How to reduce the risk of a second heart episode — AFR

Following major surgery for blocked arteries, something unexpected happened to Robert Cameron.

People had warned he'd likely get the "by-pass blues". After all, his chest had been cut open, he'd had grafts to three coronary vessels and because of an unrelated infection, he hadn't been able to leave hospital for a month.

The blues never came but something else did. Cameron, then 62, underwent a shift in perspective.

In his long career as a barrister at the Victorian bar, he'd always been slim and fit. As he worked out at the gym, he could feel the beneficial physical and mental effects.

"In court, I knew I would be much better on my feet if I had been to the gym," he says.

Always engaged in what was happening around him, he was alive to the issues of the day.

After the operation, his mood never sank, he just became uncharacteristically laid back: "Nothing much fazes me any more. I just watch the world go by.

"I don't reflect on what happened, I've just accepted that it happened and feel terribly grateful for the excellent medical treatment I received."

This is not as good as it sounds. Cameron knows what he has to do to remain out of hospital, but he can't seem to muster the motivation to do it, even though he vividly remembers the gruelling experience and never wants to repeat it.

'We are just in a holding position'

In Australia, preliminary data show 38 per cent of patients return to hospital within three months of a cardiovascular event. By a year, the rate has jumped to 57 per cent. And it goes up from there.

The most Cameron can manage is to take his drugs at the appropriate time. Eating well is difficult, exercising regularly is beyond him and sweating it out at the gym is another country.

Although he has survived two years, it took all his determination to return to work and he feels he needs more time to develop the mental will to take full charge.

Now that he is on the other side of the experience, he has noticed a distinct change in the attention from health services. Remaining well has, almost exclusively, become his personal responsibility.

"People like me are regarded as cured, but actually, we are just in a holding position. There is not the same appreciation of our ongoing situation."

Is there anything that might spur him to action?

"Yes. Were there a structure I could fit into, where people in the same situation provided mutual support – perhaps that would motivate me to participate."

Cameron's experience highlights a flaw in the way we manage cardiovascular events which include heart attacks, heart rhythm disturbances, heart failure, strokes and peripheral vascular disease.

Over the last 50 years, medical and technological advances have helped thousands of people, like him, survive their first episode. Afterwards, however, they do not normalise and return to the healthy heart population.

Despite their repairs, they are still living with damage to their heart or vessels, they are still patients and are actually at a heightened risk of a repeat event.

"We have created a population of 1.2 million survivors, but we are not providing sufficient funding and the right care to ensure they survive their survivorship," says Professor Thomas Marwick, distinguished clinician scientist and director of Melbourne's Baker Heart and Diabetes Institute.

"In the course of 50 years, we have changed cardiovascular disease from an illness associated with premature, sudden death to a chronic disease in older people.

"The perception of urgency to solve this problem has changed because it involves older people, but it is every bit as much of a problem, if not more so, to the economy and health system and, importantly, we haven't changed the way we conceptualise it."

He says the main current focus is on primary prevention, on preventing a first event. Relatively little attention is given to staving off a the next one.

Preventing a subsequent episode is known as secondary prevention and he says the management of it has long been static. "It is time to rethink it."

More lives spared

For decades, mortality from cardiovascular disease has been falling, but the trend is changing, probably driven by the obesity and diabetes epidemics.

"A new wave is coming," he says and members of the "McDonald's generation" (those raised in a world of fast food restaurants) are likely going to have a shorter life expectancy than their parents.

For 10 years, the Harvard-trained Marwick was a clinician at the Cleveland Clinic in Ohio, most recently as head of cardiac imaging. He has received multiple awards, has edited key journals in the field and is an expert in cardiac risk, which is what focuses his mind on secondary prevention.

"Cardiovascular disease is our biggest health problem, our most expensive disease and our biggest killer, taking out one Australian every 12 minutes. Why do we keep doing the same thing?

"The traditional primary prevention approach hasn't changed for decades. We evaluate risk factors in the community, we apply them to individuals and we try and change behaviour."

While the resources are directed into primary prevention, he says it is in secondary prevention where the investment will turn into more lives spared, hospitalisations reduced and costs saved.

But Marwick's novel ideas cut across the traditional approach.

"Cardiology has been fabulous at adopting evidence-based medicine, but we have done it along the lines of what used to be relevant. We have not been good at adopting the modern approach to personalised medicine.

"We are treating everybody as if they were the same and exposed to the same risk. But there is a spectrum of risk.

"We now have very expensive drugs that can change the trajectory of the disease, but we can't afford to give them to everyone. Similarly, we have anti-coagulants that are very effective but have a bleeding risk and are not for everyone.

"I am very interested in individualising risk and using that to guide decisions about who gets what."

So, what does Marwick, a foundation member of the Australian Academy of Health and Medical Sciences, believe can be achieved?

"A lot, if we stop treating everyone the same way and start providing personalised care from which individual patients are most likely to benefit. This way we could reduce the burden of disease."

But there are strong contrary views and there is much politics involved.

The National Heart Foundation and The Stroke Foundation Australia have been charged with creating a blueprint for cardiovascular care.

Marwick is anxious it will stick to the conventional model and says "doing more of the same is not going to move the needle".

Last month, he launched The Baker's report called No Second Chances, about controlling risk after a cardiovascular event and making a case for increased investment in secondary prevention.

It provided its own blueprint for the future, saying action is not just prudent, it's critical.

Six years ago, this disease cost the country $12 billion. The report says this is estimated to rise above $22 billion in 14 years.

But the push for increased attention to primary prevention recently received a bipartisan boost from Canberra. From April 1, Australians at risk of heart disease will be eligible for a multi-point heart check-up, predicted to prevent 76,500 heart attacks and save $1.5 billion over the next five years.

Medicare will provide a $72.80 rebate for a half-hour service, in which a GP will check the patient's blood pressure, cholesterol, lifestyle factors, smoking status and family history and estimate their risk of a heart attack in the next five years.

Marwick applauds engaging people more with their heart health but says not everyone is really helped by this, nor does the plan capture advances such as coronary calcium scoring which individualise risk.

Stress test

Would Robert Cameron have been helped? Since his university days he's had the same GP and every year he has diligently taken the standard tests for cardiovascular disease. There was never an indication he was in trouble.

This is how he learnt he was. Cameron was at his GP discussing a painful elbow and had stood to leave when, in a classic doorstop moment, he said, "By the way…

"It's probably nothing to worry about but when I'm walking to the train or tram, I feel this ache in my chest, like backache."

The doctor sat him down. An hour later he was having an ECG. The next day he was in hospital having a stress test and was taken directly to the cardiac ward.

An angiogram revealed three severely blocked vessels, two of which were, he remembers, 90 per cent occluded.

"It was very confronting. I couldn't work out how on earth this had happened. There had been no tell-tale signs of any problem and I had no family history."

"Had I not casually mentioned it, I'm told I probably would have had a massive heart attack with the distinct possibility that I wouldn't be here, or I'd be here in terrible shape."

This is complex because while it wasn't the routine tests, it was the GP that saved him.

The procedure was an ordeal. "Afterwards, all I wanted to do was sleep and I couldn't. The morphine didn't block the pain and the tubes restricted my movement in that alien environment made it all a fraction scary.

"All up I was 'in custody' for a month and when I got out, I had to find the determination to recuperate, convalesce and get back to work."

Last year Cameron left the bar and became a full-time senior member of the Commonwealth Administrative Appeals Tribunal. Recently a Pilates class was offered at work and, surprising himself, he participated.

It was his first step back and he acknowledges it felt good.

— Original article, The Australian Financial Review, 22 March 2019