Advancing cardiovascular health: prevention, risk management and emerging insights

This issue of the Singapore Medical Journal focuses on Cardiology and the papers are curated to highlight the ongoing research and hot topics in this field.

The review article on pulmonary hypertension (PH) in pregnancy is a collaborative effort between the Department of Obstetrics and Gynaecology and Department of Cardiology of National University Hospital, Singapore.[1] Ong et al. explored the associations between PH and pregnancy, which sometimes are encountered concomitantly and often result in negative maternal and fetal outcomes. However, with the emergence of recent new treatment options, both morbidity and mortality associated with PH in pregnancy have improved. The review provides contemporary updates in the management of pre-capillary and post-capillary PH. Accompanying the review is an article in the electrocardiography series that includes two cases to illustrate several aspects of managing PH in pregnancy.[2]

Next, Dalakoti et al. discuss preventive cardiology, an area that Singapore has focused on through Healthier SG, a national initiative by the Ministry of Health, Singapore.[3] The authors emphasise that subclinical atherosclerosis represents a key prevention strategy for early intervention. The importance of early detection and management of conventional as well as newer risk factors are reinforced. The lifetime goal of targeting lower levels of low-density lipoprotein cholesterol (LDL-C) and glycated haemoglobin, along with education may indeed shift the trajectory of cardiovascular disease and reduce major adverse events, resulting in improved population health.

Mak et al. conducted a prospective observational cohort study of patients with ischaemic heart disease admitted to the hospital.[4] They found treatment gaps in lipid management in a large proportion of the local population, with the use of statin monotherapy in the majority resulting in insufficient efficacy to achieve LDL-C goals. This is consistent with previous studies published locally[5] and in the region.[6] Furthermore, like many landmark studies, Mak et al. demonstrated that lower LDL-C levels were associated with reduction of all-cause mortality within as little as 24 months. Not every patient believes in the LDL-C hypothesis (now an established principle) due to the myths from the Internet and false social media influences. Public education will be key to drive home important messages. Community cardiology can help augment this push.[7] Furthermore, with the recent approvals of anti-proprotein convertase subtilisin/kexin type 9 monoclonal antibody and inclisiran injectables,[8] we hope for wider adoption of these efficacious therapy. Together with oral ezetimide use,[9] we aim to increase our armamentarium to reduce adverse event rates. The recent cost-effectiveness analyses should also reassure funders and policy makers.[10]

In addition, this issue includes an article focusing on use of computed tomography (CT) to quantify coronary calcification in primary care.[11] Coronary artery calcium scores can predict future cardiac events and correlates with the extent of coronary artery disease. However, it is not uncommon to see non-calcified plaques in CT coronary angiogram, and more research and insights using this modality is underway.

Finally, Xu et al. conducted a cross-sectional study investigating the association between vascular function and bone mineral density (BMD) in patients with rheumatoid arthritis.[12] They found that lower BMD at the lumbar spine, femoral neck and total hip was associated with worse natural logarithm reactive hyperaemia index, a parameter of endothelial dysfunction. Further studies to determine the underlying mechanisms will be valuable and insightful.

We hope you will enjoy this issue, which not only highlights preventive cardiology and community care , but also includes articles on ‘cardiology plus’ (cardiology and other specialties). Moving forward, we expect increased collaborations between cardiology and various subspecialties, as well as multidisciplinary approaches aimed at achieving better outcomes for patients.