In an interaction with BioPharma APAC, Dr. Low Lip Ping, Chairman Emeritus of the Singapore Heart Foundation, sheds light on the critical findings of the latest white paper focused on cardiovascular disease (CVD) prevention. Amidst rising numbers of heart attacks and strokes in Singapore, the document introduces a three-pronged strategy aimed at enhancing the current state of cardiovascular healthcare. Dr. Low emphasizes the importance of equipping clinicians with updated guidelines, fostering patient education, and supporting integrated care to tackle the nation's CVD challenges head-on.

What are the key findings of the new white paper on CVD prevention?

Almost 1 in 3 deaths in Singapore was due to heart disease or stroke in 2022 and with Singapore’s rapidly ageing population, the number of heart attacks and strokes is expected to rise. The Singapore Myocardial Infarction Registry showed the number of heart attacks increased from 8,014 in 2011 to 12,403 in 2021. Similarly, the Singapore Stroke Registry showed that the number of strokes increased from 6,143 episodes in 2011 to 9,680 episodes in 2021. 

However, with higher rates of treatment with modern medication and interventional techniques (surgery and percutaneous angioplasty), the mortality rate of heart attacks has been decreasing over the past decade – this means that even though more people are having heart attacks, more are surviving. 

Given these trends, there is a need to prevent cardiovascular (CV) disease, both the first and any subsequent episodes of heart attack and stroke among residents. 

The white paper outlines interventions supportive of the government’s Healthier SG strategy that aim to uplift the state of CV preventive care in Singapore through a three-pronged approach. This follows a review of the Healthier SG white paper, the burden of CVD in Singapore and the current state of delivery of CV preventive healthcare in Singapore. 

Can you detail the three-pronged approach proposed for CVD outcomes?

The whitepaper was developed by the Singapore Heart Foundation (SHF), the Singapore Cardiac Society (SCS) and the Academy of Medicine, Singapore (AMS), in partnership with Amgen. It highlights the need for greater efforts to prevent cardiovascular disease (CVD) in Singapore and outlines a strategy and framework for the primary and secondary prevention of CVD in patients and survivors. 

The white paper proposes a multi-stakeholder three-pronged approach in achieving good CVD outcomes by:

1. Equipping clinicians with the latest clinical guidelines in addressing the management of five main modifiable CV risk factors, namely hypertension, dyslipidaemia, type 2 diabetes mellitus, obesity and smoking, to support decision-making and to ensure that patients receive optimal care. 
2. A collaborative patient education programme through cooperation between healthcare professionals and community partners, emphasising ‘8 Enablers to Fight 5’, which highlight 8 steps to manage the 5 main controllable cardiovascular risk factors. Spearheaded by SHF  with the support of the SCS and the Chapter of Cardiologists of the AMS, this patient education will aim to counter myths, misconceptions and fake news about heart disease and its treatments in the community.
3. Supporting integrated care, including access to cardiac rehabilitation in the community, improved referral processes and access to nutrition or dietary counselling and tobacco cessation, optimal use of information technology, and continued CV research that ensure the optimal delivery of care. 

How will the updated guidelines better address the five main CV risk factors?

The clinical practice guidelines in Singapore for the five modifiable risk factors, which are used as the standard of care by many primary care practitioners in Singapore, were published in the following years - hypertension in 2017, dyslipidaemia in 2016, obesity in 2016 and tobacco use in 2013. The guidelines for prediabetes and diabetes were released in 2015, and in 2023, Agency for Clinical Effectiveness (ACE) and the Chapter of Cardiologists, College of Physicians, Academy of Medicine, Singapore jointly released the latest ACE clinical guidance and Singapore CPG for the management of lipids and hypertension. 

As volumes of clinical evidence have emerged to justify newer treatments to attain lower targets, international guidelines have also since adjusted their recommendations and treatment targets. The various updated Singapore guidelines need to reflect current evidence and align with international guidelines and standards of care.

The white paper identifies the areas of care that need to be addressed to control these 5 risk factors. It also recommends a baseline CV risk assessment for all patients to at least categorise each patient as having low/moderate-, high-, or very-high CV risk for more tailored treatment of the 5 modifiable risk factors.  

What role does patient education play in the strategy, and how will it be implemented? 

In 2021, a nationwide population-based survey found that while more than 88% recognised CVD as one of the 3 leading causes of mortality in Singapore, more than a third (37.2%) had a low or moderate knowledge scores regarding the risk factors of heart disease. Furthermore, many patients were not able to identify the behaviours that promote heart health. 

There is an urgent need to increase the knowledge on heart health and encourage heart-healthy behaviour throughout the population, and patient education is key. 

In conjunction with the release of the white paper, SHF and Amgen have also launched a campaign titled “Heart-Pressed for Time”, which aims to raise awareness on the importance of protecting one’s heart health and bring attention to how survivors can effectively manage their CVD risk to prevent another cardiac incident. The campaign will unfold a multitude of educational content, such as a video chronicling a patient’s inspiring recovery journey, and a series of infographics that will be amplified across various communication platforms.

In addition, a campaign, spearheaded by the Singapore Heart Foundation (SHF), with the support of the Singapore Cardiac Society and the Chapter of Cardiologists of the Academy of Medicine, Singapore, will cascade the updated standards of care to the community. SHF will also continue its population-wide efforts to drive primary and secondary prevention of CVD. 

How does the white paper propose to enhance integrated care for CVD patients?

The white paper proposes to enhance integrated care by providing access to necessary CV care and services, including access to cardiac rehabilitation, nutrition/dietetics counselling and tobacco cessation services, improve referral processes and the necessary financial structures to subsidise these services. Initiatives that encourage continuity of care such as CareHub, a transition programme that coordinates tailored multidisciplinary post-discharge plans for patients and their families should be supported. 

In addition, the necessary enablers to ensure the optimal delivery of care across the population should be strengthened, including the optimal use of information technology across healthcare management. Lastly, CV research should be continued to address knowledge gaps, improve delivery and efficiency of CV care, and ultimately improve individual and population-wide health outcomes. 

What actions are recommended for stakeholders to effectively prevent CVD?

CVD is a multifactorial disease and its outcomes depend on long-term behavioural change, long-term medical care and regular monitoring of overall risk. Establishing population CV health requires overcoming several challenges in the implementation of national programmes, which will require concerted efforts from stakeholders – healthcare professionals, policy makers and community partners. 

The three-pronged approach and recommendations outlined above is a good start that will bring the standard of care and CV care delivery in Singapore closer to achieving the vision of proactive prevention of CVD and CV morbidity and mortality. 

Some of these actions include: 

• Clinicians keeping themselves updated with the latest clinical practice guidelines
• Community partners supporting patient education efforts  
• Policy makers and healthcare providers prioritising and supporting enablers of optimal and continuity of care across the population