NHS Scotland: What do heart attack rates say about crisis?

Heart attacks are one of Scotland's biggest killers and among the most common causes for an emergency admission to hospital.

Changing incidence rates can provide an insight into what is happening to population health, but death rates are a better gauge of how well the NHS is coping with demand.

With statistics for both published this week, what can we make of the trends?

Heart Attack Incidence

In the year to March 2023, a total of 11,686 heart attacks were recorded in Scotland – the highest number since the current records began in 2013.

Given that Scotland's population is getting larger and older, an increase is not unexpected.

Once the statistics have been age and sex standardised to account for the fact that heart attacks are more common in older adults and men, the incidence rate for heart attacks is actually slightly lower than it was pre-pandemic and nearly 10% lower than it was a decade ago.

Reductions in smoking and better management of patients with drugs to control blood pressure and cholesterol go some way to explaining this trend.

It is also worth noting that there has been no spike in heart attacks in young people, contrary to misinformation spread online by antivaxxers who claim that Covid vaccines have triggered a surge.

For the 0-44 age group in Scotland, the incidence of heart attacks has fallen steadily from 465 in 2013/14 to 310 in 2022/23, with the rate similarly falling from 17.1 to 11.6 cases per 100,000.

This is the positive news. The picture for mortality is less rosy.

Heart Attack Mortality

Over the three years from 2020 to 2022, Scotland averaged 4,146 heart attack deaths a year – up from 3,555 between 2014 and 2016.

The age/sex-standardised mortality rate has increased over the same period, from around 76 to 80 deaths per 100,000, which indicates that while fewer Scots are now suffering heart attacks a higher proportion are dying from them.

This is especially the case for middle-aged women. Despite zero change in the incidence rate, the rate of fatal heart attacks for females aged 45 to 64 was 27.5% higher between 2020 and 2022 than it was in the three years from 2013 to 2015.

For males in this age group, the mortality rate was up 24% in contrast to a statistically insignificant increase in the incidence rate of just 0.9%.

It is fair to say, then, that something has gone wrong – and the pressures facing the NHS must be one explanation.

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Ambulances and A&E

Getting an ambulance is harder now than it used to be. The Scottish Ambulance Service is juggling rising demand from 999 calls and a reduced availability of paramedics able to respond to emergencies.

The Scottish Ambulance Service changed how it codes heart problems in 2017, so longer-term trends are difficult to verify. However, it is notable that the number of patients conveyed to hospital by ambulance for "heart problems" fell from 2,401 in 2018/19 to 1,850 in 2022/23, despite an extra 224 heart attacks having occurred that year.

Meanwhile, the most recent data – for the week beginning January 8 – shows that one in ten ambulances spent more than one hour and 35 minutes parked outside hospitals waiting to offload patients because A&E departments were at capacity.

The number of patients who spend 12 or more hours in A&E is the best gauge of how full emergency departments (and hospitals are). In that same week, a total of 1,668 people were in A&E for at least 12 hours before being admitted, discharged or transferred to another hospital. Back in January 2015, the figure was just 27. 

Little wonder then that so many ambulances end up stranded outside.

Some patients with chest pain will make their own way to hospital, while some patients with suspected heart attacks will languish in ambulances longer than they should.

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At least three cases in which patients’ hearts stopped beating while they were waiting for care have recently been reported to the Royal College of Emergency Medicine in Scotland.

John-Paul Loughrey, vice-president of the college, said the patients should all have been in resuscitation bays at the time instead of the back of ambulances.

"There isn’t quality care anymore," he said. "We are barely safe."