Why are heart attack deaths 160% higher in some areas of England than others?

A new study has found the variation in hospital fatality rates is only a small contributor to geographical variation in heart attack deaths in England

The high heart attack mortality in some areas of England is due to greater rates of heart attack and because more victims of heart attack die before being admitted to hospital, rather than worse outcomes from hospital admissions.

The study, which used data from 2015-2018, shows that hospital fatality rates vary across the 326 districts in England, however the authors found that the overall number of heart attacks and pre-hospital death rates were the biggest contributing factors to the geographical variation in heart attack mortality.

Urban districts in the north of England, where heart attack (or myocardial infarction (MI)) rates are higher, were found to have the highest death rate from MI. In the worst affected areas women were 2.55 times, and men 2.17 times, more likely to experience an MI than the lowest ranked areas.

Deaths before admission to hospital were also found to vary geographically, 15% of women and 16.9% of men who suffered an MI died before being admitted to hospital. In every district there were more pre-hospital deaths than deaths following hospital admission. women and men who had a heart attack in the worst performing districts in England were 60% and 75% more likely to die before being admitted to hospital than those in the best-performing ones.

A major factor in the pre-hospital death rate is how long it takes the individual to recognise the symptoms of MI and call for and receive appropriate help as well as the use of CPR and defibrillation.

Lead author Dr Perviz Asaria, a Consultant Cardiologist from the School of Public Health and Imperial NHS Trust, said: "We have gone leaps and bounds in standardising and improving hospital care for heart attacks over the last 20 years, however more than half of patients who die of an MI never make it into the hospital – we now need to concentrate our efforts on promoting and early interventions to save lives where heart attacks happen in the community."

Continuing improvement

The authors note that the UK has seen drastic improvements in MI mortality over the past 50 years as a result of a reduction in smoking and other risk factors alongside advances in primary prevention, treatment and specialist care. This research shows that further steps are needed to reduce the number of heart attacks in places with high death rates because the sheer size of case numbers can drive areas that benefit from low case fatality into high mortality rankings, and vice versa.

England has implemented a number of awareness campaigns for MI symptoms but these programmes are rarely targeted and adapted to communities where out of hospital deaths are high. The study also highlights a number of initiatives used in other countries that could help reduce pre-hospital mortality, such as increasing CPR competence in the general public and alerting nearby CPR trained responders to an incident via mobile alerts.

Dr Asaria said: "Pre-hospital interventions are the next easiest target for reducing heart attack deaths – and we need more research and standardisation of these. However ultimately if we can reduce the numbers of heart attacks occurring in each district we will make the biggest impact – and that requires re- focusing on prevention."

'Contributions of event rates, pre-hospital deaths, and deaths following hospitalisation to variations in myocardial infarction mortality in 326 districts in England: a spatial analysis of linked hospitalisation and mortality data' was published in the Lancet Public Health.