high risk for later serious heart problems. Whether more cost-effective
methods of treatment and, eventually, a better outcome will result from routine troponin testing
remains to be proven.

New Zealand Health Strategy • DHB Toolkit: Cardiovascular Disease • Edition 2                       45
Unstable angina: if an attack of angina differs from a person’s regular pattern (stable angina),
appearing suddenly, with greater intensity or when at rest, it is considered unstable. The most
common cause is reduced blood flow to the heart muscle due to narrowing of the coronary
arteries by atherosclerosis. An artery may be abnormally constricted or partially blocked by a
blood clot. Inflammation, infection and secondary causes can also lead to unstable angina. It may
warn of an impending heart attack.




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