[Comment] Heart transplantation at 50

Heralded as a miracle of medicine, the world received notice on Dec 3, 1967, that a diseased human heart had been successfully exchanged for a donor allograft.1 In the decade that followed, enthusiasm abated as allograft survival was limited due to defiance of the immune system.2 The introduction of the immunosuppressant ciclosporin—a watershed moment to boost rejection-free survival—and the ability to histologically survey the cardiac allograft using biopsy measurably augmented cardiac allograft outcome.

AMA PHN member survey

In response to the recommendations of the Hovarth Review into Medicare Locals (the Hovarth Review), the Government established 31 Primary Health Networks (PHNs) across Australia, commencing in July 2015. These replaced Medicare Locals (MLs) that were established by the previous Labor Government.

The fundamental purpose of PHNs is similar to that of their predecessors “to facilitate improvements in the primary health system, promote coordination and pursue integrated health care.” However, GPs are expected to play a more central role in PHNs than they did in MLs. PHNs are also expected to focus more on improving the linkages between primary and hospital care.[1][2]

In 2013, leading up to the Hovarth Review, the AMA conducted a survey of GP members to gauge their views on the performance of MLs. More than 1,200 GPs participated in that survey, with members particularly critical of their engagement with GPs and the extent to which many had failed to help improve patient access to primary care services. This survey formed the basis of AMA submission to the Hovarth Review, which recommended significant reforms including a more central role for GPs.

The AMA recently conducted a similar survey to provide members with the opportunity to give us their views on the performance of PHNs to date. Participants were provided with a number of statements and, were asked to select the options (strongly agree, mostly agree, neither agree or disagree, mostly disagree, or strongly disagree) that best reflect their opinion.

A total of 399 GPs participated in the survey, which represents a much smaller sample size than the 2013 survey. Nonetheless, it does provide a snapshot of the views of those members who participated in the survey and the results should be used to provide helpful guidance on areas where PHNs need to increase their focus.

The survey results are summarised as follows:

Understanding of the role and functions of PHNs:

61.5 per cent of respondents indicated that they have a reasonable understanding of the role and functions of PHNs (comparative data is not available for MLs).
Information about activities and services:
47.9 per cent of GPs surveyed believe they have not been kept informed about the work their PHN is undertaking and the services it supports (48.9 per cent for MLs).
GPs access to information and events of relevance:
51.4 per cent indicated that they have not been provided with information and access to events of relevance to day to day practice (57.8 per cent for MLs).
PHN engagement with local GPs:
62.6 per cent indicated that their PHN had failed to engage and listen to them about the design of health services needed in the local area (68.8 per cent for MLs).
Practice staff access to useful and effective education and resources:
46.3 per cent of GPs surveyed indicated that their practice staff have not been provided with access to useful and effective education and resources (comparative data is not available for MLs).
Valuing GP contribution:
52.8 per cent believed that their PHN does not value or recognise the inputs of local GPs (60.8 per cent for MLs).
Timing of meetings and information sessions:
46.1 per cent indicated that their PHN was holding meetings and information sessions at times that were not easily attended (52.4 per cent for MLs).
Supporting targeted programs for disadvantaged groups:
50.6 per cent indicated that their PHN has not been supporting well targeted programs that could help patients, particularly those who are disadvantaged (comparative data is not available for MLs).
Facilitating services that complement existing general practice:
52.8 per cent indicated their PHN is not focused on facilitating services that complement existing general practice services s (comparative data is not available for MLs).
Practice support for MyHealth Record:
57.4 per cent indicated that their PHN had not provided effective support for practices to implement the MyHealth Record (56.6 per cent for MLs re PCEHR).
Access to psychological services:
48.0 per cent indicated that their PHN had failed to improve patients’ access to psychological services (48.9 per cent for MLs regarding improved Access to Allied Psychological Services (ATAPS)).
Accessible mental health services for ATSI patients:
35.5 per cent of GPs surveyed indicated that their PHN had not facilitated appropriately funded and accessible services to meet the mental health care of Aboriginal and Torres Strait Islander (ATSI) patients (comparative data is not available for MLs).
Delivery of mental health and suicide prevention services and supports to ATSI patients:
43.3 per cent of GPs surveyed indicated that their PHN had not been able to improve the delivery of mental health and suicide prevention services and support to ATSI patients (comparative data is not available for MLs).
Access to services for patients requiring mental health care, but who are not eligible for National Disability Insurance Scheme (NDIS) packages:
52.7 per cent indicated that their PHN had been ineffective in facilitating for the needs of patients requiring mental health care, but who are not eligible for NDIS packages (comparative data is not available for MLs).
Psycho-social supports for patients with mental health problems:
55.9 per cent indicated that their PHN had been unable to ensure effective and timely psycho-social supports to patients with mental health problems (comparative data is not available for MLs).
Overall PHN performance:
58.0 per cent indicated that their PHN had not improved local access to care for patients (73.0 per cent for MLs).
Overall delivery of primary care:
62.6 per cent indicated that their PHN had not improved the capacity to deliver better quality healthcare overall (71.6 per cent for MLs).

PHNs have an important role to play in improving the integration of health services within primary health care, enhancing the interface between primary care and hospitals, and ensuring health services are tailored to the needs of local communities. They have the potential to have a strong impact on aged care services, mental health outcomes, chronic disease management, Indigenous health services, and services for the disadvantaged.

The AMA believes that for PHNs to be successful they must: have a clear purpose, with clearly defined objectives and performance expectations; be GP-led and locally responsive; focus on supporting GPs in caring for patients and working collaboratively with other health care professionals; have strong skills based Boards; be appropriately funded to support their operations, particularly those that support the provision of clinical services; focus on addressing service gaps, not replicating existing services; not be overburdened with excessive paperwork and policy prescription; and be aligned with Local Hospital Networks (LHNs), with a strong emphasis on improving the primary care/hospital interface. [3]

They should focus on the following areas:

Population Health – Identifying community health needs and gaps in service delivery; identifying at-risk groups; supporting existing services to address preventive health needs; and coordinating end of life care.
Building General Practice Capacity – Supporting general practice infrastructure to deliver quality primary care through IT support; education and training of practices and staff; supporting quality prescribing; training to support the use of e-Health technology and systems; enhancing practices capacity and capabilities to embrace the principles in being a medical home to their patients, and facilitating the provision of evidence-based multidisciplinary team care.
Engaging with Local Hospital Networks (LHNs)/Districts – Identifying high risk groups and developing appropriate models of care to address their specific health issues (e.g. those at high risk of readmissions, including non-insulin-dependent diabetes mellitus, congestive cardiac failure, chronic obstructive pulmonary disease, and other chronic diseases); and improving system integration in conjunction with local health networks.[4]

Given that PHNs are still a relatively new feature on primary care landscape, the jury is still out on the performance of PHNs. The AMA believes that they should be given every chance to succeed and intends conducting the same survey in a couple of years’ time to see how much of a difference they are making for GPs and their patients.

Dr Moe Mahat
Manager Policy
AMA General Practice Section

[1]Ducket et al (2015) Leading change in primary care: Boards of PHNs can improve the Australian health care system.

[2] Prof. John Hovarth AO (2014) Review of Medicare Locals: Report to Minister for Health and Minister for Sport.

[3] AMA Position statement Primary Health Networks 2015 position-statement/primary-health-networks

[4] Op Cit.

[Editorial] Does mobile health matter?

Widespread adoption of digital health applications (apps) in five patient populations (diabetes prevention, diabetes, asthma, cardiac rehabilitation, and pulmonary rehabilita-tion) could save the US health system $7 billion a year according to a report published by the IQVIA Institute for Human Data Science (formerly QuintilesIMS) on Nov 7. The report examines the impact of internet-connected mobile devices on human health and describes a doubling of health condition management mobile apps in the past 2 years.

Can sex be a trigger for cardiac arrest?

In the first study of its kind, US researchers have found that sexual activity is unlikely to trigger sudden cardiac arrest (SCA), but when the two are associated, the results tend to be fatal.

In men, around one in a hundred SCAs were associated with sexual activity, and one in a thousand for women, according to the study presented this week at the American Heart Association Meeting and simultaneously published in the Journal of the American College of Cardiology.

All SCA cases from 2002 to 2015 in a population sample of about a million people in Portland, Oregon were prospectively examined. A total of 4557 SCA cases were identified, of which only 34 were linked to sexual activity. Of those, cardiac arrest occurred during sexual intercourse in 18 cases, and immediately after in 15 cases. All but two of the cases were male.

Men who suffered a SCA related to sexual activity were on average five years younger, more likely to have had a history of cardiovascular disease and had a higher rate of ventricular fibrillation/tachycardia than SCA cases where sexual activity was not a factor.

Of the 34 cases of SCA linked to sexual activity, only six survived to hospital discharge. Only a third of cases received bystander CPR, despite the fact that sexual partners were necessarily present.

“These findings highlight the importance of continued efforts to educate the public on the importance of bystander CPR for SCA, irrespective of circumstance,” commented Dr Sumeet Chugh, a senior study author and associate director of the Cedars-Sinai Heart Institute in Los Angeles, California.

The authors said one limitation of the study was that frequency of sexual activity was unknown, so researchers couldn’t determine relative risk compared with rest or other physical activity.

They also noted that some cases of SCA related to sexual activity might also involve medications, stimulants and alcohol use.

You can read the research letter published in the Journal of the American College of Cardiology here and access the meeting poster here.

Cancer patients have increased risk of heart failure

Cancer patients have a high chance of heart failure within 12 months of diagnosis and subsequent chemotherapy treatment, a recent South Australian study has found.

The study of 15,987 patients identified 8,339 who received chemotherapy (817 children and 7,522 adults) subsequently received hospital treatment for heart failure, with 70 per cent of children and 46 per cent of adults having an index admission within 12 months of their cancer diagnosis.

The study, funded by the Heart Foundation, was led by Professor Robyn Clark, who is a senior fellow as well as Flinders University’s Professor of Acute Cardiovascular Care and Research in the College of Nursing and Health Sciences.

The research examined cardiac toxicity both quantitatively and qualitatively to gain greater understanding through a meta-review of 18 systematic reviews, linked data analysis, risk assessment, process mapping, patient interviews and a Consumer Consensus Statement.

Cardiotoxicity is a condition where there is damage to the heart muscle. It can be a complication from some cancer therapies, and as a result the heart may not be able to pump blood throughout the body as well.

“Despite being aware of this risk for over 30 years, currently there is no high-level evidence in Australia to guide clinician decision-making in the prevention, detection or management of cancer treatment associated cardiotoxicity,” Professor Clark said.

The findings from the study included the revelation that more men than women developed heart failure (48.6 per cent versus 29.5 per cent). Also, heart failure (HF) patients had increased mortality risk compared with non-HF patients, with 47 per cent occurring within one year and 70 per cent within three years from cancer diagnosis.

The study recommends an increase for patient awareness of the risks and updating clinical guidelines aims to save lives and includes close heart monitoring. When patients receive a cancer diagnosis they should get a Heart Health Check with their GP and to work with their doctors to reduce their risk factors of heart disease.

Imelda Lynch, CEO Heart Foundation SA, believes it is vital to help clinicians identify cancer patients at greater risk of developing cardiac complications and, through early intervention, to improve patient outcomes.

“The impact of this research will be far-reaching and would not be possible without the generous donations the Heart Foundation receives from our wonderful community,” Ms Lynch said.

Professor Clark’s research was published on 17 October in the Cardio-Oncology journal.

MEREDITH HORNE

Lead poisoning a top risk factor for pre-eclampsia

More than a century since a Brisbane doctor found that lead in paint destroyed children’s lives, new research from Griffith University concludes that it is a major risk factor for pre-eclampsia.

Pre-eclampsia is a disease which kills more than 75,000 women around the world each year and is responsible for 9 per cent of all fetal deaths.

Scientists from Griffith University have published their findings in Environmental Research, which measured blood lead levels of pregnant women who experienced pre-eclampsia and control groups of women who did not experience preeclampsia.

“We combined the data from a number of clinical trials to conduct a powerful analysis of pre-eclampsia research,” said Dr Arthur Poropat from Griffith Health.

Along with Dr Mark Laidlaw from RMIT University, the team found that blood lead levels are the strongest predictor of whether a pregnant woman will develop pre-eclampsia, with even relatively low levels of lead increasing the risk of the condition.

“There is a clear dose-response relationship between maternal blood lead and pre-eclampsia: doubling the blood lead level results also doubles the risk of pre-eclampsia,” Dr Poropat said.

Pre-eclampsia is a potentially fatal disease, in which pregnant women develop high blood pressure and protein in their urine due to kidney malfunction, potentially leading to cardiac and/or kidney failure, and eventual disability or death.

Reducing exposure to lead remains an important health issue in Australia because lead can be found in various sources throughout the environment.

Dr Poropat said women are exposed to lead in many ways, including lead paint, lead contaminated soils, lead water pipes, shooting lead bullets at firing ranges and other sources. Women can even be exposed by handling or washing lead contaminated clothes.

“Fortunately, most people in Australia are not at risk of lead poisoning as they are not commonly exposed to lead via their occupation or the environment. However there are certain well-documented risk areas within the country including the industrial regions of Broken Hill (NSW/SA), Mount Isa (QLD) and Port Pirie (SA).

“Regardless of where women are located or their lifestyle, women should be aware of the risks associated with lead poisoning if they are preparing to become pregnant or are currently pregnant,” Dr Poropat said.

Lead, a naturally occurring metal found in the earth’s crust, has a wide variety of uses in manufacturing. Unlike many other naturally found metals, lead and lead compounds are not beneficial or necessary for human health, and can be harmful to the human body. Infants, children and pregnant women are at the greatest risk of harm from lead.

Professor Mark Taylor from Macquarie University in Sydney led a study that was published earlier this year which was the first comprehensive snapshot of industrial lead contamination in Australia.

This study found that while concentration of lead in the air in major cities is now largely below limits of detection, contaminated soil and dust is causing problems in backyards.

Professor Taylor believes that regulation has reduced concentrations of lead in air largely below limits of detection in our major cities. However, he warns homeowners need to be careful, especially if they live in the inner city or have homes built before the 1970s.

MEREDITH HORNE

[Seminar] The future of atrial fibrillation management: integrated care and stratified therapy

Atrial fibrillation is one of the major cardiovascular health problems: it is a common, chronic condition, affecting 2–3% of the population in Europe and the USA and requiring 1–3% of health-care expenditure as a result of stroke, sudden death, heart failure, unplanned hospital admissions, and other complications. Early diagnosis of atrial fibrillation, ideally before the first complication occurs, remains a challenge, as shown by patients who are only diagnosed with the condition when admitted to hospital for acute cardiac decompensation or stroke.

The link between anticoagulation and dementia

Atrial fibrillation patients are much less likely to develop dementia if they are taking an anticoagulant, a large Swedish study has found.

Although the the increased risk of dementia in atrial fibrillation has been known for many years, until now it has been unclear whether anticoagulation modifies that risk.

The retrospective study is the largest yet to look at dementia and anticoagulation. It involved nearly half a million people, comprising everyone in Sweden who had been diagnosed with atrial fibrillation from 2006 to 2014, with a cumulative 1.5 million years of follow-up. The study found a surprisingly large number of people – 54% – were not taking an anticoagulant, the use of which is recommended to mitigate increased stroke risk.

But those who were on anticoagulation treatment had, on analysis, a 48% lower risk of developing dementia. The study results also suggested that the earlier a patient started on an anticoagulant, the less risk of developing dementia he or she had.

The researchers also found a greater effect in patients with higher risk of stroke according to their CHA2DS2-VASc score.

Despite previous suggestions that novel oral anticoagulants (NOACs) may be more effective at warding off dementia than warfarin, the researchers found no difference between the types of anticoagulant medications in dementia risk.

The researchers cautioned that because of the retrospective nature of the study, they could not demonstrate cause and effect. Randomised trials would never be done for ethical reasons, but given the biological plausibility of a causal effect, the results “strongly suggest” that anticoagulants protect against dementia, the authors said.

Other independent risk factors for dementia in the study were increasing age, Parkinson’s disease, earlier stroke and alcohol abuse.

Study co-author Dr Leif Friberg, an associate professor of cardiology at Stockholm’s Karolinska Institute, said the important implications from the findings were that patients should be started on anticoagulant treatment as soon as possible after diagnosis of atrial fibrillation and they should continue on the drugs.

“Doctors should not tell their patients to stop using oral anticoagulants without a really good reason. Patients start on oral anticoagulation for stroke prevention but they stop after a few years at an alarmingly high rate. If you know that AF eats away at your brain at a slow but steady pace and that you can prevent it by staying on treatment, I think most AF patients would find this a very strong argument for continuing treatment.”

Dr Friberg said atrial fibrillation patients often have a fatalistic view about stroke, thinking that either they’ll get it or they won’t. But they tend to be less fatalistic about dementia and are more likely to do what they can to ward off the disease. That may make risk of dementia a more compelling argument to ensure that patients stay on anticoagulation medication, Dr Friberg said.

You can read the study here.

Seven keys to treating hypertension in primary care

Blood pressure is one of the most important modifiable risk factors for cardiovascular disease. Hypertension significantly raises the risk of stroke, heart failure, coronary heart disease and chronic kidney disease, and is in fact regarded as a cardiovascular disease in its own right.

Managing hypertension has been a subject of considerable controversy over the past few years, with the debate revolving around how aggressively it should be treated, so-called white-coat hypertension, and the importance of home blood pressure monitoring.

Current Australian recommendations were updated in 2016 and include a number of changes from previous guidelines, including a new recommendation for ambulatory or home monitoring in patients with clinic BP of ≥ 140/90 mmHg.

Here are seven key recommendations from the guidelines:

Patients with suspected hypertension should have their absolute cardiovascular disease risk calculated using the Australian absolute cardiovascular disease risk calculator;
Recommend an antihypertensive for patients with a low cardiovascular risk (under 10%) and blood pressure that is persistently 160/100mmHg or higher;
Recommend an antihypertensive for patients with a medium cardiovascular risk (10-15%) and blood pressure that is persistently 140/90mmHg or higher.
Recommend an antihypertensive for patients with normal blood pressure but high cardiovascular disease risk (greater than 15%).
Use home or ambulatory blood pressure monitoring to confirm blood pressure if the clinic blood pressure is 140/90mmHg or higher.
ACE inhibitors, angiotensin II receptor blockers (ARBs), calcium-channel blockers and thiazide-like diuretics are the first-line antihypertensives of choice;
Any of these first-line antihypertensives can be recommended for patients with hypertension and diabetes, chronic kidney disease or a history of stroke.

Source: Guideline for the diagnosis and management of hypertension in adults; MJA, 2016

Click here for more information on doctorportal’s CPD module for managing hypertension.

The new hypothesis that is revolutionising medicine

Inflammation has lately become one of the hottest topics in current medical research. Last month, a breakthrough trial presented at the congress of the European Society of Cardiology looks like putting the so-called ‘inflammation hypothesis’ in chronic disease firmly on the map.

The US-based CANTOS trial randomised 10,000 patients who had already survived a myocardial infarction to a drug called canakinumab, which targets the inflammatory pathway interleukin-1 beta but does not affect cholesterol levels. The researchers found a 15% reduction in the risk of myocardial infarction or stroke, and a 30% reduction in the need for a major intervention such as angioplasty or bypass surgery, compared with usual treatment.

The trial won’t be changing clinical practice in heart disease any time soon, not least because canakinumab is a phenomenally expensive drug, and one that also has complex side effects. But the results are nonetheless hugely important, because for the first time researchers have found hard evidence for the role of inflammation in chronic heart disease, independent of lipid levels.

The principal investigator Dr Paul Ridker, a cardiologist at the Brigham and Women’s Hospital in Boston, said the findings have far-reaching implications.

“It tells us that by leveraging an entirely new way to treat patients – targeting inflammation – we may be able to significantly improve outcomes for certain very high-risk populations”.

Another fascinating finding from the study was a substantial reduction in the incidence of lung disease in patients randomised to canakinumab, suggesting that inflammation may play a role in cancer growth as well.

This finding, Dr Ridker said, will “turn the way people look at oncology upside down”.

Heart disease and cancer are hardly the only areas where researchers are looking at how reducing inflammation might reduce risk. Diabetes, HIV, neurodegenerative diseases such as Alzheimer’s or multiple sclerosis, and even depression have been the subject of research.

A study published just this month looks at how inflammation may be implicated in the pathogenesis of Alzheimer’s disease. The brains of people with Alzheimer’s typically have abnormal deposits of two proteins, amyloid beta and tau. US researchers from the University of North Carolina have shown in cell cultures how accumulation of amyloid beta can trigger an inflammatory response, which in turn damages neurons. The type of neuronal damage leads to the formation of bead-like structures containing abnormal tau protein; similar structures as these are found in the brains of people with Alzheimer’s.

Another study has shown that people with fattier, more pro-inflammatory diets tend to have smaller brain volumes and worse cognition.

Brain inflammation may also play a role in depression, according to several recent studies which found high levels of inflammatory markers in the brains of people suffering from the condition. A trial is currently enrolling to trial a biologic called sirukumab for people with major depressive disorder. This drug was initially developed to treat people with rheumatoid arthritis, but when it was trialled in that area, researchers found an interesting side-effect: patients randomised to sirukumab reported having improved moods and less depression.

Targeting inflammatory pathways in the immune system is clearly a promising avenue for drug development, but it’s far from straightforward: dampening the immune response can have dangerous consequences and can promote infection.

For example, sirukumab, the drug being trialled for depression, was recently knocked back by the FDA as a treatment for rheumatoid arthritis, as it had been implicated in several deaths from serious infection and heart disease. Similarly, in the CANTOS trial for heart disease, several deaths from serious infection were reported with canakinumab.

Dr Ridker, the lead researcher on the CANTOS trial, is now enrolling for a second trial, this time testing the anti-inflammatory effects of the immunosupressive drug methotrexate, which has long been used in the treatment of rheumatoid arthritis and whose safety profile is well understood.

Patients will be tracked not only to see if methotrexate lowers risk of cardiovascular events, but also if it reduces cancers. Time will tell, but one thing is certain: the “inflammation hypothesis” is now very much a fixture in the medical research firmament.