New Technologies

1
New Technologies Challenges in optimizing the
heart health of Australia

• Professor Simon Stewart
• Head, Preventative Cardiology

simon.stewart_at_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
Advanced age symptomatic heart disease
4
Our ageing populations
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Presentation Overview

• The inevitable link between age heart disease

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

6
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!

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

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New drugs in chronic heart failure
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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
diuretic digoxin ACE-I ? blocker
diuretic digoxin ACE-I ? blocker
diuretic digoxin ACE-I ? blocker ARB
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The impact of new drugs in CHF
Years of survival (95CI)
Men
Women
Men and Women
Survival after 1st CHF admission in Scotland
Year of admission
Jhund, McIntyre, McMurray (unpublished)
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New devices in chronic heart failure

• While cardiac transplantation is a niche
  treatment, more focus on implanting

• Smart pacing wires to synchronise the hearts
  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

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Impact of devices in chronic heart failure
Companion Study
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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
48
36
24
12
0
60
Months of Follow-Up
No. at Risk Amiodarone 845 772 715 484 280 97 Plac
ebo 847 797 724 505 304 89 ICD 829 778 733 501 30
4 103
Bardy GH. N Engl J Med. 2005352225-237.
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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
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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
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

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Impact of a multidisciplinary intervention in CHF
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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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An economic blue-print for optimal CHF management
1 device 1 team 250 patients!!!!
Stewart et al. Eur Heart J 2002
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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

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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!