Hello, I'm professor Richard Hobbs, Head of academic Primary Care at the University of Oxford. And I'm very pleased to be giving this talk on putting COVID into context talking about COVID in relation to cardiovascular disease. These are my competing interests. And I'm going to start off by talking about why cardiovascular disease remains such an important topic for health systems right across the planet.

And if you look at this slide, which is talking about WHO data over a 20-year period you can see that whether it be for under 75 or over 75, what we've seen in the world is that the most common cause of major morbidity and mortality has been long-term conditions, and of those, cardiovascular disease is by far the most important in terms of prevalence. and this reinforcement of long-term conditions being the major drivers of disease, and death on the planet, resulted in the WHO shifting its emphasis saying the management of long-term conditions was actually more of a priority for the world than malnutrition and infection.

Now, having said that obviously, the last two years, we have been inundated with the consequence of COVID-19 and perhaps not surprisingly, all attention has gone on to infectious disease and we've rather lost sight of the importance of long-term conditions during this awful pandemic. But the reality is that, in fact, the impact of COVID has been principally on people who suffer other medical problems. It isn't fit and healthy people who have suffered adverse outcomes from COVID. It acts like other coronaviruses in terms of producing either a mild illness or a flulike illness.

But in people who are very elderly or have other long-term conditions then, a proportion of them are going to suffer quite severe COVID outcomes and indeed, death and what we can see on this slide, is that in the first wave, the impact was very much on a proportion of the population, becoming extremely ill and requiring support and often dying from the COVID, but it was people, as I say with long-term conditions. Even in the second wave the same sort of impact occurred, but by the second wave, we were also suffering from the huge backlog of preventive care that had been delayed. Because COVID was either stopping patients going to a hospital, or putting them off going to a hospital and they were ignoring important symptoms or weren't managing illness, as well as they might do and that increasingly started to result in increased morbidity and death and of course, we also have seen even more impact of long-term conditions on COVID-related diseases with third and fourth waves, and we have to factor in long-term COVID into this equation as well.

So, let's just look at some of the data around COVID-19, in terms of what predicted worse outcomes and we can see this is based on primary care routine datasets in the United Kingdom. A huge data set that initially looked at 18 million patient records and some of the latter evaluations were 55 million people from British GPs were contributing data and what you can see is clearly a very close relationship between age and worse outcomes from COVID.

But if you start to drill down, it was people who had multi morbidity, who were the ones who really suffered harm, and we can see here that it was conditions, such as smoking, as to whether people had had heart disease, or strokes or diabetes. It wasn't just age, it was the interaction between age and these common long-term conditions that were resulting in worse outcomes.

Now clearly, the focus of the world's research community was on some solutions to these risks and the most significant of that has been the public health measures around vaccinations, and this is just to remind us of the extraordinary achievement of world science in generating vaccines, within incredibly short periods. This is the Oxford AstraZeneca vaccine which went from the first identification of the genome by the Wu Han Chinese scientists to a licensed vaccine for use in humans in 104 days, an absolutely remarkable achievement. And of course, we now have some 15 evidence-based vaccines that have transformed the way the pandemic has managed.

We can look here at the impact of vaccination. Very, very rapid uptake. If you look in 2021, in the first three months, the vast majority of the population had their first vaccine and then by July, the majority had had their second vaccine.

So if we look at the consequence of that vaccine program, we can see that during that same period in 2021 this dramatic change from these excess deaths in waves 1 and 2, in 2020, being hugely reduced, despite actually higher rates of COVID infections in the population, by that vaccination program.

And that was also impactful on hospitalizations as well. So, both deaths and hospitalizations substantially reduced by the vaccination program.

And as we know, despite the rapidity of the development of these vaccines, extraordinarily safe, very rare side effects and all of the side effects associated with the vaccines much more likely to occur in patients who were unvaccinated and developed COVID. So that's been the mainstay of treatment.

But perhaps, what we failed to recognize is that the excess deaths we've seen during the pandemic, and since the control of the pandemic, through vaccination are related to long-term conditions not specifically to the COVID itself and that has become even more dramatic now as deaths due to COVID itself, which are illustrated here in yellow, in waves 1 and 2, have diminished, but the excess and general deaths in the population have continued and they're related to long-term conditions. And in this slide in the dark grey are the rates for ischemic heart disease. And so what you can see is, at least half of the attributable deaths that are occurring at the moment and contributing to the continued, excess death rate in the population is actually due to ischemic heart disease not to COVID.

If we look then at stroke, very similar pattern around half of the excess deaths relating to stroke. And of course, the reason why there appears to be overlap here is because these conditions interact and you may well get patients who suffer both stroke and heart attack.

And even on heart failure, you can see that an appreciable proportion of excess deaths relate to heart failure. More than relate to COVID itself because these are patients, who are dying, who don't have a COVID contact, that precedes their death.

So I think what we have lost sight of during the pandemic is that long-term conditions were the biggest contributing factor to worse outcomes during the pandemic. And as we have got greater control over the pandemic largely through vaccination, but laterally through some innovative new anti-COVID drugs, we've lost sight of the fact, that the big target is the one that we were already failing to control before the pandemic that of long-term condition management and in particular, ischemic heart disease.

It just reinforces the importance of smoking cessation. We know that stopping smoking at any age will result on some patient gain Control of lipids particularly through statin use low-cost, safe medication. Here showing a reduction in major vascular outcomes and here showing a 10% overall reduction in mortality from the simple addition of a statin that reduces your LDL cholesterol by one mmol. And of course, blood pressure. The other triad of vascular risk factors. If you control it, you're going to reduce all cardiovascular outcomes including stroke.

What we know is that we are not or even prior to the pandemic, we weren't successfully controlling these risk factors and some of them particularly obesity and sedentary aspects were actually getting worse.

And I would therefore summarize that what we have with cardiovascular disease is the most important and prevalent long-term condition. It, fortunately has the biggest evidence base in medicine, as to what interventions will help prevent disease and the development of worse disease. And we had issues, even before the pandemic in implementing this evidence base, in terms of identifying and treating risk factors and treating them effectively, in terms of the medicines, we have available to us, but even during the pandemic, cardiovascular disease as the most important long-term condition, that we face in clinical practice that was responsible for more COVID-related aspects to COVID-deaths than any other conditions. And that we still have this big issue of excess mortality in the population because we lost a lot of preventive care during the pandemic, which we need to catch up on and we need to more effectively manage this gap in what we can do and what we are doing in relation to vascular disease management. Thank you very much.

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