Searching for the best way to prolong life

New treatments and technologies are being developed to treat cardiovascular disease, but the debate is still raging over which is best and the most cost-effective, as Rhiannon Smith reports

Polypill prescription?

The concept of the polypill is simple. It combines small doses of several medicines that lower cholesterol and blood pressure – both important risk factors for cardiovascular disease (CVD) – into a once-daily pill, which could be given to everyone over the age of 50 to reduce their risk of heart disease, heart attacks and strokes.

In studies, healthy people over 50 who took the polypill for 12 weeks reduced their blood pressure and cholesterol. Researchers predict this reduction in CVD risk factors could cut heart attack and stroke risk by 72 per cent and 64 per cent respectively.

The idea that a pill a day could keep the doctor away certainly sounds tempting, but the polypill can’t be prescribed in the UK yet. There have been criticisms that the research has looked at too few patients over too short a time. The concept of the polypill as a cure-all for CVD prevention does not sit easily for everyone.

General practitioner Dr Margaret McCartney argues that the number of people who would have to take the polypill, in order for just a few to benefit, would be very high. “What we have to ask ourselves is whether a pharmaceutical intervention is the best we can do for public health?”

The idea that a pill a day could keep the doctor away certainly sounds tempting, but the polypill can’t be prescribed in the UK yet

While Simon Kendall, a cardiothoracic surgeon at the James Cook University Hospital, Middlesbrough, argues that the polypill “is very much an industry-led innovation for profit”.

Early-warning biomarkers

Testing people for biomarkers, molecules such as proteins or lipids that can help identify early signs of cardiovascular disease before they become ill, is a more targeted approach to treating cardiovascular disease (CVD).

Examples are C-reactive proteins, which are released by the body in response to inflammation. At high levels this is a risk factor in people with no symptoms; while brain natriuretic peptide, which is produced by the heart when its muscles are stretched, is currently used to test the severity of heart failure and is also being investigated for its ability to predict the risk of heart failure, atrial fibrillation, heart attacks and stroke.

A 2010 report by the European Commission, which looked at how medical innovations can reduce the burden of cardiovascular disease, says “the need for biomarkers to guide CVD management is clear” and that this could play an important role in the paradigm shift from treatment to prevention of cardiovascular disease.

As exciting as this prospect is though, experts agree that more research needs to be done to determine how biomarkers can be applied to patients’ lives.

Fractional flow reserve

While new biomarkers may pave the way to better identifying disease, a technology called fractional flow reserve is already helping doctors to refine their decisions about who to treat.

Fractional flow reserve uses a wire inserted into an artery to measure blood flow and helps doctors weigh up whether to operate on patients with narrow arteries due to heart disease or if they would be better managed on drugs. And, according to cardiothoracic surgeon at Middlesbrough’s James Cook University Hospital, Simon Kendall, it “throws all the old rules out the window”.

In the past doctors have made decisions about surgery based on the measurement of how narrow a patient’s arteries look on a scan.  But fractional flow reserve can determine the actual effect on the heart that this narrowing is, or isn’t, having.  This enables doctors to decide more accurately who really needs surgery.

A patient may have a scan that appears to look fine, but actually have significant problems, explains Mr Kendall, whereas those whose scans look bad might not have any real problems affecting their daily life. So using this technique can avoid unnecessary or ineffective operations, sparing people needless surgery and also saving costs.

Another exciting development is computerised tomography fractional flow reserve, a technique that uses a scan to make the same measurements. It is still in trials but, if it works, says Dr Martyn Thomas, director of cardiology and cardiothoracic services at St Thomas’ Hospital in London, says it could “virtually eliminate” the need for some of the other tests for heart disease that are currently used.

TAVI’s new hope

Aortic stenosis – the failure of the aortic valve in the heart to open properly – is the most common problem affecting heart valves in the elderly. Left untreated, most people die within five years of being diagnosed.

The conventional treatment is open heart surgery. But for around a third of patients this type of major operation is not an option as they are either too old or unwell to undergo such invasive surgery safely, or are at risk of complications during or after the operation.

A surgical technique called TAVI – transcatheter aortic valve implantation – is offering these patients new hope. In TAVI, the faulty valve is replaced by inserting a replacement through a catheter – a small, flexible plastic tube – into a large blood vessel. It is much less invasive than normal valve replacement surgery.

This technology is in its early stages, but enthusiasts say it has enormous potential. “TAVI is a really phenomenal procedure. It has completely changed the way we treat aortic stenosis,” says director of cardiology and cardiothoracic services at London’s St Thomas’ Hospital, Dr Martyn Thomas.

TAVI is very beneficial in the sickest of patients, improving their quality of life and reducing hospital stays. But it costs around nine times more than the £2,000 cost of a standard aortic valve replacement operation.

This balance of the use of resources is questioned by some experts. Simon Kendall, a cardiothoracic surgeon at James Cook University Hospital, Middlesbrough, says: “This is an example where we’ve found a very expensive way of prolonging life for a little bit. It does work and it does make people feel better, but these are very frail people who get a little bit of extra life. It is probably best to get people staying fit when they are younger.”