Changes in the practice of cardiology

The practice of cardiology has evolved significantly over the years. The availability of current diagnostics and therapeutics has enabled physicians to treat increasingly complex cardiovascular diseases (CVDs). Despite this, the burden of CVD is increasing in Southeast Asia, with ischaemic heart disease and cerebrovascular disease accounting for the majority of cardiac-related deaths in this region.To address these unmet needs, we must first acknowledge that Asian-specific data is required to better understand treatment effect on Asian populations, in particular the heterogeneous composition in Southeast Asia. This issue of the Singapore Medical Journal (SMJ) features a collection of local and Asian original research and review articles, which centres on current and novel approaches to treating CVD.

Managing cardiovascular risk factors is the cornerstone of cardiology practice. In the practice of preventative cardiology, there is an ongoing controversy with regard to managing cholesterol levels to lower cardiovascular risk. In particular, the 2013 American College of Cardiology/American Heart Association Cholesterol Treatment Guidelines adopted a statin-centric approach, disregarding low-density lipoprotein (LDL) goals. Similarly, the revised 2015 American Diabetes Association guidelines also recommended high-intensity statins for diabetic patients. In contrast, the Europeans adopted an LDL-centric approach based on cardiovascular risks.How do we adopt these seemingly differing recommendations in our daily practice? Are the risk prediction models developed based on Western populations accurate in Asian patients? Are Asians more intolerant of high-dose statins? The review article by Yan et al summarises the key findings and recommendations of these various guidelines. The Singapore Ministry of Health (MOH) guidelines on lipids have not yet been published. These two articles (Yan et al and the yet to be published MOH guidelines) will discuss key principles for effective management of cardiovascular risk locally.

Teong et al focused on the treatment effect of valsartan, an angiotensin receptor blocker (ARB), in a group of hypertensive Asians, as measured using central aortic systolic pressure (CASP).This study used the BPro (radial pulse wave acquisition device) watch to measure the CASP by capturing radial arterial waveforms at the wrist.The BPro watch, developed by Dr Ting Choon Meng, a Singaporean doctor and an inventor of medical devices, was validated to accurately measure CASP. This study is important to the cardiology community, as CASP has been shown to predict cardiovascular events better than brachial blood pressure. Moreover, ARBs are thought to act more favourably on CASP than other classes of antihypertensive drugs, albeit only in Western populations. This open-label prospective cohort study, which demonstrates the changes in CASP with treatment over 12 weeks in an Asian population, reflects the potential in marrying the use of locally developed medical technology and research to address a knowledge gap in this region.

Another healthcare innovation with high potential is the use of remote monitoring or telehealth. Remote monitoring of blood pressure has been implemented in several healthcare systems in the region, including our institution. This allows time-efficient intervention by healthcare providers without requiring the patient to visit the clinic. An open channel of communication allows the doctor or nurse to titrate hypertensive medications over the phone. Likewise, remote weight monitoring in heart failure patients allows for intervention (e.g. increase in diuretic dose) before the patient goes into acute heart failure and requires hospitalisation. Remote transmission of data from cardiac implantable electronic devices (CIEDs) is now available. These CIEDs include pacemakers, implantable cardioverter defibrillators and cardiac resynchronisation therapy-defibrillators. In a pilot study by Lim et al, 57 patients with CIED were followed up for six months using scheduled wireless remote transmissions, in addition to routine clinic visits. This study highlights the feasibility of such technology to improve patient quality of life, patient safety by earlier detection of problems and compliance to device monitoring. However, the study also underscores the need for proper information filtering in the era of ‘big data’. In the study, 98.2% of transmissions did not contain alerts that required intervention, and of the unscheduled alerts, only 33.3% required some form of intervention. However, with further streamlining of the healthcare data management process and integration into clinical care, remote monitoring may be a good tool to improve healthcare resource utilisation.

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