Late last year, Statistics Canada released new figures detailing the leading causes of death in the country. Based on 2007 data, the report noted that cancer and heart disease were the two leading causes of death for Canadians, and these were responsible for slightly more than one-half (51 per cent) of the 235,217 deaths that occurred that year.
Cancer accounted for 30 per cent of deaths and heart disease 22 per cent. Stroke, in third place, accounted for 6 per cent. The proportion of deaths from cancer was up slightly since 2000, while heart disease and stroke declined.
Among individuals aged 35 to 74, cancer was the leading cause, while for those aged 85 and older, it was heart disease. The proportion of deaths due to cancer reached its highest level for individuals aged 55 to 64, where it accounted for almost half (48 per cent) of deaths. In contrast, the proportion of deaths due to heart disease increased steadily as the population aged.
The situation in Canada appears to be unusual. In most countries, heart disease continues to be the number one killer. For instance, in the U.S. in 2007, 25 per cent of all deaths were attributed to heart disease, while cancer was responsible for 23 per cent.
Mortality rates from heart disease have been in decline for some time and this reflects advancements in knowledge and technique across many areas of care. Heart disease is becoming less of an acute disease to be survived and more of a chronic illness to be managed over peoples’ lifetimes.
With this in mind, The Beat undertook a series of interviews with some of the Heart Institute’s senior management team to explore the implications of the Statistics Canada information. What do these numbers mean for patients and for those involved in cardiovascular care, education and research, particularly in the short term, over the next five years or so?
Their responses echo what has been and will continue to be an evolving landscape of cardiovascular disease management in the country. What is abundantly clear is that much progress has been made and, despite the numbers, there is much more work to do. Here is what they had to say:
Decades of Progress
“The trend of reduction in cardiovascular disease in our society has been going on for a long time, and consequently, as people age, they’re more likely to get cancer than they were in the past, when death occurred at a younger age,” said Dr. James Robblee.
“The methods for preventing heart disease that have emerged over the last decades—smoking cessation, better recog-nition of the role of lipids, better control of hypertension, better control of diabetes—and advances in cardiac surgery have all contributed to the reduction in mortality from cardiovascular disease. I think that what we’re seeing is an enormous success of prevention plus treatment in increasing the survival of people who might otherwise have died of heart disease,” he continued.
“Heart disease is highly preventable, and the major lifestyle risk factors to prevent it have been identified,” noted Dr. Robert Roberts. “If you can treat your blood pressure, and if you can treat your cholesterol, and if you try to exercise and don’t smoke, we’ve proven over and over again in clinical trials that 30 to 40 per cent of heart disease can be prevented based on those factors alone.”
The past five decades have also seen tremendous advances in the treatment of heart disease, he explained. For example, said Dr. Roberts, “In the 1960s, the death rate for a heart attack was 30 to 40 per cent. Today, if we get you to the Heart Institute in time, that death rate is 4 per cent.”
“That decline in death rate comes from our acute programs, such as our STEMI heart attack protocol,” said Heather Sherrard. “We are also seeing declining crude heart attack rates as a result of getting people onto best practice guidelines and due to strong prevention and rehabilitation programs.” Dr. Robblee also credited dropping heart disease mortality rates to improved intensive care procedures and the increased use of implanted defibrillators in patients with congestive heart failure.
Coupled with the reduction in morbidity and mortality from cardiovascular disease is the fact that, “overall, mortality rates from cancers, with a few exceptions, have really not changed much over the last century,” commented Dr. Andrew Pipe. This disparity in progress has now led to cancer becoming the number one cause of death in Canada.
“We’re going to have to work as strongly on the prevention aspect of cardiovascular disease as on high-end cardiovascular care.” – Dr. Thierry Mesana, Chief, Cardiac Surgery, UOHI
The Changing Patient Population
“We’ve had tremendous advances in the cardiovascular world compared to cancer, but it’s important to remember that more than 50,000 people a year are still dying of cardiovascular disease in Canada alone,” reminded Dr. Terrence Ruddy.
A major challenge in the treatment of heart disease in the years ahead will be the aging of the Canadian population, explained Sherrard. “People are surviving all sorts of diseases, so our cohort of patients is aging, and we have to do a lot of work with the people who haven’t benefited from the emergence of heart disease prevention strategies. While the raw number of heart attacks, for example, is dropping, what’s left are these older, much sicker people.”
The patients that physicians are now seeing are much sicker than they were in the past, because “in the past, they simply didn’t get to cardiac surgery as a treatment; they either died before that or they were considered too ill to do surgery on,” commented Dr. Robblee.
Surgical and other advances have allowed doctors to consider much older patients as candidates for surgery than in the past, explained Dr. Thierry Mesana. “We definitely have a lower mortality rate now than we had just a few years ago—and that’s with the patients we have now, who are higher-risk older patients than we had 20 years ago. We’ve increased our understanding of the biology of surgery and of the complications—the post-operative care is much better than it was a few years ago. The whole discipline has evolved, not just the technique of surgery.”
“I remember in the early 1980s, we defined the elderly as being 65 or older, and almost 90 per cent of our patients were under 65. Now, our fastest-growing group is patients over the age of 90,” said Dr. Robblee.
The rapidly aging population brings in new ethical dilemmas, said Dr. Mesana. “Where is the limit for what we’re willing to do?” he asked. “As a surgeon, when I refer an 80-year-old for cardiac surgery, I know that 20 years ago that would have been crazy, but now we do it. But where do we draw the line? We need strict control of ethics, indications for treatment and good practice, because if we’re going to get into this business of treating very old people, we have to make sure that we’re doing the right thing.”
“We also have more technologies and techniques available,” said Sherrard. “So, we’re going to see continued cost pressures as baby boomers age. They have a high level of expectations for what we can do for them, and that elderly bubble is going to get very large.”
Improvement in the acute treatment of and reduction in immediate mortality from cardiovascular disease will have the long-term effect of increasing chronic heart disease in the population, “and one of the big areas of chronic heart disease is heart failure,” explained Dr. Ruddy. “Heart failure will be a big growth area over the coming years, just with the aging of the population.”
“Heart failure is going to become a much more prominent diagnostic category than it currently is,” agreed Dr. Pipe. “The increase in chronic disease in the population underscores the need for an increased emphasis on primary disease prevention.
“If you’re not expending every resource possible on prevention programs over the next five years, then you’re missing out in a major way because you’re going to be incurring deaths or unfunded liabilities for the health care system of the future,” he said. “I think it’s eminently cheaper to treat someone for hypertension for 20 years than to treat a single heart attack.”
“We’re going to have to work as strongly on the prevention aspect of cardiovascular disease as on high-end cardiovascular care,” agreed Dr. Mesana.
As researchers learn more about the common underpinnings of many chronic diseases, said Dr. Pipe, “there’s a considerable danger in taking organ-specific approaches to morbidity and mortality. For example, if you look at the issue of vascular disease, which is the common pathway, you start to introduce renal dysfunction and peripheral vascular disease. Hypertension has important implications for dementia, which not a lot of people are aware of.
“I think we’re going to see much more emphasis on integrated approaches to chronic disease management in the near future,” he continued. “If you address the major risk factors for cardiovascular disease, you’re also addressing the modifiable risk factors for every other chronic disease. We’re going to see trends in integrated chronic disease management, and that’s going to cut across disciplines.”
“Because of the chronic aspect of heart disease and the multiple conditions that go along with it, you need to bring other players into standard care,” agreed Sherrard. “For example, we’ve started an infection-control outpatient centre here, and we’re putting in a diabetes outpatient clinic. We’re making it easier for team members from other specialties to see our patients.”
Another trend in patient care that Sherrard expects to see more of in the next five years is an increase in home monitoring of patients and improvements in related technology. “You want to minimize the amount of time that elderly patients are in the hospital because of the potential for infections, falls and all the other things that can go wrong,” she stated. “That’s why we do automated calling and home monitoring; those sorts of things show a statistical difference in outcomes. The frail elderly do very well on home monitoring, and we want to keep them out of the hospital when they don’t need to be there.”
“If you address the major risk factors for cardiovascular disease, you’re also addressing the modifiable risk factors for every other chronic disease.” – Dr. Andrew Pipe, Chief, Prevention and Rehabilitation, UOHI
Dr. Roberts sees a trend toward increasing use of less-invasive surgery over the next 10 to 15 years. “The day must come when you’re not splitting someone’s chest open to treat heart disease. Angioplasty and stents are both far less invasive alternatives to surgery. Now, with surgery, we have started to do small keyhole, minimally invasive procedures. Up until now, you had to open up the chest to repair or replace a valve. But now they are starting to put valves on the ends of catheters so that we can replace a valve non-invasively. Recovery is faster and, economically, it will be a tremendous boon. It keeps beds free for those who need them.”
Dr. Mesana agreed, but urges caution: “We’re trying to offer newer, less-invasive procedures, but we do sometimes have to be careful that less invasive does not mean less efficient. We’re moving into this field with caution and are gradually understanding which procedures are the best for patients. I think, eventually, you’re going to see surgeons doing things closer to what interventional cardiologists are doing.”
“I think we’re going to see the blending of those two disciplines—cardiology and cardiac surgery—they’re going to start sharing the same procedure types, and universities are going to have to start thinking about that when it comes to training these physicians,” concurred Sherrard.
The movement toward less-invasive treatment also impacts cardiac anesthesiology, said Dr. Robblee. “More of our work is going to be done outside of the traditional cardiac operating room for these less-invasive and electrophysiology techniques that are coming down the pipeline. A great number of them require anesthesia support, and we recognize that our job will move somewhat away from its focus on the operating room and the ICU, and into those other areas.”
Dr. Ruddy sees technology in interventional cardiology and electrophysiology continuing to improve, providing additional options to surgery. These include better stents with smaller sizes available to open smaller arteries and more effective ablation techniques for treating irregular heart rhythms. He singled out atrial fibrillation as a growing problem with an aging population. While the condition is usually not fatal, it severely compromises quality of life and increases the risk for stroke. In addition, he added, with improved imaging techniques, “we’re identifying more disease earlier, and once you identify a disease, you can treat it earlier.”
The “missing piece” in early prevention, explained Dr. Roberts, “is the part that’s due to genetics,” which may account for about half of any individual’s risk for cardiovascular disease. Research at the Heart Institute, and worldwide, has begun to understand the genetic variations that contribute to cardiovascular disease risk, and how those factors interact with an individual’s lifestyle and environment, he commented.
Funding and the Future
Whether the drop of cardiovascular di-sease to the number two killer in Canada will affect funding, either for research or clinical care, is not yet clear. “I think it will have implications for funding, but that makes sense,” said Dr. Mesana. “What we’ll have to do is pay attention to what we do with our money.”
In contrast, “I’m not sure that will have that big of an effect on funding since it’s still a major cause of premature death,” thought Dr. Robblee. “I don’t think we’re going to say we’ve reached our goal, so we’re not going to fund these things to the same extent anymore—we’d lose progress.”
For the Heart Institute itself, explained Dr. Roberts, research funding has actually increased 90 per cent since 2004, and endowments have doubled. “All of that has happened at about the same time that our clinical load in some areas has almost doubled,” he said.
“We’re doing a good job at preventing and treating heart disease, but it would be a mistake to think that it’s now on its way to elimination. It’s still number two, and it still kills a lot of people,” continued Dr. Roberts.
The participants agreed that to build on the impressive gains made in cardiovascular medicine will require continued research and innovation. Just as important as advances in technology, treatment and surgical technique will be new approaches in the delivery of care, increased collaboration across specialty areas and a willingness to prioritize prevention. “There’s still a lot of work to do in cardiovascular medicine,” agreed Dr. Robblee. “We want to get down to the next level—we’ve been passed by cancer, and hopefully we’ll be passed by something else before too long.”