Clinical Governance: Cardiology and Cardiac Surgery from GP to the Theatre - Health Resource International West Africa (HRI)


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Friday, 30 June 2017

Clinical Governance: Cardiology and Cardiac Surgery from GP to the Theatre

Dear Colleague

Lets talk proper medicine, lets set the stage for meaningful discussion about strengthening our health system. We share courtesy of PULSE UK the fact that GPs play key role in the
linking / referral trajectory that ends in good outcome. We have chosen to start with an area of medicine cardiology and cardiac surgery that leaves many of us de-spirited because our system is so unready to support our skills. After reading the piece below you will agree that the Nigerian health system needs to be strengthened urgently to help doctors of all specialties raise our game:

READ ON and lets get your usual feed backs- forget the Quacks!

Dr. Yassir Javaid talks about the crucial role of GPs in overcoming barriers to
optimal care in aortic stenosis

Aortic stenosis occurs when the aortic valve becomes partially narrowed, which is often due to the calcification associated with aging, and which results in reduced blood flow out of the heart.

Aortic valve disease is common. Aortic sclerosis is present in 25% of people over 65 years of age, and is associated with age, hypertension, smoking, the male gender, low density lipoprotein levels and diabetes mellitus. Nearly 9% of these patients will develop aortic stenosis over a five-year period.

Cost of underdiagnoses:

The early diagnosis of valvular heart disease is critically important, as severe, symptomatic valvular heart disease patients who do not undergo aortic valve replacement (AVR) have no long-term option for preventing or delaying disease progression; survival after the onset of symptoms is 50% at 2 years and 20% at 5 years. Without AVR, symptomatic severe patients have a high mortality: 3-4% after symptoms first appear and 7% on a waiting list for valve replacement, compared to 1-2% in a fit patient post-AVR.

A patient with a heart valve problem may be asymptomatic, but will often present with a heart murmur. While heart valve problems can be picked up with a stethoscope, any heart murmur should be referred for prompt investigation by a physician, usually involving an echocardiogram.

Suboptimal surveillance and non-timely referral :

However, many symptomatic patients with severe aortic stenosis are not referred to a heart team for valve replacement evaluation.

There is not only a failure to recognise aortic stenosis sufficiently, but also a failure to refer for surgery sufficiently early, and to give closer attention to asymptomatic patients.

Treatment options :

ESC/EACTS guidelines for aortic stenosis recommend AVR for those patients with severe aortic stenosis and symptoms. Trans-catheter aortic valve implantation (TAVI) is recommended for severe symptomatic aortic stenosis in high-risk patients, whose risk profiles warrant TAVI, as assessed by the 'heart team'.

ACC/AHA guidelines recommend that severe, symptomatic valvular heart disease patients should be evaluated for AVR. As is the case with the ESC/EACTS guidelines, these also recommend that a multidisciplinary patient evaluation for surgery be conducted to assess surgery as a treatment option.

Yet despite these recommendations, these patients may remain unreferred for surgical evaluation for a number of reasons, the principle of which is overestimation of risk.

NICE interventional procedures guidance on TAVI for aortic stenosis states that the evidence on the efficiency of TAVI in patients with aortic stenosis who are considered to be unsuitable for surgical AVR is adequate, and that it is a technically challenging procedure that should be performed by clinicians and teams with special training and experience in complex endovascular cardiac intervention. It also recommends that a multidisciplinary team, comprised of an interventional cardiologist, cardiac surgeon, cardiac anaesthetist and an expert in cardiac imaging, should determine the risk for each patient.

Surgical AVR, first reported in 1960, remains the gold standard for patients at low or intermediate operative risk, because it is associated with excellent long-term outcomes and low perioperative risk.

Up until 2012, medical treatment and balloon aortic valvuloplasty were the only treatments for inoperable patients, with an overage survival after the onset of symptoms of 2-3 years.

Over the past decade, TAVI has become the treatment of choice for patients considered to be at high risk for surgery, and for high-risk patients with severe, symptomatic aortic stenosis.

TAVI can be performed with only mild sedation rather than a general anaesthetic, and is gradually being assimilated into intermediate and lower-risk patients.

Africa Center for Clin Gov Research & Patient Safety
@ HRI West Africa Group - HRI WA
Consultants in Clinical Governance Implementation
Publisher: Health and Medical Journals 
8 Amaku Street Housing Estate, Calabar
Cross River State, Nigeria
Phone No. +234 (0) 8063600642

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