Access to specialist cardiac investigations and surgery

Coronary angiography

Coronary angiography is a special x-ray investigation that allows the extent and location of any narrowing of the coronary arteries (blood vessels supplying the heart) to be estimated. It is usually carried out to confirm a diagnosis of angina or to assess whether surgery would be beneficial for those patients who are not responding to medical treatment and lifestyle modification.

Although the level of angiograms for Wirral is higher than the England average, variations exist across the district. As the map below shows (figure 8), angiography rates are consistently lower in the deprived areas, which also have the highest mortality from CHD. The lowest angiography rates are found in Tranmere, Birkenhead and Seacombe, all wards that have CHD SMRs above 110. Overall, Birkenhead PCG has the lowest rate of angiography, while Bebington & West Wirral PCT has higher than the average rate of angiograms. Interestingly, the ward in which the local hospital is located and where angiography is performed, has a higher than expected rate of angiography.

Figure 8. Map showing CHD SMRs (1997-1999) and angiography rates per 100,000 population, 1999-2000, by ward

Although variations in angiography rates between the sexes are also evident (for every three males undergoing angiography there will be two females), this is perhaps unsurprising given that CHD is more common in men. Women also have narrower coronary arteries, which may be less amenable to surgery. Nevertheless, more work is needed to ensure that inequity between men and women does not exist.

In seeking to address the geographic and socio-economic variations demonstrated above, it is important to take a 'levelling up' approach. This means targeting additional efforts and resources at those areas with low rates and high need without reducing access in adjacent areas.

Coronary revascularisation

The aim of coronary revascularisation is to improve the blood supply to the heart. There are two main procedures: by-pass grafting (CABG) and angioplasty (PTCA). As with angiography, Wirral generally has a higher revascularisation rate than the England average but again, inequity exists across the district (see figure 9)

Figure 9. Map showing CHD SMRs (1997-1999) and revascularisation rates per million population, 1999-2000, by ward

As shown in figure 9, there is an inverse relationship between deprivation and revascularisation rates. The more deprived wards, where heart disease death rates are higher, also tend to have lower revascularisation rates.

This disparity stems directly from the differential access to angiography described above as patients are not referred for revascularisation without first having an angiogram. As already noted, the variation in access to angiography reflects a complex mix of factors, which need to be fully understood and addressed to ensure appropriate treatment options are accessible to those who most need them.

The NSF for CHD includes challenging targets for revascularisation rates (both CABG and PTCA) to be achieved over the next five-to-ten years. Currently there is a shortfall of over 300 procedures per year for Wirral. Significant additional resources will, therefore, be needed to meet the targets for our population. As already noted, the variations in access to surgery that currently exist will need to be addressed by 'levelling up'. This will mean relatively more procedures being performed for Birkenhead residents in the future.