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Core Clinical Programmes

Core Clinical Programmes

The National University Heart Centre, Singapore offers 6 core programmes that have been selected for their relevance and strategic importance in light of Singapore’s ageing population.
These programmes are:
 
  • Heart Failure Programme
  • Congenital and Structural Heart Disease Programme
  • Women’s Heart Health Programme 
  • Acute Coronary Syndrome Programme
  • Heart Rhythm Programme 
  • Vascular Medicine and Therapy Programme

What is Heart Failure?

Heart failure is a syndrome of multi-system/multi-organ dysfunction directly or indirectly caused by impairment to the ventricular functions. The cornerstone of heart failure is the elevated filling pressure to the right and left ventricles, best expressed as high right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP). More often than not, the cardiac output (CO) is inadequate for the metabolic needs of the organs, or that it may be relatively insufficient for the degree of utilisation. The resultant pathophysiological changes are complex, but it can be appreciated by renin-angiotensin-aldosterone-sympathetic system (RASS) activation. Increased plasma volume from salt and fluid retention eventually leads to volume overload, and pulmonary edema.
 
Some experts describe heart failure as ‘cardio-renal anemia syndrome’, reflecting the vicious cycle dysfunctional ventricular pump functions have on the rest of the organ systems.   
 
Based on the contraction fraction of the left ventricle, heart failure can be differentiated as:
  • HFrEF (heart failure with reduced ejection fraction less than 40%) 
    • The problem lies in ineffective contraction – less oxygen-rich blood is pumped to the rest of the body as the heart muscle in the left ventricle does not contract with sufficient force. 
  • HFpEF (heart failure with preserved ejection fraction more than 40%) 
    • The problem lies in ineffective relaxation – this causes less blood to enter the heart as the ventricles do not relax properly even when the heart contracts normally.

Causes for heart failure include:

  • Ischaemic heart disease – ischaemia occurs when there is a reduction of blood flow carrying oxygen to a particular part of the body; the muscle of the heart suffers from abnormal function as a result of a reduction of oxygen-rich blood flow.
  • Heart attack or myocardial infarction
  • Hypertension
  • Diabetes
  • Valvular heart disease – a group of conditions characterised by the damage or abnormality of one of the four heart valves 
  • Cardiomyopathy – this refers to diseases relating to the heart muscle where the heart enlarges, thickens or becomes rigid due to damage or abnormalities of the heart muscle.
Heart failure is a common condition with serious consequences. 
 
The occurrence of heart failure increases as we get older and is a progressive condition that will impact the social, mental and physical well-being of the patient. 

 

How do we make the diagnosis of heart failure?

Diagnosis of heart failure is essentially clinical, i.e. based on history and physical examination. European Society of Cardiology Acute and Chronic Heart Failure Guideline in 2012 detailed the following:
 
​Symptoms
Signs
​Breathlessness
​Elevated jugular venous pressure
​Orthopnea
​Hepatojugular reflex
​Paroxysmal nocturnal dyspnoea
​Gallop rhythm
​Reduced exercise tolerance
​Cardiac murmur
​Fatigue, tiredness
​Ankle swelling
​Abdominal swelling
Reference: European Society of Cardiology
 
There are, however, less typical or common presentation of heart failure, such as feelings of bloating and night coughs. 
 

How do we investigate?

An in-depth understanding of patients’ cardiovascular performance is important for accurate diagnosis and for administering appropriate treatment for patients. Invasive and non-invasive functional and blood circulation evaluations with the use of laboratory tests, echocardiography or even pulmonary artery catheter (PAC), among others, may be performed to fine-tune diagnostic intricacies of complex syndromes; functional studies such as cardiopulmonary stress test (CPET) – a non-invasive assessment of a patient’s cardiovascular and respiratory system during exercise, may be conducted to determine exercise capacity and determine prognosis. Finally, perfusion stress test and coronary angiography may be required to determine the role of Coronary Artery Disease (CAD) in causing heart failure.

​Non-invasive methods 
​Invasive methods
  • ​Electrocardiogram
  • Chest X ray
  • Laboratory tests including renal and liver function, full blood count, iron studies
  • Cardiac biomarkers including BNP^
  • Echocardiography
  • Myocardial perfusion imaging
  • Stress echocardiography
  • Cardiac magnetic resonance imaging (CMR)
  • Cardiopulmonary exercise test
  • Right heart study
  • Coronary angiography
  • Endomyocardial biopsy

The principle of management – therapy

Based on established international guidelines, there are categories of therapeutic drugs that are ‘mandatory’ in heart failure due to their efficacy. These include Beta-blockers, Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin II receptor blockers, mineralocorticoid receptor antagonist, specific funny-channel inhibitor (Ivabradine), and digitalis. Anti-platelet and anti-coagulation drugs are frequently prescribed according to indications.
 
In addition to guideline-driven drug-based optimal medical therapy, the National University Heart Centre, Singapore (NUHCS) Heart Failure Programme is also equipped with capabilities of implanting medical devices such as cardiac resynchronisation therapy (CRT) and automatic implantable cardioverter defibrillator (AICD) in suitable candidates to achieve clinical benefit beyond drugs. Atrial fibrillation (AF) and ventricular tachycardia ablation can also be performed if these rhythm disturbances are directly contributing to heart failure control. 
 
The emphasis of the NUHCS Heart Failure Programme comprises of: 
  • Seamless, coordinated care from multiple disciplines
  • Nurse-led phone-based tele-monitoring of clinical progress, and remote tele-monitoring of body weights
  • Pharmacy-led Medication Titration and Monitoring Clinic as well as Medication Titration and Reconciliation Clinic  
  • Close networking with Arrhythmia clinics, for optimal management of electrical conduction abnormality and implantable device optimisation
  • Heart failure cardiac rehabilitation to help symptomatic patients return to an active and satisfying life via supervised exercises
  • Empowering patients via counselling and education to better manage their heart disease as well as medications
  • Incorporation of research and clinical databases to advance the boundary of clinical knowledge. Patients and caregivers occupy the centre of a complex matrix of healthcare disciplines.
  • Other heart failure-specific therapy within our capability: inpatient ultrafiltration therapy for diuretic resistant inpatients, ambulatory home-inotrope therapy for the advanced patients, as well as ECMO (extracorporeal membrane oxygenator) for the advance cardiogenic shock inpatients

National University Heart Centre, Singapore Heart Failure Programme

The National University Heart Centre, Singapore (NUHCS) Heart Failure Programme is built on a multi-disciplinary, holistic healthcare delivery platform to care for patients with heart failure syndromes.
 
The programme consists of heart failure physicians, nurse coordinators, pharmacists, physiotherapists, and psychiatrists, working in close relationship with dietitians and specialists from other disciplines such as pulmonologists and endocrinologists. We work particularly closely with our psychiatry and palliative care colleagues to better manage advance bodily symptoms and alleviate depressive moods. The sub-programmes of NUHCS heart failure include Heart Failure Discharge Clinic, Heart Failure Rehabilitation Programme, Heart Failure Arrhythmia and Devices Clinic, and Cardiomyopathy Clinic. NUHCS also runs dedicated Post-myocardial infarction clinic and Valve clinic that care for related cardiac conditions.
 
The diversification and sub-specialisation of the umbrella NUHCS Heart Failure Programme enhances and streamlines the comprehensive approach to diagnostics, therapy and rehabilitation of heart failure syndromes of all kinds. The cornerstone of the NUHCS Heart Failure Programme is the heart failure specialist-run multi-disciplinary clinics. These consist of new cases, follow-up and discharge clinics to address the specific clinical needs of patients. Specialised pharmacy clinics are also created, focusing on better understanding of the prescribed drugs, drug-drug interactions, and compliance of patients and caregivers. 
 

How do we measure outcome?

NUHCS Heart Failure Programme is designed to provide quality care to patients. Guideline-based medications utilisations are tracked to ensure 100% compliance to international guideline recommendations. Clinical outcome events such as 30-day and 6 months re-admissions, inpatient and intermediate-term deaths are tracked constantly to ensure the best possible outcome for the patients. 
 

Research

NUHCS works closely with the Cardiovascular Research Institute to conduct various competitive-grant funded bench-to-bedside researches. It also takes on numerous industry-sponsored international trials to test out therapies in heart failure. 
 

Partnership with primary healthcare for Heart Failure patients

Family physicians play an important role in the holistic care of a heart failure patient. They can provide patient care ‘closer to home’ and improve patient satisfaction, assist in appropriately treating patients according to guidelines given the longer waiting time at the institutions, avoid unnecessary emergency heart failure and AF admissions through early medical attention and treatment, improve current heart failure and AF knowledge base among patients and family members, and last but not least, provide timely ‘end-of-life’ discussion. 
 

Final Word

The holistic management of heart failure must include aggressive lifestyle modifications. These consist of smoking cessation, regulation of salt and fluid intake, and adoption of calibrated exercises wherever possible. Additionally, adopting and maintaining an optimistic view of heart failure outlook is critical in fighting off negative sentiments and depression. Above all, family members and loved ones play a crucial role in supporting patients through the thick and thin of the disease.
 

Our Doctors

Dr Chai Ping
 

Our Heart Failure Coordinators

Ms Seow Yen Hoon
Ms Tan Poh Tin
Ms Christine Tioh

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Introduction 

With the tagline “Growing up with you”, the Congenital and Structural Heart Disease (CHD) Programme offers CHD patients at NUHCS a continuum of care throughout their lifetime. 

Additionally, under the care of a multi-disciplinary team of specialists, parents with a history of CHD are offered specialised care from before pregnancy till after their child is born. These include:
  • Pre-natal testing
  • Genetic counselling
  • Ante-natal screening and imaging during pregnancy
  • Screening of their newborns for CHD

The programme also manages patients with acquired structural heart disease such as valvular heart disease 

Specialised conditions 

This programme includes the diagnosis and management of:
  • Congenital heart disease in children
  • Adults with congenital heart disease
  • Complications of congenital heart disease such as:
    • Heart arrhythmia
    • Heart failure
    • Pulmonary hypertension
    • Acquired valve disease/structural heart disease

 

Treatments offered 

The treatments offered include:
  • Congenital heart disease correction surgeries
  • Specialised percutaneous implantation of devices in the heart to seal congenital defects without the need for an open-heart surgery

Specialised care for complications arising from CHD such as:

  • Heart arrhythmia
  • Heart failure
  • Pulmonary hypertension
  • Transcatheter aortic valve implantation
  • Mitraclip mitral valve repair
  • Left atrial appendage closure
  • Paravalvular leak closure
  • Percutaneous mitral Valvuloplasty 

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Introduction 

Cardiovascular disease (heart disease and stroke) is the number 1 killer of women in Singapore. However in 2009, < 10% of the women taking part in the Singapore Heart Foundation’s Go Red for Women Heart Health Awareness Survey were aware of this important fact. 

The NUHCS’ Women’s Heart Health Programme offers a programme dedicated to deliver holistic care to women with and at risk of heart disease. 

This programme offers a wide range of cardiovascular services tailored just for women focusing on personalised and holistic patient care. We work closely with specialists and health professionals from other medical fields to provide one-stop, multidisciplinary patient care.

Its unique feature is the collaborative care of women with or at risk of heart disease by an all women’s multi-disciplinary team consisting of:

  • Fitness experts
  • Nutritionists
  • Mental health experts
  • Occupational therapists
  • Obstetricians and gynaecologists
  • Rheumatologists
  • Women health nurse clinicians

Specialised services

  • Preconception counselling in women with heart diseases and high cardiovascular risks
  • Heart diseases in pregnancy
  • Heart diseases in women including Takotsubo cardiomyopathy, non-obstructive coronary artery diseases, heart diseases related to autoimmune conditions, heart failure with preserved ejection fraction
  • Cardiovascular health screening and risks management

Treatments 

Treatment plans offered involve a personalised, holistic approach with cardiac treatment options and technologies, involving cardiologists from all sub-specialty areas and medical experts from other disciplines. 

In addition, this programme offers:

  • Cardiovascular risks evaluation to identify risk factors for heart diseases and other common diseases that affect women
  • Cardiac diagnostic evaluation with an integrated approach tailored to the unique features of heart diseases in women
  • Cardiovascular risk management that encompasses a comprehensive approach of managing cardiovascular risk factors unique to women 
  • Specialty management of the cardiovascular conditions that affect women more than men
  • Services with specific emphasis on lifestyle modifications to achieve heart healthy lifestyle including healthy cooking and eating, personalised exercise prescription, stress management, smoking cessation and more

Acute Coronary Syndrome Programme

Introduction 

The Acute Coronary Syndrome Programme is aimed at providing timely care for patients presenting with a heart attack (myocardial infarction). 

In medical jargon, the term “door-to-procedure” is defined as the time taken from presentation at the hospital to the initiation of a treatment procedure. This “door-to-procedure” time is currently set internationally at < 90 minutes. This is the duration from diagnosing a patient with a heart attack to the moment the affected coronary artery is unblocked by coronary angioplasty.

By working with the nurses and specialists from the NUH Emergency Department, the NUHCS team has reduced the “door-to-procedure” time for a patient suffering from a heart attack to 45 minutes. In fact, 96.5% of NUHS patients were treated within 90 minutes compared to 37% in the United States of America (USA) National Registry of Myocardial Infarction (NRMI) reports.

Additionally, we now work collaboratively with NTFGH and the Singapore Civil Defence ambulance service in expediting patient care for patients with suspected acute coronary syndromes.

Specialised conditions 

This programme includes the diagnosis and management of acute coronary syndrome which include heart attacks or its prelude. 

The treatments offered include:
  • Medical treatment with medications to help relieve symptoms and improve blood flow in the coronary arteries
  • Specific surgeries depending on the severity of the condition such as:
    • Coronary angioplasty and stenting
    • Coronary artery bypass grafting surgery (CABG)
  • Emergency treatment for patients presenting with a heart attack that includes
    • Thrombolysis (the use of medications to break down clots which may have caused the heart attack)
    • Coronary angioplasty and stenting/ballooning
  • Optimisation of cardiovascular risk factors and care to minimize disease recurrence. 

Heart-Rhythm-Programme

Introduction 

Heart rhythm conditions (arrhythmias) often require complex procedures that are available in tertiary cardiovascular centres such as NUHCS. 

The NUHCS’ Heart Rhythm Programme or Arrhythmia Service forms an important partnership with the Heart Failure Programme, where it co-manages high-risk patients. 

The collaboration between the heart rhythm and heart failure programmes is important as heart failure patients frequently have arrhythmias. Cardiac devices such as biventricular pacemakers and defibrillators improve outcomes and quality of life in heart failure patients. Electrophysiological study and ablation may also be required in these patients to manage rhythm disorders.

With an ageing population,  inappropriately slow heart rhythms (bradycardia) and conduction blocks are increasingly common as is arrhythmias such as atrial fibrillation.

In addition to having experience in these tertiary-level cardiovascular services, NUHCS is a regional referral centre for arrhythmia and heart failure related disorders.

Specialised conditions 

This programme includes the diagnosis and management of:
 
  • Heart arrhythmias such as:
    • Premature (extra) bears
    • Supraventricular arrhythmias
    • Ventricular arrhythmias
    • Bradyarrhythmias
  • Heart failure
  • Congenital and structural heart disease with arrhythmia
  • Cardiac implantable devices 
  • Pacemakers
  • Biventricular pacing (cardiac resynchronisation therapy)
  • Implantable defibrillators
  • Implantable loop recorders

Treatments offered 

The treatments offered include:
  • Counselling on lifestyle changes
  • Medications that help:
    • Control and regulate the heart rate
    • Reduce the risk of stroke
  • Surgical procedures such as:
    • Electrophysiological study (EPS) with radiofrequency ablation
    • With/without 3-dimensional electroanatomical mapping
    • The implantation of a pacemaker, which is a small electronic device that maintains the heart rate
    • Specialised (biventricular) pacemakers in the treatment of heart failure to “resynchronise” the heart leading to an improvement in heart function, reduction in heart failure hospitalisation and improvement in survival.
    • Implantation of a cardioverter defibrillator that is capable of detecting a dangerous heart rhythm when it occurs and deliver a “shock” to rescue the patient
    • Implantation of a loop recorder to diagnose infrequent arrhythmias, aid diagnosis in unexplained syncope or suspected occult atrial fibrillation 

Vascular-Medicine-and-Therapy

Introduction 

The Vascular Medicine and Therapy Programme brings together specialists from cardiovascular medicine, vascular surgery, radiology, neurology and nephrology to provide personalised care for patients.

The lack of awareness for atherosclerosis (hardening of the arteries) often leads to patients seeking late treatment for multi-level ailments that involve the brain, heart, kidney and lower leg arteries. This results in a higher incidence of lower limb amputation, diseases of the heart and blood vessels as well as death (mortality). 

One key component of the programme is limb preservation service. By introducing a personalised patient care plan comprising of cardiologists and vascular surgeons, NUHCS aims to reduce the rate for lower limb amputation in these patients.

Specialised conditions 

This programme includes the diagnosis and management of vascular disease or diseases of the blood vessels (both arteries and veins) such as:
 
    • Atherosclerosis
    • Varicose veins/Chronic Venous Insufficiency/Venous ulcer
    • Deep vein thrombosis
    • Diabetic vascular disease

Treatments offered 

The treatments offered include:
 
  • Counselling for lifestyle changes
  • Medical treatments
  • Surgical procedures to repair the affected blood vessels
  • Other non-surgical treatments such as:
    • Structured exercise programmes
    • Compressions bandaging
    • Physical therapy

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