Category Archives: Cardiology

The Cost of a Cure: What’s the Right Price?

Recently, two significant pharmaceutical breakthroughs have resulted in a renewed debate about the costs of drug therapy. In the last year, a new drug class for the treatment of Hepatitis C has been released by two different manufacturers and has been found to cure a once incurable chronic liver disease for nearly 90% of patients who are treated with a full course of therapy. The drug appears to be safe and highly effective—however, the cost of a curative course of therapy is nearly 80K dollars. As you might imaging, there are already barriers to access for many patients including those treated in the Veterans’ Affairs (VA) system as well as those on government based insurance programs such as Medicaid.

In the last several months, another remarkable, potentially “game changing” drug has been approved and released into the market. These drugs, made by Regeneron and Sanofi, are intended for patients who do not achieve adequate cholesterol reduction with standard statin therapy (the current standard of care).   According to some analyses, these drugs, when used in the appropriate patient population, may result in the prevention of thousands of cardiovascular related deaths. However, just as seen with the new hepatitis C drugs, the price tag for therapy is exorbitant—nearly 15K dollars annually. With the Hepatitis C drug, therapy is only required for approximately 12 weeks and then is no longer needed—with the cholesterol drug, the therapy will most likely be lifelong.

This month a study examining the cost effectiveness of these new cholesterol drug has been published and concluded that the drugs are far over-priced (nearly 3 fold) for the benefit that they produce. Based on a pure economic analysis, researchers concluded that the drugs should actually cost between 3K and 4K dollars annually rather than the current 15K price tag.

Did Healthcare Reform Forget Big Pharma?

The purpose of the Affordable Care Act (ACA) (as touted by supporting politicians and its authors) is to make health care accessible and affordable to all Americans. Certainly this is a noble goal and one that we should continue to strive to achieve. However, the legislation has failed to meet this mark. While addressing physician reimbursement and clinical behaviors (and limiting choice and physician autonomy), the ACA has done nothing to regulate the high price of pharmaceuticals. Big pharma is allowed to charge exorbitant prices (whatever the market will bear) without regulation. It is clear that pharmaceuticals must reclaim their research and development investments and make a profit—however, many of these drugs are far overpriced and pricetags are simply designed to exploit the system and maximize corporate (and CEO profits). IN addition, many of the most expensive drugs in the US are sold overseas and in Canada at a fraction of the cost. This seems to me to be clear evidence of the pharmaceutical industry taking full advantage of the inherent wealth in the US today.

However, Would it not follow that if we placed limits on the prices of new drugs and paid “fair and equitable” charges, that healthcare costs would significantly decline?

It seems our politicians have sought to attack the problem from a few angles and have failed to address other significant sources of excessive healthcare spending. While reimbursement for physicians and physician groups are set clearly in the crosshairs of the ACA, it appears industry and litigators are not even on the radar. There is hope—legislation is being introduced that will allow legal purchase of drugs from Canada for Americans. In addition, pharmaceutical companies would be required to disclose what they charge for the same drugs in other countries. I believe this is a step in the right direction. Lets continue to innovate and provide new therapies for ALL Americans. But lets do it in a way that is cost effective. The latest studies make it clear that these drugs are overpriced. We must find a way to negotiate a fair and reasonable price that promotes and rewards innovation BUT also provides access to the newest and most effective therapies for all who need it.

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Turf Battles and Collateral Damage: Are We Really Putting the Patient First?

Last week, Medpage Today reporter Sarah Wickline Wallan tackled a very controversial issue in medical practice.  In her piece, Ms Wallan explores the ongoing battle between Dermatologists and AHPs (Allied Health Professionals) over the performance of dermatologic procedures.  As independent NPs and PAs begin to bill for more and more procedures (thus potentially talking revenue away from board certified Dermatologists) specialists are beginning to argue that the AHPs are practicing beyond their scope of practice. According to the Journal of the American Medical Association, nearly 5 million dermatological procedures were performed by NPs and PAs last year–this has Dermatologists seeking practice limits–ostensibly to protect “bread and butter” revenue streams from biopsies, skin tag removals and other common office based interventions.

In response to this controversy and the article, I was asked to provide commentary for Med Page Today’s Friday Feedback.  Each week, the editors at MPT discuss a controversial topic and have physicians from all over the country share their feelings on the issue in order to provide readers with a mulit-specialty perspective.  This “Friday Feedback” feature is typically released on the web near the end of the day on Fridays and often spurs a great deal of social media activity and discussion.  Based on reaction to Ms Wallan’s article our topic this past Friday was “Specialty Turf Battles”.  Each respondent was asked to provide commentary on the growing angst between Dermatologists and Allied Health Professionals.    As I began to reflect on the issue itself and its potential impacts on all aspects of medicine, I felt that a complete blog would be a more complete forum to discuss my thoughts.

First of all I want to say that AHPs are essential to providing care in the era of the Affordable Care Act.  NPs and PAs are able to help meet the needs of underserved areas and do a remarkable job complementing the care of the physicians with which they work.  With the rapidly expanded pool of newly insured, as well as the increase in administrative tasks (electronic documentation) assigned to physicians, AHPs must help fill in the gaps and ensure that all patients have access to care.  In my practice we are fortunate to have many well qualified AHPs that assist us in the care of our patients both in the hospital as well as in the office.

We must remember, however, that physicians and AHPs have very different training.  Each professional posses a unique set of skills and each skill set can complement the others.  Many of us in specialty areas spend nearly a decade in post MD training programs and learn how to care for patients through rigorous round the clock shifts during our Residency and Fellowship years.  In addition, we spend countless hours performing specialized procedures over this time and are closely supervised by senior staff.  Most AHPs, in contrast, do not spend time in lengthy residencies and often have limited exposure to specialized procedures.  Turf battles have existed for decades and are certainly not limited to Dermatology–nor or they limited to MDs vs AHPs.  In cardiology in the late 1990s, for instance, we struggled with turf battles with Radiology over the performance of Peripheral Vascular Interventions.  In many areas, these battles resulted in limited availability of specialized staff to patients and a lack of integrated care.  Ultimately, the patients were the ones who suffered.

Fortunately, in the UNC Healthcare system where I work (as well as others across the country) we have taken a very different approach.  After observing inefficiencies and redundancy in the system, several years ago our leadership (under the direction of Dr Cam Patterson) decided to make a change.  The UNC Heart and Vascular Center was created–Vascular surgeons, Cardiologists, Interventional Radiologists, and Cardiothoracic surgeons–all working under one cooperative umbrella.  Patients are now discussed and treated with a multidisciplinary approach–Electrophysiologists and Cardiothoracic surgeons perform hybrid Atrial Fibrillation ablation procedures, Vascular surgeons and Interventional Cardiologists discuss the best way to approach a patient with carotid disease–all working together to produce the BEST outcome for each individual patient.  We have seen patient satisfaction scores improve and we have noted that access to multiple specialty consultations has become much easier to achieve in a timely fashion.  Most importantly, communication among different specialties has significantly improved.

Unfortunately, with the advent of the ACA and decreasing reimbursement I suspect that turf battles will continue.  Financial pressures have become overwhelming for many practices and the days of the Private Practice are limited–more and more groups will continue to “integrate” with large hospital systems in the coming years.  Specialists such as Dermatologists and others will continue to (rightly so) protect procedures that provide a revenue stream in order to remain financially viable.  However, I believe that our time will be better spent by working together to improve efficiency of care, quality of care and integration of care.  NPs and PAs are going to be a critical component to health care delivery as we continue to adapt to the new (and ever changing) ACA mandates.  We must put patients FIRST–turf battles and squabbles amongst healthcare providers will only limit our ability to provide outstanding, efficient care.  Let’s put the most qualified person in the procedure room–and make sure that ultimately patients get exactly what they need.

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The Dangerous Stranger Lurking in the Dark: Using the AliveCor Device to Identify Asymptomatic Atrial Fibrillation

Surgery has many well defined risks–we perform procedures when the benefits far outweigh the risks.  As healthcare providers, it is our job to carefully discuss the risks and benefits of any medical procedure with our patients prior to the planned procedure and make sure that they understand what we are doing, why we are doing it and what our ultimate goals include.  We often discuss bleeding, infection, and other common post operative risks and then other risks that are specific to the particular procedure being performed.  Now there may be a new perioperative clinical marker–atrial fibrillation–that can identify patients at risk for other complications such as stroke, long after discharge from the hospital.  Atrial fibrillation is the most common heart rhythm problem in the entire world and is associated with stroke in patients who are at risk.

This past week the Journal of the American Medical Association published a new study examining both the incidence of atrial fibrillation after ANY surgery as well as the conferred risk of stroke.  The study involved over 1 million patients and the results were quite alarming–nearly 28K patients had peri-operative atrial fibrillation and of those, almost 14K patients experienced strokes that occurred after discharge.  Even more disturbing was the fact that the rate of atrial fibrillation was even higher in non cardiac surgery patients (as compared to those undergoing cardiac surgery).  Many surgical patients may be discharged without knowing that they have atrial fibrillation or that they are at risk.  Some may present with cryptogenic strokes and suffer life changing devastation.  The data is very clear about the prevention of stroke in atrial fibrillation.  Based on a risk score (known as the CHADS2-vasc) we are able to quickly calculate and assess risk for stroke (based on several common predisposing factors) and appropriately choose an anticoagulant for each patient.  It is also clear that anticoagulation in high risk populations reduce stroke rates significantly.

There is no doubt that atrial fibrillation results in significant morbidity and mortality in the US today.  According to data from Circulation published in 2013, one in every 19 deaths is due to atrial fibrillation related stroke and nearly $37 billion dollars is spent on patient care due to this disease.   Even  more disturbing is the fact that many patients with atrial fibrillation are totally asymptomatic and may not even know they have the arrhythmia at all—many patients’ first presentation with atrial fibrillation is sadly a presentation with a devastating stroke.  The recent article in JAMA further emphasizes the negative impact that silent atrial fibrillation can have on patients.  As clinicians, we remain vigilant for the presence of atrial fibrillation and often we are able to identify and screen those at high risk–however, many patients are missed and preventative therapy with anticoagulation is never prescribed.

What is the Answer?  How can we better screen asymptomatic patients for atrial fibrillation in a cost effective, broad based way?

The Alive Cor iPhone EKG application and device is the first of its kind.  It is an FDA approved device that can record a single lead electrocardiogram directly from your fingertips, display the tracing on the iPhone screen and transmit the tracing to the cloud for review.  The device is now available direct to consumers for purchase and no longer requires a physician prescription.  In May, a clinical trial was published that demonstrated that the Alive Cor device could be used to easily screen large groups of consumers for atrial fibrillation in a cost effective way.  In the study, which was published in May in Thrombosis and Haemostasis, investigators screened 1000 asymptomatic pharmacy customers for atrial fibrillation using the Alive Cor device and found that 1.5% of them actually had atrial fibrillation upon screening.  The cost effectiveness per stroke saved in the US was estimated to be a cost savings of nearly 20%.

Given the high prevalence of both symptomatic and asymptomatic atrial fibrillation worldwide, it is essential that healthcare providers strive to do a better job screening for this sometimes silent disease.  The identification of patients at risk for stroke from atrial fibrillation (and subsequent anticoagulation) is the best way to reduce both the cost and devastating morbidity and mortality associated with the disease.  With technology such as the AliveCor device readily available to both patients and clinicians it is essential that we begin to utilize this device for massive, cost effective screening efforts.  As healthcare reform shifts focus on prevention of costly disease,   we must continue to focus on improving screening and care for those at highest risk.

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Making Donald Ross Proud: Erik Compton Overcomes Adversity (and Two Heart Transplants) to Compete in the US Open

This week, the center of the golfing universe is centered on Pinehurst, North Carolina as the United States Open Championships get underway on Thursday.  Designed by Donald Ross and frequented by golf legends such as Bobby Jones, Harvie Ward and Ben Hogan, Pinehurst number 2 is an iconic layout for professionals and amateurs alike.  Golf, in general, takes meticulous preparation, dedication, discipline–and for those who are successful at the highest levels–an uncanny ability to battle and overcome adversity.  As a below average amateur golfer, I certainly have a healthy respect for the abilities of PGA professionals.

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These men and women spend countless hours practicing and perfecting swings and are quickly able to assess their own weaknesses and move to correct them in a timely fashion.  The world of sports can teach us many life lessons and can help better prepare us to do battle in our daily lives.  The traits of successful professional golfers are applicable to medicine in many ways.  Sports figures have always been a source of inspiration for me.  This week, one particular golfer in the US Open field should serve as an inspiration for us all—PGA professional Erik Compton’s daily courage and his willingness to overcome any obstacle can help each of us meet even the fiercest medical or business related challenges and provide better care for our patients.

At age 9, Erik Compton was like any other child.  He was active and loved sports.  However, he became ill with a cold like illness (just like many other kids that age).  Unfortunately, Erik’s cold symptoms lingered.  He began to become very short of breath and was no longer able to keep up with other kids his age.  Eventually he was evaluated by a specialist and found to have viral myocarditis and a significantly reduced left ventricular ejection fraction.  After three years of therapy and worsening congestive heart failure, Mr Compton was listed for a heart transplant and in 1999, he received a new heart.  Through hard work, goal minded behavior and dedication, Erik led a relatively normal life through high school and became one of the top ranked amateur golfers in the United States at the high school level.  He was recruited by many universities and attended the University of Georgia on a full athletic scholarship.  As a college golfer, Mr Compton not only battled the numerous golf courses, bunkers, water hazards and the like, but also battled fatigue and swallowed numerous anti-rejection pills each day. He worked his way onto the Nationwide Tour and eventually earned his PGA card.  Unfortunately, Mr Compton suffered a massive myocardial infarction (MI) in 2007 and was left with another cardiomyopathy in his transplanted heart.  While driving himself to the hospital from the golf course, he called his family to say goodbye.  The goodbyes were not to be–six months later, he received a second heart transplant.

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(Photo adapted from http://www.ErikCompton.com)

At this point, many of us would have simply given up.  “Why me?” we might ask.  Instead, Mr Compton embraced his next life challenge.  Within weeks, he began to walk and exercise regularly and he was determined to play competitive golf once again.

Mr Compton battled back from a second heart transplant and ultimately re-joined the PGA Tour.  Last season, he was awarded the inaugural PGA Tour Courage Award.  Two weeks ago, he sunk a putt in a sudden death playoff in order to qualify for the US Open field.  Mr Compton’s story is compelling for many reasons.  As a golfer and transplant survivor, he exhibits unnatural courage under duress.  For patients and physicians, Mr Compton’s example can provide insight into successfully battling disease and should inspire us all to do better with whatever gifts we are given.  I have never heard Mr Compton complain during an interview–rather, he chooses to focus on the positive–the fact that he is able to once again compete on the PGA Tour and he clearly enjoys EVERY single day, EVERY single minute.

Most importantly, Mr Compton’s story should serve as a call to action for all of us–we must do more to raise awareness for organ donations.  Last year, there were more than 4000 persons on the active transplant waiting list–yet only 2600 heart transplants actually occurred.  Every single year, patients die while waiting for an organ.  Factors such as blood type, body size and other immune system antigen compatibilities often determine how quickly patients are able to receive a heart.  Organ donation is simple–in most states it simply requires answering a question on your driver’s license application.  Organ donors are critical to providing life to those with diseases such as Mr Compton.  Fortunately, through innovation and research we have other therapies that can help patients with end stage cardiomyopathies–Left ventricular assist devices (LVADs) can now serve as destination therapy as well as a bridge to transplant in critically ill patients.  Although the artificial heart has not yet panned out as we would have liked, the advent of 3D printing of organs may hold real promise for the future.  However, until we have other solid alternatives, we must continue to raise awareness for organ donations and work to ensure that more people on the transplant list have organs available to them.  As healthcare workers, we must include questions on organ donation as part of our routine office visits in order to ensure that our patients are at least AWARE of the process and can contemplate decisions with their families while they are young and healthy.

Ultimately, many will die while awaiting organs this year.  Patients and families who have donated during times of tragedy are true heroes–they have provided LIFE for others from the hands of tragic and untimely death.  This week, I continue to be amazed at the ability of PGA golfers to tame the beast that is the historic Pinehurst number 2.  I am even more amazed by the fact that Erik Compton is among the field and walking in the footsteps of Donald Ross, Ben Hogan, Harvie Ward and Bobby Jones.  I think each of these golf legends would be quite proud. In fact, I suspect that Donald Ross himself would enjoy a round with Mr Compton—and would likely invite him to sit in the rockers on the world famous porch at the Pinecrest Inn (a legendary hotel in the village of Pinehurst once owned by Mr Ross) after an afternoon walk on Pinehurst Number 2.

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(Image from my personal collection.  Golfers from all over the world come to Pinehurst for a round of golf and recount the day on the course on the porch at the Pinecrest Inn)

 

Big Brother is Watching…And Your Healthcare Privacy Rights May Suffer: More Affordable Care Act Fallout

Data is essential in healthcare delivery and it is often what guides us in improving outcomes.  Utilizing data obtained from large populations helps us better decide what aspects of disease prevention and treatment need more of our attention.  I have shared my concerns about the sanctity and security of these data in a prior blog from July.  These data are important and allow us to evaluate at risk populations and target our interventions.  In the US, participation in surveys is 100% voluntary.  The Centers for Disease Control obtains most of its data from diagnoses reported by healthcare institutions (there are certain disease that are mandated by law to be reported).  However, with the advent of the Affordable Care Act (ACA), some corporations and businesses have taken the acquisition of data a step too far.  In George Orwell’s novel 1984, the author presents a vision of an dystopian society where “Big Brother” watches every move ordinary citizens make in an attempt to maintain order (and advance his own agenda).  We have all seen the recent government abuses within the National Security Administration (NSA) and within the Internal Revenue Service (IRS).  As the ACA is implemented, I am concerned that Big Brother may already be here and working in the US healthcare system today as well.  In medicine, the doctor-patient relationship is sacred–data disclosed for healthcare should be sacred as well.

Although our country has always been based on basic tenets of freedom of choice, right to privacy and other key freedoms, some institutions see Obamacare as a ticket to interfere with the daily lives of American citizens.  For instance as reported in the last several weeks by the New York Times,  Pennsylvania State University now is attempting to require all employees, including senior faculty, to undergo physical exams and answer online health questionnaires that contain very personal and very sensitive health information.  It is obvious that the pressures of the ACA and the need for cost containment is motivating these types of mandates.  From the business standpoint, the university is hoping to reduce risk and liability by modifying at risk behaviors in its insured employees.  However, none of these data will help the faculty do a better job for their employers and I am sure that the Penn State University administration clearly see this as a way to save healthcare dollars.  The next logical step, however, may be to deny or terminate employment based on health risk and potential cost to the system.  Where does the rabbit hole end?  Is this the beginning of health status discrimination in the workplace?

Many senior faculty at Penn State are refusing the mandate based on invasion of privacy–even though the university is planning to levy substantial daily fines for non responders.  Several prominent professors have stated that if they are forced to participate they will simply answer the questionnaires randomly and provide far fetched ridiculous answers–simply play the conscientious objector.  Many other Americans are waiting to see how this pans out–there is concern that this type of activity will begin to spread to other institutions and industries.  Labor unions are already beginning to lobby against these mandates–in the case of Penn State, union employees are exempt.  At what point are our private lives and medical histories private?  What is the separation between workplace and home? Where do we draw the lines and do we allow others (government and employers) to draw the lines for us?

The spirit of risk reduction and working with employees to improve their health status and live better lives makes good sense–however, there are better ways to accomplish this goal.  Health fairs, educational seminars and free health screenings for cholesterol and high blood pressure make good sense–but all of these activities should be voluntary.  Asking highly personal questions such as sexual preference, prior drug or alcohol use and the state of one’s marriage should not be a part of a wellness program at work.  In the case of the Penn State questionnaire there are even questions related to how you get along with others in the workplace–including your boss.  These issues are private and should remain that way. In defense of the institution, the development of these wellness programs are not entirely their fault.  In fact, the ACA provides a 30% discount for the implementation of a comprehensive wellness program–virtually assuring that every business will “voluntarily” submit to these types of invasion of privacy. Although the university administrators claim that the data is secure and is not available to supervisors and those in the administration, it concerns me greatly that this will not be the case– (just ask those Americans who had unlawful wire taps and those that were bullied by the IRS due to their associations with certain political groups).  Big Brother is watching….from your doctors office, from your bedroom and from your back porch.   I am afraid that this particular blog may leave you with far more questions than answers….maybe we should ask Big Brother.

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Going Up In Smoke: The Falling Lifespans of Women in the US Today

As I have stated many times in the past, women are undertreated and underserved when it comes to cardiovascular disease and stroke.  Now, more than ever, this may even be more important due to several recent studies that have been published in the last few weeks.  Several investigations have demonstrated two troublesome facts:  In certain areas of the country, life expectancy for women is decreasing AND women who smoke are much more likely to have lung cancer than men who smoke.  These facts argue for more aggressive treatment of women and more targeted gender specific prevention efforts–no longer can women’s risk for disease be discounted. Although awareness efforts are continuing, we continue to fall short in identifying and treating women with cardiovascular disease.

In a study published last week in the journal Health Affairs, researchers compared mortality rates from 1992-96 with those from 2002-06 in 3,140 counties in the United States.  In the study, female mortality rates increased in 42% of counties while rates in men only increased by 3.4%.  Factors associated with lower mortality rates in women included higher education, location not in the south or west and non use of tobacco.  These findings are incredibly troubling in that over the same time period, mortality rates in men have fallen in these same counties.

In a related article published this year in the New England Journal of Medicine, it was found that smoking in women is associated with a higher risk for lung cancer, cardiovascular disease and death as compared to smoking in men.  Among men, the risks of death from smoking have plateaued since the 1980s.  In the 1980s women who smoked were 13 times more likely to die from lung cancer –in contrast, women are now found to be 26 times more likely to die as compared to those who do not smoke.  However, there are data that show that smokers who quit by age 40 are able to reduce their risk for death significantly and in fact add 10 additional years to their life span.

So, altogether, it seems that smoking for women is a significant public health issue.  Women are smoking in greater numbers and those that began smoking in the 1960s are now seeing the long term effects–this cohort of women is truly the first group of long term female smokers that have been studied.  The results are truly sobering.  As healthcare providers we must do our best to prevent chronic disease.  Certainly in this era of cost containment and the new Affordable Care Act, we must strive to modify risk.  Smoking cessation is something that all providers, regardless of specialty, must work to encourage.  In fact, I believe that individual cost and  access to insurance coverage should be based on one’s smoking habits.  Those who choose to smoke should pay significantly higher premiums as they will be using more resources down the line.  Physicians will be held accountable for documenting smoking status and smoking cessation counselling–why then can’t patients and consumers of healthcare be held accountable for their own reckless behaviors (such as smoking).

But, back to the issue at hand.  Once again, we find that women are under treated and underserved.  According to recent studies, women are less likely to be referred or counseled for smoking cessation. In addition, data from the NCBI indicates that women have more difficulty quitting.  According to NCBI researchers, unique factors affecting a woman’s ability to successfully stop smoking include concerns over weight gain,  mood variability and withdrawal symptoms associated with hormonal changes during the menstrual cycle.

Ultimately, we must do a better job helping women with smoking cessation.  Mortality statistics such as the those recently presented serve as a failing report card when it comes to prevention activities in women.  We must identify female patients at risk and push for smoking cessation.  Once again, we must empower women to take an active role in their healthcare and engage them in healthy lifestyle modification activities.

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Singing the Blues: Stress, Depression and Risk for Stroke

Depression is common in US adults over the age of 65.  As we age, we are faced with our own mortality and often lose family and friends to disease.   According to the CDC, over 80% of elderly adults have at least one chronic medical condition and nearly 50% have more than two.  Dealing with multiple prescription medicines, multiple doctor visits and treatments add stress to life.  Many seniors live on fixed incomes and financial pressures are often quite significant.  To make matters worse, seniors are often misdiagnosed and many medical professionals do not recognize depression in this age group.  Many physicians believe that feelings of sadness experienced by the elderly is just part of the natural aging process.  Older patients themselves do not even recognize that they are depressed and believe that their feelings are part of the natural aging process–they never seek help.

Just a few days ago, the AHA Journal Stroke published a study linking increased risk of fatal stroke in older Americans.  In the study, over 4000 adults in the Chicago area were followed and their level of psychological distress was measured using standardized, reliable assessments.  The results of the investigation demonstrated a statistically significant increase in both fatal and nonfatal stroke in patients who were depressed and had increased levels of psychosocial distress.  Clearly, there is an association between mental health and cardiovascular disease.  Prior studies in patients with congestive heart failure have also demonstrated negative outcomes in patients with untreated or concomitant depression.  In fact, in this newly published stroke study, a clear dose response relationship was seen between the level of psychological distress and stroke;  those with higher levels had a 2 fold incidence in fatal stroke and a 30% increase in incident stroke rate.As scientists, we are driven to demonstrate a cause-effect relationship when approach disease.   In order to treat a disease, we must target specific biologic connections.  However, the biology of the association between stroke and emotional distress is difficult to definitively determine and has yet to be proven.  Several biologically plausible hypotheses have been offered:

1.  Emotional distress and depression may create higher levels of stress hormones and inflammation that contribute to events.

2. Patient who are emotionally distressed and depressed may be more likely to be non compliant and unengaged in their own healthcare.  They may be more likely to live unhealthy lifestyles.

3. Emotional distress and depression may produce a hypercoagulable state where a patient is more likely to form a thrombus and experience a thrombotic event (embolic stroke).

The emotional well being of a patient can clearly have an impact on cardiovascular health.  As healthcare providers, we must diagnose and treat depression, anxiety and other mood disorders as part of routine care.  As cardiovascular healthcare professionals, we must develop relationships with mental health providers, counselors and psychiatrists so that we are able to refer our patients for specialized care when appropriate.  The link between emotional health and physical illness is real.  The heart-brain connection has been reported in the past and studies such as this one in the journal Stroke continue to emphasize the complexity of this association.  Elderly patients are at particularly high risk for the detrimental effects of psychological distress simply due to its high prevalence in this population.

As we enjoy the holiday season and move to the New Year, let’s all commit to providing comprehensive care for our patients.  Let us all strive to recognize signs of psychological distress and help our patients deal with their feelings in a productive, positive way.  Help our patients by recognizing financial strain and prescribing generic medications.  Make it clear to your older patients that depression and sadness is NOT a part of the aging process.  Help integrate care by communicating with primary care providers and other specialists in order better coordinate care for our patients.  Regardless of the specific biology of the association between emotional distress and cardiovascular disease and stroke, we can reduce risk by helping our patients to improve their own psychological health.

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Psychosocial Effects of Acute Cardiovascular Events: Spousal Depression, Anxiety and Suicide After Myocardial Infarction

Cardiovascular events can have far reaching impacts.  Certainly the patients having the events are clearly affected in a life-changing way.  Patients are prescribed new medicines, are asked to make lifestyle changes and alter work and exercise habits.  However, families and loved ones are also greatly affected when cardiovascular disease strikes a spouse.  Most often, the focus is on the patient suffering the event and the spouse is left to worry and deal with fear and other emotions on their own.
Much has been written in the past about the effects of the death of a spouse on the emotional well being of the surviving family members.  As recently as this year, a study in Circulation examined the risk of death and MI in individuals following the death of a spouse or loved one.  These investigators found a significant increased risk (21 fold) of myocardial infarction (MI or heart attack) in the surviving spouse in the first 24 hours following the death during periods of intense grief.  To date, no one has directly examined the impact of specific cardiovascular events such as MI on the emotional well being of loved ones.  This week the European Heart Journal  published an interesting study on the effects that heart attacks (myocardial infarction or MI)  have on the emotional well being of spouses of patients.  The investigation evaluated over 16,000 spouses of patients suffering both fatal and non-fatal MI over an 11 year period.  Spouses of patients who suffered either fatal or non-fatal cardiac events were more likely to have anti-anxiety (benzodiazepines) or antidepressants prescribed.  In the group of patients that suffered from fatal heart attacks, these spouses had increased rates of depression and suicide as compared to control.  This study highlights another aspect of post MI care that providers must consider–the care of the family and spouse.  Attention must be paid to the individuals suffering alongside the affected heart attack patient.
Grief and anxiety are common reactions to illness and death in a close family member.  As providers we must be aware of the potentially serious negative impacts these intense emotions may have on those closest to the patient.  Athough we are certainly charged with caring for the patient, we must remain aware of family needs as well.
Here are my thoughts:
1. Communicate: Communication with family throughout the illness or event is of paramount importance.  Make every effort to provide information and insight to the spouse and other family members.  If a negative outcome is possible do your best to talk about these possibilities
2. Provide support:  When speaking with the family, make sure that you are able to offer emotional support.  Let them know that although you are clinically objective and working for the patient’s best interest, that you CARE.  Empathy is critical. Make sure that you alert appropriate support staff such as clergy, social workers, and case managers to visit with families of critically ill patients.
3. Follow up and Process:  Often when a spouse is lost to either a chronic or an acute illness or event, closure helps with emotional healing.  I believe it is important to provide support to the family in the days or weeks following a death or major cardiovascular event.  Schedule an appointment in the office to meet with the surviving spouse.  If you suspect depression, anxiety or other emotional disturbances, contact that patient’s primary care provider and facilitate treatment.
Grief can be a powerful negative influence in our overall health.  Clearly, the trauma surrounding a heart attack or cardiovascular death can cause significant emotional upset.  In some cases, as demonstrated by the European Heart Journal  study, this upset can progress to significant anxiety, depression and even suicide.  As caregivers, we cannot underestimate the impact that significant medical events have on spouses and families.  We must strive to not only care for the patient experiencing the event but also attend to those who share the life journey with the patient as well.
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Things Aren’t Always As They May Seem: The Challenge of Diagnosing and Treating Cardiovascular Disease in Women

Recently, television personality Rosie O’Donnell was in the headlines after suffering a heart attack.  Her presentation with an acute coronary syndrome (ACS) was atypical; her symptoms were different from the traditional symptoms seen in men having a heart attack.  Earlier in the day  of her event, Ms O’Donnell had helped  a woman from her car.  That evening she blogged that “a few hours later my body hurt, and that  i had an ache in my chest. both my arms were sore. everything felt bruised.”  Ms O’Donnell’s symptoms were persistent and she began to wonder if her symptoms might represent a heart attack.  She decided to take an aspirin (a particularly good idea in her case) but continued to deny the symptoms until she consulted her physician the next day.  She immediately underwent a cardiac catheterization and was found to have a 99% blockage of her left anterior descending artery (LAD).  She had a stent (small metal tube to open the blocked artery) placed and is likely to recover completely.
Her case highlights one of the biggest challenges in caring for women with cardiovascular disease–lack of recognition by clinicians and denial and delay by patients experiencing the symptoms.  Women in the US today account for a large number of the nearly half million deaths from CV disease and Sudden Cardiac death.  Yet, as I have discussed in previous blogs, women remain underdiagnosed and undertreated.  The best way to impact disparities in care is through education and awareness.
Recognizing the signs:
Traditionally, male heart attack victims present with crushing sub-sternal chest pain, shortness of breath, diaphoresis (sweating) and nausea.  Sometimes the pain may radiate into the neck or jaw.  Women and men are biologically quite different as we all know.  There are distinct differences in the way cardiovascular disease develops, progresses and ultimately presents clinically.  Certainly, women can present with classic symptoms.  However, often women present quite atypically.  Moreover, some diagnostic tests are less accurate in women as compared to me.  Diagnosing both acute and indolent cardiovascular disease in women can be quite challenging.Women tend to take care of their children and spouse first, often ignoring their own healthcare needs for long periods of time.  This may dismiss symptoms and carry on with their daily routines in order to avoid disrupting the family.  Coronary artery disease in women tends to be more diffuse (more widespread) and involves more small vessel disease.   Women also tend to present later than their male counterparts and often with more advanced disease.  Some of this may be explained by hormonal and biologic differences.  Symptoms in women may be quite vague and may include feelings of dread or anxiety, fatigue, or flu-like illness.  These vague symptoms can make prompt diagnosis much more difficult.   Women can also present with classic chest pain just as we described in men but often women deny the symptoms could be related to heart disease.
Making a Difference in Outcomes:  
1. Educate women and providers of healthcare to women about the risk factors for cardiovascular disease.  Make sure that every woman understands the signs and symptoms of heart attacks and how they may be different in female patients.
2. Actively screen at risk women for cardiovascular disease.  Ask about risk factors such as hypertension, smoking, high cholesterol, diabetes and family history of CAD.  Aggressively evaluate women with multiple risk factors even in the absence of classic symptoms.  Make sure that female patients understand what the risk factors are  how they can modify those risks.
3. Empower women to take control of their own healthcare.  Actively engage women in the prevention of disease.  Make sure women understand that they must act quickly when symptoms occur.  Denial of symptoms and delay in treatment most often results in much poorer outcomes.
The Upshot:
Rosie O’Donnell was fortunate.  She had symptoms consistent with a heart attack (although somewhat atypical).  For a little while she denied the symptoms but ultimately took an aspirin and sought care.  Luckily, she was able to get to a hospital and have a procedure done to open a blocked coronary artery before significant heart damage was done.  We must all learn from this case and educate our friends, families and colleagues on the risks of cardiovascular disease in women.  Through education, awareness and advocacy we can make a difference and reduce cardiovascular deaths in women.
Rosie O'Donnell in July 2011.

Going for the Gold: Long QT Syndrome and Olympic Glory

Sudden cardiac death in athletes is more common that you might think. Many of us can remember the tragic death on the court of the great college basketball player Hank Gathers of Loyola. Common causes of death in athletes include Hypertrophic Cardiomyopathy (HCM) and Long QT syndrome (LQTS). Screening of high school and college athletes has been a hot topic of debate lately. How do we screen, who do we screen and when do we screen? Certainly, in today’s healthcare environment, economics play a role–we must be cost effective with our screening techniques while at the same time effectively identifying at risk young athletes.
When athletes are identified as having a condition that puts them at risk for sudden death, it often results in the end of a career. In certain cases of HCM or LQTS patients must be implanted with an Implantable Cardioverter Defibrillator (ICD) in order to protect them from sudden death. In other cases medical therapy is prescribed. Certainly, this type of diagnosis can be a devastating, life-changing event for a young person.
In recent days, many of us have been glued to our televisions watching the Olympic games. Many of these athletes have trained their entire lives for one competition, one event, one lap in the pool. One competitor in particular has defied the odds and has stirred debate about how electrophysiologists deal with young athletes at risk for sudden cardiac death. Swimmer Dana Vollmer won the Gold medal in the 100 meter butterfly in London. An article published this week in the New York Timeshighlighted her Olympic journey. Ms Vollmer has LQTS and as a 15 year old high school athlete was told that the only way she could continue to compete was to have an ICD implanted. She was diagnosed after experiencing dizzy spells while in the pool during training sessions. After a thorough evaluation by a local cardiologist she was found to have LQTS. Ms Vollmer chose not to have an ICD implanted. However, her mother agreed to sit in at each and every workout and competition with an external automated defibrillator (AED) sitting at her feet.LQTS accounts for nearly 2000 deaths annually and the risk is three times higher in competitive athletes. There are guidelines and criteria for management that have been developed in both Europe and the US (known as 36th Bethesda conference criteria and the European Society of Cardiology guidelines). Both sets of guidelines rely on expert opinion–there are very little data available on sports participation in LQTS patients to guide our decision making.A study done at Mayo Clinic recently published in the Journal of the American Medical Association (JAMA) reviewed records of patients with LQTS (age 6-40 years) from 2000 to 2010. Of the 353 patients, 63% were not involved in sports and 88% chose to stop competitive sports once initially diagnosed. 130 patients remained in competitive sports and 20 of these patients had ICDs implanted. Only one of the patients who continued to compete in sports had an event–an aborted cardiac arrest while warming up for a game–twice. He received two life saving shocks for ventricular fibrillation. Both episodes occurred in the setting of medical non compliance–he failed to take his beta blocker prior to competition. In this particular retrospective review of LQTS athletes, only one patient had an event. This certainly brings up much controversy in how we treat these young competitive athlete patients.

One of my colleagues, Dr Wes Fisher has blogged about this controversy in the past. (Please see his blog here http://drwes.blogspot.com/2012/05/dark-side-of-ekg-screening-in-athletes.html). Dr Wes eloquently gives us a glimpse into the negative repercussions of EKG screening in athletes. However, we must remember that screening athletes is a tricky business. On the one hand we must make sure that young people are safe when competing in sports. On the other hand, we must be careful not to ruin a potential Gold medal career with speculation.

Ms Vollmer is an inspiration to all of us–both doctor and patient. She was given a potential life-threatening diagnosis at the age of 15. Still a teenager, she had to make an adult level decision that would affect the rest of her life. She has very supportive parents who helped her make the choice and ensured that she would be safe while competing and training. A two-time Olympic champion, Ms Vollmer was able to overcome great challenges and continued to believe in herself and in her abilities. Even though she had a potential life threatening heart condition, she continued to live and enjoy life to its fullest.

There remains much controversy on how best to screen athletes and how best to treat disorders such as LQTS. Not every competitive athlete patient with LQTS needs an ICD. Clearly, from the Mayo review, not every athlete with LQTS has an event. As physicians treating heart rhythm disorders, we must carefully review each case and partner with our patients to make good decisions. Together we can follow Dana Vollmer’s example and continue to “Go for the Gold”.

Dana Vollmer celebrated after setting a world record in the 100-meter butterfly on the way to winning an Olympic gold medal.
(Photo: Doug Mills, The New York Times)