Sunday, September 15, 2019

Right from the HEART

Apr 08. 2019
From left: Sharon Tong, Dr Mark Chan, Associate Professor Angelique Chan, Claus Zieler and Professor Dianna Magliano.
From left: Sharon Tong, Dr Mark Chan, Associate Professor Angelique Chan, Claus Zieler and Professor Dianna Magliano.
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Specialists from across the board in Singapore discuss the challenges of cardiovascular diseases and its prevention in an increasingly ageing population

During a recent panel discussion on “Healthy Hearts, Healthy Ageing” organised by Bayer in partnership with NUS Enterprise, the entrepreneurial arm of the National University of Singapore (NUS), Mark Chan, a 45-year-old cardiologist, surprised participants by telling them he suffers from hypercholesterolemia, a condition characterised by very high levels of cholesterol in the blood, and has been on medication for the last six years.

The slim and youthful looking Chan went on to say that he gives out his personal health details in an attempt to convince his patients to follow his instructions and take their medication rather than decide for themselves the right course of treatment. 

“A few weeks ago, the chief executive of a multinational came to see me. He and I are the same age and have exactly the same blood pressure and cholesterol levels. I told him, ‘you need to start blood pressure and cholesterol medication right away’. He replied that he was going to try exercising and cutting out salt first,” says Chan, a senior consultant cardiologist at the National University Heart Centre and deputy director of the Cardiovascular Research Institute, Singapore.

“It’s amazing that someone who is so well-educated doesn’t have the level of health literacy to take primary prevention when we know that hypertension and hypercholesterolemia are the major drivers of strokes and heart attack,” he continues.

“It isn’t because you are well that you are safe from silent risk factors. My patient is not alone in believing that a change of lifestyle is enough to cure him.”

Hypertension, cholesterol and obesity are all risk factors for cardiovascular disease (CVD), which covers everything from stroke, heart attack, atrial fibrillation and coronary disease.

A device to measure blood sugar levels./AFP photo

Yet CVD is easy to treat and also preventable: taking the right medication helps cut the risk of CVD by 50 per cent and when combined with a healthier lifestyle – the right diet, no smoking or drinking and exercise – the risk goes down by another 40 per cent. 

“Stroke, heart attacks or peripheral blockage lead to amputations. These can kill you or put you in bed for life. You won’t be able to lead a normal life, you may not be able to walk, talk or swallow. Medical science can’t tell you whether you will die or be disabled. But what it tells us is that we have medications that are able to prevent a stroke or reduce the risk of that stroke,” says Claus Zieler, senior vice- president of Bayer Pharmaceuticals Division Asia Pacific.

Worldwide, says Chan, CVD affects slightly over 400 million adults. Half of those patients are in Asia. Moreover, a third of deaths are due to CVD. Cardiovascular disease refers to a condition in which the blood vessels are not supplying the heart and the brain gets into trouble because of fatty plaque. The plaque builds up in the arteries causing a hardening known as atherosclerosis, which leads to heart disease and stroke. If a clot blocks a blood vessel that feeds the heart, it causes a heart attack. If it blocks a blood vessel that feeds the brain, it causes a stroke. If blood supply to the arms or legs is reduced or blocked, it can cause difficulty walking and eventually gangrene.

The prevalence of CVD is higher among the elderly and in Asia, as elsewhere, the ageing population is on the rise. An increase in age is inevitably accompanied by a concurrent increase in chronic medical conditions like CVD. 

Non-adherence to treatment can be blamed on many factors, both social and cultural. Associate Professor Angelique Chan, Executive Director of the Centre for Ageing Research and Education, Duke-NUS Medical School, adds that lack of money, transportation problems and no caregiver are also problems regularly encountered. 

Patients prone to blood clots and atrial fibrillation receive oral anticoagulant therapy with vitamin K antagonist drugs, the most common of which is warfarin. Warfarin has been used for decades in preventing clotting but comes with complications as the medication interacts with other drugs such as antibiotics, statins and NSAIDS. It also interacts with foods with a high concentration of vitamin K such as broccoli and green leaf vegetables.

That means patients require careful monitoring, monthly blood tests and dose adjustment. Another side effect is bleeding. This can occur when there’s an imbalance in the dose and can lead to death. The new drug new oral anticoagulant therapies was later introduced as an alternative to warfarin and does away with the need for monthly blood checks. It is also taken just once a day, generating better compliance and making it a safe alternative. However, it is considerably more expensive than warfarin. While new medicines and preventive approaches have reduced CVD deaths by more than 70 per cent in many countries since the 1970s, the challenges of living with and managing CVDs in the long-term remain for seniors and their caregivers. The burden increases exponentially if one suffers a heart attack or a stroke, which can lead to severe disabilities and require frequent hospitalisations and intensive long-term care.

Chan praises the Singapore government for its preventive actions, among them encouraging people to lead healthier lives by giving them free fitness bands and vouchers if they take more than 10,000 steps a day. 

“There is also a nationwide campaign to reduce sugar consumption, with the government actively engaging the food industry to reduce sugar if they want to do business in Singapore. We also have a strict smoking policy that has resulted in a sharp decline in smoking rates over the last ten years,” says Dr Chan.

Other activities include competitions in communities to lower blood pressure and engaging people to take care of their health. Several mobile apps have been created such as the atrial fibrillation app that provides everything from basic records to medical updates and games.

In the field of medication, a lower dose of new oral anticoagulant therapies has been introduced to use with antiplatelet medication such as aspirin for the treatment of coronary artery disease (CAD) and peripheral artery disease (PAD), both common forms of CVD caused by atherosclerosis. 

Research suggests that by combining aspirin with an anticoagulant, a serious cardiovascular event can be more effectively prevented. The main treatment goal in patients with CAD and/or PAD is to maintain healthy blood flow to prevent serious events.

The recent Compass study recruited 27,395 patients from more than 30 countries including Australia, Malaysia, South Korea, and Thailand and was stopped early due to overwhelming efficacy. Within just one year of the publication of the ground-breaking study, the new combined regimen had been approved by the Food and Drug Administration (FDA) in the USA and the European Commission (EC) in Europe. In Asia Pacific, the new regimen has been approved in Australia, South Korea and Thailand. Further approvals are expected in more countries in Asia Pacific in 2019 this year. 

“Coronary and peripheral artery diseases are common forms of cardiovascular diseases affecting many people in the Asia Pacific region. Even with currently available treatments, patients remain at an unacceptably high risk of serious cardiovascular events, which can lead to disability, loss of limbs and death. The approval of this new regimen provides doctors and patients with a much-needed improved treatment option,” says Zieler.

However, antiplatelet therapy alone has been shown to be only moderately effective, presenting clinical limitations and the scope for a new approach. Despite current guidelines and secondary prevention therapies, one out of 10 patients will experience cardiovascular, myocardial infarction or stroke in the next two years. Also, despite traditional risk reduction strategies, patients with PAD and critical limb ischemia are still at 20 per cent risk of limb loss within one year.

CAD is the most common type of heart disease with a mortality rate in Asia varying from 103 to 366 per 100,000 adult population and rising. 

It occurs when fatty deposits, cholesterol and plaque, build up in the arteries, obstructing the blood supply to the heart. This plaque build-up can cause the arteries to narrow and harden, which may limit the supply of blood, and then oxygen, to the heart and brain. Depending on the degree of artery narrowing (stenosis), patients with CAD experience symptoms such as chest pain, shortness of breath and heart attacks.

Around 202 million people worldwide are estimated to be affected by PAD. Patients with PAD are six times more likely to die from cardiovascular causes than those without the disease. PAD is a common circulatory problem affecting the peripheral arteries, mainly in the lower limb. PAD starts when fatty deposits, cholesterol and plaque, build up in the arteries, obstructing the supply of oxygen-rich blood to the limbs. Sometimes a blood clot forms on top of the fatty deposit, blocking the artery completely and requiring surgery to restore blood flow. If this is not possible, amputation may be necessary. Many people with PAD have little or no symptoms, although as fatty deposits grow, leg pain (claudication) and numbness can occur. 

As part of the Healthy Hearts, Healthy Ageing collaboration, Bayer will draw on NUS Enterprise’s expertise and experience in engaging the regional start-up ecosystem to develop a report which gathers research data and critical insights from multi-disciplinary teams of experts across the region. The report is expected to launch in June and examine the CV health imperatives associated with ageing populations across the Asia Pacific. It will recommend key actions for embracing health innovation to support the prevention of major CV events and long-term preventive care in seniors living with CVD. 

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