Media Release

6 July 2004

New guidelines commissioned on best ways to treat heart attacks

New guidelines about the best way to improve New Zealand's treatment of people with heart attack or severe acute heart disease are being developed, the Ministry of Health announced today.

The Cardiac Society will be working with the Ministry of Health and the New Zealand Guidelines Group to produce appropriate advice about the best management of acute coronary syndrome, announced Clinical Services Strategy Manager Dr Andrew Holmes.

The Guidelines Group is being funded $180,000 to evaluate the latest international research.

"This is a superb opportunity to incorporate the expertise of the Cardiac Society, within a multidisciplinary team, to develop evidence-based advice for doctors and other health professionals on the most appropriate care for New Zealanders with acute coronary syndromes.

"This new evidence-based guideline will complete a suite of guidelines covering cardiovascular disease, stroke and diabetes," said New Zealand Guidelines Group Chief Executive Catherine Marshall.

Dr Holmes said there is considerable debate internationally and within New Zealand amongst health professionals about the effectiveness of medical treatment compared with surgical treatments.

"It's very difficult for doctors to have sufficient time to keep up with and compare the many new studies and decide what they mean for their day-to-day practice. Yet it's important doctors are able to systematically apply the results of the accumulated research evidence so our management of disease best takes advantage of improvements in knowledge, technique and skills gained both here and internationally.

"Guidelines help us systematically apply the evidence. Without such guidelines it's a bit like trying to do your tax return in your head."

"In particular, the guidelines will help clinicians steer a path through the ongoing debate about whether and when acute invasive surgery or aggressive drug treatment gives the best long-term outcomes for patients who experience severe chest pain, are short of breath or who have collapsed due to acute heart disease.

The value of funding these evidence-based guidelines was that it allowed a group of New Zealand experts to weigh up the benefits of these two main treatment options with the costs and opportunity cost and advise on the best balance of options to suit New Zealand, Dr Holmes said.

"New Zealand has high rates of heart disease compared with other similar countries, and its treatment costs hundreds of millions of taxpayer dollars each year, so it's important we take the time to get guidelines that deliver the best health outcomes.

Cardiac Society members will provide input for the Guidelines Group under the clinical leadership of Dr Gerard Wilkins, current New Zealand Regional Chair of the Cardiac Society.

"This is an important and constructive step to improve health outcomes in this complex area of heart disease with changing management strategies. The Cardiac Society members welcome the opportunity to work with the Ministry of Health assisted the New Zealand Guidelines Group" Dr Gerard Wilkins said.


The evidence-based guidelines are expected to be produced next year.

ENDS

Background

What is the New Zealand Guidelines Group?
The New Zealand Guidelines Group (NZGG) is an independent not-for-profit organisation set up to promote effective, evidence-based care in the health and disability sector. Over the last two years NZGG has developed guidelines for the assessment and management of cardiovascular risk, atrial fibrillation, cardiac rehabilitation, type two diabetes and stroke. For more information see www.nzgg.org.nz

How serious is heart disease in New Zealand?

Cardiovascular disease is the leading cause of death in New Zealand, accounting for more than four in every ten deaths. Cardiovascular diseases affect the heart and circulatory system. Of the different types of cardiovascular diseases, coronary artery disease is the major cause of death, followed by stroke, which is the greatest cause of disability in older people.

Cardiovascular disease is also the leading cause of years lost to premature mortality, accounting for a third of life years lost between 45 and 64 years of age.
Although coronary artery disease is declining in New Zealand, it still results in the highest number of deaths of cardiovascular disease-related deaths (91 per 100,000). It is the second leading cause of death following cancer. Coronary heart disease accounted for 23 percent of all deaths in 1999, of which just over 52 percent were attributable to myocardial infarction (heart attack). Eighty-five percent of coronary heart disease deaths occur in those over 65 years.


How much does it cost?

In the early 1990s the cost of coronary artery disease was estimated at between $306 million and $467 million ($179 million in direct costs). Hospital costs for stroke have been estimated at $58 million; the cost of stroke to the country as a whole has been estimated at $154 million a year. Cardiovascular drugs alone cost in excess of $100 million and contribute to over 20 percent of Pharmac expenditure.


Who gets cardiac disease?

Cardiac disease affects everyone but the burden of cardiovascular disease is greatest among Maori and Pacific people.

• death from all cardiovascular diseases is higher among Maori than the general population. Coronary heart disease is the leading single cause of death for Maori.

• Maori have the highest rate of hospital admissions for heart failure (nearly three times that of Europeans/others).

• Pacific peoples have the highest mortality rate for cerebrovascular disease and the highest hospital discharge rate for stroke.

• The chance of being dependent at 12 months post stroke is three times higher among Maori and Pacific peoples than among Europeans who have a stroke.

• Maori and Pacific peoples have the highest discharge rates for both rheumatic fever and rheumatic heart disease.

How seriously is heart disease treated?

One of the 13 population health objectives of the New Zealand Health Strategy is to reduce the incidence and disease impact of cardiovascular disease in New Zealand. In addressing this priority a Cardiovascular Expert Advisory Group was established to assist the Ministry of Health to identify those cardiovascular areas that would have the greatest population impact. An action plan has been developed, which includes the following priority areas:

• cardiovascular risk screening and management

• acute coronary syndrome

• secondary prevention

• cardiac rehabilitation

• organised stroke care

• cardiovascular disease and Maori

• cardiovascular disease and Pacific peoples.

The Cardiovascular Action Plan is currently being implemented over three years. Its main work includes:

• development of New Zealand cardiovascular cardiac and stroke guidelines for DHB providers

• development of national service specifications for cardiac and stroke services

• addressing inequalities, particularly for Maori and Pacific peoples.

• consumer education

• addressing workforce issues.

Who is most at risk from cardiovascular disease?

The following factors increase cardiovascular risk.

Cigarette smoking - linked with a two- to three-fold increase in coronary artery disease, stroke and peripheral vascular disease.

Hypertension (high blood pressure) is a major risk factor for coronary artery disease and stroke. One in five men (22 percent) over 15 years old and slightly fewer women (18 percent) have high blood pressure.

Cholesterol -the higher the cholesterol level the higher the risk of death from cardiovascular disease.

Diabetes is associated with a two- to three-fold increased risk in coronary artery disease in men and a four- to five-fold increase in premenopausal women.

Obesity -obese people (ie, with a body mass index (BMI) of 30 or greater) are two to three times more likely to develop coronary heart disease.

Physical inactivity - people who are sedentary are nearly twice as likely to die from coronary artery disease than active people. Over one third of New Zealanders (40 percent) are physically inactive.

Absolute risk and cumulative effect of risk factors. Risk factors are cumulative. The presence of two or more risk factors results in a higher absolute risk of cardiovascular disease.


What can people do to reduce their risk of cardiovascular disease?

They can:

• quit smoking (getting advice from a doctor and nicotine replacement therapy)

• reduce their high blood pressure (eat less salt, lose weight, eat better and take blood pressure reducing medication)

• improve their lipid profiles, lower their cholesterol levels (dietary advice, the use of plant sterols, weight loss, exercise and most effectively - use cholesterol-lowering medicines)

• more intensively control their diabetes

• change lifestyle factors (eating better, reducing weight and increasing physical activity).

What are the treatment options for people with cardiovascular disease?

Options include drug therapy, revascularisation and cardiac rehabilitation.


Drug therapy

In those with established coronary heart disease, there is substantial evidence of benefit (ie, reduction in coronary artery disease morbidity and mortality) with the use of aspirin, beta-blockers, ACE inhibitors and lipid modifying (cholesterol) drugs.

• Aspirin is an antiplatelet therapy effective in reducing mortality in people who are having or have had myocardial infarction and in preventing an initial or subsequent stroke.

• Beta-blockers stop the heart from beating as fast. They reduce the risk of all-cause mortality, coronary mortality, recurrent non-fatal myocardial infarction and sudden death in people after myocardial infarction.

• ACE inhibitors can reduce rates of death and hospitalisation for people who have a recurrent non-fatal myocardial infarction and who have left ventricular dysfunction.

• Statins can reduce the need for revascularisation (either angioplasty or coronary artery bypass surgery) by as much as a third (37 percent) although this option is not widely followed (a recent study showed 32 percent of patients with a previous heart attack were on a lipid-lowering agent).

Revascularisation

Revascularisation is a procedure that either opens up the existing blood vessel (angioplasty) or bypasses the blockage of the coronary arteries (coronary artery bypass graft (CABG)).

Older studies (to the mid-1980s) show that compared with medical treatment, coronary artery bypass surgery causes a greater risk of death in the first year but reduced risk of death at five and 10 years. Greatest benefit occurred in people with more severe disease. Intracoronary stents (small metallic mesh tubes to hold blood vessels open) have been found to be superior in the long term compared to angioplasty. More recent studies are less conclusive of the benefit of surgery over medical treatment alone. The issue of medical treatment versus revascularisation is subject to ongoing research and debate.


Cardiac rehabilitation

Cardiac rehabilitation is a multidisciplinary approach that aims to modify cardiac risk through lifestyle change, to improve functional capacity and self-confidence and to reduce psychological distress. Rehabilitation programmes usually include exercise, risk factor modification, education (including diet) and counselling. In the past, cardiac rehabilitation has been chiefly prescribed for patients following a heart attack but it is now recognised that people with all forms of cardiovascular disease may well benefit from this approach by reducing risk of death by a fifth.

Currently 37 centres in New Zealand offer basic cardiac rehabilitation. The provision of cardiac rehabilitation varies considerably across the country. There is variation in facilities, equipment, format of the service, duration of the programmes and the number of sessions offered. In a recent audit of a large institution, the National Heart Foundation identified that 56 percent of those eligible for cardiac rehabilitation do not attend, and of those who do attend only 19 percent actually complete the programme. Reasons for non-attendance could include lack of referral from health professionals and lack of knowledge of cardiac rehabilitation services by patients.

A New Zealand guideline for cardiac rehabilitation has recently been completed by the National Heart Foundation and the New Zealand Guidelines Group. It provides comprehensive information on the management of the rehabilitation of cardiac patients, information on audit of cardiac rehabilitation services and a set of performance indicators. It is intended that the cardiac rehabilitation guideline will inform future development of National cardiac service specifications. A copy of the guideline can be viewed on the New Zealand Guidelines Group website.


How do doctors decide on who to operate on?

Patients are rated according to their level of need (how sick they are) and how likely they are to benefit from surgery (which does carry some risk). Access to revascularisation procedures are then prioritised using referral guidelines for specialist assessment, access criteria for first specialist assessment and clinical priority access criteria (CPAC) for access to procedures or surgery.

These guidelines and criteria have been developed by clinicians since 1997 and take into account both the ability to benefit from revascularisation procedures and the need of patients requiring these procedures. Final prioritisation decisions by clinicians take into account both the CPAC score at which procedures are carried out and the funding threshold of hospitals. Such decisions are reported on quarterly by hospitals.