The changing face of cardiovascular care in Australia

Modern cardiovascular care has been blessed with therapeutic innovations that have reduced morbidity and mortality. From invasive management for acute coronary syndrome (ACS) to nurse-led heart failure management programs and anticoagulation for stroke prophylaxis in atrial fibrillation (AF), therapeutic advances have led not only to improved cardiovascular outcomes, but also the need for greater sophistication in balancing benefits with harms and costs (Box). With such complexity, decisions about management increasingly require access to risk stratification and evidence-based clinical decision support.

In this issue of the Journal, we commence a series of articles aimed at reviewing current and future challenges in cardiac care, including new diagnostic and management approaches to chest pain, primary prevention strategies based on absolute cardiovascular disease risk, and acute and chronic care of coronary heart disease (CHD), AF and heart failure.

Ongoing monitoring of cardiovascular outcomes by the Australian Institute of Health and Welfare (AIHW) has demonstrated reductions in cardiovascular mortality and morbidity. From 1968 to 2007, age-standardised death rates from cardiovascular disease fell by over 75%, from 1020 to 232 per 100 000 men and from 718 to 170 per 100 000 women.1 These gains exceed those observed in all other major diseases.2 Drawing on international data, the reduced rates have been attributed in about equal parts to effective primary prevention targeting hypertension, hypercholesterolaemia and smoking, and to more effective treatments for acute cardiac conditions, as well as improved secondary prevention and chronic disease management.3,4

However, a disproportionate burden of cardiovascular disease remains among people in rural and remote areas, those with linguistically and culturally diverse backgrounds, Indigenous peoples and older patients with multiple comorbidities. Geographic remoteness, communication difficulties, socioeconomic disadvantage, cultural disparities and limited evidence of intervention effectiveness are some of the factors that account for this uneven distribution.1,5

A rising prevalence of obesity and the associated increase in diabetes potentially herald a reversal in the declining rates of cardiovascular mortality. Between 1995 and 2007–08, the proportion of Australians aged 35–44 years classified as being overweight or obese increased by over 7 percentage points.1 Recent AIHW data suggest a plateau in previously observed declines in ACS events, although declines in CHD deaths are still evident. Registry data also show that about 50% of ACS events occur among patients with established CHD.6 These data reinforce the need for more widespread implementation of primary prevention targeting people at high absolute risk of CHD,7 combined with better secondary prevention in patients with established CHD.

Diagnostic and therapeutic innovations in cardiovascular care come with increased costs attributable to the technology itself, plus those associated with training, recruitment and subsequent interventions. The value of these innovations lies in their promise to reduce deaths and morbidity, but their widespread uptake often occurs in the absence of robust evidence of benefit across the full spectrum of outcomes for patients and health services.8 Even when such evidence is available, their real-world value depends on effective implementation in cardiovascular health services. Generalisation of the benefits and risks observed in clinical trials of emerging pharmacotherapies and devices requires appropriate health service infrastructure to support effective adoption. New technologies will likely bring the need for accurate clinical risk assessment and customised management into sharper focus. For example, in investigating chest pain, routine use of high-sensitivity troponin assays or computed tomography coronary angiography in the emergency department is likely to lead to unacceptably high false-positive rates, and unnecessary investigations and treatment with little impact on patient outcomes.9 In light of the potential for harm from novel diagnostics and pharmacotherapies, evidence-informed patient selection is key to their clinical and cost-effectiveness. This is paramount, given the increasing numbers of patients with chronic disease, advancing age and multiple concomitant treatments.

The challenge of determining value for individual patients, by balancing potential benefit and potential harm, is common to most of the interventions in the Box. Transcatheter aortic valve implantation (TAVI)10 for severe aortic stenosis (AS) is a good example. As patients with this condition are often very old, and half die within 12 months of symptom onset, the challenge is to distinguish between patients who are dying from severe AS and those dying with it. Similarly, when choosing between TAVI and open aortic valve replacement (AVR), the risks of increased stroke and limited long-term clinical data for TAVI must be weighed against the risks of acute postsurgical complications from AVR in this older high-risk group.

Effective transition of clinical decision making and care from the acute hospital setting to general practice and patient self-management are key to preventing avoidable cardiac events and readmissions. Transition-of-care initiatives include nurse-led heart failure management programs in the community that have reduced rates of rehospitalisation and mortality.11,12 Similar programs have potential in the management of AF and secondary prevention of CHD.13

Another paradigm shift is the development of integrated, statewide cardiac care networks, which seek to provide clinicians outside urban centres with rapid expert assessment of patients with acute cardiac conditions and prioritised transfer to tertiary centres. Federal health reforms associated with new funding arrangements and enhanced performance accountabilities will also act as a catalyst for further clinical service redesign to increase care access and integration. At a health service level, local hospital networks and Medicare Locals will facilitate collaborative implementation of multidisciplinary services that shift more of the care of patients with chronic cardiac conditions from the hospital to the community. This will demand a commensurate increase in clinical decision-making capacity in primary care.

All these changes will require better knowledge about the effectiveness, safety and accessibility of cardiovascular care in real-world settings14 by way of clinical and procedural registries, which allow benchmarking of clinical care and patient outcomes, rapid identification of evidence–practice gaps, and timely evaluation of benefits and harms of new technologies.15,16 The costs of maintaining nationally representative registries may be increasingly offset by automated data input from electronic health records and administrative datasets that quickly profile what, where and when cardiovascular care is provided. If implemented well, the timely collection of clinical data, and its standardisation using universal clinical definitions, will facilitate more accurate interjurisdictional comparisons.17 Public reporting of analyses of such data, conducted under the auspices of the AIHW and the Australian Commission on Safety and Quality in Health Care, should bring greater transparency, objectivity and accountability to cardiovascular care delivery. This enhanced data collection infrastructure should also facilitate applied clinical research that evaluates the comparative effectiveness of emerging and competing health care technologies and treatments, and constructs and validates new risk-prediction rules and management algorithms.

Continued investment by clinicians and health services in pursuing a “translatable” evidence base to inform decision making will be needed to ensure improved access to, and effective implementation of, cardiovascular innovations.