 So, good evening everyone, I'm Richard Fall and on behalf of my co-chair, Norman Sharp. I'd just like to welcome you to this, this is our second public lecture in our 50th anniversary lecture series. Great provocative title, Hard Attacks and Stroke, Getting the Blood Flowing Again, so that sounds pretty good. As you all know, Hard Attacks and Stroke say are two of the major causes of death and disability in our community. Great challenge. And tonight we've got three of New Zealand's preeminent experts in this area and they're going to describe how these diseases develop and how they contribute to all the health. And then they're going to move on to describe the recent huge advances in medical technology and use how the medical technologies use various techniques to restore blood flow and to get the heart and brain working again. Pretty good. So these developments have actually transformed the management of strokes and heart attacks and strike up significant logistical challenges. How are we going to roll this out right across the country and they'll touch on that I'm sure. So it's really important that we acknowledge the support and the partnership that these lectures are presented in partnership with the Auckland Medical Research Foundation. And just before I ask Norman Sharp to introduce our first speaker, I'm going to ask Sue Brewster, who's the Executive Director of the Auckland Medical Research Foundation, just to say a few words. Sue. Well, thank you very much, Sue Richard. And it is my pleasure to reinforce Professor Falls. Welcome to everyone here tonight and to our Auckland Medical Research Foundation guests and supporters that come along to our public lectures every year and some of you will also be new here tonight. So the first in the lecture series was held last month and yes, our public lectures this year in 2018 are a little bit different. This year we have the privilege of partnering with the Magnificent Faculty of Medical and Health Sciences in celebration of their 50th year anniversary. So over the last 63 years, Auckland Medical Research Foundation has provided significant funding into cardiovascular research. I think we've funded research from the pioneering days of heart transplants and bypass surgeries right through to the modern-day projects of technology-assisted cardiac rehabilitation. Anything's possible. But we couldn't do this without the support of our amazing people who donate the money to fund our world-class medical research. This funding literally provides the heartbeat and there is no pun intended for our extraordinary researchers, many of them who work here at the Faculty of Medical and Health Sciences. These researchers work tirelessly to undertake their life-changing research and provide the genuine advances in medicine and health that benefit us all. I'd like to acknowledge the outstanding calibre of our presenters here tonight and I'm sure we're all going to learn a lot. So, in closing, please do take the two minutes it'll take to fill out your feedback forms that are in the folders so we can continue to deliver all that's important to you. I hope you enjoy tonight's presentations and live here with increased knowledge not only of heart attacks and strokes but also into how to get that blood flowing again. Thank you very much and enjoy. Good evening and welcome. What a fantastic turnout. As I came in the door tonight, some bright spark who knew me from my former life said, oh Norm, they've brought you off the bench again knowing I'm a basketball fan, a breakers fan and you know what coming off the bench means. No, mate, they've taken me off the shelf but here I am. It's great to be with you and what a fantastic attendance. I think that in and of itself speaks so strongly to the community of the medical school in the broader sense in Auckland. At the outset, I'd like to actually acknowledge the founding members of the medical school in this 50th year, many of whom I knew well working in Auckland as a young doctor at the time having graduated from that southern school in 1968. I think it would be not unkind to call them collectively a white-coated hierarchical but lively bunch which they were. It was very much a former era in medicine as you may reflect. But I do recall in the precinct here between the hospital and the medical school the sense of excitement with the first intake of 60 students and so on and so forth and the traffic building up across the road back and forth. And I think if any of the foundation professors were here in the 50th year they would be very well pleased with what they saw. We should acknowledge them and thank them. Also I'd like to briefly pay a tribute to Jeff Todd, Sue Brewster and the AMRF. More than $60 million invested in medical research in Auckland since the 1950s since their inception. An absolutely fantastic contribution. And I think this in and of itself is a major factor or has been a major factor in securing the school's current solid international reputation. Finally, by way of introduction, I have to mention the Heart Foundation. And it happens to be the Heart Foundation's 50th anniversary year this year too. The foundation being constituted in 1968. It was first suggested by the Auckland grandfather of clinical cardiology Jim Lowe taken up by colleagues in the main centres, medical and business people. I knew many of them. And through their vision and generosity of spirit like just as with the AMRF the Heart Foundation came into being. And I think if I can mention one person that vision and generosity of spirit was epitomised in Auckland by David Cole, a cardiothoracic surgeon who was the second dean of the school for many years, a wonderful man. Of course, in the 1960s, currently Heart Disease was epidemic. People were dying in the 40s and 50s. Frequently it was not uncommon. And since then, currently Heart Disease death rates have gone down by about three quarters as a result of education prevention and a revolution in clinical care. The aims of the foundation from the outset were to support research, education and laterally actually patient support on a national basis. And the foundation has invested more than 65 million in research. This is in heart research, nationally, biomedical, clinical and public health. And this is in projects and people as the AMRF does so well. The fellowships in particular I think have been the forte of the Heart Foundation and there are two endowed chairs, one in Christchurch and one in Auckland. The first chair in Cardiovascular Studies was endowed in 1987. Some in the audience will remember Professor Willem Lubber who took that chair as the inaugural chair. It is now held in Christchurch by Mark Richards, a former Heart Foundation senior fellow who has grown and developed his team efforts and he now directs the Christchurch Heart Institute which is a world-class research program bench to bedside and into the community. The second chair is with us tonight in the form of Professor Rob Dowdy, the chair in Heart Health. Rob, too, was a former Heart Foundation senior fellow, appointed to the chair in 2011 and developing and leading a broad program, again across the board as it were encompassing basic clinical and community-based research. So without further ado, I'll ask Rob to take us ahead and tell us about heart attacks and strokes. Rob? Well, thank you Norman, Sir Richard, Sue, Dean, ladies and gentlemen, good evening and it really is my pleasure to be here to talk with you this evening and my title is very simple. So I've got the simple bit and I was told to make this light-hearted just now so I'm going to have to rewrite my whole talk in front. But I'm going to talk to you about what these things are, heart attacks and strokes. I'm going to start pretty basic. Your heart pumps blood around your body, as you know, through your arteries and veins and it delivers to our bodies the blood and nutrients and the oxygen that all of the tissues in our body need. So we're going to be talking about major places in the body supplied by some pretty important blood vessels and you'll hear about the treatments that we're going to talk about in a minute. We term medically, we term those conditions cardiovascular disease and the main focus of the clinical events we're talking about are heart attacks and strokes as you know them. So as we're sitting here, we're talking about the heart and your heart is quietly working away there. So here's a beautiful image of the heart. This is reconstructed from cardiac MRI imaging of the heart provided to me here by Professor Martin Nash and his colleagues at the Auckland Bioengineering Institute at this university. Really illustrating some of the technology we have to work with to understand how the heart actually works. So while we sit here for the next 90 minutes your heart is going to beat more than 6000 times. So in a room this size, we're going to share between us more than 1.2 million heartbeats. While you're thinking about that, I'll carry on talking. So it can be argued that we really live in very fortunate times. As Norman's already mentioned, we've seen a 75-80% reduction in the risk of dying from heart disease and stroke over the last 50 years. A really remarkable story over what is a relatively short period of time of improving risk factors and advancing of treatment. We can also think ourselves fortunate we live in a country with a publicly funded healthcare system and I'm not going to answer questions on that one. We have incredible teams who are dedicated to delivering the very best in healthcare and many of you in this room may have experienced or been touched by some components either for you and your families for that healthcare. We have researchers of international standing locally here at the University of Auckland and in all areas from public health through to basic science. The expert clinicians and their teams both in the hospitals and the communities in this region really are again of international standing and we have similar clinical and academic excellence across the whole country. So we are in very fortunate times I think. I'm going to set the scene really in the next few minutes for what you'll hear in relation to treatments and the advances of treatments for these common conditions heart attacks and strokes. Before I do that I'm going to take you back in time a little bit so it's always nice to go back it's the 50th anniversary so we can look back a little bit and for those of you who like history then Dwight Eisenhower you'll be very familiar I'm sure with him in Europe during the Second World War and he was elected as the 34th President of the United States in 1952 at the age of 62. On the 25th of September 1955 he was playing golf in Cherry Hills Country Club if you have a look at it it's a very nice place and he experienced some symptoms of discomfort in his chest. He was attended to by his personal physician Dr Snyder and Dr Snyder stayed with his personal physician overnight administered a number of drugs including some morphing and if you're interested there is a side story about Dr Snyder the personal physician and when you touch into that story what I take away from it is I never ever want to be a personal physician to a President of the United States there's a lot written about this gentleman 12 hours later it recognised this man was not doing quite as well he was taken to hospital an ECG was delivered into the hospital a place that just simply records the heartbeat electrically you can now record that on your mobile phone and a heart attack was diagnosed at that point 12 hours later and you're going to hear from others about potential delays in treatment delay in presentation delay in treatment he was treated in an oxygen tent initially spent six weeks in hospital and we don't even truly know to this day whether oxygen is a good thing to give to people with a heart attack or not at that point now the impact of this was huge so in that era there was been a lot of strife over many decades and the day after the President's heart attack was the worst day in trading on Wall Street since the end of the Second World War the Dow Jones fell 6% $14 billion was wiped off the share market at that point simply wiped one person's heart attack one event the President did survive his heart attack as I'm sure you're all aware he went on to have a stroke two years later we're going to hear about heart attacks and strokes more as we progress the next few minutes and he survived another seven heart attacks he survived 14 cardiac arrests until he finally died at the age of 78 in 1969 so quite a story for one person who's been touched by cardiovascular disease and you'll probably note that most heart attacks are not followed by the same impact on the share market as this one was we'll also just pause and go back a little bit to that era because that really is an era where heart disease management was starting to change and we're going to talk about this again a little bit as we go through but as you'll be aware people with heart disease, people with heart attacks may die suddenly and they may die very quickly from that problem and they die because their heart stops beating they're called ventricular fibrillation the treatment and management of which is resuscitation and defibrillation so the first successful resuscitation of a patient was undertaken in 1953 and Dr Zoll whose name persists associated with defibrillation 50 years on from there undertook the first external defibrillation of a patient in 1956 a British cardiologist we have to get back to Britain at some point Desmond Julian recognised around that point and presented at the British Thoracic Society the need for monitoring of patients and the need for monitoring very closely of people who are having a heart attack and who are presenting to hospital and the need for resuscitation if the heart rhythm becomes a dangerous heart rhythm and this was published and a year later in Kansas City in Bethany hospital an 11 bed unit funded by private donations New York Foundation was opened as the first coronary care unit as it was recognised at the time and coronary care units as I'm sure you're all aware are a fundamental part of heart attack management in all of our hospitals in the world and Dr H.W. Day in the early 70s in a paper perhaps this quote from the end of his paper really sums up that era that the 60s had been the era of the cardiologist with the defibrillator in his hand I won't go into the wording of this obviously I'd argue that actually probably it was in other people's hands and probably the nurses in the coronary care units overnight actually too but it was a point the point is it was resuscitation era it was early development of of advanced care and resuscitation so very basic care but this is 50 years ago and you'll hear others as we progress come back to the themes that are still there and still present for how we treat people with heart disease it is the 50th anniversary so let's go back to 1968 so this is an extract from the New Zealand yearbook from 1968 and that was then the New Zealand population of 2.7 million people and this is a figure there I think this was a hand drawn figure rather than some fancy Excel or other program plot of showing that the major causes of death in that era of heart disease and cerebral hemorrhage cancer up there as well but the major causes of death identified at that stage even 50 years ago the population was different as well so here are population graphs of 1968 with the different decades of our age and how that's changed you can see visually there with the baby boomer population now moving through middle aged and also the advancing age of our population so not uncommonly people surviving in the 90s or the hundreds and still experiencing cardiovascular disease and all the challenges of management for people of advanced age so a lot has changed a lot is the same but a lot has changed over that 50 years that we're talking about so I'm going to talk a little bit now about what heart attacks are I'm going to talk about the potential causes which hopefully will round this up and lead into some of the advances in treatment so we're talking about blood vessels we're talking about blood vessels blocking and those arteries blocking affecting the major organs in our body and the clinical effects from those problems we need to understand those blood vessels a little bit more to understand why these processes happen and this is atherosclerosis and I'm sure you're all very familiar with this process lots of different terminology as we have in medicine medicine loves to have four or five names and we all choose to use them in a different way at a different time but atherosclerosis, plaque in your arteries hardening of the arteries whatever you like to call it and there on this illustration here on the left hand is the illustration of an artery could be any artery in the body but there's the plaque laid in deposits building up in the wall of the artery need to consider this over a lifetime this doesn't develop over weeks or days this is a process developing over a lifetime and I'll come back to that theme in a minute and this will progressively potentially narrow an artery and this can affect a number of different places in our body so it affects our heart and our brain we're talking about that today heart attacks and strokes but it affects other areas in the body as well it affects our legs from the point of view of the circulation to the legs it affects our gut and that's often forgotten about it can cause substantial symptoms for people it affects our kidneys and kidney problems and kidney failure remain to be an important problem these all develop all of this atherosclerosis develops on the background of risk factors over a lifetime of exposure and probably before we're actually born so let's think about the heart for a moment, a heart attack so here's a CT scan these are images derived from a simple x-ray very fast x-ray there are catheters inside the body these images provided to me by my colleague Associate Professor Malcolm Legart on the left there is the heart with the coronary arteries running around the outside of the heart and then with rendering of that image the heart itself is removed on the right-hand side not from the patient but from the image leaving the coronary arteries for you to see there and you can see they're very small these are arteries only a few millimetres in diameter but as I've talked about they're doing that function of supplying the nutrients to the heart muscle every single time the heart muscle beats so it's no wonder that we run into a problem when one of those blocks and so they do block and these arteries block at the site of one of those narrowings most commonly so in the heart a heart attack is caused where the artery inside is rough and friable and blood clot forms at the site of that plaque in the coronary artery and the blood clot then forms to block the artery and this is a sudden event and if you talk to people who've had a heart attack it's often out of the blue so it doesn't come with warning symptoms over weeks or months it will happen out of the blue the situation with the stroke also relates to blood vessels and to blood clots and for some of those as you'll hear from Professor Baba those blood clots come from other places in the body to lodge and to block in a crucial artery supplying the blood to the brain so do these heart attacks and strokes matter well let's step back and think from a global perspective first of all they do matter so the World Health Organization as I'm sure again you're very familiar talks of non-communicable diseases now as being our major challenges ahead and has done for some time this is cardiovascular disease this is cancer, this is respiratory disease and diabetes and cardiovascular disease heart attacks and strokes is a major cause of death around the world so you can pluck all sorts of figures about 18 million people dying a year from cardiovascular disease or one heart attack and one stroke occurring every 40 seconds so I don't know how long I've been talking for but already we're clocking through the heart attacks and strokes as we're talking today in the United States one in three people die of cardiovascular disease it's also important to remember we shouldn't just be focusing on first rates from these problems people survive and live with heart disease and survive and live with the sequelae of a stroke and so for example here it's estimated that more than 90 million people in America alone are living with heart disease for the years ahead so very important implications in relation to patients so does it matter in New Zealand? yes it does matter but this is the great news story which we've already mentioned the substantial reduction in the death rates from heart disease and stroke over the last 50 years so the peak in those graphs the peak in the graphs is in the late 1960s so that is 50 years ago so it's quite appropriate to be talking about this on a 50th anniversary so it is an epidemic as Norman has already mentioned and high smoking rates risk factor management all evolving and then changing over that time these substantial reductions in the risk of dying of these two common problems in the last 50 years fantastic, great news incredibly important but there is a lot more to understand and a lot more to be done for these two common conditions so it is still highly relevant in New Zealand heart disease and stroke so they're the second and third leading cause for why any of us in New Zealand will die incredibly important and that's following on from all cancers lumped together you can see the numbers there for the estimate of the number of people living in New Zealand with heart disease and living with the effects and disability of a stroke so these are large number of people in our population living with the effects of these conditions but let's think about things a slightly different way as well and heart disease and stroke account for more than 10% of all illness, disability and premature death in our country so again very, very important identifiable causes for disability and this is not just a problem of older age it's often still thought that ah well heart attacks are only what affect older people we're all going to die of something anyway so really let's just get on with thinking of other things that's not the case at all so heart attacks and stroke affect younger people so let's think of working age people over the age of say 65 so 1 in 3 people with a heart attack are of working age and 1 in 4 people with a stroke so these affecting people perhaps in their prime of their life making huge contributions to their family their whānau and to society in general so the implications here are broad and we could go on and talk about that in great detail at another time we need to consider the inequity that is still present in New Zealand and I've just selected to illustrate this the age of onset of these two common conditions so you can see here that for Māori and Pacific the average age of onset for a heart attack or stroke is substantially less than for New Zealand European people living in the country right now and however you cut the statistics however you look at it Māori and Pacific people do much worse for their heart disease, stroke for many other conditions and we need to recognise this and obviously a lot of work is going on and should go on to address these inequities these problems happen because of common risk factors and these risk factors have been known about for a long time but there's a multitude of risk factors it's right from birth so it's the world we're born into it's the families we're born into it's housing, inequalities deprivation it's our education and then it's personal factors about us that we take through our lifetime so this is a lifetime concept in relation to cardiovascular disease physical inactivity and you're probably all now thinking right now of your children or your grandchildren who you're still telling to get off playstation and go outside and be physically active like you were poor diet, smoking these problems are still very prevalent so how do we integrate all this information to understand this this is a huge amount of information for us to integrate individually at any point in our life course to understand what our potential risk is and I really just want to pay a tribute and acknowledgement to Professor Rod Jackson at this university and his wide team in the university and outside of the university who have been involved in this work to understanding how to predict our risk of heart disease by integrating that information for us as an individual it's getting to the level of precision medicine where we can understand about us not just as a group of people but us as an individual and this is a publication from just last week in the Lancet of the data that's been derived from 400,000 New Zealanders this is decades of work in understanding how we can actually is going to be at risk of developing a heart attack or a stroke over the coming years the challenge now is to implement this it's to actually use this to actually appropriately manage people who are at high risk advise people and take this forward through that life course and this as I say this is decades of research this may look relatively simple this is decades of research huge amount of funding and a very broad research platform to be able to achieve this kind of result that can now be used in clinical practice we should talk a little bit about good news so the New Zealand Health Survey from the Ministry of Health from last year has some good news in it so all of you 80% of you you can all stand up if you're one of these 88% thought your health was good, very good or excellent when you answered the health survey so that's pretty good isn't it smoking rates are decreasing that's pretty good too so we should probably just stop here and then go home and have dinner and pat ourselves on the back but it's not all good news is it and this sort of information is really crucial contemporary information that we can take forward and do something different with 600,000 adults in New Zealand still smoke regularly 1.2 million adults in New Zealand are obese and that's 200,000 adult population and another third are overweight that's 2 thirds of the population that are overweight or obese 100,000 children are obese and all these factors as we put in that life course of disease are incredibly important for the risk of heart attacks and strokes if you look at the richest homes that children are born into maybe 3% of those children will be obese if you look at the poorest homes at least 20% so we live in difficult times and a lot of difficult challenges to grapple with this is from the front cover of the economist 15 years ago so this isn't just from a few months ago and we're still talking about the same things and I think really illustrates and captures the attention very nicely and then there's practical problems that really are quite frightening so in this survey when people answered questions about picking up prescriptions that we have to go to a pharmacy and pay for the prescriptions or get to the pharmacy to then pay for our prescriptions a quarter of a million adults didn't pick up a prescription within the last year so they had sought out healthcare for a problem that was identified that was considered to need a prescription of a prescribed drug and that's a quarter of a million adults didn't pick up those prescriptions so it's pretty bad when you think of the long term implications of what that does so I'm going to finish just with symptoms and if you bang your head tonight on the cupboard before you go to sleep you're going to know what happened and your head's going to be sore you catch your thumb in the door your thumb's going to be sore and your thumb's going to tell you that your thumb's sore heart attacks and strokes don't work like that be having a heart attack it's difficult for people to rationalise what's going on and there's a multitude of reasons why people may not recognise and may not do something about those symptoms and I just really want to pay a tribute both to the Heart Foundation and to the Stroke Foundation but major initiatives for heart attack awareness here illustrated as I'm sure you've seen with television adverts and posters very very effective advertisements and some lovely stories came through I think almost immediately following those of people who had responded because they'd seen the advert so these sort of activities make a difference and here the fast acronym for recognising the signs, the symptoms and signs of a stroke and the common theme these are medical emergencies you need to do something about this this is not sitting around for 12 hours with your personal physician at your side overnight thinking that things might get better you dial 111 and you go to hospital so I'm going to end here and I would like though to pay a tribute to all my colleagues my academic colleagues in the broad university sense the clinical colleagues, the public health physicians and the many many patients who've contributed to the research that you'll hear a little bit more about that's contained within the data some of the data I've already presented we have a huge willingness in New Zealand for people to take part doing this for all sorts of regions many of which are altruistic and we live and should respect that and I really do take my hat off to people contributing to the research that goes on I enjoy working in this field, in this country it's a challenge but I think we're actually at a very very exciting point you could say the 50 years each of those points have been very exciting I think we live in a very healthy environment across the country to be able to grapple with and address some of these important issues I will also thank the Heart Foundation Norman has already mentioned this but I'd like to extend a thanks to the Heart Foundation really on behalf of everybody who has benefited from the funding project grants, individual ideas that have made a difference it's more than 200 people being touched by fellowships and all of those then snowball and continue and that's a lot of work and a lot of funding that really has seen this through it's a team effort and the Heart Foundation has been part of that team for the last 50 years also like to acknowledge the Auckland Medical Research Foundation for the funding to medical research in this region and also for supporting the series here thank you It's a privilege to introduce Jerry he's a senior cardiologist in Waikato Hospital and he's led unprecedented improvement in clinical care in that region which I would be so bold to suggest is perhaps the most challenging geographically and demographically in our small country he's the former chair of our Cardiac Society and Honorary Associate Professor in the University of Auckland and currently Medical Director of the Heart Foundation and having heard about heart attacks and strokes, Jerry will now tell us how we treat heart attacks Thank you Jerry I took half of my slides I do want to have some of my time I'm going to talk not so much about what's new and how we treat heart attacks in this film Busting Medicine and Stents so I'm pleased to see the neurologists to finally catch you now if they're usually about 10 to 20 years behind what we do in cardiology but our challenges in New Zealand is how we improve care for everyone in New Zealand as Norman mentioned I work in the Midland region that's a very geographically diverse and challenging area to deliver health care and we are passionate about equity equity of care for New Zealanders as Norman mentioned and Rob mentioned as well this is the 50th anniversary of the Heart Foundation as well formed in 1968 by Sir David Hay and like-minded people at that stage there was an epidemic of heart disease in New Zealand one in two New Zealanders smoked 40% of our diet involves saturated fats as part of our diet we've had a dramatic reduction in cardiovascular events since then half of that's been due to preventative measures and half of novel treatments that we now have available to us in New Zealand Rob took us through some of this but just to emphasise way back in the 1940s you came in with a heart attack you may as well toss the coin whether you survived or not so if you survived the heart attack you were likely to die of a clot somewhere else due to prolonged bed rest with the clot going to the lungs in the latter days in the 1980s we have the era of clot busting medicine and then we started putting stents in in the 1990s and some of the pioneering work that's informed what we've done over the years has been supported by Heart Foundation Research in this New Zealand some of Professor Sharpe's work looking at ACE inhibitors after a heart attack and people with heart failure one of my colleagues in Waikato he in 1996 he came back to Waikato having been in Florida on a Douglas White fellowship where he learned primary angioplasty and Waikato was the first unit in the country where we performed primary angioplasty when someone came in with a heart attack 24 hours a day so again supported by the Heart Foundation I want to share with you two patients and two slightly different stories Rose is a 71-year-old lady who lives in Manukau and Eddie is a 78-year-old man who lives in rural Taranaki and they both present with chest pain with similar ECGs so somebody want to have one of the physicians Phillip would you like to interpret the ECG do you remember how to interpret ECGs okay okay and what would you be considering at this stage okay yep so when we see people present with chest pain first question that we are asking is why when you go to a doctor's surgery with chest pain is a sign-up and all doctor's surgeries are ED departments please come to the front of the queue this is what we want to know whether you're having one of these events which is a large heart attack one of the arteries usually in a large vessel an proximal vessel is completely blocked and that increases your risk not only of sudden death but also more permanent damage that can lead to heart failure quickly to get on with strategies to try and open up the artery to reduce the likelihood of sudden death and also to preserve heart muscle in the longer term the sooner we do this the better and that's a picture of an artery that's been explained from someone that had a heart attack but what you can see here is a lot of clot in the artery the plaque is actually ruptured and that artery would have been closed completely and what we do know we are much more likely to achieve benefit in the longer term by opening up the artery as soon as possible so the sooner we can get on and make a diagnosis we can get on and administer treatment to try and open up the artery if we can put stents in we should get on and do that and the rationale behind that is we get greater muscle salvage so we're going to open up the artery we're more likely to get sustainable flow to the artery compared to clot busting medicine that results in less recurrent angina less heart attacks and we avoid the life threatening complications of some of the clot busting medicine that we give in New Zealand this is one of the complicated flow charts around what we actually do so someone presents with chest discomfort here what we want to do is find out again make a diagnosis early and if you can have an angioplasty or a stent put in with 120 minutes from when you first see someone first medical contact you should get on and put a stent in however if that cannot be achieved patient should not be denied clot busting medicine so that's a really important thing for us in our treatment paradigms and this is similar we've got a similar diagram flow chart for this in New Zealand but this is the latest ESC guidelines so again 120 minutes is a sort of cut off that we start considering if you can get from somewhere else that performs angioplasty within 120 minutes then it's reasonable to try to transfer that patient to the angioplasty centre if you cannot you should not deny that patient clot busting medicine if we look at what we're doing currently in New Zealand and this is from 2013 about 1 in 3 New Zealanders receive clot busting medicine about 40% of New Zealanders receive angioplasty but about 20% of New Zealanders receive no form of treatment for a blocked artery when they present with a big heart attack if you receive no treatment you tend to do worse self-explanatory you tend to these patients tend to be more likely to be females nursing home residents and if they are admitted to hospital they tend to not receive the same treatment on discharge so you do not do well if you do not receive either clot busting medicine or angioplasty so getting back to our patients rose her pain onset was at 6 o'clock she drove herself to Middlemore hospital good idea Phillipa arrived at 11.30 was transferred from Middlemore to Auckland Public arrived at Auckland Public at High Pass midnight that's her main artery down the front of the heart it's blocked high up and she gets the artery opened up with a stent seven and a half hours from symptom onset what about Eddie so Eddie had two previous heart attacks so he sort of thinks he knows what's going on he awakes at 12.50 with his chest discomfort dials 111 the ambulance gets him pretty quickly at 140am he arrives at Taranaki emergency department at 2.30 he gets given his clot busting medicine fairly quickly at just after 3am 2 hours 20 post symptom onset so again getting Eddie from Taranaki to Waikato which is the nearest angioplasty centre that's not going to happen within 2 hours so his treatment is appropriate so he should be given clot busting medicine and we'll talk about it we'll just see how this develops so again the evidence around clot busting medicine it works well particularly if it's given early but the risk is bleeding and bleeding into the brain which is serious and can occur in up to 1% of patients so that's the risk we expose people to when we give clot busting medicine but again we should not deny people with a serious heart attack clot busting medicine if they cannot get to an angioplasty centre within 2 hours so back to Eddie it's 5am he's got an ongoing chest discomfort his ECG's not changed much at all and he's referred to us we get a phone call on a typical foggy Waikato morning so can you help so what Taranaki want to send him up to us to consider an angioplasty at this stage so he arrives at Waikato at 10am and again the guidelines would say the current European guidelines once you receive clot busting medicine you should be transferred to an angioplasty centre immediately so not sit around and wait to see if the artery opens up or if the artery does not open up because we cannot predict that at all well and we know that approximately 1 in 3 blocked arteries do not open up after being given clot busting medicine Alan that's a lot of clot in that artery I don't think you'd be keen to try to suck that so that artery there is full of clot all the way down there but this is Eddie's angiogram so he comes to our cath lab arrives at 11.30am and the artery responds for the heart attack extended and opened just before midday so again if we look at what happened to Eddie he arrived at the scene the ambulance arrived to take him to hospital he's given the clot busting medicine he's transferred to Waikato when things don't look as though they're going well finally arrives at Waikato and gets his artery opened up 11 hours from first medical contact Phillip have we done him any good probably not done a lot of good if you think back to the myocardium and the time so how might we improve time to treatment so lots of efforts over many years have gone into what happens when someone comes through the front door trying to streamline things we're now starting to look at what happens down this end so how can we improve getting patients to recognise the symptoms sooner can we bring the treatment forward to the patient by that the ambulance can do an ECG we've got the technology now where an ECG can be done on an ambulance sent to someone in the emergency department a heart attack diagnosis decisions made about giving treatment at that stage whether it's clot busting medicine or going to an angioplasty centre we're able to collect data in New Zealand about what's happening we're fortunate we've got a large registry that allows us to see what's happening to people who come in with heart attacks to suspect it's heart attacks across our country and we're able to look at a number of things and this is looking here at time to giving clot busting medicine what we can see here I'm not sure how well this projects but where the clot busting medicine is given pre-hospital again it should be an old brainer if you can give it in the ambulance it's going to be given you're going to achieve the timelines and the recommended time within 30 minutes out to 60 minutes sooner but as you can see there's a lot of variations still in delivery of clot busting medicine in New Zealand angioplasty is what we talked about with Eddie been sent to us in Waikato you can see there's a lot of variation here as well but the median time is just over 5 hours to get in the archery opened up so again the reason I show this is just to emphasise the importance of data if you don't measure what you do you don't understand what we can do to try and improve things it's important that we do continue to collect data and we can drill this down into each region each hospital is of what's going on locally so if we go back to Eddie Eddie really should be transferred immediately to a PCI capable centre after commencing the clot busting medication we also need to look at developing systems of care that support early diagnosis and rule in treatment remember I said about 1 in 5 people do not get treatment when they present with a heart attack we need to actually why is that and you don't understand why that is to develop systems that support early diagnosis and early treatment where appropriate for treatment clot busting medication we need to support that decision making earlier and we now are fortunate we've come together with St John's the cardiac network which I also chair and the cardiac society to develop a national STEMI pathway that recognises this and recognises the importance of getting people from A to B quickly and making the decision sooner rather than later so again if you look at what we want to do with Eddie and what pathway helps us to achieve we hope so again that's how he was treated what we want to do is make the decision to give us treatment when the ambulance picks them up so can they get on and initiate treatment in the ambulance yes no there's no point in going to Taranaki Taranaki is not a place we can do angioplasty so he should be transferred to the plastic capable centre we're not saying he would necessarily go to the cath lab to have a stem put in the middle of the night but if he needs it he's in the best place for us to make that decision so again that's just emphasising components of the pathway so we're saying patients should be transferred as a routine logistically this is going to take a little bit of while for us to work through in New Zealand but it's something that we are aspiring to and again the important thing is all of us is trying to align all our systems what about Rose so her archie was opened seven and a half hours from first symptoms Alan good bad it's not bad Rob good bad not good enough it's not good enough so again if you get back to what we were talking about earlier with that flow chart when she hits the medical system things move through pretty quickly what she did wrong is that she waited and it's not uncommon for people to wait because they don't know as Rob mentioned most people do not have a classical symptoms of a crushing elephant on their chest so it could often be very bad trying to work out what's going on but if we look at delays to treatment today delays are attributable to the patient so not quite knowing what's going on accounts for up to two thirds of the time before we get on and open up with the art trade more likely to arise in older people women people with diabetes and patients with lower socioeconomic status and public health campaigns are really important to try to increase awareness this is our last campaign with the heart foundation we ran it again last year we will run it again this year and what you see here is that pre-campaign it's increased during the campaign and there's a legacy effect for a period of time afterwards the problem is that it doesn't stay you've got to keep doing the campaigns also, and Rob alluded to this let's not forget that one in ten people with ischemic heart disease blockages in the arteries their deaths occur outside hospitals so what else did roles do that we would advise not to do in the heart foundation campaign she drove herself didn't she why do we recommend Darling 111 so it's to get prompt access to the fibroliter so if she develops a a rhythm problem it can be recognised and treated quickly and what we have seen and this is again data from ANZAC QI I'll bring you over to the end here comparing 2015 2016 patients with heart attacks arriving by ambulances they have increased slightly over that time period by about 6% so again it's an small but important finally just to mention Good Sam anybody heard of Good Sam so Good Sam's an app that's available was launched at the resuscitation meeting in Wellington a couple of weeks ago we all can sign up for this I think it's important that we all consider signing up for this if you know CPR we in New Zealand we need to become a community of lifesavers if you have a cardiac out of hospital cardiac arrest in New Zealand you've got just over a 10% chance of leaving hospital what's going to save more people's lives is people knowing CPR and knowing how to use an AED where the AEDs are Good Sam helps alert if there's an arrest outside here and you sign up to Good Sam Good Sam will notify you where the AED is so I'd encourage you to have a look at this on either the Apple store or Google Play and if you know CPR please consider signing up for it finally just to mention journeys sharing stories we found this really powerful and a motive on the heart foundation real people sharing their own stories to help and support others so if you haven't looked at the heart foundation website I'd recommend you have a look at the journeys section so Norman I'll finish up there and thank you very much for your attention Top of the evening after you're going to go to the brain of course and the final lecture this evening is presented by Professor Alan Barba Alan is the clinical leader of the Auckland City Hospital Strike Service and also is the Neurological Foundation of New Zealand Professor of Clinical Neurology in the Department of Medicine University of Auckland he's one of our preeminent neurologists and strike specialists he graduated from Otago and completed his Neurology training in Auckland in 1997 he then went on to the University of Melbourne and there was a PhD there in 2000 graduated in 2000 as thesis which is going to be touched on tonight of course is the fact that he looked at the role of advanced imaging techniques and identifying patients with the potential to respond to acute stroke therapies and after he returned to New Zealand in 2001 established an international leading stroke unit Auckland City Hospital and he was appointed to the Neurological Foundation Chair here in 2008 and as you'll hear in his talk tonight he's an innovative and leading researcher he's focusing on the use of advanced neurophysiology MRI imaging techniques and stroke and he's got a very engaging topic tonight pulling out plots to treat strokes, Ellen, over to you I feel a bit vulnerable being the only neurologist in this crowd up the front so I'll just get my talk up it's great to be here talking with you tonight and I'm going to talk about stroke but let's figure out what we're talking about a stroke is a sudden onset of a focal brain deficit caused by a problem with the arteries that's why it's called a stroke you get struck down the symptoms come on almost immediately and the arteries either block in about 80% of the cases or they burst in about 15% to 20% of the cases and I'm going to talk about the blocking sort of strokes so we've heard a little bit about atherosclerosis and atherosclerosis occurs in the heart arteries but it occurs elsewhere and it occurs in characteristic places and one of the characteristic places is in the carotid artery just in here, don't feel them both at the same time and where the artery branches there's turbulent blood flow and you get an atherosclerotic plaque laid down and it's but this is a characteristic place and you can see these in life this is an angiogram, these are the vertebrae there's some fillings and teeth this is the carotid artery this is the internal carotid artery go straight up into the brain and you don't have to be a rocket scientist to see that's not a good thing so that's what we would call a critical stenosis and blood can clot and block that and all sorts of terrible things can happen so they account for about a quarter of strokes and the other third of strokes are due to embolism from somewhere else and the usual side of embolism is the heart and the most common cause of embolai is a fibrillating heart and if the heart's fibrillating and not pumping clots form even on the inside of the body and if they get big enough they can break off they can go anywhere in the body or the brain they can eventually get to an artery that's too small for them to go any further and they block it off and you're in big trouble and this is a little cartoon if you watch down here that's a clot these are the arteries supplying the brain that's the middle cerebral artery supplies most of one half of the brain the clot comes up it's too big to go any further the brain downstream but all of this brain further out is getting reduced blood because over the top you're getting collateral flow from the other arteries it's coming around to try and keep the brain alive unless you break this clot down very quickly that infarct core that stroke gets bigger and bigger and that happens over a few hours and so like the heart you've got a few hours in which to do some good and you've seen this tonight already and to be honest if you remember nothing else from my talk tonight remember this, remember fast and I know most of you have probably heard this but people don't know what strokes are if you have chest pain, you're a middle aged man you know you're having a heart attack there are difficulties if you wake up in the morning and your arms numb people often think well I've just slept on it funny they don't go to the doctor that can be a problem and they're just not sure what's happening now big strokes people get to hospital pretty quickly but these smaller and medium sized strokes is a big problem for us so if someone has something suddenly because strokes get struck down they had some sort of funny turn think fast and so get the person to smile if one side of their mouth doesn't come up that's a clue now there are other causes of an uneven smile but they come on more slowly they come on suddenly that's a clue that it may be a stroke get them to lift up their arms if the arms paralyze that's pretty obvious but if it drifts down like that they might be having a medium or small stroke and then get them to say something because language in most of us sits on the left side of the brain the part of the brain that looks after language and if that's been affected by the stroke the person may not be able to understand what you're saying or they may not be able to express what you want to say or the muscles that make your speech may be weak and they've got slurred speech and the T is for time and that's the reason why and Jerry alluded to this is that you've got a limited amount of time to do something before it's all over before that infarct core has expanded and the strokes as big as it's going to get and look at the watch to see you know what the time is well when I was a junior doctor which doesn't feel that long ago but strokes were the last people with strokes were the last people seen on the ward round they were usually clarked in by the medical students and you saw them last on the ward round and they were in the corner and that was because there was nothing that you could do apart from good nursing care and physio-occupational and speech language therapy and since I was a junior doctor things have changed and as difficult it is to agree with Jerry he's right we're 10 to 20 years behind the cardiologists we've known since 1993 that stroke units for every 18 people you treat in a stroke unit compared with a general ward one more survives and is not disabled having said that we've only had stroke units in our hospitals and all of our big hospitals in the last five years it's taken that long to get stroke units in all hospitals a single aspirin for someone having an ischemic stroke for every 100 people you treat you prevent one from dying or disability so it's not the best treatment in the world you've got to treat 100 people to save one but it's very cheap and very effective we've known that giving alteplase the clot busting drug we still use alteplase but we're going to start using it anyway so we're following cardiology again giving alteplase into the vein clot busting drug we've known since 1996 that that's effective but still only about 10% of people with stroke actually get it in this country and that's not unusual around the world but what I'll probably talk around about the most is clot retrieval so this is going and fishing out the clot and this is really exciting after we did a visit with nothing happening in stroke medicine between 1996 and 2015 we've now got something we can do and it's for the biggest strokes the ones that are the most devastating so it's really exciting so this is a case of mine Mr A. the initial's been changed and that's not his age but you get the idea 64-year-old was getting ready for work six or seven years ago he'd been up, had a shower 20 past seven in the morning he had a sudden onset of right-sided weakness such that he fell over and he had slurred speech he got to hospital just over an hour later and he had no movement or feeling on the right side of his body and he couldn't speak at all so right-sided body the left side of the brain looks after the right side of the body so he's got a problem on the left the left hemisphere part of the brain looks after your language and so he's got we call a dysphasia this is a big stroke this is a scan and these are the temporal lobes so under the temples these are his eyes okay that's his lens that's the nerve that goes from the back of the eye to the brain and these are the muscles that actually move the eyes anyway these are the arteries okay that's the middle cerebral artery on one side and that's the middle cerebral artery on the other side and when you're looking at a scan when I'm in the head lecturing students look for the difference between the two sides and this artery is nice and juicy and this artery stops there can you see that? and that's a clot and so this is a zangiogram so we get a little wider you can't even see that but a little bit thicker than that maybe that feed it up through the femoral artery this is actually the catheter you can see it here squirt, die and take X-rays as you're going I'm sort of exactly like the coronary angiography this is new for stroke so we're really excited about it this is the middle cerebral artery and look what happens it stops dead this is a skull I don't know if you can see that but there's nothing there's no blood flow there that's a big problem this is a massive stroke these are the biggest strokes you can have and a significant number of people with a stroke like this died maybe 60-70% and the rest of the people are left disabled these are the biggest strokes you can have this is a perfusion study this is some of the advanced imaging this is where there's reduced blood flow that's almost half as brain and that's going to die in the next few hours probably in the next six hours now we've got the clot busting drug but this is the problem with clot busting drugs for big strokes this is what we show patients when they come in with a little pictogram of these are the benefits and the risks these are 100 figures and for every 100 people we treat with the clot busting drug for stroke we help 13 really well they go home basically normal and about a third of people we help or they go home normal we actually harm three because you cause bleeding you open up the clot the brain's dying it's all mushy that's not a medical term and if you open up and restore blood flow you can get bleeding into the brain and so for every 100 people we treat we cause bleeding in three the cardiologist you cause it for every 100 it's one but for us it's three the problem with alteplase is this two thirds of the people it has absolutely no effect on and the reason why that is is because it's no good at dissolving big clots don't have to worry about these these are the different arteries but for Mr A when I start that infusion running into his vein there's only a 30% chance it's going to open up the artery there's a 70% chance that it's not going to open up the artery and that trust me that makes your heart sink so it's effective but it's not particularly effective and it doesn't dissolve big clots so for a long time we've been looking for ways at trying to open up clots and we've tried suckers we've tried corkscrews we've tried everything and we were involved here in a large Australasian stroke trial we're basically all the stroke doctors in Australia and New Zealand took part and it was one of five international studies that were published at the same time testing what we call a stent retriever which is a little bit of chicken wire very fancy and expensive and what you do is you feed it up through the femoral artery squirting so you know where you are this is the middle cerebral artery stem this is where Mr A's got his clot and unlike previously where we used to nibble at the clot and suck the clot and corkscrew the clot from the proximal end from this end with this technique you actually go all the way through the clot and then you open up the chicken wire stent coming back and so that means you're not pushing the clot further upstream and you're not breaking bits of clot off going upstream and then once you've got it like that you pull and suck and you convert a patient like this to this so that was the artery that was blocked and you restored the blood flow to most of one half of his brain and you just hope it was soon enough to prevent that infarct core from having expanded too much this is the clot so that's fingernail fingernail's about a centimetre that's the little chicken wire stent this clot's two or three centimetres long and it's not a surprise that the clot busting drugs don't dissolve that it's just a big clot and by the following day he'd gone from being paralysed down the right side not being able to speak to having mild right-sided weakness he went home after four days and when I saw him for follow-up at three months he had a 60 to 70% chance of dying and an almost 0% chance of having a good functional outcome and he would have still been in hospital at three months so that's endovascular clot retrieval so how are we doing so this is brand new this is really exciting and so far we've treated 310 patients in New Zealand most of these are in Auckland but Christchurch is ramping up they've done 50 and Wellington's done a few and they're ramping up people are about 64 years of age our eldest person is 92 we don't have an age cut-off if the 92-year-old is driving and delivering meals on well she gets the treatment slightly more men than women and these are the number of cases so this is a good example of taking part in research improves clinical care so we're bounselling 11 through today and we're bouncing along on the bottom and these are the people that were in our trial and there aren't that many of them but it meant that here in Auckland we were ahead of the pack in the world because we took part in the trial we know how to do it we're experienced with it and when our trial and the other four trials were published at the same time in 2015 the numbers have taken off and this is where we project at the end of this year and it'll be double that next year so exponential growth so this is hot off the press and we're one of the more active centres in the world so how do we do this is for the cardiologists we call it a tiki score not a timi score and we open about 87% of the arteries either completely or near completely and if you don't open the artery the brain's going to die and so the ability to open up 80 odd% of the arteries as opposed to 30% with the clock-busting drug it's a no-brainer that was that was not intentional so how good is it it's really good and these are the biggest strokes these aren't the small ones do you know about the concept of number needed to treat the number needed number of people you need to treat to get something the number needed to treat to see a significant improvement is 2.6 so for every 2.5 people we treat we see a significant benefit in one and by significant benefit I mean moving someone from private hospital level care to rest home care or from rest home care to going home but needing help or from going home and needing help to being independent so a shift of one point on that scale so for every 2.5 people we treat for every 5 people we treat one goes home normal that wouldn't have and for every 6 people we treat there is one less person who requires long-term hospital level care so back of the envelope calculation there's 210 patients we've treated so far there are 130 odd who are significantly improved people who are independent who wouldn't have been and there are 52 people who have avoided hospital level care and talking to hospital there's no hospital managers here they're only interested in this figure hospital level care is $100,000 per year for the rest of that person's life so they like that because if there's 52 more of them you add that up it's a lot of money saved so how do we do this in New Zealand well timing is everything you know time is brain so as sooner you start treatment the more likely this is going to work it's technically challenging you need a highly skilled team and at present there are only 3 places in the country that can do it so this is like cardiology 20 years ago and so we do it at Auckland and we do it at Wellington and we do it in Christchurch and we have piggybacked on the cardiac experience with flying people up and down the country so these are helicopter flight times so the patients we've treated here at Auckland a significant number of them have come from outside of the Auckland metro area Northland we cover Taranaki we had our first patient from Hawkes Bay in the weekend and similarly in the South Island Christchurch provides a service so as I said when I started when I went off when I was trained to be a neurologist and I said I wanted to do stroke my senior colleagues thought that that was fine but I'd have to do something else proper as well because there was nothing that could be done about stroke and over the years we followed behind the cardiologists with the stroke units the clot busting drugs and now with stent retrieval pulling out the clots this is really exciting it's just fantastic we're only just starting we're only doing the big strokes at the moment but I've got no doubt in the next few years we'll be going into smaller and smaller arteries these are drain pipes compared with what the cardiologists are doing and so in the next few years we'll be going into the branches smaller and smaller branches and treating patients with stroke like this so I will stop there and thank you very much for your attention well it's 8.30 exactly and I'd like to do just two things to wind this up first of all thank you as an audience I think it's been practically a full house and you've been wonderfully attentive, very patient and the questions have been terrific indicating your close attention I'd rank you above any sort of average class of medical students for attention well I don't mean that really but on your behalf to thank the sponsors as were AMRF Heart Foundation but particularly the speakers I think you've heard three superb presentations those are all state of the art believe me and I'm just going to thank them personally I've been contemplating for the last half hour whether I should really sample the contents of these boxes before handing to them but I'll leave that just please as we finish up show your appreciation for these wonderful presentations really thank you