Heart disease — America’s No. 1 killer — has a surprising problem, according to cardiovascular disease experts. It’s not scary enough.
“You get a cancer diagnosis, and everybody moves. They move heaven and earth. Families move. People move,” said Ami Bhatt, chief innovation officer at the American College of Cardiology. “You say, ‘heart disease’ and people don’t move in the same way.”
The attitude of many, if not most patients, is that they’ll get to it. They’ll improve their diet after the holidays, and they’ll start that exercise program once the weather warms up. All of this needs to change.
That was the message from Bhatt and other cardiovascular surgeons and experts in heart disease prevention and medical innovation who came together Feb. 26 at the Harvard T.H. Chan School of Public Health to sound a wake-up call.
They pointed out that cardiovascular disease’s continued status as the country’s leading cause of death despite decades of progress means much work remains. There have been dramatic advances in areas such as minimally invasive surgery and transplant surgery, while visions of the near future feature a growing use of artificial intelligence that leverages all of medical knowledge in real time to provide patients increasingly personalized care.
But when it comes to prevention, the prospect of a disease diagnosis tends to elicit only a casual response among patients, leaving those who deal with it daily scratching their heads.
“This happens to me every single week in the clinic when I’m seeing patients,” said Joseph Woo, chair of Stanford Medical School’s Department of Cardiothoracic Surgery and associate director of Stanford’s Cardiovascular Institute. “I try to remind them that cardiovascular disease kills more Americans every year than every single cancer combined, and if they ever heard they had a cancer inside, regardless of how slow-growing a cancer it would be, they would want it out or treated right away.”
“I try to remind them that cardiovascular disease kills more Americans every year than every single cancer combined.”
Joseph Woo
Jorge Plutzky, director of preventative cardiology at Brigham and Women’s Hospital, said the problem may stem from the fact that many aren’t aware that cardiovascular damage isn’t a result of old age but accumulates over decades. He said patients should not wait until they have to be treated but to “know their numbers” — LDL or “bad” cholesterol, blood pressure, weight, and sleep quality — from an early age.
He recalled conversations with patients who view cholesterol-lowering meds skeptically and juxtaposed them with a recent a conversation with a 28-year-old cardiology fellow who decided to start taking statins because his LDL cholesterol, while not high, was not in the optimum range.
“That frames a lot of the challenge for us because what does that cardiology fellow at the Brigham know that that patient doesn’t know?” said Plutzky, an associate professor of medicine at Harvard Medical School. “Bridging that gap is really at the core of effectively communicating what the issue is and why you want to do it. Doctors aren’t initiating a statin early because they think it’s harmful. They’re initiating early because they think there’ll be benefits.”
“Doctors aren’t initiating a statin early because they think it’s harmful. They’re initiating early because they think there’ll be benefits.”
Jorge Plutzky
Last week’s event, “Understanding heart disease: Advances in risk assessment, diagnosis and treatment,” also featured Tommaso Danesi, section chief of valve surgery and director of the Endoscopic Valvular Program at Brigham and Women’s Hospital. The event, a Dr. Lawrence H. and Roberta Cohn Forum, was moderated by Melody Mendez, an anchor and reporter at NBC10 Boston, and hosted by the Chan School’s Leadership Studio.
Panelists discussed a variety of developments in cardiovascular disease care. Perhaps most dramatic is a heart transplant technique that uses a machine to keep the donor heart pumping during transport to the transplantation site rather than being stopped and stored on ice while moving from donor to recipient. The transplant is completed with the heart still beating, which improves patient recovery time.
Endoscopic surgery has also advanced significantly, with heart valve replacement requiring just a three-inch slit and allowing patients to go home after four days. Physical function returns to baseline after just two to three weeks, Danesi said, compared to two to three months with traditional open-heart surgery, in which the entire chest cavity is opened.
Advances have also come in nontraditional areas, Bhatt said. Wearable fitness devices, for example, can be considered a sign of rampant “consumerism” but also can be viewed as a way for patients to gain agency over their health and know at least some of their numbers, a positive development in an area like cardiovascular disease.
Similarly, Bhatt said, the rapidly expanding use of the latest generation of weight-loss medications by patients without a clinical diagnosis has been disparaged as a sign of vanity, but it’s also the case that the drugs — and their associated weight loss — have been associated with improved health.
“Our population is getting healthier,” Bhatt said. “You don’t have to be a full-fledged diabetic with heart failure, or risk, to benefit from GLP-1.”
“Our population is getting healthier. You don’t have to be a full-fledged diabetic with heart failure, or risk, to benefit from GLP-1.”
Ami Bhatt
New drugs, techniques, and technology define the recent past and near future of cardiovascular disease, but age-old problems persist, Plutzky said. Patients routinely skip screenings that could identify problems in advance and, even when prescribed medication, many stop taking it because life’s pressures intervene: They move; their prescription runs out and they can’t get a refill; or they have trouble connecting with a doctor.
One answer Plutzky described is to use “navigators” to augment the care and attention of physicians between office visits. The navigators reach out to patients and provide intermediate follow-up after surgery to implant a stent to keep a blood vessel open, for example, or when a patient is struggling with rising LDL cholesterol levels or blood pressure.
“It’s quite shocking, the extent of undertreatment we find, even in an excellent system like ours,” Plutzky said. “We can immediately say, ‘OK, that prescription is now waiting for you. Here’s the basis for why you want to do that, and let’s get you back into treatment.’”
Plutzky said the approach spares busy doctors the need to address prescription refills — a mundane but important part of the patient’s treatment — provides contact and encouragement to the patient in the months between appointments, and as community-based outreach, helps lower barriers to access.
“This strategy has been extremely effective in terms of getting people into the right treatment,” Plutzky said. “It doesn’t rely on education, affluence, or other things. It simply says this person’s LDL is very high, they should be on treatment, and we can get that initiated in a fairly simple and effective way.”
