Every ten minutes in the UK, someone dies from coronary heart disease.
Heart disease is not a historical problem that medicine has largely solved. It remains the single leading cause of death in the UK, ahead of all cancers combined. It kills more Black adults at younger ages than white adults. And it is one of the most preventable conditions in medicine - with well-established interventions that genuinely reduce risk substantially.
The gap between what is possible and what actually happens is not a gap in medical knowledge. We know what prevents heart disease. The gap is in who receives timely risk assessment, who receives the conversation about prevention early enough to act on it, and who gets the benefit of medications that have been proven to save lives.
For Black and African communities, that gap is particularly consequential. Black adults have higher rates of hypertension, diabetes, and obesity - the three major modifiable cardiovascular risk factors - and they develop these conditions earlier. Cardiovascular disease in Black adults often presents a decade sooner than in white adults, and in many cases could have been prevented or substantially delayed with earlier intervention.
What heart disease actually is
Coronary heart disease (CHD) - the most common form of heart disease - is caused by atherosclerosis: the gradual buildup of plaques containing cholesterol, inflammatory cells, and fibrous tissue in the walls of the coronary arteries (the arteries that supply the heart muscle itself with blood). As plaques grow, they narrow the artery lumen, reducing blood flow to the heart muscle. When a plaque ruptures, a blood clot forms on it, suddenly blocking the artery - causing a heart attack (myocardial infarction).
Atherosclerosis begins in childhood and adolescence and progresses silently for decades before causing symptoms. Risk factors accelerate its progression.
Angina: When a coronary artery is significantly narrowed (typically 70% or more), exercise or stress increases the heart's oxygen demand to a level the narrowed artery cannot meet. This causes ischaemic chest pain (angina) that is predictably brought on by exertion and relieved by rest. Angina requires medical assessment but is not itself a heart attack.
Heart attack (MI): When a plaque ruptures and a clot blocks a coronary artery completely (or nearly completely), the heart muscle downstream is deprived of oxygen and begins to die. This is irreversible if not treated urgently. Time is muscle.
Heart failure: The heart's pumping function is impaired - by a previous heart attack, by hypertension, or by other causes - and cannot meet the body's circulatory demands. Causes breathlessness (particularly lying flat), fluid retention in the legs, and fatigue. Highly treatable but currently incurable.
Atrial fibrillation (AF): An irregular heart rhythm that causes clots to form in the heart that can travel to the brain, causing stroke. Detected on ECG. Treated with anticoagulation.
Why the atypical presentation problem matters for Black patients
The classic presentation of a heart attack - crushing central chest pain radiating to the left arm, with sweating and nausea - is less common in Black patients and in women than in white men. A significant proportion of heart attacks in Black adults present atypically: as unusual fatigue in the days before the event, as jaw pain or upper back pain without chest pain, as breathlessness, as indigestion-like discomfort, or occasionally with no chest symptoms at all.
This matters enormously because atypical presentations are more likely to be misattributed to anxiety, musculoskeletal pain, or gastrointestinal causes by healthcare providers. Studies consistently show that Black patients and women receive ECGs and troponin measurements less quickly than white male patients presenting with chest symptoms. Diagnostic delay in this context costs lives.
If you have cardiovascular risk factors and develop any unexplained symptoms in the upper body - even without classic chest pain - go to A&E and explicitly state your cardiovascular risk factors. Do not let the absence of classic chest pain reassure you that nothing cardiac is happening.
Know your numbers
The four most important numbers for cardiovascular health. Everyone over 40 should know them:
Blood pressure: Target below 130/80 mmHg. Hypertension is the single biggest modifiable cardiovascular risk factor and is more common, more severe, and less well-controlled in Black adults. See our hypertension guide.
LDL cholesterol: Target below 3.0 mmol/L for most people; below 1.8 for those with established cardiovascular disease. High LDL drives atherosclerosis. Statins reduce it effectively.
HbA1c: Target below 42 mmol/mol (non-diabetic range). Diabetes doubles cardiovascular risk. Even prediabetes (42-47) increases risk.
QRISK3 score: Your 10-year risk of a cardiovascular event, calculated by your GP using an algorithm incorporating all your risk factors and demographics. NICE recommends offering statin treatment when QRISK3 is 10% or above. Ask your GP for your score.
Case study: Kwame's wake-up call
Kwame, 52, a civil servant from Ghana based in Birmingham, came to see me after his younger brother died suddenly of a heart attack at 49. Kwame had no symptoms but was frightened.
His cardiovascular risk assessment: blood pressure 148/92, LDL cholesterol 4.1, fasting glucose 6.4 (prediabetic), BMI 31, moderate work stress, no exercise.
QRISK3 score: 23% - high risk.
We made a specific plan: amlodipine 5mg for blood pressure (as a calcium channel blocker, the appropriate first-line choice for a Black patient); atorvastatin 40mg for cholesterol; referral to NHS Diabetes Prevention Programme for prediabetes; 30-minute walk five days per week starting immediately.
Two years later: blood pressure 122/76, LDL 1.8, HbA1c 41 (normal), lost 9kg.
QRISK3 score: 9% - below the treatment threshold. Effectively halved.
"My brother's death saved my life," he told me. "I just wish I had not needed that to make me act."
The evidence-based interventions that genuinely reduce cardiovascular risk
Blood pressure control: Every 10mmHg reduction in systolic BP reduces cardiovascular events by approximately 20%. The most powerful intervention for reducing stroke risk.
Statin therapy: In people with elevated QRISK3, statins reduce the risk of heart attack and stroke by approximately 30% at standard doses and 45% at high doses. The absolute benefit depends on baseline risk.
Smoking cessation: Smoking doubles cardiovascular risk. Cessation reduces excess risk within 1-2 years, approaching non-smoker risk within a decade.
Exercise: 150 minutes per week of moderate aerobic exercise reduces cardiovascular mortality by 35%. Walking counts.
Dietary change: Mediterranean-pattern eating (olive oil, fish, legumes, vegetables, nuts, moderate wine) reduced cardiovascular events by 30% in the PREDIMED trial. The principles translate to an African-origin diet.
Aspirin: Low-dose aspirin for primary prevention is no longer recommended for most people without established cardiovascular disease - the bleeding risk outweighs the cardiovascular benefit. For secondary prevention (after a heart attack or stroke) it remains essential.
Sources: British Heart Foundation - Heart Statistics 2024; NICE Clinical Guideline CG181 - Cardiovascular Disease Risk Assessment 2023; Yusuf S et al, The Lancet 2004 (INTERHEART study - nine modifiable risk factors); Estruch R et al, NEJM 2013 (PREDIMED Mediterranean diet trial); Cholesterol Treatment Trialists Collaboration, The Lancet 2012 (statins); NHS Digital - Health Survey for England 2022.
