MY heart attack risk is much higher than the likelihood I will be hit by a bus. As I join cardiologist Dr Warrick Bishop at Daci & Daci Bakers in New Town, it’s a comforting thought. From our elegant window seats, it’s quite the 3D movie experience as traffic comes straight at us from the top of Augusta Rd before swinging hard right, city-bound, on to Elizabeth Street.
It takes a few minutes to chill out in the face of these Metro monsters, which is exactly how we should not respond to our heart health, says Warrick.
Heart disease is the leading cause of death in Tasmania and complacency is a killer, with common preventable risk factors including poor diet, sedentary lifestyle and smoking.
Warrick is on a mission to introduce more preventative cardiology into practice. In trying to track the killer before it has a chance to strike atypical candidates, Warrick joins a cutting-edge contingent of cardiologists agitating for change.
“Historically, the detection and treatment of coronary artery disease relates to either the presence of symptoms or the occurrence of an event such as a heart attack,” he says. “Once a patient has been diagnosed, the way forward is clear.”
Treatment begins, re-establishing or improving arterial blood flow and minimising recurrence risks. This secondary prevention is vital and well-established. Warrick’s focus is primary prevention. In other words, how to avoid a heart attack in the first place.
Primary prevention practice is based on population-based risk assessments gleaned from observational data, but Warrick contends it is time to radically bolster that approach.
Today’s advanced CT imaging of the heart gives doctors the ability to evaluate artery heath before the onset of a problem. He says some technologies sit well ahead of current guidelines, and not all doctors keep up with the guidelines.
“There are gaps in the dissemination of knowledge and my hope is to work to close that gap,” he says.
In his 2016 book, Know Your Real Risk of Heart Attack, he argued for individual risk assessments for heart attack candidates who might otherwise fly under the radar. The technology is already helping high-risk patients, but Warrick wants the Government to subsidise the cost of its extension. He says wider use of CT imaging technologies such as calcium scoring (a measurement of the amount of calcium in the walls of arteries) will save lives.
“If people are really high risk, there’s no question they should be on medication to reduce risk. If people are really low risk, then it’s hard to make a case for them to be on anything.” Between them is that large intermediate group, 10 per cent of whom will have a heart event in the next decade, according to risk calculators. Which 10 per cent is the leading question. Let’s find that out, says Warrick.
“If we can put those 100 guys through a scanner and define who looks like they might be the 10 to have an event, we can pour energies into them.”
Such a change to monitoring, potentially led from Tasmania, would represent a paradigm shift in conventional management, he says.
Think of it as a mammogram of the heart, he suggests. That standard breast-screening program is offered free to all Australian women aged 40. Currently individuals can request cardiac scans, but it will cost them. Warrick wants to see cardiac scanning for risk included on the Medicare Benefits Schedule.
He’s not saying it would be cheap to have the procedure publically funded, but with the average heart attack journey costing the system $50,000-$150,000, he says there are savings to be made, of money and lives.
He blames sluggish uptake for a broader rollout partly on the lack of a financial driver of the kind that incentivises the development of many other medical treatments.
“For something like a [new] chemotherapy drug, it’s obvious the people who [will benefit]. It’s the recipients of that drug, who are suffering from cancer. And it’s the owners of the patent on that drug.
“In imaging the heart, it’s not clear to see who the [financial] winners are. There is no money to draw. The cardiologists don’t get paid to do it, the radiologists who use the equipment don’t make money out of it and, for the equipment owners who build CT scanners, it’s a tiny slice of their business.
“And the people that might benefit haven’t had an event, so they don’t know that they might benefit.”
Warrick is one of a six-member expert group that has been commissioned by the Heart Foundation to provide a position for the national organisation regarding cardiac CT imaging for risk. He sees his inclusion on that panel as real progress. The powers that be are starting to listen.
“My longer-term hope is to see a shift toward using the imaging in appropriate cases broadly in Tasmania so we can be more proactive and individualised about heart attack risk.”
Appeared in The Mercury (Tasmania) http://www.themercury.com.au/news/tasmania/news-story/00c9459a0b13b95751e3495d80e60545