22 LISTENER FEBRUARY 29 2020
getting old and unfit, but when they get
treated, they say they didn’t realise how
limited they actually were.” Intra’s volume
of coronary angiography and stenting is
flat, a result of better medical management
of coronary artery disease and fewer people
smoking. “And the people who come to pri-
vate practice tend to look after themselves
well – they don’t smoke, they eat well and
most are close to ideal body weight. They get
coronary disease because of heredity. They
often say, ‘Why me?’, but it often turns out
they have a strong family history.”IMPROVING EQUITY IN HEART HEALTH
For people taking heart medicines to try to
prevent coronary disease, under-treatment
rather than overtreatment is the main
problem in New Zealand, says University
of Auckland epidemiologist Rod Jackson, a
world leader in heart-risk prediction.
Jackson and public-health medicine spe-
cialist Dr Suneela Mehta’s research suggests
that about half of people at the highest risk
of having a heart attack or stroke (a risk
of 15% or more in five years) aren’t being
prescribed the strongly recommended
treatment of blood-pressure and cholesterol-
lowering drugs. About a quarter of New
Zealand adults (aged 30-74) in their study
had a predicted five-year risk of between 5%
and 14% – the current threshold at which
drug treatment should be considered and
discussed – and 5% had a risk greater than
15%.
The figures come from the Vascular Risk
in Adult New Zealanders study, which esti-
mated the heart risk of 1.8 million residents
who’d had contact with publicly funded
health services. The anonymised informa-
tion used encrypted versions of patients’
national health identifier numbers to link
their hospitalisations, drug dispensing, lab
tests, primary-care enrolment and hospital
outpatient visits with estimated risk by sex,
age, ethnicity, level of deprivation, diabetes
and heart-drug use.HEART DISEASE TREATMENT
D
octors hope that new medi-
cines that will reduce the risk of
heart disease and death for the
200,000 people in New Zealand
with type 2 diabetes will be
taxpayer funded this year. Heart disease is
the main cause of death for people with
diabetes. Their incidence of cardiovascular
complications is two to four times greater
than for people
without diabetes.
Heart Foundation
medical director
Dr Gerry Devlin
says the NZ Cardiac
Network, which he
chairs, has pushed
for the new drugs,
which not only
reduce deaths and
hospitalisations but
also the numbers going on kidney-trans-
plant waiting lists. “If you want to look at
a drug that addresses equity and improves
outcomes, look no further than these.”
The drugs, known as SGLT inhibitors,
reduce the overall risk of death by 20%,
and death from heart disease by 40%.
They are thought to be protective partly
because of their diuretic effect, but Auck-
land diabetes specialist Dr Rinki Murphy
says there are many other mechanisms
that aren’t as well understood.
Murphy says diabetes causes
higher sugar in the blood,
which, if uncontrolled,
over time can act like rust,
causing inflammation
that makes the blood
vessels more likely
to block or haemor-
rhage. “The underlying
pathway by which the
sugar rises in the first
place isn’t very clear, but
insulin, the key hormone
regulating blood sugar,
is unable to act
effectively. This
process, called‘This is a game changer’
Drugs that reduce heart-disease risk among
those with type 2 diabetes are coming.
insulin resistance, is specific to people
with type 2 diabetes and not only
predisposes them to having high blood
sugar, but also to having blocked blood
vessels, so it’s a double whammy.”
Murphy says she attended confer-
ences when the cardiovascular benefits
of the drugs were announced in 2015.
“The data showing fewer deaths and
lower incidence
of heart and
kidney disease
were a surprise –
people actually
stood up and
clapped.” She
says Australia
has funded the
drugs for about
five years, but
our Govern-
ment’s drug-buying agency, Pharmac,
announced only in January that it is
looking to fund one or more of the
medicines here and is seeking commer-
cial bids from suppliers.
The SGLT inhibitor tablets cost about
$90 a month for patients who pay for
it themselves, but less than 1% of Mur-
phy’s patients in the public sector can
afford to do this. If the drug is funded,
she says, it is likely most people with
diabetes would move on to the medica-
tion after metformin alone no
longer controlled blood-sugar
levels. People with heart
or kidney disease would
go on them immedi-
ately. “This is a game
changer for people
with diabetes,” she
says. “The drugs are
recommended in every
international guideline
for diabetes management
but we are still unable to
use them here.”“Data showing fewer
deaths and lower
incidence of heart andkidney disease were a
surprise – people actually
stood up and clapped.”About half of people
at the highest risk
of having a heart
attack or stroke aren’tbeing prescribed the
recommended treatment.Rinki Murphy: drug
funding will be “a game
changer for people with
diabetes”.