For all the strides we've made against heart disease, it still accounts for 26 percent of all deaths in the U.S. This year alone, it will cost $316 billion in health care, medications, and lost productivity. A push for better preventive care hasn't solved the problem. And advances in the field aren't being incorporated into practice routinely or quickly enough. NEWSWEEK gathered four cardiologists to discuss the future of the field. Senior writer Claudia Kalb spoke with Dr. Elizabeth Nabel, president of Brigham & Women's Hospital and former director of the National Heart Lung and Blood Institute; Dr. Paul Ridker, director of the Center for Cardiovascular Disease Prevention at Brigham & Women's Hospital; Dr. Eric Topol, director of the Scripps Translational Science Institute and chief medical officer of the West Wireless Health Institute; and Dr. Clyde Yancy, president of the American Heart Association and medical director of the Baylor Heart and Vascular Institute. Excerpts:
Why isn't prevention working? Or is it working and, if so, where?
Yancy : What we've seen over the last four decades has been a steady reduction in deaths due to heart disease and stroke, especially in the last 10 years. This is clearly a function of better systems of care, new devices and technologies. But there's some very provocative research that demonstrates that about half of the reduction has in fact been due to prevention strategies. The real question is, how can we do more with prevention? It's not sexy, it doesn't generate a lot of dollars, but it certainly generates some benefits that may be far-reaching and real.
Nabel: We had a pretty steady rise in heart-disease rates up until about 1965 to 1970 or so. Since then, there's been a really marked steady decline. So instead of men dying in their 50s and 60s in the 1940s, '50s and '60s, people are now dying of heart disease in their 80s and 90s. As Clyde alluded to, studies have suggested that about half of that steady decline is due to prevention measures and about half to improved medications and technology improvements, such as bypass surgery and valve replacement.
Topol: I think the point has been well made that there's been progress. But I think it's worth emphasizing that heart disease is still the leading cause of death and disability. Beyond the things that have already been cited, part of the problem is we're not able to characterize things very well for prevention. For example, [high] blood pressure, which is notoriously underdiagnosed and inadequately managed—we rely on spot blood-pressure checks rather than continuous assessment, which is now possible in the era of wireless medicine. That's something we can do a much better job on.
What are the challenges we're up against?
Ridker: We know a lot more about the root causes of heart disease than we did 20 years ago. But it's still about going to the gym, exercising regularly, throwing out the cigarettes, and changing lifestyle.
Yancy: We're beginning to understand that there's a certain ecology of health that may predispose [you to] disease in ways which we didn't consider before. The density of fast-food restaurants in certain neighborhoods, the availability of recreation, the ability to purchase fresh fruits and vegetables. I think we have to consider the totality of everything—not just risk factors and genetics, but other very intriguing considerations.
How can we encourage prevention?
Nabel: One of the pieces that I found to be quite difficult and frustrating from a policy perspective is the notion of behavioral change. We can put into place all sorts of guidelines [and] recommendations, but at the end of the day, unless that body of knowledge is fully implemented, that knowledge goes nowhere. Policymakers have responsibility for this; the physician community has a big responsibility for this. Some people suggest that the only way you can really change behavior is through economic incentives. And I think that's an interesting concept, particularly as we're thinking about health-care reform.
Do you support economic incentives for doctors who improve patient care?
Nabel: I think some kind of economic incentive is probably going to be a component of our payment reform and will be a critical part of shaping physicians' behavior in the future.
Ridker: There really is almost no financial incentive right now for cardiologists or general internists or even primary-care physicians to spend a whole lot of time doing the things that all of us are advocating.
Yancy: There may be a greater opportunity, truly, in public policy. I really think the recently announced salt-reduction initiative [in New York] is one of those steps forward. The no-smoking ordinances. There are some big gains that can be had with what I would like to think are only moderately intrusive or minimally intrusive public-health statements. We can't forget about the potential power of going into the policy space and looking at food, because obesity drives a lot of this.
Topol: I just want to go back to a critical point that Betsy made about behavioral change. This is a very serious issue. For example, the data that Paul Ridker generated on [measuring inflammation in the arteries through a blood test for the protein] CRP a decade ago—it took many years before that was ever implemented into clinical practice. And I think many patients were hurt not having that information. Another example is [the clot-busting drug] Plavix. There are compelling data now showing that patients should be tested to see if they metabolize the drug to an active form [before it is prescribed]. But that's not being implemented into daily practice. It's really sad if we have to give physicians financial incentives to integrate new knowledge into their practice. It's frankly pathetic. Just as we are all frustrated by patients not wanting to adopt healthier lifestyles, the resistance to change in the medical community and this call for financial incentives to change their practice, that's a sad state.
Yancy: Eric, I'd be interested to hear from you—what else is out there to sway physicians? All four of us are educators—we write guidelines, publish statements, present lectures. What haven't we done that we might consider doing?
Topol: It's difficult enough to get to the physicians; they're not an organized body. Look how they sit on the sidelines as health-care reform has been attempted. So they just are basically busy taking care of patients and their lives. A lot of this is not actively resisting change, but it has the appearance of an ossified community.
Nabel: I think the standard mantra is that it often takes 10 years for a fundamental discovery to be fully implemented. And there are a lot of people who say, "What is it about you physicians? Why don't you get it?" And so I think that we do need an urgent wake-up call that unless we as a community do a better job of being much more responsive, we're certainly going to be marginalized in a whole variety of ways.
Too many cardiac patients are being readmitted to hospitals after treatment. Why? Yancy: There's a transition of care that has been undervalued. The physician of record takes care of the patients at the hospital; the patients [get discharged] and all of a sudden they've missed their meds or their follow-up visit or they didn't pay attention to their symptoms or we didn't prompt them to. Whatever the issue is, the end result is that about 25 percent [of patients] are coming back to the hospital within 30 days. That's way unacceptable.
Ridker: I may be a little more optimistic than my colleagues on this one. I'm a big believer that an educated patient is a good patient. And we're in an era where the access to medical information by our patients is unprecedented, particularly through the Internet. We pay for angioplasty and bypass and medications that work, and we should because they work really well. We do a less good job paying for things like cardiac rehab and preventive services that we also know work. And I find that the educated patient is asking for these secondary kinds of services. With globalization and the Internet now part of our lives, I find my patients asking much more intelligent questions, and I'm finding myself having to sit down and give more thoughtful answers than I might have in the past.
How will genetics play into the future of heart disease?
Nabel: We know a lot about rare cases of heart disease that are caused by a single gene mutation, but what we're learning now is that there are genetic contributions to the more complex chronic forms of heart disease that many of us will have as adults. That's where the new frontier will be. I think there's a lot of hope, there's a lot of promise, there's a lot of work that needs to be done.
Ridker: I'm of the belief that genetics is overwhelmingly worthwhile because it's going to point us toward exquisite biology. And it might take us 50 or 60 years without the genetics to get there. I think patience is required here, yet I think it's an unprecedented era that we live in.