Director of Public Health Annual Report 2022: Preventing heart disease and stroke in Buckinghamshire

2.3 Social economic and environmental risk factors

2.3.1 Healthy work

The work people do can affect their risk of cardiovascular disease. Stress at work can take several forms described as job strain and low effort-reward work. Job strain describes work with high demands combined with low control. Low effort-reward describes work where there are limited career opportunities, low salary and low social approval. Both higher job strain and low effort-reward work are associated with an increased risk of death from cardiovascular disease [52] and are more common in people with lower income or in lower job grades.

A study of 10,000 British civil servants found that behavioural risk factors could only explain a third of the difference in the incidence of coronary heart disease between different civil servants.[53] Biological risk factors, such as metabolic syndrome (a medical term for the combination of diabetes, high blood pressure and obesity), accounted for around another third of the difference.[54] The study found that work grade affected the risk of central obesity (excess fat around the waist – a known risk factor for cardiovascular disease) and metabolic syndrome and that civil servants in the highest grade work were least likely to have central obesity or metabolic syndrome.[55] Jobs that had higher job strain or stress were associated with an increased risk of obesity.[56]

Working longer hours increases the risk of cardiovascular disease – international evidence has shown that people that work [55] hours or more per week are 17% more likely to die from heart disease and 35% more likely to die from stroke, compared to people working 35-40 hours a week.[57]

2.3.2 Extreme temperatures

Both low and high temperatures are associated with increases in death from cardiovascular disease.[58] Globally ‘non-optimal temperature’ accounted for 1.96 million deaths globally according to the Global Burden of Disease study.[59]

Higher temperatures increase the risk for death from heart disease, heart failure and heart attacks.

Very cold temperatures increase the risk of heart attack and stroke. People who have pre-existing long-term conditions are most at risk of falling ill in the days after temperatures drop. Elderly people are especially vulnerable in winter months. Before the COVID pandemic circulatory diseases accounted for around a fifth of all excess winter deaths.[6]

2.3.3 Housing

The quality of housing and our ability to keep our houses warm is important.

Cold homes are associated with an increased risk of cardiovascular disease and other health issues.[61]

When there is a cold snap in the weather, hospitals see an increase in patients with a heart attack almost immediately and an increase in stroke around five days after the start of the cold weather.[62] Cold temperatures below 12° cause blood vessels to narrow, causing an increase in blood pressure and blood viscosity,[63] leading to an increase in heart attacks and stroke.[64]

The risks of ill health are even higher for people who are homeless. Homeless people have a threefold increased risk of cardiovascular disease and an increased risk of death from[65] cardiovascular disease.

2.3.4 Air quality

It is estimated that poor air quality is responsible for up to 36,000 deaths per year in the UK, and the majority of UK deaths attributable to outdoor air pollution are from heart disease and stroke.

Evidence from nine cities across England showed that the risk of out of hospital cardiac arrests and emergency admission for stroke was higher on days with higher pollution.[66] Air pollution rates are highest in more deprived neighbourhoods in England.[67]

Tackling air quality through active travel can have dual benefits in reducing cardiovascular disease risk – studies show that people that live in places where walking and cycling are convenient and safe have lower levels of obesity and diabetes.[68]

2.3.5 Cardiovascular disease and COVID

Studies have shown that cardiovascular disease is associated with poorer outcomes from COVID-19 infection[69] and many of the risk factors for developing cardiovascular disease (such as being obese, having high blood pressure or having type 2 diabetes) are also risk factors for worse COVID-19 outcomes. The risk is greatest for people with poorly controlled disease.

However, evidence is emerging that the reverse is also true – that COVID-19 disease may be a risk factor for cardiovascular disease. Firstly, cardiovascular complications may occur during initial COVID-19 infection, including blood clots and damage or inflammation to heart muscle.

Secondly, cardiovascular events are more likely to occur up to a year after COVID-19 infection. The risk of any cardiovascular event is 63% higher (45 additional people affected per 1,000) and the risk of a major event (heart attack, stroke or death) is 55% higher (23 additional people affected per 1,000) than people who have not had COVID-19 infection. These increased risks of cardiovascular events affect working age adults as well as older adults and affect those without as well as those with pre-existing cardiovascular disease.

Thirdly, it is not known what the longer-term effects of COVID-19 infection are yet, but they could include an increased risk of future cardiovascular disease. An estimated 1.7 million people in the UK reported experiencing long COVID in March 2022, of which common symptoms include chest pain, palpitations and shortness of breath.

Lastly, the pandemic itself has had an adverse impact on many of the risk factors for cardiovascular disease.

The pandemic has led to a worsening of some people’s mental health and economic circumstances and increased the proportion of people with unhealthy behaviours, such as eating unhealthily, gaining weight, doing less physical activity and drinking more alcohol. The pandemic also reduced access to routine health care and preventive interventions, such as NHS health checks to detect cardiovascular disease risk factors and management of high blood pressure and diabetes.