1. New Technologies & Challenges in optimizing the “heart health” of Australia Professor Simon Stewart Head, Preventative Cardiology 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. Advanced age = symptomatic heart disease 0 5 10 15 20 45-54 years 55-64 years 65-74 years 75-84 years > 84 years MEN WOMEN 0 5 10 15 20 45-54 years 55-64 years 65-74 years 75-84 years > 84 years Population prevalence (%) Over the average life-time, 2 in 3 men & 1 in 3 women in Western countries will develop 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. 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!

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 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 SOLVD-Trial (1991) Risk of death ↓ 23% CIBIS-2 Trial (1999) Risk of death ↓ 33% 0 5 10 15 20 CHARM TRIAL (2003) Risk of death ↓ 30%

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 The impact of new drugs in CHF Year of admission Years of survival (95%CI) Jhund, McIntyre, McMurray (unpublished) Men Women Men and Women SOLVD-T Enalapril US Carvedilol RALES Spironoalactone Survival after 1 st CHF admission in Scotland

11. 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 Atrial Lead Right Ventricular Lead Left Ventricular Lead

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

13. Impact of devices in chronic heart failure: SCD-HeFT Study Months of Follow-Up Mortality Rate 483624120 Amiodarone Placebo ICD 0.4 0.3 0.2 0.1 0.0 60 No. at Risk Amiodarone84577271548428097 Placebo84779772450530489 ICD 829778733501304103 Hazard Ratio (97.5% Cl)P-Value Amiodarone vs. Placebo1.06 (0.86-1.30)0.53 ICD vs. Placebo0.77 (0.62-0.96) 0.007 Bardy GH. N Engl J Med. 2005;352:225-237.

14. Chronic heart failure: an increasing economic burden 0.00.51.01.52.0 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??

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. 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

17. Impact of a multidisciplinary intervention in CHF 1.0 4321 0.0 0.8 0.6 0.4 0.2 0 5786 Year of follow-up All-cause mortality 910 1.0 4321 0.0 0.8 0.6 0.4 0.2 0 5786910 Minimum follow-up HBI (n = 149) UC (n = 148) HBI (n = 149) UC (n = 148)

18. Cost impact of implementing what we already knew!! Outcome per 100 patientsHBI GroupUC GroupDifference Survival Time405 years285 years120 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 $3,059,91 2 + $207,460 Cost per life-year gained + $1728

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

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. 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!