Singapore collaboration

A well-established research connection between the Christchurch Heart Institute and the National University of Singapore is enabling innovative work with significant global implications, changing the way heart failure is viewed from one art of the world to another.

It is no exaggeration to describe members of the Christchurch Heart Institute as international cardiac research pioneers.

Since the mid-1980s, the University of Otago, Christchurch-based group has been at the forefront of global natriuretic peptide research. Natriuretic peptides are a family of heart hormones which (in part thanks to the work of the Christchurch Heart Institute) are now widely acknowledged and applied in the testing and management of most forms of heart disease.

The Christchurch Heart Institute (CHI) grabbed the international research community's attention in 1985 as the first to prove how the cardiac natriuretic peptide ANP affects the human body, including its actions on the heart, kidneys and circulation. A decade later it was first to show the hormone BNP could be used to diagnose heart failure. In 1996, the group cemented its place as leaders in the world of cardiac research with its discovery of peptide NT-proBNP and a subsequent treatment strategy based on serial measurement of levels of the hormone in patients' blood.

CHI director Professor Mark Richards has worked with the group, formerly known as the Christchurch Cardioendocrine Research Group, for more than 25 years. His personal expertise in cardiac research, specifically clinical and translational work, led the National University of Singapore to headhunt him to establish a research programme to emulate the successful Christchurch model.

Richards says Singapore is facing an epidemic of cardiovascular disease, like many nations that have rapidly evolved from developing to first-world economies.

“The National University of Singapore observed that the Christchurch Heart Institute had a translational character, which means we do things right from the cell and the DNA, all the way through to the patient in the clinic. They wanted something similar set up with that across-the-board, or bench-to-bedside capability.”

Richards has been working jointly in Singapore and Christchurch for about five years. The collaboration is already paying dividends for both parties.

“The Singapore connection is becoming increasingly relevant to New Zealand. We have some quite large shared projects running in parallel, triggered and enabled by that connection.''

For example, a large heart-failure study with exactly the same design and questions in both countries is looking at characteristics of heart-failure patients, how they are managed and their outcomes. And, Richards says, some significant – and intriguing – differences are already emerging that will change how heart failure is viewed from one part of the world to another.

New Zealanders develop heart disease much later than their Asian counterparts, he says. New Zealanders and those in the UK, USA and western Europe are admitted to hospital with their first episode of heart failure between age 70 and 75. In Singapore and large parts of Asia the average age is late 50s to early 60s.

Diabetes also appears to be a bigger issue in Asia than in New Zealand or other western nations. Half of newly-diagnosed Asian heart-failure patients have diabetes, compared with about 20 per cent in New Zealand.

Richards says the Singapore collaboration is enabling research projects that would otherwise not happen.

“Singapore puts a lot more money into life sciences; we can take advantage of that. We can produce a good idea and there may be money and equipment to take that forward in Singapore which would not be possible here.”

The Singapore connection has also enhanced the reputation of the CHI – and New Zealand scientists in general – on the international research scene.

“Singapore is a very cosmopolitan place and a lot of very senior people from all disciplines of health sciences are visiting to give talks and getting to know who is there. Me being there and developing a group there has become noticed, and Christchurch has become further noticed as a result,” Richards says.

One particularly significant achievement for the Christchurch group is the inclusion of its heart-failure treatment strategy in clinical guidelines set by august bodies such as the American Heart Association and European Society of Cardiology. The group's heart-failure test and treatment strategy means patients' care is guided by their levels of NT-proBNP.

“Our markers, or tests, for cardiac peptides are validated and recommended in all international guidelines now."

"What this means is that if you talk to a cardiologist in Singapore or Washington or London or Paris or New Zealand, they will all quote the same guidelines for treatment and apply the same attention to NT-proBNP results. I think it's one of the surest signs of validity and acceptance of our work globally.”

Research into the group's impact on patient care is no less impressive.

An international study of follow-up trials by respected researchers in 35 centres who adopted the CHI's heart-failure strategy found it resulted in 35 per cent fewer deaths in patients aged under 75.

The group is also working with other research centres internationally to define the best use of the acknowledged heart marker, troponin, to determine which patients suffering chest pain can safely be sent home from the emergency department. Richards says this is revolutionising the use of emergency department space in Australasia and further afield.

“If you add the results of our work in accelerating diagnosis in the emergency department, reducing length of stay in hospital and monitoring treatment against our NT-proBNP strategy, we are reducing mortality from heart failure by 20 per cent.

“When you consider that there might be 25 million people in the world with heart failure and they are facing something like a 20 to 25 per cent annual mortality, that's more than a million fewer lives lost per year should our findings be applied worldwide.”

These achievements mean the group is regularly invited by eminent global cardiac groups to collaborate.

The list of countries in which the CHI has ongoing research connections and joint publications is extensive.

It includes a long-term relationship with Massachusetts General Hospital and Harvard University in Boston; groups in Austria, Germany, the Netherlands, Spain, the UK, Australia and Switzerland, as well as many parts of Asia.

Collaboration is not only a desired situation but, because of New Zealand's low levels of investment in health research, an essential one, Richards says.

“There is no question we need to be more collaborative. New Zealand has always tracked along as almost the lowest country in the OECD for the amount of money it puts into health sciences research. We are concerned with health care and spend 10 per cent of our national funds on the health system, but we put only a fraction of one per cent of GDP into health research and we haven't increased that, in fact it has slowly shrunk in real terms, over decades,'' he says.

“If we want to foot it on the international stage we have to use others' resources and ride on their financial coat tails. We have to be bright enough and come up with the ideas for other well-funded places to put money into our research.''

If history is anything to go by, the Christchurch Heart Institute will have plenty of good ideas to continue saving lives in New Zealand hospitals and those around the globe.