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OUR HIDDEN AGEING: TIME TO LISTEN TO THE HEARTA thorough clinical exam is critical to detecting heart valve disease You may be familiar with heart attack and stroke but few know about heart valve disease Ageing blood vessels can damage vital organs and place stress on heart valves Heart valve disease can cause serious complications including heart failure, stroke, blood clots and death Authors Prof Tom Marwick, Baker Heart and Diabetes Institute, Melbourne. Prof Seana Gall, Dr Marie-Jeanne Buscot, Dr Rachel Climie, Dr Hoang Phan, Menzies Institute for Medical Research, University of Tasmania Prof Marj Moodie, Dr Lan Gao, Dieu Nguyen, Deakin University, Melboune Prof Ajay Mahal, Teralynn Michelle Ludwick, Marie Ishida, University of Melbourne Reviewers Prof David Kaye, Alfred Hospital, Melbourne, VIC Prof David Celermajer, Royal Prince Alfred Hospital, Sydney, NSW Prof Derek Chew, Flinders Medical Centre, Adelaide, SA Prof Greg Scalia, The Prince Charles Hospital, Brisbane, QLD Prof David Playford, The Mount Hospital, Perth, WA Dr Peter French & Dr Ren Tan, Canberra Hospital, ACT Dr Paul Macintyre, Royal Hobart Hospital, TAS Prof Liza Thomas, Westmead Hospital, NSW Reference: Our Hidden Ageing: Time to Listen to the Heart The Baker Heart and Diabetes Institute acknowledges the provision of an unrestricted educational grant from Edwards Lifesciences, used for the analyses and preparation of this report.Foreword 2 Abbreviations 3 Executive Summary 4 Key Findings 6 1. Heart valve disease as part of the current burden of cardiovascular disease 8 2. Clinical aspects of heart valve disease 18 3. Cardiovascular ageing and valve disease 22 4. Management of Heart valve disease 26 5. Economic and societal costs of heart valve disease in the elderly 32 6. Cost-effectiveness of interventions for heart valve disease 42 7. Case studies 52 8. Conclusion 54 Calls to Action 56 References 58 Appendix 64 CONTENTS If you’re over 65, ask your doctor to listen to your heart More than a quarter of a million Australians have heart valve disease & don’t know it Heart valve disease is rising rapidly and it’s serious . However, it is often treatable Minimally-invasive valve replacement for more people over 65 could save $117 million in a year $ 1FOREWORD The vascular system is the main transport system in our body. It permits blood to circulate and transport nutrients, oxygen, carbon dioxide, hormones, and blood cells to and from the cells in the body to provide nourishment, to help fight disease, and to maintain stability of the body’s metabolism. The heart valves have a critical role to play in ensuring the flow of blood through the heart. A number of age-related factors increase mechanical stress on the heart valves, and the same processes that cause abnormalities in the blood vessels can damage the coverings of the valves. Complications of heart valve disease include mortality, heart failure, stroke, blood clots, and heart rhythm abnormalities. The incidence and prevalence of aortic and mitral valve disease both increase with age. Therefore, it’s not surprising that, as the population ages, heart valve disease is emerging as a serious and increasingly common health issue. About half a million Australians already have valve disease - aortic valve disease is the most frequent cause of significant disease - with this figure projected to grow over the next three decades. Perhaps more concerning, more than a quarter of a million Australians have undiagnosed heart valve disease. The availability of non-surgical valve replacement has reduced barriers to interventions in the elderly. Increasing access will increase the number of these procedures, with overall higher healthcare costs. However, it also delivers greater benefits because earlier diagnosis and treatment reduces the long-term consequences of these diseases, and preserves productivity, which remains important in the elderly. Early intervention in the form of non-surgical valve replacement could prevent productivity losses of up to $117 million in a single year. Although heart valve conditions are serious, they are eminently and increasingly treatable. That’s why this whitepaper, led by experts from the Baker Heart and Diabetes Institute together with specialists from The University of Melbourne, University of Tasmania and Deakin University, is so important and timely. OUR HIDDEN AGEING: TIME TO LISTEN TO THE HEART 2ABBREVIATIONS AQoL – And indices of Quality of Life AHA - American Heart Assosciation AS – Aortic Stenosis AVR – Aortic Valve Replacement BAV – Bicuspid Aortic Valve CVD – Cardiovascular disease ECG – Electrocardiogram GDP – Gross Domestic Product HF – Heart Failure HILDA – Household, Income and Labour Dynamics in Australia ICER – Incremental Cost Effectiveness Ratio LV – Left Ventricular MAS – Moderate Aortic Stenosis MR – Mitral Regurgitation MS – Mitral Stenosis MVD – Mitral Vascular Disease MVR – Mitral Valve Replacement PNMA – Productive Non-Market Activities QALY – Quality Adjusted Life Years RV - Right Ventricular SAS – Severe Aortic Stenosis SD – Standard Deviation TAVI – Transcatheter Aortic Valve Implantation T2D – Type 2 diabetes VHD – Valvular Heart Disease WTP – Willingness To Pay WW – Worried Well 3When it comes to cardiovascular issues, many people are familiar with heart attack, stroke, heart failure, and coronary artery disease. We appreciate that the heart has an essential role, including sending blood around our body, providing tissue with the oxygen and nutrients they need. Each day, the heart pumps about 7500 litres of blood via a blood vessel system stretching more than 100,000km. The mechanics of the circulation are important to the smooth operation of this system. Much like an important part of a machinery that can break down, the heart can malfunction if all parts aren’t working well. This includes small but incredibly important components such as the valves between the atria and ventricles that make sure blood flows in one direction through the heart. Valves are also located at the “exits” or “doorways” of the heart for this same reason—to make sure blood flows in one direction. In a lifetime, these valves will open and close more than two billion times. When the large blood vessels are functioning well, they optimise the efficiency of pumping blood around the body. However, ageing causes the blood vessels to progressively lose elasticity and become stiff, impacting the vascular structure and function. Arterial damage increases mechanical stress on the valves, which are also susceptible to the same threats as the arteries. Heart valve disease can cause many serious complications, including heart failure, stroke, blood clots, and heart rhythm abnormalities. In the context of a rapidly ageing Australian population, recent overseas reports of large, age-related increases in the incidence and prevalence of aortic and mitral valve disease are important. In Australia between 1990 and 2017, increases in the numbers of people, deaths and disability-adjusted life years from non-rheumatic valve diseases have ranged from 50-170%. Valve disease is often unrecognised until it provokes a crisis. There are 500-600,000 Australians living with heart valve disease in 2021; it is estimated that there are also 254,000 with undiagnosed disease. This number will grow substantially to 336,000 in 2031 and to 435,000 in 2051. In particular, the numbers with moderate to severe narrowing of the aortic valve – arguably the most treatable valve lesion because of the development of non-surgical valve replacement - will continue to climb to 200,000 in 2031 and 266,000 in 2051. Moderate to severe leakage from the mitral valve is present in about 150,000 Australians in 2021, and will increase to 200,000 in 2051, but it is currently less amenable to intervention. Thus, a primary barrier to addressing this problem is timely recognition, followed by access to interventions, especially for the elderly. Most of us know that high blood pressure and high cholesterol levels are risk factors for heart disease but few of us are aware of the importance of ageing on the cardiovascular system. With an ageing population in Australia and in many countries globally, it is critical that we change that. So what can we do? Regular physical activity, because it helps to maintain the elasticity of the arteries, may slow down vascular ageing. Other lifestyle strategies such as smoking, controlling blood pressure, and EXECUTIVE SUMMARY OUR HIDDEN AGEING: TIME TO LISTEN TO THE HEART 4Heart valve disease has flown under the radar for far too long. That’s why we have examined this issue in detail. Urgent attention is critical, and we recommend: • Individual and social marketing campaigns to increase awareness of heart valve disease and other manifestations of cardiovascular ageing, particularly amongst GPs, healthcare and health advocacy groups. A benefit might be that more patients get heart murmurs checked. • Strategies involving primary care. These might include educational updates and upskilling. People >65 years should have heart checks during GP visits for other problems. For people 65 and older who are not engaged with primary care, an extension of the current preventive cardiology item numbers (MBS 699 and 177) to include cardiac auscultation (listening to heart murmurs) should be considered. • Support for emerging technologies. Development of translational research streams to more rapidly evaluate novel technologies for management of structural heart disease. Investment and clinical application of AI-supported and hand-held echo will require adjustments in current funding arrangements, which preclude these approaches from reimbursement. • Health service design, including improving access to echocardiography. These steps might involve early detection and out-reach echocardiography programs in rural areas. • Policy. Dedicated funding for service level interventions that improve access and equity to transcatheter valvular interventions (minimally-invasive interventions). This will require planning, training and resourcing, along with financial incentives to drive clinical change. • Guidelines. Development of national heart valve disease guidelines to facilitate decision-making. poor diet are also important. Nonetheless, there is no strong evidence that these strategies prevent valvular heart disease. However, while we know heart valve conditions are serious, they are increasingly treatable. From a clinical perspective, the most important thing is to recognise valvular disease so that the patient doesn’t end up presenting in a crisis. In addition to a primary care physician or nurse checking for cardiac symptoms (breathing problems, chest pain, dizzy spells, blackouts), a careful physical exam of the cardiovascular system (including listening with a stethoscope) should be part of the annual review of patients over the age of 65 years. Abnormalities can be evaluated further with echocardiography – the test of choice for valvular disease. We also know the social and economic costs of valvular disease are significant. Offering transcatheter aortic valve implantation (TAVI) for people 65 years and above could potentially prevent the productivity loss of $117 million due to withdrawal from productive activities in a single year. Our analyses found exposure to heart disease was associated with a decline of up to 24% in the likelihood of people participating in any employment, while earning losses were estimated to be as high as $19,000 per person, depending on heart disease severity. 5The disease burden of degenerative valve disease far exceeds other causes of valve disease - despite the high ongoing prevalence of rheumatic valve disease in the Aboriginal community. There were 50-170% increases in the numbers of people, deaths and loss of disability adjusted life years from non-rheumatic valve disease between 1990 and 2017 in Australia. Although heart valve conditions are serious, they are eminently and increasingly treatable. Aortic valve disease is the most frequent cause of severe valvular heart disease. Its most common manifestation is aortic stenosis (AS), which is present in around 3% in those aged >65 years. There are currently 150,000 people in Australia with moderate to severe aortic stenosis, and this is likely to climb to 200,000 in 2031 and 266,000 in 2051. There are large increases in the incidence and prevalence of aortic and mitral valve disease with increasing age. Therefore, the magnitude of this problem will increase with the ageing of the Australian population. In 2021, 500-600,000 Australians were living with heart valve disease. There are estimated to be 254,000 Australians with undiagnosed heart valve disease. This is projected to grow to 336,000 in 2031 and 435,000 in 2051. Mitral regurgitation (MR) is the most common specific type of heart valve disease, and is strongly age-related, with a prevalence of 1-2% in those aged <60 years and 9-11% in those aged >70 years. The 520,000 Australians with MR in 2021 will increase to 670,000 in 2051, with 30% having moderate to severe disease. Key Findings 6Heart valve disease can cause many complications, including heart failure, stroke, blood clots, and heart rhythm abnormalities, so early detection is critical. Heart valve interventions involve replacement, either with an operation, or – increasingly – using a catheter procedure, repairing valve leaflets (usually for regurgitant valves) or splitting a stenotic valve with a balloon (valvuloplasty). The low risk and high tolerability of TAVI is enabling this intervention to be undertaken earlier in the course of disease. Increasing the proportion of patients receiving timely TAVI will result in greater benefits including more quality of life (QALY) gained and fewer life years lost and cases of heart failure, but with higher healthcare costs compared to the current approach of ‘watchful waiting’. The increment in cost for each year gained at full QALY is low from a healthcare system perspective at around $10,000 per QALY gained. The avoidance of cardiac symptoms (especially heart failure) is also economically beneficial in the elderly because of curtailment of losses in annual value of earnings from work, as well as childcare and volunteering activities. The common symptoms of heart valve disease – especially exercise intolerance – are often misattributed to ‘old age’. Timely diagnosis is based on awareness and clinical examination – especially listening to the heart sounds. Access to echocardiography is a vital component in managing valvular disease in the community. Primordial prevention of valve disease (like other forms of cardiovascular disease) is focused on healthy living. In the patients in whom valvular heart disease is recognised before intervention is required, frequent medical follow-up is essential. 7Next >