Mr. Neil Johnson:

I thank the committee for the invitation to address it. I represent Croí, the west of Ireland heart and stroke foundation, and the NIPC. Croí is a charity which was established in 1984 to lead the fight against heart disease and stroke in the west. The NIPC was established in 2014 and is an independent medical research and education institute committed to driving the cardiovascular disease prevention agenda in Ireland. In the context of a cardiovascular health policy, we wish to highlight some key challenges for Ireland, to outline some unmet needs and to make some specific asks of members as guardians of our health service.

Despite the enormity of the Covid pandemic, we must not be distracted from the fact that cardiovascular disease remains the biggest cause of death globally and in Ireland. The burden of this disease is enormous and growing, driven in particular by the increase in diabetes and obesity. Covid-19 has added an additional burden. Thousands of our patients have had their heart procedures and hospital appointments cancelled or postponed. Consider those who could not get to see their doctor, those who delayed or avoided seeking help and who are now living with the consequences, those with long Covid cardiac complications and together we have a tsunami of post-Covid cardiovascular disease burden coming down the tracks. From a policy perspective, this burden requires urgent attention if our health system is to cope.

Against this background, we live in the absence of a formal national cardiovascular health strategy. As already mentioned, the last strategy expired in 2019. We urgently need a comprehensive strategy to tackle classical cardiovascular disease, that is, cardiovascular disease caused by atherosclerotic disease, or ASCVD, whereby lifestyle and behaviour factors such as high cholesterol, smoking, diet, lack of exercise, etc., are largely preventable risk factors.

We also need to tackle age-related heart conditions, which are primarily a function of vascular ageing. The development of a strategy needs to embrace the views and needs of all stakeholders across the continuum of care, and the patient perspective is central to that. Chronic diseases, of which heart disease is a major contributor, place the greatest demands on our health system, largely presented in the third age, that phase of life from 60 years onwards. Global and national age demographics predict a growing aged population in the coming years. We are living longer but we are not adequately focused on reducing the consequential health burden. We need a specific third age strategy for early detection, early diagnosis and early treatment of age-related heart conditions such as hypertension, atrial fibrillation, heart failure and heart valve disease. All these age-related conditions, which can be life-threatening and cause chronic disability, could be detected by annual low-cost diagnostic tests, for example: taking a simple blood pressure measure for hypertension, a major cause of heart attack and stroke; checking a pulse for atrial fibrillation, the major cause of devastating stroke; a blood test, proBNP, as a marker for heart failure; or a simple stethoscope examination, which can detect a heart murmur indicative of heart valve disease. Croí recently launched a pilot third age programme in County Mayo supported by HSE West and Mayo County Council and we look forward to publishing the outcomes of this shortly.

What has been and remains significantly absent from our national approach to cardiovascular disease is a serious commitment to prevention. We urgently need a dedicated national cardiovascular disease prevention strategy. In parallel but equally important to the development of acute care and interventional cardiology, we need to advance preventive healthcare and the science of behaviour change. The NIPC has commenced the development of a national white paper in this regard and, when it is completed, we would welcome the opportunity to present it to the committee. In Ireland what little focus there is currently on prevention from a strategy perspective is on secondary prevention, primarily cardiac rehabilitation for those who have had an event. However, despite the overwhelming evidence of the benefits and importance of cardiac rehabilitation, we have neither agreed nor adopted a national standardised model of care. Equally, a crucially important area of need is primary prevention, where the focus should be on those at highest risk. These are typically individuals without any symptoms but whose cardiovascular disease risk profile puts them at a high risk of a heart attack or stroke. At the Croí Heart and Stroke Centre in Galway we have just completed a very successful demonstration of an effective community-based intervention programme called MySláinte. The development of this evidence-based programme was supported by innovation funding through Sláintecare and it has delivered compelling evidence on the effectiveness and benefits of a multidisciplinary, nurse prescriber-led prevention and rehabilitation programme for high-risk individuals. It was set up during the Covid pandemic as a completely virtual programme and was the only one of its kind in Ireland. In the context of challenges, we wish to impress on the committee the growing burden of disease our citizens face, exacerbated by Covid. Ireland now needs unprecedented policy action to reduce premature death and disability, with its associated enormous economic costs.

As for our calls to the committee, we seek its support as follows. We urgently need a radical national cardiovascular health strategy which can tackle the human and economic burden of the disease. Unlike the previous strategies, we need equal focus on prevention and acute care, and the development of a strategy must involve patients as key stakeholders. We need a strategy which will respond to the burden of atherosclerotic disease. ASCVD is the umbrella term for heart conditions caused by fatty build-up in the lining of the artery wall, the major cause of heart attack and stroke. High cholesterol plays a big part in ASCVD. One cause of high cholesterol has its origins in a genetic condition known as familial hypercholesterolemia, FH. Approximately one in 500 Irish people has this condition and regrettably remain undiagnosed until they experience a cardiac event, usually before the age of 40 which is very often fatal. If someone has FH, there is a 50:50 chance that a parent or sibling has it. In Ireland this lethal condition remains underdiagnosed and undertreated because we do not have a strategy on screening, detection, referral, specialist care or treatment. The absence of a national strategy on FH is allowing our citizens to die prematurely from an easily detectable and easily treated lethal condition.

We need a strategy which responds equally to the degenerative heart conditions linked to vascular ageing. In particular, we need to address forgotten conditions such as heart valve disease, which is common, serious and treatable. One in eight people over the age of 85 has moderate to severe heart valve disease. The prognosis for untreated severe aortic stenosis is worse than most cancers, yet heart valve disease has not even been mentioned in our previous cardiovascular health strategies. We ask the committee to ensure that, going forward, this treatable condition comes into focus to ensure early and timely diagnosis and treatment. The cost-effectiveness of annual mini cardiac screens, for example, for everyone over the age of 60 might be worth evaluating. We need a strategy which adopts and implements a national model of care for cardiac rehabilitation, supported by the necessary resources to provide comprehensive programmes that are accessible to all. We need a strategy which embeds primary prevention as a central activity in the proposed community hubs, and we strongly recommend the adoption of the Sláintecare-funded Croí MyAction programme as a suitable and scalable model.

In light of recent media attention on the importance of first responder CPR and defibrillation, we call for greater emphasis on bystander CPR training and suggest it be an obligatory part of the senior cycle curriculum in second level schools. The more people trained the greater the likelihood of effective, life-saving CPR in cases of out-of-hospital cardiac arrest.

We also need national policies and guidelines for sports and community organisations with regard to first responder training, defibrillator access and equipment maintenance, etc. Most importantly, we need support for a critical incident and trauma debriefing service. At Croí, we have noticed an increasing demand for this service, as more public access defibrillators have become available.

I thank the committee for this opportunity to address it.