Exploring cardiovascular inequalities across local authorities in England

Key findings from the report

• Cardiovascular mortality rates amongst under-75s and working age adults in England differ significantly between the ten most and least deprived local authorities.
• Premature mortality rates for many cardiovascular diseases are 3 or 4 times greater in the most deprived local authority compared to the least deprived.
• Working-age mortality from cardiovascular disease has increased over the past 5 years. This change is more pronounced in the most deprived local authorities.
• The prevalence of important risk factors for cardiovascular disease, such as obesity and diabetes, is higher in the most deprived local authorities.

Why we did this analysis

Previous BHF work has shown the significant role that deprivation plays in cardiovascular disease in England, and in the United Kingdom as a whole. In this new analysis, we examine how the inequalities in cardiovascular health are even more extreme across the 10 most and least deprived local authorities in England.

The report examines a range of indicators relating to cardiovascular disease, including premature and working-age mortality, how many people are living heart and circulatory conditions, and how common key risk factors are.

Characteristics of the most and least deprived local authorities

The median age in these local authorities ranged from 31 in Manchester, to 45 in Harborough. The most deprived local authorities generally had younger populations than the least deprived authorities.

The proportion of 16–64-year-olds in employment ranged from 61.6% in Middlesbrough to 87.6% in Hart. The rate of employment was higher in the least deprived areas compared to the most deprived.

The proportion of the population who identified as non-white ranged from 3.5% in Hartlepool to 51.3% in Birmingham.

Premature mortality

Cardiovascular mortality in people under 75

In the 10 most and least deprived local authorities (LAs), premature (under-75) mortality rates from cardiovascular disease (CVD) fell over the two decades leading up to 2020, though improvements slowed significantly in the 2010s. The ten most deprived local authorities have consistently experienced higher premature age-standardised death rates (ASDRs) than the 10 least deprived LAs, and this inequality has deepened over time.

In 2001–03, the average ASDR in the 10 most deprived LAs (191 per 100,000 people) was 98% higher than the 10 least deprived (97 per 100k). In 2020–23, it was 120% higher (112 per 100k, vs 51 per 100k).

In the past 5 years mortality has increased on average, at both ends of the deprivation spectrum. Between 2017–19 and 2021–23, the average premature mortality rate from CVD in the most deprived LAs increased by 9 deaths per 100,000 people (a 9% increase). In the least deprived LAs death rates rose 5 per 100,000 (a 12% increase).

In 2021-23, the rate of premature CVD mortality was significantly higher in all the ten most deprived LAs compared than the 10 least deprived.

In Blackpool the premature CVD mortality rate was more than 3 times as high as the rate in Hart (135 vs 42 per 100,000 population, respectively).

Coronary heart disease mortality in people under 75

Coronary heart disease (CHD) is the most commonly diagnosed type of heart disease and the single biggest cause of premature death in England.

On average, premature deaths from CHD have declined over the past two decades, levelling out since 2010 and increasing slightly post-COVID-19 pandemic. Across this period, the 10 most deprived LAs have consistently experienced higher rates of CHD death than the least deprived LAs.

Despite improvements, the average rate of premature CHD death in the most deprived LAs in 2021/23 (65 per 100,000 persons) is still higher than the rate in the least deprived LAs 2 decades ago (57 per 100k in 2001/03).

Inequality has worsened. Between 2001–03 and 2021–23, the average number of people dying prematurely from CHD fell more proportionally in the least deprived LAs than it did in the most deprived (56% vs 47%, respectively).

For males and females, the largest relative reductions in CHD mortality have occurred in the least deprived LAs.

The recent increase in premature mortality from CHD has also occurred in both males and females. However, it was most pronounced in males from the most deprived LAs, where the average ASDR increased by 10% between 2018–20 and 2021–23.

The most recent data for 2021-23 further illustrates this division, with the 10 most deprived local authorities recording significantly higher premature CHD mortality than all the 10 least deprived LAs.

Blackpool had the highest rate of premature CHD death, at 78 per 100,000 people. This was almost four times the rate in Hart (20 per 100,000).

Stroke mortality in people under 75

On average, premature deaths from stroke have declined over the past 2 decades, although this progress has slowed since the 2010s. As with premature deaths from CVD overall, the ten most deprived local authorities consistently experienced higher ASDRs from stroke than the 10 least deprived local authorities.

Between 2001–03 and 2021–23, the average premature ASDR from stroke fell by 53% and 55% in the 10 most and least deprived LAs, respectively.

The relative difference between the average rates of the 2 groups did not change substantially over the past 2 decades – the rate in the most deprived group remained roughly double that of the least deprived (18 and 8 deaths per 100,000 people, respectively, in 2021–23).

The most recent data for 2021/23 further illustrates this division, with the 10 most deprived local authorities recording substantially higher ASDRs for stroke compared to the 10 least deprived.

In 2021–23 Blackpool experienced the highest number of premature deaths from stroke, at 22 per 100,000 population. This was more than 3 times the rate in Elmbridge (7 per 100,000 population).

Working age mortality (20-64s)

Working-age mortality from CVD

Differences in CVD mortality are also apparent if we look at people of working age (20-64). Over the past decade, working-age CVD mortality has consistently been higher in the 10 most deprived LAs compared to the 10 least deprived.

In the most deprived LAs, working age mortality from CVD has increased since over the last decade. For women, this increase only began after 2017–19.

In males, working-age mortality from CVD has increased by 14% in the most deprived LAs and decreased by 11% in the least deprived over the last decade.

Working-age mortality from CHD

There is also a large disparity in coronary heart disease mortality in working age adults, between the most and least deprived LAs.

Among working-aged women in the least deprived LAs, deaths from CHD are very rare. In the most deprived LAs, mortality averaged more than 10 per 100,000 throughout the decade.

Among men in the most deprived LAs, average working-age mortality was more than double that of the least deprived LAs and increased by 16% between 2017–21 and 2023–23. In the least deprived LAs there was very little change over this period.

Morbidity

Coronary heart disease prevalence

This graph shows the crude prevalence of diagnosed CHD in each of the 10 most and least deprived local authorities in England.

In most cases, the prevalence of CHD is higher in the most deprived areas compared to the least deprived, despite the most deprived areas generally having younger populations (see Figure 2).

Of the twenty LAs in this analysis Blackpool had the highest prevalence of CHD (4.3%). Manchester and Wokingham had the lowest CHD prevalence (2.1% and 2.2%, respectively), despite the median age in Wokingham being 10 years older than in Manchester.

Heart failure prevalence

There is no age-standardised heart failure prevalence data available for local authorities. The age standardised prevalence of heart failure is much higher in more deprived areas of England.

Aside from Blackpool, there is no clear difference between the crude prevalence of heart failure between the ten most and least deprived local authorities. This is likely because the most deprived LAs are, on average, much younger (see Figure 2), and heart failure prevalence increases with age. These demographic differences are likely obscuring the true burden of heart failure in these populations.

In Blackpool, where the median age is 43, the diagnosed prevalence of heart failure was 1.8%. In Surrey Heath, which also has a median age of 43 years old, the prevalence was just 0.8%.

Stroke prevalence

This graph shows the crude prevalence of diagnosed stroke in each of the 10 most and least deprived local authorities in England.

Despite having mostly younger populations, the most deprived LAs tend to have a higher, or comparable, prevalence of stroke to the least deprived LAs. Blackpool had the highest prevalence of stroke, at over 2.5%.

Risk factors

Hypertension prevalence

There is no age-standardised hypertension prevalence data available for local authorities. We know that, at a national level, the age standardised prevalence of hypertension is much higher in more deprived areas of England.

There is no clear difference in the crude prevalence of hypertension between the 10 most and least deprived local authorities. This is likely because the most deprived LAs are, on average, much younger (see Figure 2), and hypertension prevalence increases with age.

Blackpool and Hartlepool have the highest prevalence of hypertension of the 20 LAs shown here.

Obesity prevalence

Obesity significantly increases the risk of developing cardiovascular disease. In the UK, around 1 in 9 CVD deaths are associated with high body mass index (BMI).

In the most deprived LAs (except Birmingham), the prevalence of obesity is higher than any of the least deprived LAs.

This is despite obesity being more prevalent among older people and the least deprived LAs being older on average compared to the most deprived.

Diabetes prevalence

Diabetes is an important risk factor for many cardiovascular diseases. Adults with diabetes are 2-3 times more likely to develop CVD, and nearly twice as likely to die from heart disease or stroke as those without diabetes.

Of the local authorities in our analysis, Blackburn with Darwen had the highest prevalence of diabetes in 2022/23 (9.6%). Elmbridge had the lowest (5.0%). In all but one of the most deprived LAs, the prevalence of diabetes is higher than in all the least deprived LAs. This is despite the fact that the most deprived LAs generally have younger populations.

In Manchester and Liverpool, the prevalence of diabetes was more comparable to that in less deprived areas. This may be partly due to having a younger population.

Conclusions

• Previous BHF work has shown the significant role that deprivation plays in cardiovascular disease in England, and in the United Kingdom as a whole. In this new analysis, we highlight how the differences in cardiovascular health are even more extreme when we look at the 10 most and least deprived local authorities in England.
• Indeed, Blackpool, which is the most deprived local authority in England, has consistently experienced the highest prevalence and incidence of cardiovascular disease, and cardiovascular mortality, of all the LAs included in this analysis.
• Cardiovascular mortality rates amongst under-75s and working age adults in England differ significantly between the 10 most and least deprived local authorities.
• Premature mortality rates for many cardiovascular diseases are 3 or 4 times greater in the most deprived local authority compared to the least deprived.
• Working-age mortality from cardiovascular disease has increased over the past 5 years. This change is more pronounced in the most deprived local authorities.
• The prevalence of important risk factors for cardiovascular disease, such as obesity and diabetes, is higher in the most deprived local authorities.

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