Cardio ThinkLab

Reshaping HF Management at NHCS

In Singapore, 23 people die from cardiovascular disease every day. The Singapore Heart Foundation reported that cardiovascular disease accounted for 31.4% deaths in 2022.[1]

Singapore is a rapidly aging nation compounded with the rise of chronic disease. In 2017, it was reported that 62% of the elderly aged 60 years and above were living with ill-health due to cardiovascular disease.[2] Despite existing management strategies, ranging from oral medication to devices, prognosis remains poor, where heart failure cases globally have doubled from 33.5 million in 1990 to 64.3 million in 2017.[3]

The Cardiovascular Care System in Singapore

The National Heart Centre Singapore (NHCS) is the pioneer cardiovascular care provider in Singapore. NHCS provides a one-stop comprehensive centre that provides preventive, diagnostic, therapeutic and rehabilitative care services. It is also the only heart and lung transplantation centre in the country.

The centre consistently aims to optimise treatment strategies for better outcomes and has seen over 9,000 surgeries and more than 10,000 patients. It also heralds clinical outcomes comparable to international benchmarks, with patients regularly being treated for hypertension, hyperlipidaemia, and other complex cardiac diseases.

Notably, the Mechanical Heart Device Program supports patients with advanced heart failure, especially those who suffer from end-stage heart disease under the age of 60 requiring heart transplants. Advanced therapy, through the Heart Transplant Programme set up in 1990, has seen over 90 heart transplants over the years.

On the research front, the NHCS is a regional educational heart centre that trains medical and nursing students and offers training to overseas doctors from the APAC region, with 80-90 ongoing clinical trials.

The NHCS Heart Failure Programme

With a strong focus on heart failure care, the NHCS Heart Failure Programme serves to improve patients’ quality of life with aims of reducing admission and medical costs. The NHCS Heart Failure Programme was introduced in 2002, as one of the first programmes in the Asia Pacific region.

Dr David Sim elucidates that despite the wide range of drugs in the market, the lack of drugs with good uptake remains to be a pressing issue. The Asia Pacific region, especially, lacks proper guidelines and protocols, where “heart failure patients must be treated with more urgency to prolong survival”. Worldwide, alarming statistics show that the lack of timely appropriate drug treatment for heart failure decreases the chances of recovery for the patient.[4]

To tackle the growing heart failure problem and critically prolong lifespan, the NHCS has a checklist system put in place at time of admission where patients are immediately identified for suitability of life-saving drugs. An NHCS Heart Failure Nurse will then assess and monitor the admitted patient with a screening form every day, and recruit suitable patients to the Heart Failure program. Dr Sim regrets that in many cases, “patients are admitted into the programme too late”.

At the NHCS, adherence to the checklist system has allowed for better and higher compliance, with up to 99.3% of patients taking their beta blockers. Patients enrolled in the program also do much better, as compared to patients not in the program.

Post-discharge Treatment Optimisation

It is crucial to understand that heart failure care does not stop when the patient is discharged. Patients are reviewed by the Heart Failure Programme Team and given patient and family education before discharge. The option of tele-consultation is also exclusively offered by the NHCS Heart Failure programme, where highly-skilled nurses and pharmacists can assist patients in real-time. Since 2007, specially trained heart failure nurses are equipped to up-titrate drugs for post-discharge patients in the comfort of their own homes.

Dr Sim stresses that heart failure is a multifaceted chronic disease, where strong patient education and a multidisciplinary team is crucial in supporting a patient’s journey. Patients must learn to understand the symptoms accompanying the type of heart disease that they have. This is where medical professionals can help to better educate patients in the day-to-day management of the disease. A holistic care approach that goes beyond medication, such as making lifestyle adjustments, dietary and water restrictions, and smoking cessation, are all elements that help in the treatment of heart failure.

Delivering Care to Elderly Patients

Akin to many heavily populated countries, many elderly patients lack appointment compliance, due to constraints in mobility and accessibility. In these instances, home programmes where doctors travel to deliver care, can grant access to patients living in rural parts of the world. Collaborating with community nurses is also crucial in these environments, where patients are likely to be better educated and compliant in taking their medication. This will provide higher-risk patients who require advanced therapy such as heart pumps, to be better taken care of.

“If patients lack proper treatment, 50% of them will be gone within 5 years.” – Dr David Sim

Heart failure treatment requires appropriate prompt medication. Improving the functional status of the patient – educational, nutritional and psycho-social care, can contribute greatly to the treatment plan. Together, an all-rounded multidisciplinary team can better equip patients with the knowledge to help achieve these goals and improve heart failure outcomes.


1. Report on Registration of Births and Deaths 2022 by the Registry of Births and Deaths, Immigration and Checkpoints Authority, Singapore and Ministry Of Health. Heart Disease Statistics
2. Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease Study 2017. Seattle, WA: IHME, 2018.
3. Bragazzi NL, Zhong W, Shu J, et al. Burden of heart failure and underlying causes in 195 countries and territories from 1990 to 2017. Eur J Prev Cardiol. 2021. doi:10.1093/eurjpc/zwaa147
4. Butler J, Yang M, Manzi MA, Hess GP, Patel MJ, Rhodes T, Givertz MM. Clinical course of patients with worsening heart failure with reduced ejection fraction.J Am Coll Cardiol. 2019; 73:935–944. doi: 10.1016/j.jacc.2018.11.049

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