International Symposium On Surgical Options In Heart Failure Management

10 Feb 2003

By Dr Balaji Sadasivan

Venue: National University Hospital

Introduction

It gives me great pleasure to join you today at the International Symposium on Surgical Options in Heart Failure Management, organised by the Department of Cardiac, Thoracic and Vascular Surgery of the National University Hospital. I would like to extend a special welcome to our overseas faculty, who have travelled to Singapore to share their expertise and wisdom with us.

Importance of Heart Failure in Public Health

Ischemic heart disease and heart failure are major public health concerns in Singapore, especially in an ageing population like ours. In 2001, ischemic and other heart diseases were the second leading cause of death in Singapore, accounting for a quarter of all deaths. Ischemic heart disease also accounted for 4% of hospital admissions in Singapore, with heart failure resulting in another 1.2% of admissions.

Our statistics mirror the situation in other developed countries. In the United Kingdom for example, heart failure accounts for about 2% of all hospital admissions and 5% of admissions to hospital medical wards. In the United States, heart failure afflicts an estimated 4 million Americans, and contributed to approximately 287,000 deaths in 1999.

Clearly, heart failure imposes a heavy burden of disease on our community. An editorial published in the New England Journal of Medicine in October last year commented that we were in the midst of an epidemic of heart failure, as evidenced by increases in the number of hospitalizations for heart failure, the number of deaths attributed to heart failure, and the costs associated with care. In the United Kingdom, heart failure costs the NHS #60 million a year, equivalent to 1-2% of the total NHS budget, with hospital admissions accounting for 60-70% of this expenditure.

Historical Perspective

And yet, heart failure is not a modern disease, brought on by the excesses of our society today. Descriptions of heart failure exist from ancient Egypt, Greece and India. Blood letting and leeches were used for centuries, and it was more than 200 years ago that Sir William Withering first published his treatise on the use of foxglove in 1785, although it wasn't till the early 20th Century that digitalis began to be considered useful in patients with heart failure and normal cardiac rhythm.

We have made enormous strides in the management of heart failure patients since those early beginnings.

Medical Management of Heart Failure

Major advances in our understanding of the pathophysiology of congestive heart failure and the knowledge gained from large-scale clinical trials have contributed significantly to how we manage our heart failure patients today. Various classes of medications, such as diuretics, ACE Inhibitors and Beta Blockers, have been shown to improve symptoms and reduce the risk of death in patients with heart failure, and are now an established cornerstone in the medical management of these patients. Optimal therapy can increase survival, improve well-being and avoid hospitalisation. As such, the importance of effective counselling and education of patients and their caregivers cannot be over-emphasised in assuring adherence to a regimen that is generally complex, demanding and expensive.

Heart Transplantation

In spite of these advances in medical therapy, there are certain patients whose conditions cannot be alleviated by standard medications. Heart transplantation offers new hope for some patients who would have previously perished. Once nearly abandoned because of immunologic obstacles, heart transplantation is now considered a treatment option in a group of carefully selected patients with severe end-stage heart failure. However, this option is inherently limited by the availability of suitable donor hearts.

Over the last 5 years in Singapore, 11 heart transplants were performed, but another 13 patients died while waiting for donor hearts. End-stage heart failure patients do not survive for long and the timely availability of hearts for transplant is critical in saving these patients. As such, we need to have a large pool of people who are willing to pledge their organs for donation.

Alternative Surgical Options

Thanks to rapid technological advancements over the past decade, some alternative surgical and device treatment options have become a reality.

Gone are the days when heart failure associated with fluid retention was treated by Southey's tubes inserted into edematous peripheries to drain fluid. Those are now relics from the 19th and the early 20th Centuries.

Today, at the start of the 21st Century, we have cutting-edge strategies like implantable mechanical assist devices, ventricular reduction and remodeling surgery, and cardiac resynchronization therapy.

Mechanical Heart Device Programme

Although such cutting-edge technology may seem like very attractive options, we may not always be able to predict which technologies will be effective in practice. The Ministry's Health Service Development Programme, or HSDP, was set up in 2000 with the aim of funding new state-of-the-art technology on a pilot basis. Pilot projects which are found to work well and are affordable will be retained and gradually incorporated into mainstream services.

A good example is the Mechanical Heart Device Programme at the National Heart Centre, which is being supported by HSDP to the tune of $6 million over 5 years. This HSDP Programme provides subsidies for left ventricular assist devices and other artificial mechanical heart devices which are used as a bridge to recovery in patients with post-cardiotomy shock, or patients with cardiogenic shock secondary to myocardial infarct or myocarditis. They may also serve as a bridge to transplant in selected patients with intractable heart failure who are awaiting a suitable donor heart to become available.

Importance of Primary Prevention

But despite the tremendous advances we have achieved in the management of heart failure patients, heart failure remains a condition with a very poor prognosis. Recent data from the Framingham Heart Study showed that although rates of death after the onset of heart failure declined by about one third from the 1950s to the 1990s, among subjects who were diagnosed with heart failure in the 1990s, more than 50% were dead at five years.

In our combat against heart failure therefore, we must continue to devote our energies to the primary prevention of this grave and debilitating condition. As you all know, coronary heart disease, along with hypertension, is one of the major risk factors for heart failure. The Ministry has adopted several key strategies to prevent and control coronary heart disease. These include reducing the prevalence of major risk factors for the disease, early detection of diabetes mellitus, hypertension and hyperlipidemia through screening, and optimising control through effective treatment. Ongoing primary preventive measures include the National Healthy Lifestyle Campaign, which aims to effect a change in behavioural risk factors such as diets high in cholesterol, smoking and lack of exercise.

Risk factor clinics have already been set up at polyclinics in the form of Chronic Comprehensive Care Programmes (CCCP) for diabetes, hypertension and hypercholesterolemia.

The Ministry will also be producing a set of clinical practice guidelines on heart failure, which will contain evidence-based recommendations on practical aspects of heart failure management relevant to Singapore.

Conclusion

Heart failure is a complex clinical condition that requires a multi-pronged, multi-disciplinary approach for optimum control, management and prevention. All of us, doctors, healthcare professionals and medical institutions have an important role to play in relieving the burden that heart failure places on patients and on society.

The rapid changes in the management of heart failure and the constant emergence of new technologies also pose challenges for all of us who care for these patients. Our professional responsibilities behoove us to ensure that we keep up-to-date with all the latest developments in this field. Indeed, it is no less than what our patients expect from us.

I would like to take this opportunity to thank the organisers for their initiative and their hard work in putting together a very interesting and comprehensive programme. I understand that the Department of Cardiac, Thoracic and Vascular Surgery in NUH aims to develop heart failure surgery systematically over the next five to ten years. This Symposium is certainly a step in the right direction. I am sure that this Symposium will provide an excellent platform for participants to learn new techniques and share experiences in the management of heart failure, and I have no doubt that all of you will benefit from it.

I wish you a very fruitful and successful Symposium. It is now my pleasure to declare the International Symposium on Surgical Options in Heart Failure Management open.

Thank you.