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New Technologies & Challenges in optimizing the “heart health” of Australia

Professor Simon Stewart Head, Preventative Cardiology. New Technologies & Challenges in optimizing the “heart health” of Australia. simon.stewart@baker.edu.au. Presentation Overview. The inevitable link between age & heart disease.

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New Technologies & Challenges in optimizing the “heart health” of Australia

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  1. Professor Simon Stewart Head, Preventative Cardiology New Technologies & Challenges in optimizing the “heart health” of Australia simon.stewart@baker.edu.au

  2. Presentation Overview • The inevitable link between age & heart disease • Chronic heart failure: an exemplar of poor outcomes, hope and plenty of costs! • Back to the future: the potential value in better systems of care

  3. Over the average life-time, 2 in 3 men & 1 in 3 women in Western countries will develop symptomatic heart disease MEN 20 20 WOMEN 15 15 Population prevalence (%) 10 10 5 5 0 0 45 45 - - 54 54 55 55 - - 64 64 65 65 - - 74 74 75 75 - - 84 84 > 84 years > 84 years years years years years years years years years Advanced age = symptomatic heart disease

  4. Our ageing populations

  5. Presentation Overview • The inevitable link between age & heart disease • Chronic heart failure: an exemplar of poor outcomes, hope and plenty of costs!

  6. An “epidemic” characterised by: Chronic heart failure • Damaged heart with system wide impact (lungs, kidneys & brain) • Very poor quality of life: shortness of breath & fatigue • Clinical instability: costly admissions! • Premature death: sudden versus slow!

  7. Chronic heart failure: More malignant than cancer? Stewart et al. Eur J Heart Failure 2002

  8. Uncovering a hidden epidemic • 325,000 men & women with CHF • 200,000 more with “latent” HF • 100,000+ hospital admissions • 1 million+ days of hospital stay • $1 billion+ health care costs

  9. New drugs in chronic heart failure 20 SOLVD-Trial (1991) Risk of death ↓ 23% CIBIS-2 Trial (1999) Risk of death ↓ 33% 15 CHARM TRIAL (2003) Risk of death ↓ 30% 10 5 0 diuretic digoxin diuretic digoxin ACE-I diuretic digoxin ACE-I  blocker diuretic digoxin ACE-I  blocker diuretic digoxin ACE-I  blocker ARB diuretic digoxin ACE-I

  10. RALES Spironoalactone US Carvedilol SOLVD-T Enalapril The impact of new drugs in CHF Years of survival (95%CI) Men Women Men and Women Survival after 1st CHF admission in Scotland Year of admission Jhund, McIntyre, McMurray (unpublished)

  11. While cardiac transplantation is a “niche” treatment, more focus on implanting: Right AtrialLead Left VentricularLead Right VentricularLead New devices in chronic heart failure • “Smart” pacing wires to synchronise the heart’s pumping action • “Automated” defibrillators to start the heart when it stops • “Assist” devices that “turbo-charge” blood flow in the heart • New cells to re-grow the heart

  12. Impact of devices in chronic heart failure: Companion Study

  13. Impact of devices in chronic heart failure: SCD-HeFT Study Hazard Ratio (97.5% Cl) P-Value Amiodarone vs. Placebo 1.06 (0.86-1.30) 0.53 ICD vs. Placebo 0.77 (0.62-0.96) 0.007 0.4 0.3 Mortality Rate 0.2 0.1 Amiodarone Placebo ICD 0.0 0 12 24 36 48 60 Months of Follow-Up No. at Risk Amiodarone 845 772 715 484 280 97 Placebo 847 797 724 505 304 89 ICD 829 778 733 501 304 103 Bardy GH. N Engl J Med. 2005;352:225-237.

  14. CHF-related Healthcare Expenditure 7% Outpatient Dept Primary Care 6% 69% - Hospital Admissions Drugs 18% Cost of Devices for 1000’s of patients?? Chronic heart failure: an increasing economic burden Sweden (1996) SEK 2579m (74%) UK (1991) £UK 360m (60%) France (1990) FF 11.4b (64%) USA (1989) $US 9b (71%) NL (1988) NLG 444m (67%) UK (2000) £UK 1042m (70%) 0.0 0.5 1.0 1.5 2.0 Percentage of total health care expenditure

  15. Presentation Overview • The inevitable link between age & heart disease • Chronic heart failure: an exemplar of poor outcomes, hope and plenty of costs! • Back to the future: the potential value in better systems of care

  16. Home visit at 1-2 weeks post discharge by a nurse & pharmacist Clinical history and physical assessment Patient education – warning signs Medication management Psycho-social status Repeat phone calls & patient initiated calls More intensive/appropriate follow-up Promote self-care behaviour Increase GP & cardiology vigilance for high risk patients Trigger long-term community management Multidisciplinary, home-based intervention in CHF

  17. 1.0 1.0 600 HBI (n = 149) UC (n = 148) 0.8 0.8 500 400 0.6 0.6 Total unplanned readmissions 300 All-cause mortality Minimum follow-up 0.4 0.4 200 0.2 0.2 HBI (n = 149) HBI (n = 149) 100 UC (n = 148) UC (n = 148) 0.0 0.0 0 0 1 2 3 4 5 6 7 8 9 10 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 Year of follow-up Year of follow-up Impact of a multidisciplinary intervention in CHF

  18. Cost impact of implementing what we already knew!!

  19. An economic blue-print for optimal CHF management 1 device = 1 team & 250 patients!!!! Stewart et al. Eur Heart J 2002

  20. Multiple targets along the “heart health” continuum KEY ISSUES TO IMPROVE HEALTH OUTCOMES: • Cost-effective early detection at community level • Key targets (smoking, HT, metabolic syndrome) • Platform for introducing new therapeutics • Developing the evidence • Re-align health care flexible systems of care

  21. Key challenges to the “heart health” of Australia: Summary • Improve flow of information on evolving epidemic: geo-mapping & linked data • Picking the right individuals for more expensive therapies • Going back to “basics” to apply what we already know will improve outcomes!

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