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

Professor Simon StewartHead, Preventative Cardiology

simon.stewart@baker.edu.au

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

Advanced age = symptomatic heart disease

0

5

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15

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45 - 54

years

55 - 64

years

65 - 74

years

75 - 84

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> 84 years

MEN

WOMEN

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45 - 54

years

55 - 64

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65 - 74

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75 - 84

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> 84 years

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vale

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(%

)

Over the average life-time, 2 in 3 men & 1 in 3 women in Western countries will develop symptomatic heart

disease

Our ageing populations

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Australia Canada France Greece Italy Japan Sweden UK

Po

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lati

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(m

illio

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65 years and over

<65 years

(14% to 29%)

(19% to 31%)

(19% to 34%)

(22% to 52%)

(23% to 54%) (19% to 33%)

(21% to 36%)

(21% to 47%)

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Australia Canada France Greece Italy Japan Sweden UK

Po

pu

lati

on

(m

illio

n)

65 years and over

<65 years

(14% to 29%)

(19% to 31%)

(19% to 34%)

(22% to 52%)

(23% to 54%) (19% to 33%)

(21% to 36%)

(21% to 47%)

Presentation Overview

♥ The inevitable link between age & heart disease

♥ Chronic heart failure: an exemplar of poor outcomes, hope and plenty of costs!

Chronic heart failure

An “epidemic” characterised by:

♥ 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!

0 6 12 18 24 30 36 42 48 54 600.00.10.20.30.40.50.60.70.80.91.0

Heart Failure

MI

Lung

BowelProstate

Bladder

Month of follow-up

Sur

viva

l (%

)

0 6 12 18 24 30 36 42 48 54 600.00.10.20.30.40.50.60.70.80.91.0

Heart Failure

MI

Breast

Bowel

Lung

Ovarian

Month of follow-up

Sur

viva

l (%

)Chronic heart failure: More malignant than cancer?

Stewart et al. Eur J Heart Failure 2002

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

New drugs in chronic heart failure

diureticdigoxin

diureticdigoxinACE-I

diureticdigoxinACE-I

diureticdigoxinACE-I blocker

diureticdigoxinACE-I blocker

diureticdigoxinACE-I blockerARB

SOLVD-Trial (1991)

Risk of death ↓ 23% CIBIS-2 Trial (1999)

Risk of death ↓ 33%

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CHARM TRIAL (2003)

Risk of death ↓ 30%

The impact of new drugs in CHF

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2.4

1986 1988 1990 1992 1994 1996 1998 2000 2002

Year of admission

Ye

ars

of

surv

iva

l (95

%C

I)

Jhund, McIntyre, McMurray (unpublished)

Men

Women

Men andWomen

SOLVD-TEnalapril

US Carvedilol

RALES Spironoalactone

Survival after 1st CHF admission in Scotland

New devices in chronic heart failure

While cardiac transplantation is a “niche” treatment, more focus on implanting:

♥ “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

Right AtrialLead

Right VentricularLead

Left VentricularLead

Impact of devices in chronic heart failure: Companion Study

Impact of devices in chronic heart failure: SCD-HeFT Study

Months of Follow-Up

Mo

rtal

ity

Rat

e

483624120

Amiodarone

PlaceboICD

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0.3

0.2

0.1

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60

No. at RiskAmiodarone 845 772 715 484 280 97Placebo 847 797 724 505 304 89ICD 829 778 733 501 304 103

Hazard Ratio (97.5% Cl) P-ValueAmiodarone vs. Placebo 1.06 (0.86-1.30) 0.53ICD vs. Placebo 0.77 (0.62-0.96) 0.007

Bardy GH. N Engl J Med. 2005;352:225-237.

Chronic heart failure: an increasing economic burden

0.0 0.5 1.0 1.5 2.0

UK (2000)

NL (1988)

USA (1989)

France (1990)

UK (1991)

Sweden (1996)

Percentage of total health care expenditure

$US 9b (71%)

SEK 2579m (74%)

FF 11.4b (64%)

£UK 360m (60%)

£UK 1042m (70%)

NLG 444m (67%)

Drugs 18%

Primary Care 6% 7% Outpatient Dept

69% - Hospital Admissions

CHF-related Healthcare Expenditure

Cost of Devices for 1000’s of patients??

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

Multidisciplinary, home-based intervention in CHF

♥ 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

Impact of a multidisciplinary intervention in CHF

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Year of follow-up

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tal

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ed r

ead

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ns HBI (n = 149)

UC (n = 148)

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4321

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0 5 7 86

Year of follow-up

All

-cau

se m

ort

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Minimum follow-up

HBI (n = 149)

UC (n = 148)

HBI (n = 149)

UC (n = 148)

Cost impact of implementing what we already knew!!

Outcome per 100 patients HBI Group UC Group Difference

Survival Time 405 years 285 years 120 more life-years

Costs

Home-based Intervention $100,000 - + $100,000

Unplanned hospital stay $2,170,470 $2,367,081 - $196,611

Elective hospital stay $147,046 $103,108 - $43,938

Additional care/treatment $849,856 $589,723 + $260,133

Total Cost of Health Care $3,267,372 $3,059,912 + $207,460

Cost per life-year gained + $1728

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Percentage of all-cause recurrent stay in 122,000 patients initially admitted for heart failure in the

year 2000

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Total cost of optimal heartfailure management *

Expected reduction in recurrenthospital stay due to optimal management

An economic blue-print for optimal CHF management

Stewart et al. Eur Heart J 2002

1 device = 1 team& 250 patients!!!!

Multiple targets along the “heart health” continuum

High Risk Individuals with sub-clinical CVD

Early/milderforms of CVD

Chronic/severeforms of CVD

Delay onset Slow progression

Dise

ase f

ree

CVD

fata

lity

Minimise severity

High Risk Individuals with sub-clinical CVD

Early/milderforms of CVD

Chronic/severeforms of CVD

Delay onset Slow progression

Dise

ase f

ree

CVD

fata

lity

Minimise severity

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

Summary

Key challenges to the “heart health” of Australia:

♥ 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!