The plot thickens
 

Ty was forced to stop competitive sports

Jeff's other daughter, Stacy, moved from Park City, KY to Kansas City, MO last year. They consulted a pediatrician for their daughter Ty for anxieties created by the newness of relocation. Ty's QT interval was around 500 ms. At that very moment, we would begin to understand fully how 40 extra ms, a length on a heart tracing no greater than several hairs laid side by side, could change so many lives forever. Her brother Tanner was then tested, and his QTc was 490 ms. Gracie, the youngest, had a normal QTc. Ty and Tanner were placed on beta blockers. They were taken out of competitive sports, and alarm clocks were removed from their bedrooms. Caffeine was forbidden. Their pediatric electrophysiologist, Dr Lana Tisma-Dupanovic at Children's Mercy Hospital in Kansas City, told them that the death rate for long QT "can be reduced by almost 100% if the patients are placed on beta blockers." But unfortunately, only 60% to 70% of patients with a long QT will have an abnormal genetic test. "That is where it becomes difficult," she said. Holters, stress testing, and the clinical presentation will guide therapy. "It has become more common to find the long QT in children now that it is standard of care to perform an ECG anytime a pediatrician is contemplating pharmacologic therapy for [attention-deficit/hyperactivity disorder] ADHD and other emotional issues," Dr Tisma-Dupanovic added. Everyone who knows and loves this family is grateful someone was looking for it.

More twists of fate, yet
 
Amanda, with the normal ECG, was later found to have a completely different missense mutation in the SCN5A gene, a less lethal situation than her sister Stacy's mutation at the KCNH2 location. It is amazingly rotten "luck" to have not one but two QT-modifying genetic mutations in one family. Add this to our odd cystic-fibrosis gene (only 17 reported cases worldwide) and pheochromocytoma (my brother's recently confirmed mutation), and you see how unique we are as a cluster of individuals. We agreed, half-jokingly, "It is a wonder we don't all have gills," referring to the famed mutant Waterworld movie characters. If Jeff, the grandfather of Ty and Tanner, does not test positive for both of these genes, Sonya (our blood relative) will be placed under suspicion for a QT-modifying gene as well. 
 
Genetic testing has come light-years in a decade
 

Genetic testing can avert tragedy

I dealt with a horrendous tragedy in our community over a decade ago. A nine-year-old boy collapsed on the sidewalk on his way to say good-bye to his 17-year-old brother, who had suffered brain death after an anoxic injury from a motor-vehicle accident. The family buried both of their boys on the same day. The mother had "seizures" at the funeral and had been on Dilantin since her childhood. Her QT was borderline. A single daughter survived. At that point, the only QT genetic test available, according to the long-QT registry, was somewhere in Texas. They accepted genetic material from the deceased as a free service for research purposes. I was told sharply, "Do not call us back. We will call you. We are backlogged forever. It might be seven years." I called every other year but, as projected, it was around seven years when they finally pronounced the tests "inconclusive." I plan to contact them and redirect them unless they've already found their way to adequate testing.
 
"Will Ty and Tanner receive defibrillators at some point?" I asked their doctor. "They may, depending on their clinical course," said Dr Tisma-Dupanovic. "The size of the device can be problematic, and device upgrades are required as the child grows." In some extreme cases, she added, "Children as young as three months have received a device, but it is rare because it can take up a large portion of the abdomen. They require an update when the patient's weight increases to greater than 10 kg," she said. Because of the lack of implantable cardioverter defibrillator therapy in most children, she directs some aggressive changes in family dynamics. She recommends they purchase an automated external defibrillator (AED) and train all family members of a responsible age in cardiopulmonary resuscitation. Ty and Tanner now play golf instead of soccer. Their first-degree relatives are all being tested. "It is amazing how well they implemented the changes and dealt with the diagnosis," Dr Tisma-Dupanovic said. "Some families have a very tough time going through the phases of grieving when the diagnosis is made, with anger and denial," she said. "It is a pleasure to provide care for this family," she added.

How legislation can save lives

I asked Dr Tisma-Dupanovic what we could do now to help. "Some coaches are great about pulse checks and referring to a school nurse," she said. "I'd also like to push for the need for AEDs at all schools. They need education regarding the specifics of device utilization and how to maintain it," she said. "It needs a new battery every six months."

I recounted my failed efforts at that very legislation a few years ago when I traveled to Frankfort with the now-incarcerated KY State Representative Steven Nunn (who pleaded guilty to murder), begging for legislation for AEDs in each school, and even after a mother brought a picture of her deceased son, a baseball player, they turned us down flatly. They wouldn't legislate it because they couldn't fund it. Ty and Tanner's mom, Stacy, said, "Our insurance paid for an AED for each of the kids. We have Blue Cross/Blue Shield. They didn't even know how to go about getting us an AED and kept trying to get us a heart monitor to wear. I stressed 'portable' AED, and finally someone understood. I was amazed at the lack of knowledge, but they claimed no one had ever asked them about it. I think most people assume their insurance would not pay for an 'at-home' AED. But I persevered and asked three different people the same questions five different ways to get the answers. We had to go out of network for equipment, but I think they cost $1300 each." Stacy and Scott, according to Dr Tisma-Dupanovic, have been amazing parents in dealing with the long-QT issue, exhibiting both courage and persistence.

Affordability of testing
 
I contacted the managing director of Gene-Dx, Dr Sherri Bale, in Gaithersburg, MD and told her I had reviewed an amazingly detailed report on Amanda's testing. I was impressed with the 3.5 pages of family history and explanation, complete with a family tree. "For patients with no coverage, there is a $2500 out-of-pocket cost," said Sherri, "but we work with the insured to keep their personal cost to a minimum." Medicaid apparently doesn't participate in coverage for testing, and Medicare coverage is limited because most of those have other insurance. "For very specific genetic tests, the cost can be as low as $350," she added.

So, now you know the "rest of the story" as it unfolded in this beautiful young family, beginning with the day where everything changed for them, forever. A simple piece of paper and a tiny drop of ink have saved their children and their children's children for generations to come. An affordable 8x11-in electrocardiogram, painless and inexpensive, performed in less than 60 seconds by a caring pediatrician is all it required to identify this prolific serial killer. We are grateful that the "stranger beside us" who waited patiently, undetected and poised to take its prey, now threatens far less and can hide from this family no more.

Many patients fall into the current doughnut hole of VAD implant criteria and drown in a watery grave while we stand on the shore, life preserver in hand, waiting and waiting until their heads no longer bob on the surface. The new implant criteria should acknowledge that it is wholly unfair to ask that the heart be completely incapacitated but pompously insist that renal function be "adequate" in order to proceed with a VAD. This new conclusion can now be drawn, thanks to the body of literature and experience now available with VAD therapy. It would be unfair, however, to proceed without acknowledging that it is also a delicate balance to decide who is too sick for a biventricular pacing device but too well for an LVAD. There will be gray areas, but those questions represent the interface of medicine as both art and science and therefore will require careful consideration from an individualized perspective. 

In prior blogs, I've referred to several patients who have had fantastic success with an LVAD. One of my patients, however, has now passed away. He was the youngest of all the patients and failed two bypass surgeries from diabetes and continued smoking until very late in his disease process. He succumbed to a drive-line infection but lived almost two years with good quality of life provided by God and his device. His youngest children will remember him well. (I confess I have not been able to bring myself to contact his minister, where a posthumous message awaits me.) Another patient, several years out, is still flying high, doesn't want a heart transplant, and hardly has time to keep her appointments because she is too busy. I saw our practice's most recent VAD patient at a play. He had to jump the hurdles of gut bleeding from RV hypertension, angiodysplasia, renal insufficiency, and insulin-requiring diabetes to grab one. In the year following his implant, he drove to my house, stepping out of his truck beaming like he'd just dove "a perfect 10" off a cliff. He's out at the local restaurants. He spent part of the summer on a houseboat. His family had a great Christmas holiday. He's 100 pounds lighter and off insulin. It's nothing short of a miracle and he's having the time of his life because he "has a life." Plugging up at night and unplugging in the morning is a small price to pay from his perspective.

So the optimal approach to the questions regarding timing of LVAD implant is to plow through the morbidity/mortality data for both medical management and device therapy, consider the cost of the implant, the insurance coverage, and then weigh all these things against the cost of repeat hospital admissions for heart failure and pharmaceuticals for our patients and their impact on quality of life. We should then discuss every aspect of both management options with the patient and family, and finally ask ourselves that all-time-favorite-patient-generated question: "Doctor, what would you do if it were you?"

Then, without hesitation and by all means, do it!

See also:

3B or not 3B? Should patients get an LVAD before reaching end-stage HF?

I admit it feels really good to get that off my chest.

I owe my heretic philosophy to a lecture by Dr P Gabriel Steg that I stumbled upon quite by accident many years ago while in Barcelona, waiting for that year's European Society of Cardiology lectures to begin. I heard a voice echoing down the hall of what I thought was an empty convention center while waiting for another lecture to begin. I followed the sound as I had 30 minutes to kill. I opened the door to a gigantic auditorium where probably a thousand attendees sat listening to information on the now-defunct rimonabant compound. Dr Steg had an amazing PowerPoint that explained the finite mechanism of hormone production of the abdominal fat pad and the horrible metabolic derangements produced by it. I recall understanding for the first time how being "fat" kills a person, how the inflammatory response causes plaque rupture, fluid retention, hypertension, stroke, clot, blockage, and even lends itself to vascular spasm. Gabriel might not agree with this extreme interpretation of his presentation, although I don't know for certain. We've discussed many other things, but I've never had an in-depth discussion on his views of sugar metabolism. I assure you, however, that hundreds of patients in Glasgow, KY have been changed forever by his lecture. I am truly grateful to him.

Heretic statement #2: "More people die of 'borderline diabetes' than true diabetes because it is not given the respect it deserves." Melissa Walton-Shirley

I do not believe in the term "borderline" diabetes. It makes about as much sense as saying one is "borderline" pregnant. You either "are" diabetic or you "aren't." You either have blood glucose of less than 140 after 75 g of glucose or you don't. If you eat a slice of pie and your blood sugar hits 160, you are a type 2 diabetic. Perhaps all you need to do is lose weight, push back the plate, exercise, and reverse it, or you might be one of the unfortunate who need four insulin shots per day. I submit it is the same disease process, just different extremes of insulin resistance. Both versions can spell blindness, diabetes, heart attack, and dialysis.

For laypersons that follow my blog, there is a distinct difference between unfortunate "true" type 1 diabetics who have had the misfortune to suffer the death of their insulin-producing islet cells. They have a completely different disease process. Unless they undergo an islet-cell or pancreas transplant, they will always be a type 1 diabetic and will require insulin supplementation. Contrast this to the typical type 2 diabetic. About 95% of those in my practice are overweight, don't eat properly, and rarely exercise until they receive "the diagnosis." It is amazing to me that about 95% of them have no clue that they are completely "curable." It is a matter of lifestyle change. With rare exception, I've hardly met a true type 2 diabetic who could not get off insulin after losing about 50 pounds. Nothing is more frustrating to me than someone who relates to me, "Well, I'm terribly sick with diabetes, doctor. I've had to go on insulin," while folding their hands in resignation, accepting a fate of dialysis, amputation, blindness, heart disease, and stroke. I really want to shake them out of their complacency.

I do have about 10 normal-weight individuals in my practice who have impaired glucose metabolism and are not type 1. I'll leave it to the endocrinologists to explain it. I don't know if it is production of an imperfect insulin molecule or if there is severe genetic resistance, but they do exist. In Glasgow, KY, they are an extreme minority.

Heretic statement #3: "There is an inherent prejudice in the medical community against the use of the term diabetes even after an impaired glucose-tolerance test is completed." Melissa Walton-Shirley

You have no idea the number of times I have opened the door to a patient who is positively beaming with the fantastic news: "My doctor told me I'm really not diabetic like we initially thought! I'm just borderline!" Yippee! I think as I close the chart over a postprandial blood sugar of 240. I want to then beat my head against the wall until I am unconscious. It would be the only true escape from such indifference to the obvious ability to save lives, legs, vision, and healthcare dollars (in concert with making America smoke-free, of course!). The last patient who argued with me regarding this issue had a postprandial blood sugar of 420 (no exaggeration) who seemed "borderline," convinced at first of his diagnosis.

The new guidelines published on assessment of hemoglobin A_1c, although most welcome, in my less-than-humble opinion are a fantastic first step in detection of the disease that kills so many human beings on a daily basis but fall just short of what will actually "make" the diagnosis of so many diabetics. I order a nonfasting two-hour glucose challenge with 75 g of glucola on most patients who present for hospital admission from whatever cause if they have some weight to lose or if they have a single abnormal blood sugar on the chart. I am amazed at the heights to which those glucose levels soar, but it is required that I show it to the patient in black and white before most are motivated to do anything about it. 

Heretic statement #4: "If your physician tells you that you are just a 'borderline diabetic,' don't believe it." Melissa Walton-Shirley

Run screaming to the nearest gym, fresh produce aisle, and a good nutritionist.

I'm willing to bet that you are sweeter than you think.

See also:

New guidelines suggest blood glucose testing for all inpatients

Cocoa Beach, FL is our favorite respite, where time melts like Salvador Dali's clocks, draping itself over palms and boardwalks. It spreads itself over gritty powder-white sand and lingers on comfortable worn flip-flops. The ocean, blue as the sky, gives up mounds of shells and is my constant companion on long morning walks and nighttime excursions. I love this beach. I long for it at times, but there has been no other time that I have been needier of this refuge than the last two years of my practice.

Like an old sea captain who reflects backward on his career, I took inventory this weekend of my time on the high seas of private practice. Although challenging, the first two decades of my career were smooth sailing and most rewarding, but there is truth in the saying "there is nothing more deceptive than the calm before the storm." An able and wise cocaptain stood beside me through rough waters and celebrated victory upon victory. He still stands beside me today. We still rise to every challenge but are both a bit battle-worn, not from physical demands so much as from the politics and change in our local medical climate.

We have learned much from two years of turmoil. We have toughened up with assaults from our own government, which has locked in private practitioners at the other end of the spyglass, cannons at the ready, to dismantle old practices that have served the multitudes. Private practitioners are scapegoats, with threats to decrease our reimbursement by one-quarter, a misguided attempt to correct the sins of mismanagement and waste, and for that portion of the population who drink, smoke, and eat us into financial oblivion, individuals who are always expecting the treasure chest of government funding to be ever at the ready. They have no thought of the efforts and sacrifices required to fill it. Our income and those in our employ who have also entrusted their future to us are ever vulnerable. Add to this the pain of loss of consortium of our former colleagues who have fallen victim to the more attractive cousin of socialized medicine, hospital acquisition, and the sting of abandonment by the very institutions we have helped to build and sustain. With the weight of disappointment of the immediate past and the reality of the consequences of the temporary definition of legal collusion, another year of disappointment of last year's magnitude is at first difficult to contemplate.

Despite my clothing heavy from the water coming into our ship, I am miraculously now more optimistic. In part, I owe it to the lessons I have learned from nature on how best to cope with the adversities of a hostile practice environment. I have learned that sharks do not adapt to their environment but rather adapt all that is around them to theirs. I either must steer clear or outsmart their tiny brains, which understand only pain and hungry greed. I will sustain by being as reliable as the ocean tides and as truthful as the promise of a rising moon. I will give up the dead yearnings of yesteryear much like the sea spits out its dead each morning on every shoreline that edges its mother earth. I will accept the need to endure occasional raging winds but will still enjoy the warmth and comfort of calm waters. I will be a survivor and will hang onto whatever driftwood, plank, or passing ship that might lend itself in times when there is need of rescue, as long as it is a vessel with honorable intention. If the intentions are ever otherwise, I would rather let go and sink slowly to where the waters become murky and dark. For a brief moment, interrupted only by the sounds of sea birds, I once again, and hopefully for the last time, allow myself to sink, free falling into that small corner of my imagination to that unthinkable place. My toes first sense the cool depths of resignation, then my legs and my face, immersed and though hungry and panicking for air, a comfort compared to a life of piracy chosen by a few and a life fully mapped with few choices for others. I see in the distance other ships passing above me and contemplate their offers of assistance but stay submerged until that dreadful chapter of my imagination is finished.

I open my eyes and step back into reality. I feel the sand beneath my feet, the sounds of children playing in the waves. I stand to walk back toward home accompanied by a hint of dread at the thought of the beginning of another year. It will be a year of strategy, some certain disappointments, surviving . . . but then I abandon those negative feelings for a ship that passes with flags flying, sails full of wind, the ocean spray peeling off the bow as it parts whatever waters that lay before it. I am the proud captain of my ship. I author the manifest, the ports of call, and with the help of God, the destination. I realize that I have a beautiful family, a warm home, and a great life partner that welcome me at the end of every day's journey. I have tens of thousands of patients who are treading those murky waters of uncertainty who view me as their life preserver, their anchor, and their guide. They are adrift in a far more unsettling sea than what we as medical professionals will ever perceive.

As I reach my destination, I realize the sun that so gently caressed my skin this last hour, while now setting on a crimson horizon with the fingers of night dangling toward earth will rise over a glorious first new day of 2012. The subconscious scales that weighed my future are now tipped toward the positive. I have willed myself in the space of this hour to believe with every fiber of my being that right will triumph over might. I am resolved that I will be productive and happy. I will approach the year with a clear focus on each patient and each decision before me. My calm resolve perceived as weakness by some will be my navigation tool and my greatest strength.

My New Year's wish for all of you is that 2012 will bring you prosperity, happiness, health, and, most of all, peace in a future that often times is what we make it. May you always be your own captain. 

The human beings I champion in the political and medical trenches are people like my mother's only sibling, who arrived at my ER door in the mid-1990s with an inferior MI who suffered an IC bleed after I delivered tPA. I sat by Uncle Gordon's bedside for four days watching Cheyne-Stokes respirations and sweat roll down the forehead of a man who reached his hands out to me in the ER and said, "There's my Missie. Come here old sweet. She will help me." This man I loved like a father, who had no children and loved my brother and me as his own died at the hands of lytic therapy with my prints on the weapon. I sob as I write this piece and wished for a year that it had been me who had died instead. This horrible pill to swallow is made even more bitter by the fact that if he had arrived at a door in Marysville, TN, just an hour south of us, which had performed PCI without surgery on-site for years prior, he would have likely gone home in a couple of days. He could have farmed the land he loved for another 15 years before he would die a more timely death. Combine this story with the scores of others who fail lytic therapy, like my partner's patient, who is a single parent and lives with sudden death looming large over her life on a daily basis because she was trapped here in our ER due to weather that turned us into a no-fly and no-drive zone during her MI. We had a cath lab upstairs, for Pete's sake, but could not have performed a PCI back then even if we'd had an interventionalist on-site, due to state regulations. What about the gentleman I treated who had knee surgery who was not a candidate for lytic and required transport, but by the time he arrived at a PCI center, had lost 15 years of good-quality life? The medical team rejoiced at that save, but a lost opportunity for more good-quality life was forgotten at his funeral that happened a decade and a half too early. It took us six years, three governors, scores of battles at Kentucky Hospital Association meetings, multiple empty promises, and navigating around unholy alliances until we were able to expand PCI without surgery on-site. Why in the world should saving lives and money be so difficult?

The shortsightedness of our complacency for myocardial rescue is unforgiveable in this country. When we first started the push in Kentucky to become the 38th state to allow PCI without surgery on-site, I was astonished by the answers given to me by our much more practical European counterparts. They would often reply, "What do you mean by the term without surgical backup on-site. I've never had it." One physician, annoyed by my question, said, "It's a ridiculous question. The patient requires a lifesaving procedure. Why would you even consider such an issue as requiring a transport? Doesn't happen in my country. You do what is necessary." Another said, "I've been performing this procedure for 30 years in downtown Paris and I've never required an emergency surgical procedure."

Indeed, we don't approach acute-MI therapy in the manner in which it is approached in many other countries. I once interviewed a physician from Poland who worked in a government subsidized AMI station. "My door-to-balloon times are 12 minutes," he stated. He explained there are no elevators; just a drive-through-window type approach where the pants were pulled down, some Betadine doused on the site, and in 12 minutes the heart attack is over and a huge hunk of myocardium is saved. After the lifesaving business has been attended to, there is time for introductions and social graces later. For those lucky individuals who receive a timely PCI in that fashion, there are bound to be a gazillion fewer automatic implantable cardioverter-defibrillators (ICDs) or admissions for patients drowning in their own fluid from pump failure. By looking at these extreme models for primary PCI, we know that we can and should do better for our ACS patients in the US. We should bury our heads in shame if we have been any part of what helps to grind down the necessary machinery to expand access to primary PCI without surgery on-site.

As staunchly supportive as I am of primary PCI without surgery on-site, I am even more staunchly supportive of regulation, monitoring, and reporting. Crooks should be prosecuted, but patients who are in dire need of this service should not be denied access because of the sins of the few. We should no longer choke at the gnat of the complication rate of <0.05% of PCI without surgery on-site while we hungrily gobble the camel of the 40% of patients who fail lytics or are not lytic eligible or the 4% who die of IC bleeding like my uncle. We need to educate our tertiary centers that just because we have "prehospital ECGs" it does not guarantee arrival at a PCI-capable site. Furthermore, let's not forget those who begin their infarct in a non-PCI hospital or those who arrive by private car. Let's remind our colleagues that even if you are sharing the same piece of geography across the street from a PCI-capable center, just packaging the patient and unpackaging the patient and running across the street with them burns precious myocardium. Studies have clearly shown that for every minute wasted the LVEF declines. Why not let the interventionalist do the driving to wherever the infarcting patient arrives if it is so close? Vanquish the smoke screen of mystery surrounding this procedure. I've stated before that we should treat the need to open an artery with the same respect that we treat the need to open an airway. Just because the funeral is five years later, an untimely death from preventable pump failure is no less a tragedy. Our guidelines writers, who are good and decent men and women, are beginning to understand the need for updating our guidelines but, for reasons I cannot understand, require much encouragement on the behalf of cardiologists who serve the underserved before they will jump-start the much-needed process that will lead to better acute cardiology care in America. Any of you with influence should open a dialogue today that insists on monitoring and expansion of access to these services simultaneously. Join me in condemning the lackluster presentations on this issue that I heard on the NCDR data delivered at a major meeting, with just enough negative slant to take the wind out of sails that were beginning to fill with hope for necessary change.

It is time we take a page from the history books of other countries like the Czech Republic, which mapped its country and found a route so short to a timely PCI that those off-site arrivals fare as well as on-site arrivals for outcomes. It is time we write a new page in the history book of this country, which embraced the much-needed mapping for trauma patients but failed to even utter the words "cardiology," "heart attack," or "heart failure" in a healthcare reform bill that will reform nothing in the realm of ACS. It is time we champion those who number among the half million patients who suffer the same fate on an annual basis at the hands of ST-segment elevation MI but are denied access due to the unfounded fears that surround the issue of expansion of access to a timely PCI. It is time we checked unfounded fear and the unforgivable darkness of greed that taints this issue. Those in tertiary centers who are fat and happy with PCI labs bursting at the seams need to be far more concerned with the scores of ICDs of the noninsured required at the end of their annual fiscal budgets than the rare complications that occur from a PCI. I submit that if we diffuse the lifesaving technology of primary PCI to the masses and preoccupy ourselves with the benefits, instead of hiding behind the unfounded fears of excessive risks and monetary losses, we will save lives and create more grandparents who can lead more productive lives. 

I hate to admit that the US is behind on any issue, but folks, we are dreadfully behind in promoting a timely PCI for all patients in our country. In the wake of our complacency we leave a growing population of cardiac cripples who pant for air as they sleep, walk to the mailbox, or just sit in their chairs waiting for life to be over. As their personal lives are devastated by our failure, they are breaking our medical banks from recurrent admissions for primary pump failure, device needs, and a laundry list of medications that compete for the monies necessary for personal basic necessities. We can do better and we should do better. Some of us forget that we even took an oath to do better. For all the "Uncle Gordons" of the world, my conscience insists that none of us should rest well until we really do better for all patients who suffer from an acute MI in America.

See also:

Survey says: Most cardiologists support elective PCI sans on-site CABG . . . with caveats

Cardiologists get it on both ends now. Blue Cross Blue Shield (BCBS), which pays just one of its state CEOs a salary of $4.6 million per year, tells me daily I can't get a stress exam on someone with risk factors because they aren't having chest pain. "But she's not going to be 60 years old for a few weeks," one BCBS physician told me, despite the fact that her ovaries had been missing in action for 25 years. Another day, I could not get a stress exam on an asymptomatic gentleman a year after he had a silent MI. He was still infarcting and recovered his LV function after a quick PCI. They wanted me to wait another year before I could get a follow–up stress exam because he wasn't "having typical symptoms" (duh). Now the CMS is telling me that the new trend in medical fashion will be "If you miss the diagnosis, you won't get paid for the workup." Will you also stop reimbursing normal head CTs after a loss of consciousness for an MVA? Will you embed FBI agents in every pathology department in the country to radio the White House that Ms Jones, with RUQ pain and a negative GB ultrasound, who had visited every ER in the district, had no gallstones? How about a negative colonoscopy for rectal bleeding? It is a sure bet that this political snowball will pick up a lot of testing and workup while rolling out of control downhill toward hell.

The opportunities to save money in all walks of medicine are as abundant as eggs on the White House lawn on Easter weekend. They are free. All you have to do is to bend over and pick them up. For the love of all things sacred in medicine, CMS--who in the world are you talking to? Do you ever ask anyone who is actively engaged in a full-time practice what they think will work to rein in cost? I've said it until I'm blue in the face. When you are looking at a budget and need to cut costs, the very first thing you do is examine the most expensive items on your expenditures, and I submit to you with absolute confidence that that is NOT CROOKED MEDICINE!

If you don't believe me, call Suze Orman, Dave Ramsey, even Donald Trump. They would open the books on medicine and point to congestive heart failure as the big-ticket item. Then they would ask, "What drives the cost of this item upward?" We as drones in the medical world would say, "Mr Trump, it's undetected and undertreated hypertension. It's rampant glucose intolerance that most overweight Americans have at this very moment who are being patted on the back and told it's just 'borderline diabetes.' Ms Orman, it's lack of exercise and improper diet. Mr Ramsey, it's greater than 50% medical noncompliance. It's America's love of smoking and the pathological paranoia that if you have to step outside to smoke, you'll wind up in a prison camp somewhere. It's the glaring omission of the need to map America and get every ST-elevation MI a primary PCI in a timely fashion and the need to make PCI stations as abundant as Wal-Marts. It's time to treat PCI without surgery on-site with the same respect as the need for intubation in respiratory arrest. It's time to emphasize the need for changes in the "healthcare reform plan," that diatribe that made War and Peace look like a comic strip, the one where trauma, family medicine, and obstetrics were mentioned, but NOT ONE TIME was the word "cardiology" uttered or the need to reduce heart-muscle damage by doing a better job at treating heart attacks. It's our convoluted thinking that you should be able to sue your doctor for a million dollars, your doctor who was trying to help you, had a good track record, and had a poor outcome, despite the fact that most Americans who bring those suits had never exercised regularly, ate right, or made much effort on their own to maintain good health. We have to stop the mentality that it's okay to drive 120 mph, but if you hit a tree and get a wound infection, you get a million dollars annually for life (or more correctly, your malpractice lawyer gets a million dollars to spend for life).

Furthermore, we cardiologists, who employ a substantial work force to fill out your forms and do your billing inquiries and kill trees and wreck carpal tunnels from all the necessary keystrokes, do not deserve to have our salaries reduced on a whim. Every year, it's a new threat of a 20% or 30% reimbursement cut when there is an opportunity to save billions by just having a conversation with the White House. Insist on driving real campaigns that target compliance, make all public buildings in the US smoke-free, and map America for timely primary PCI. Quit just talking about malpractice reform and DO it! Offer incentives for hypertension screening, dietary instruction, and access to and utilization of exercise facilities for every business in America. Do not engage in a pathetic witch hunt, but go ahead and lay a trap for the crooks that are few and far between in cardiology.

If you are running for public office, especially the highest level of office in our country—specifically I am addressing you, President Obama, and you, Mr Romney or Mr Gingrich—you owe it to us to sit down with a physician who is actively engaged in full-time private practice to understand the most important issues we face in our country. Instead of just being reactive, let's become proactive and at the same time react wisely and logically. Go ahead. Be bold. Focus on detection and prevention. Don't be afraid to drive up the immediate cost of healthcare by looking for renal-cell carcinoma or triple As or carotid disease. It will save in the long run by preventing two years' worth of chemo, radiation, and hospice care. Save billions of dollars in nursing-home stays for stroke. Drive the utilization of calcium scoring to detect asymptomatic coronary artery disease. Incentivize easy access to blood-pressure screening. Teach America how to check their pulses and screen for undetected afib. Make PE and health curricula in grades 1 through 12 just as important as math and science. After all, if we can't teach kids how to live longer, healthier, and more productive lives, we have taught them nothing of value.

A great first step, and about the only thing the CMS has done that makes any sense whatsoever, was to make a feeble attempt at obesity screening and counseling. Someone must have had a TIA up there to have actually tried to address a real issue. I applaud that, but it was a drop in the bucket. Politicians cannot micromanage what goes on in a cardiologist's office, but you can help us by laying the groundwork for success by just convening for a week on cardiovascular issues alone. If you don't know what to do, instead of just picking some crazy scheme, for the sake of the future of American cardiology, why not pick up the phone and ask someone who is actually practicing it? CMS, by putting all the drivers of our most expensive DRG under the political microscope in cooperation with the scientists who actually fight in the trenches of cardiovascular disease every day, you can be successful in putting American medicine on the right track. It is only through the utilization of this formula that we can successfully improve healthcare spending. Otherwise, you will fail, and so will we. 

See also:

Stents, ICDs, inappropriate? Then, under new audit program, CMS won't pay

I saw a funny silent Marty Feldman clip once. The hilarious bug-eyed comedian was an undertaker in a small town competing with a mortician who also ran a funeral parlor just across the street. Each morning, they greeted each other warmly as they passed on the busy main street flanked by restaurants and dry-goods stores. Swathed in long black coats and top hats, the two crept about the town oddly with shovels, ropes, and whatever tools necessary to promote their business. Apparently, times were hard, so occasionally, one would knock the other unconscious, slip him into a wooden box and hastily start the funeral only to discover the box was empty. Suddenly, a shovel would crack the other's head and down he would go into another waiting wooden box! The cat-and-mouse game automatically started again until one could catch the other off guard. That same dogged determination driven by stiff competition is pervasive in all walks of American industry, and unfortunately, on occasion it creeps into the practice of cardiology. The greatest majority of us act honorably and courteously, but this piece is for those who occasionally do not.

Case in point: An acquaintance recently evaluated his patient for noncardiac surgery and explained that the surgery was risky, but he was well medicated and his stress nuclear demonstrated minimal ischemia in a small segment. Unfortunately, the patient suffered cardiac complications perioperatively at another facility but was discharged home in stable condition. Instead of the original attending cardiologist being informed of the need to pursue a workup or that complications had even occurred, he found out only when records were requested and the patent's care was transferred to the cardiologist who attended the patient in the other town. Fortunately, the original attending took the initiative to contact the patient, who was very relieved to hear from him. The original cardiologist remarked that if that same patient had gone to one of the larger hospitals in a true tertiary center, there would never have been any issues with referral back into his practice. Hunger, however, can motivate strange behavior. I insist it is no excuse to ignore the four Cs of competition.

The first two Cs stand for: Continuity of Care: I can't stress enough the worth of 20 to 30 years of knowledge of a patient's habits, intolerances, personality traits, and strengths. It's sometimes difficult to translate those subtleties like preferences, quirks, or psychosocial issues that are often not reflected in the medical record. On the other hand, the implication of a lapse in continuity of care issues can be more blatant. A patient was on her way to the cath lab for chest pain one morning when her usual attending cardiologist stopped the nurse and said, "Wait a minute, that's my patient. Does the angiographer know she's been spiking fevers to 103 at home over the last week and has lung cancer and a recent normal stress nuclear that addressed her chest pain? To which the nurse replied, "Uh . . . I don't think so . . . I'll call." Needless to say, the cath was quickly canceled and she was referred back to her surgical oncologist for treatment.

The next two Cs stand for Common Courtesy: Bob Harrington's interview with Clyde Yancy on civility was excellent. Although it may be difficult to remain civil in extreme instances, every effort should be made to respect a long-term doctor-patient relationship. I've always made great effort to get patients referred to our facility back to their original cardiology-care providers. I believe that if one is too lazy to build one's practice by reputation and hard work, with all probability, one is too lazy to take care of the patients they catch in their net. Even when patients come for a second opinion, we should call the other physician, if the patient will allow it, to discuss the case. It's a bit uncomfortable at times, but it keeps the lines of communication open and it fosters good karma. On almost every occasion, I learn something that helps with patient care.

In this tough economic medical environment where things may heat up over time, if we mind the four Cs of competition, the focus of our work, our patients, will be served best. Continuity of Care and Common Courtesy together make good practice and are the essential of the most important C of all, one that is most essential to fulfilling our duties as a cardiac healthcare provider: Character. 
 

• I'll try to get a date for bivalirudin with the entire cath lab team. I'll comb his hair and dress him up and spray on some great smelling cologne and see if I get any takers. Hey, maybe if I tell them that none of their mothers like him . . . 
• I'll continue to be happy with plain old enoxaparin for thromboembolic prevention for now. So far, it's held up well against the early assault by the soon-to-be "new kid on the block," apixaban.
I won't invest in vorapaxar, unless Mattel purchases the right to use its name as an alien predator for a Christmas toy. "Vorapaxar meets Godzilla?"
• I'll send out a mass email advising my CAD patients to put in applications for a second job, or they might just start now to open a new savings account, kind of like the Christmas club. They'll need it to afford the rivaroxaban I'm going to have to prescribe them as the latest add-on when they get their next ACS. Gee, wonder if the FDA will give us that indication? (Tongue in cheek.)
• I'll pound my buddy Aetna to wave the copays for beta blockers, ACE inhibitors, and statins across the board for post-MI patients. But I probably won't be able to find him because his good friends Blue Cross and Humana have probably taken him out behind the barn to give him "what for." They should thank him for participating in this trial, but based on their superior ability to recognize what's good for them and patients (like prevention coverage), I don't think Aetna will get any love anytime soon.
• I'll try to be "nicer" when heart-failure intervention trials are presented. I get kinda steamed when the basic tenants aren't part of the ground floor of any CHF trial design. No drug or slate of drugs for CHF will ever have a snowball's chance in Hades to work if the patients are drinking 3 liters of fluid per day and licking salt off the backs of their hands. The avoidance of these velociraptors of "CHF Park" is "an aim not devoid of merit." (Quote—John Hammond sans the CHF slant.)
• I might get a nice album of pictures to add to our consent forms so I can talk longer to patients before they have their procedures or maybe even let them read more so they won't have the procedure I know they really need, and maybe throw in my vacation videos and sit around a campfire and sing "Kumbaya." (Kidding—I already do a long consent and I'm all for whatever will help a patient feel more comfortable. Really, I'm kidding, so please . . . no hate mail.)
• I'm still going to be good and mad until every ACS patient in my country gets a safe and timely PCI, so I guess that means I'll be mad forever unless I move to Europe, in which case, I could have been happier 30 years ago. 
I sure won't give dronedarone to my patients with permanent afib, like I was going to ever do that anyway. Seriously, the drug absolutely should not be used for permanent atrial fib, hemorrhoidal pain, or acne.
• I will try to get my patients to take high-dose statins. I don't know if it's going to translate into a decreased event rate, but it just makes me feel better to slide all those LDL and HDL numbers into the normal category. I also hear it does wonders for obsessive-compulsive disorder. 
• I can't wait for evacetrapib and some of its siblings to be born in America. In the meanwhile if someone walks up to you, kind of shadylike, and tells you they have some knockoff compound that starts with a "T" for sale . . . out of the trunk of their car that "works just as well"—I'd keep walkin'.
• As for niacin, the problem child of the lipid arena, I'll probably not stop it, but not sure I'll start it either. I might could use it in the spa to negate the need for blush . . . Just sayin'..
• Hmm . . . I'm thinking about using colchicine for a fib prevention post heart surgery. It seems like it just might work, but the investigators reminded us that it isn't FDA approved for the treatment of pericarditis or treatment of the pericardiotomy syndrome  and well, over the course of decades hasn't really been FDA approved for much of anything. Well, I never knew that, yet I've utiizied it several times for those indications so . . . thanks for that . . . and I suppose you're going to say I’m fat too. (Sticking tongue out now.)
• Finally, thanks to the investigators who actually care enough about a drug that’s going generic to study it. It seems that boosting the maintenance dose of clopidogrel to 225 or 300 mg/day overrides genetic resistance for the unfortunate 30%  of the population who will get no bang for their four bucks (after May 2012) for the standard 75-mg dose. I'd love to start boosting the doses immediately in my patients who demonstrate resistance either in the laboratory or clinically, then check my VerifyNow results as I titrate, but alas, the FDA does not currently approve of such, and there is that pesky issue of lack of proof for improved clinical outcomes, so I guess the next questions are: When can we get started poking around in the DNA of our CAD patients? Will it require we mortgage the farm or win the lottery to purchase a look at our genes? The benevolent edge of this study—looking at a drug that will actually be widely affordable in seven months in the US—will no doubt be blunted by the enterpreneurial-genomic axis of the situation.

Well, that's an irreverent look at the American Heart Association 2011 Scientific Sessions' late-breaking clinical trials thus far. It was one of the most memorable meetings I've attended in a long time, and was an honor and a privilege to attend! Not kidding this time . . . Really!!!

The same phenomenon was noted in the POWER trial. Obese patients were given, for free, the opportunity of a lifetime; a cure for their diabetes and hypertension, the ability to avoid a stroke, and the opportunity to nearly vanquish the risk of a heart attack. Coaches stood ready, practically begging for an opportunity to help them. Access to websites, emails, phone support, and face-to-face visits resulted in a dismal 52% of patients who were able to achieve the goal of a 5% weight loss.

So what exactly goes on in the mind of an individual who won't take years of hassle-free decades of life for free? How can you "make" someone love not having to buy bushel loads of medication or pant for air when they walk to the mailbox? How can you make them see that looking younger and feeling great are still compatible with the aging process?

The answers to these questions are as complex as the disease process itself, and we must insist upon finding the answers, but first we have to ask the right questions. Is it a fear of side effects? Is it the actual experience of having had a side effect? Is it because you know someone who had a side effect? How willing are humans to take medications if they aren't having immediate symptoms? Have they been socialized that taking medication is a sign of weakness? Do they have trouble swallowing? Do they have memory issues? Do they not buy into the belief system that exercise, diet, and control of a disease process by pharmacologic means will actually help?

Since there were improvements in compliance in the MI FREEE trial and measurable weight reduction in 52% of the cohorts in the POWER trial, the findings indicate that success can be achieved by combining the best of both trials. Third-party payers should provide free coaching and inexpensive options for medications. Access to remote support is cheap and readily available for most patients. These studies prove that any effort above what we are currently doing in traditional medicine will translate into some measure of success.

Perhaps when we design these trials, a psychological survey should be presented and an in-depth analysis performed of exactly what makes these noncompliant cardiovascular patients tick. We should invite our friends the psychiatrists to jump on board with each study. When we start to design trials that acknowledge the psychological aspects of compliance by utilizing measurable tools for study and modification, then we will truly get somewhere. Then and only then can we "give away" longevity, well-being, and good health to the masses.

See also:
Cutting copays for post-MI drugs helps outcomes, with no added cost to insurers
POWER program: Phone, internet intervention achieves, maintains weight loss

See:

• POWER program: Phone, internet intervention achieves, maintains weight loss
• SATURN: Maximum doses of rosuvastatin and atorvastatin equally regress atherosclerosis
• Cautious optimism welcomes new CETP inhibitor, evacetrapib
• AIM-HIGH: Results raise controversy over early stopping
• AIM-HIGH fallout: Experts disagree over niacin's niche

See:

• Cutting copays for post-MI drugs helps outcomes, with no added cost to insurers
• Customized informed consent improves communication
• C-PORT E: Elective PCI doesn't require surgical back-up

B: Because this technology is still not evenly distributed throughout the US, patients are dying without a timely primary PCI. Nonprimary centers must be sustained in order to provide lifesaving interventions for those suffering from an acute event. TheC-PORT E trial is about the one-millionth piece of evidence that shows that PCI without surgery on site, with regard to both primary and nonprimary PCI is safe. We are so late in promoting access that it's embarrassing.

C: Congestive heart failure continues to be our most costly and lethal DRG. Until our guidelines writers convene often enough with the goal of maintaining and creating more PCI centers in underserved areas, patients will continue to die while others will be discharged with a poor EF. This translates into higher drug bills, more devices, and greater disability enrollment. At the same time, those centers that are operating under the radar, without adequate reporting, and quality measures should be sanctioned and reimbursements cut if after a grace period they are not willing to comply with monitoring.

Dr Ralph Brandis spoke to Managing Editor Shelley Wood of heartwire in June 2009 on the subject:

"We've actually had some outside people doing some analysis of our paper [the NCDR data] and . . . they think that, based on the data we have collected, the clinical-practice-guidelines team should look long and hard about changing their class 3 recommendations and making them either a 2a or 2b" for elective PCI, Brindis commented. That said, he continued, "I can't anticipate what they are actually going to do, and I suspect they are going to wait for C-PORT Elective before making their final recommendations."

Well, it's way past showtime, folks. Can anyone really look me straight in the eye and tell me that primary PCI without surgery on site for STEMI should really be a 2b indication? If so, I think intubation as a 2b indication makes just as much sense. There isn't much difference between dying now and dying three years from now after years of poor quality life while suffering from preventable primary pump failure. (Some argue that dying early on is more merciful.) As much as I revere, respect, and appreciate my friends and colleagues who are interventionalists, pulling this off in a nonsurgical center is not rocket science, or maybe I should more appropriately insist it is at least the same rocket science that makes it so feasible in a surgery-on-site center.

The 30-year-long warm-up performed by such groups such as Dr Gabriel Stegg and the "daring lifesavers" in downtown Paris, who have performed PCI safely with no in-house safety net for three decades, should be our template. For the life of me, I don't know why it has taken so long to upgrade these guidelines. Or, let me rephrase that: In the name of so many lives cut short or lost because of our reluctance to promote this lifesaving procedure full on, why, on this side of God's green earth, has it taken so long?

See:

• ISAR-REACT 4: Bivalirudin preferable to abciximab/heparin in NSTEMI
• AIDA STEMI: No benefit of IC over IV abciximab
• TRACER: Novel thrombin blocker vorapaxar stumbles in ACS, ups bleeding risk
• ADOPT: Extended apixaban no better than standard enoxaparin for VTE in medically ill
• ATLAS ACS 2: Low-dose rivaroxaban looks good in ACS

During the 1960s, heart-attack treatment and prevention of reinfarction was deplorable. It consisted of bed rest and chicken soup. Then came nitro, aspirin, and later, heparin. Beta blockers and statins were then added to our armamentarium. We lurched light-years ahead with CABG. Finally, the appearance of the mightiest of the mighty therapies: PCI came into our midst kicking and screaming, flexing its muscles and burrowing its way into the world of ACS with balloons, wires, and stents. All of this came at a price, but we physicians are rarely aware of exactly how much of our patient's money we are spending for them.

Like a snowball rolling down hill on a particularly good day for packing and shaping, the veritable laundry list of drugs for our patients potentially adds a new layer of pharmaceuticals each year or two. We now have "add-on" meds like aliskiren, soon the CETP inhibitors, and now potentially low-dose rivaroxaban for its new indication for ACS.

There is little doubt that the planning has been extensive for the sale and marketing of this drug. There is also little doubt that our US patients will likely pay for both the development and the world's supply of this medication. At what point will a battle-worn US patient revolt, weary from the financial burden we have thrust upon them? But aren't they revolting already and not telling us?
Study after study has demonstrated that compliance at its best is around 50%. I used to think it was just hardheadedness, lack of dedication to good health, or lack of education that drove that statistic. Now, in this environment of economic despair, it is also the lack of funds that dictates who buys what and when. Intelligent, sophisticated patients are literally begging for mercy every time I write a prescription.

At some point, someone is going to have to own the process and ask when it's time to go backward and delete things from our medication list that might no longer be needed. Someone has to decide which things are antiquities and which medications have retained their relevance.

In deep winter, on a snowy day, we layer up with coats, shirts, long johns, hats, scarves, and gloves. But when we come inside, into a different environment, we have to shed some of that insulation. If we don't, we could easily overheat to the point of becoming ill. It's time to examine the possibility of shedding some of the old pharmaceutical clothing that is suffocating our patients. Dr Paul Armstrong from the University of Alberta even questioned if one "needs to subtract aspirin" from our patient lists in this era of cardiovascular polypharmacy.

One can never know where they are going unless they know exactly where they have been. We've come a long way to get to this point. ATLAS ACS just might get us thinking in a better direction.

See also:

ATLAS ACS 2: Low-dose rivaroxaban looks good in ACS

Bivalirudin: What can I do? Is there anything I can change? Is it my packaging? My age? Is the dose difficult to remember? Is it cost? I promise I'll change. I'll do anything to make this work. Just give me a chance.

Interventionalist: Gee, it's not really you. You haven't done anything wrong. I'm just not feelin' it. 

Bivalirudin: From a patient perspective would you rather have a two-hour infusion of me during a procedure or remain tethered to a drip of that abciximab stuff for 12 hours?

Interventionalist: [silence]

Bivalirudin: Is it the cost? It's surely not the cost thing.

Interventionalist: I don't know how much anything in American medicine costs, so it's not that.

Bivalirudin: So, I know what it is . . . go ahead, just say it. It's something from my past . . . the HORIZONS trial, isn't it? It's that thing with early stent thrombosis! I'm telling you, it isn't the way it looked! 

The interventionalist hesitates, hangs his head and starts to slowly walk away. The vial of bivalirudin watches him longingly. The interventionalist stops and looks back to say, "It's just that, well. . . . This is never going to work. . . . You and I . . . I just can't explain it. I'm so sorry. . . . It's just not going to work, okay?"

Dr Gregg Stone told heartwire's Sue Hughes, way back in 2007, that "major bleeding as defined in HORIZONS had virtually the same impact on mortality as did definite stent thrombosis, and since major bleeding was more common than stent thrombosis, bivalirudin-assigned patients had lower mortality." Furthermore, the hospital cost of a dose of abciximab for 12 hours is around $1424 dollars, vs $1365 for bivalirudin (interestingly, the patient cost was 3.7 times greater for both of them). 

In most places where bivalirudin has been able to prove itself, it doesn't seem to fare any better than the latest reality-show conquest. Like the latest "ex–Mr Kardashian," it can't seem to stay in a relationship, but unlike that unfortunate fellow who just couldn't seem to do anything right, bivalirudin is Mr Perfect; still, no one wants to take him home. 

See also:

ISAR-REACT 4: Bivalirudin preferable to abciximab/heparin in NSTEMI

HORIZONS published: Bivalirudin benefits in STEMI

I learned some things, as I always do when I attend any meeting, whether it is medical fact or mere perspective. CV surgeon Dr Douglas Johnston from Cleveland Clinic discussed surgical therapy of mitral regurgitation and allowed plenty of time for question and answers. Dr Ted Feldman from Evanston, IL of MitraClip fame is never a disappointment. Dr Juan Villafane, pediatric cardiologist and current KY chapter ACC president, amassed an impressive roster of speakers.

There were several Kentucky physicians in a veritable showcase of talent from a wide range of specialties. I got to see old friend Dr Earl Austin, CV surgeon extraordinaire from Louisville, who chaired one of the sessions. We heard from Dr Anil Attili, an interventional radiologist from the University of Kentucky; Dr Alison Bailey, director of cardiac rehab at the University of Kentucky; and Dr Bart Dawson from Norton Commonwealth Cardiologists in Louisville. Recognizable names in part for their expertise as well as having performed procedures on my patients included Dr Chris Johnsrude from the Kosair Children's Hospital. Dr Louis Bezold from Kentucky Children's Hospital spoke on echocardiography in MR. Practical information on valvular repair, implications of residual tricuspid regurgitation (TR), TAVI, and timing of surgery were just a few of the practical offerings of the day. Information on pulmonic insufficiency and aortic regurgitation were also covered extensively. There were presentations from a pediatric standpoint that this "adult" cardiologist still found helpful; for instance, I don't think I ever really grasped the implication of the mortality impact of residual TR after mitral-valve repair. Another wonderful sidebar of any meeting is an opportunity to network. I met Dr Susan Smyth, current division chief of CV medicine at the Gill Heart Institute at the University of Kentucky, who invited me to do a ground rounds there. I was able to see Dr Rita Coram again, interventional talent from University of Louisville, who is on the current state ACC board. I felt as if I were at a national meeting, complete with CME opportunity!

My only disappointment was the number in attendance. There are approximately 440 ACC members in the state of Kentucky, yet I counted at most 70 physicians in any particular session. My own conspicuous absence from participation in the past years is embarrassing enough, but in this current environment of medical-political turmoil, our participation is now critical. "We had twice the attendance this year over last year," Dr Villafane pointed out, proving that interest seems to be growing in a collective effort to improve our state's medical climate.

I asked Dr Villafane, "What exactly can be accomplished by participating in our state ACC chapter?"

"For the past two years, eight representatives from Kentucky have gone with me to Capitol Hill to meet with seven legislators, including Mitch McConnell, Senate Republican leader, Democratic Congressman John Yarmuth of the third district, and Republican Congressman Brett Guthrie, second district . . . to advocate for our patients and threats to access to quality care, tort reform, Medicare, etc," he replied. "Our chapter is promoting quality-assurance registries to monitor optimal CV care," he added. "We formed a 'coalition for a healthy Kentucky' with 11 other major health organizations, including the AHA, American Academy of Pediatrics, the Kentucky Medical Association, and others to fight childhood obesity and deal with tobacco issues. We joined the AHA annual legislative conference last year," he added proudly.

Mark your iPhone calendars now! Next year's Kentucky chapter of the ACC will meet on Saturday, August 11, 2012 at the Rudd Heart and Lung Institute at Jewish Hospital in Louisville. The focus will be "Hot topics in cardiomyopathy," and I look forward to it.
Perhaps a special session should be added at the end of the day; a session where cardiologists have an opportunity to meet with their lawmakers and politicians. Every state governor should make it a priority to know what is happening in the trenches in the war against the number-one killer of their constituents. This virtual Venn diagram of physicians and legislators would be fitting for the difficulties we face today in both private and academic cardiology. The area where these two important rings intersect is the necessary common ground from which lifesaving expenditures and savings of healthcare dollars can spring forth. It would be a great draw for a crowd who is dedicated to both the survival of their patients and now the survival of our profession. With outstanding Kentucky physicians like Dr Juan Villifane and Dr David Moliterno leading us in the Bluegrass State, how can we miss? 

I joined the practice of a seasoned jack-of-all-trades cardiologist, Jim H Whiteside, MD, FACC, who preceded me by seven years. He navigated solo, established the first CCU, echo service, and delivered the first thrombolytic in the state of Kentucky. He did the first pacer implant in our hospital. On the opening day of our cath lab back in 1991, I did three caths back-to-back with television cameras rolling, the hospital gambling on good PR because we were going against the grain: cathing with no in-house surgery safety net beneath us.

Things went well in our cath lab that day and still do. Serving a grateful community, we rolled along together for another seven years, sharing every-other-night emergency cardiology calls, with an internist filling in for rounds every few weekends. It was not a perfect solution, but it was our best effort to survive a tough schedule. I remember one 36-hour period when I did 19 cardiology consults in our 120-bed hospital. The schedule was definitely rocking.

With the addition of an excellent interventionalist to our group, we worked together for seven more years, becoming nearly as close as brothers and sisters. Then a miracle happened. A new CEO came to town—one with vision and compassion. He cared about the appearance of the hospital and the well-being of the employees. His priority was a team approach, with that team consisting of everyone from the surgeons to the valet-parking crew. We focused on the goal of developing primary PCI without surgery on-site for the entire state of Kentucky along with the Ephraim McDowell Regional Medical Center in Danville. It took us six years, three governors, and multiple cabinet-level and state-hospital-association meetings to pass it. We celebrated and supported our wonderful interventionalists at both hospitals as they completed the first state-approved primary PCIs in Kentucky without surgery on site. There with high-fives all round. A dedicated and hard-working cath-lab crew stood by our side at all hours of the night. We knew we had the community's back and they had ours. It was a marriage made in heaven.

As unexpected and destructive as an earthquake, our beloved CEO fell victim to sudden death, ushering in a dark period for our whole team. To further affect our routines, like everywhere else in the US, reimbursement patterns shifted, the noncardiology hospitalists came to town, and, like Pac-Man gone viral, gobbled up the admitting duties of many private-practice family-medicine and internal-medicine groups.

Then, they gobbled up our beloved friend and interventionalist. We got the invite as well, but we declined. Leery of big-corporation politics and keen to retain control of the day-to-day inner workings of our office—the hiring of staff, their bonuses, and time off—we are still on our own, although from time to time we consider reexamining the invitation. We have not totally ruled it out for the distant future, and we accept that sudden changes in health, family dynamics, or further change in reimbursement legislation could be the catalyst.

So how is our practice of nearly 40 000 patients navigating all the upheaval?

Things are different. There are two teams now; the hospital-employed and the independents. The new interventionalist, however, is kind and considerate, a pleasure to work with. Patients are loyal to us, but some on each team get caught in the net of uncertainty from time to time. The new nurse practitioners on the hospital-acquired team are doing their best to help balance it all, but both teams at times walk around the telemetry unit not knowing if there has been some sort of a rift if a patient is not admitted to the correct team, a mistake in naming the correct team, or just benign neglect of continuity of care. Just as in all other hospital venues, there is great haste on behalf of the noncardiology hospitalists to get the "chest painers" with negative troponins to an outpatient status. Oftentimes, formal in-patient cardiology consults aren't requested. There are both good and bad aspects of that habit.

The night call is definitely easier, but catching up on what happened in the hospital is sometimes a little more challenging in the office. Since reimbursement reigns as king, all subspecialties are sometimes pushed to discharge patients who should have stayed for a cath or other workup. It's a new era, where patients are sometimes allowed to go home still feeling poorly, with no answer as to the etiology of their symptoms, just as long as it's deemed "safe" and a good outpatient workup is planned. The benevolent edge of American medicine is being dulled by legislation and politics. Patients loathe not having their primary-care physician as their attending in-house doctor. The hospital census is lower for many facilities. The models that work for tertiary centers and large cities do not seem like an optimal fit for suburban or rural America.

One cardiologist who, like me, is concerned about what is happening to private-practice cardiologists all over the country put it like this. "What really baffles us," he began, "is the lack of loyalty. They forget that for years, we were the team that got up at night to take care of patients and missed loads of family time in dogged dedication to the hospital's needs. Though the stance seems to be, 'You were paid well for your time, and you should be grateful for that much,' it's still difficult to imagine that the hospital and even other physicians whose patients we have served well have forgotten our past service. I know one patient got three echos ordered in one month, simply because one hand did not know what the other was doing. If they had called us first, we could have saved the patient time and money. Recently, though, we were informed that the hospital instructed their new hires to send all testing to the hospital."

Another seasoned private-practice cardiologist related it in a different way. "The hospital governing board and members of the administration have been told over and over again about issues in the department—lack of staffing, wait times of up to several weeks just to get a stress exam performed, lack of communication with outpatients regarding life-saving dietary instruction, hypertension education, smoking cessation, etc—but no one steps up or makes an effort to improve things. Private-practice cardiologists who've worked in our city for years are told that they cannot make suggestions for positive change unless they go through the newly anointed figurehead. There is a decline in quality of communication that could positively impact patient care, and nothing happens."

These days, my partner often points out that he is in a different place in life's journey from me. He has the option to retire, but for the love of the game—and rightly so for a former star Vanderbilt running back—he still plans to play for many years to come. Although I have other options and can practice in a different region of the US or pursue other interests, I am in love with cardiology. My family and my husband's family live here in south-central Kentucky. I have so many grateful and wonderful patients that I am motivated to at least retain Glasgow, KY as my home base.

But what is the firmly established private-practice cardiology team to do in this new world of hospital acquisition? In the late 1980s, when I finished med school, my parents gave me what I still think is the best advice. "Always work hard. Smile and support others when they do a good job. Shake hands with your patients warmly, and dedicate yourself to making them feel better both physically and emotionally. Let them know you are happy to see them, and the rest will come naturally. If you do these things, with the best intentions, you will be successful. If others are not behaving honorably, their actions will catch up with them."

My parents' formula for success should work for everyone, not just cardiologists: it's excellent advice that should hold up through the ages. But the rules of the medicine game are changing—are hard work and best practices rewarded? Is the patient, rather than the hospital or the physician, the center of everything we do? Some days, in some places . . . I wonder. 

See also:

Hospital bound? Private-practice cardiology in uncertain times

MWS:
Words can't begin to tell you how much your calls and visits have meant to me. The morning of surgery, everyone was so kind and helpful, but it was your bear-hug that kept my mind straight. The fall arrangement is beautiful and is on my kitchen bar as an ever reminder of all the support and love of friends and family. Your calls after I have come home mean so much too. . . . Keep me in your prayers.
Love and God Bless,
Sherry
9/26/2006

Renal-cell carcinoma represents around 3% of all adult malignancies, but it accounts for around 75% of the carcinomas I find, closely followed by gut and lung cancer. One year, I diagnosed three. I might skip a year and then diagnose two. This year, I've already hunted and killed two GU tumors. It lives where I live; in a world of cigarette smoking, hypertension, and obesity. It is easily detectible by a simple ultrasound but is often obscured by an economy obsessed by cost/benefit ratio. In this current environment of healthcare reform and conservative workups, I fear the death rates will only increase. There are 58 000 kidney cancers annually in the US and 13 000 deaths, 80% of them renal-cell carcinomas. I submit it's time we leave this horrifying discovery to chance no longer. We should stalk it with the same voracity as the fictional character Hannibal Lecter stalked his delicacies and then enjoyed them "with some fava beans and a nice Chianti." Guidelines writers need to help us turn the hunter into the hunted.

Hematuria and flank pain are easy red flags for a renal-cell tumor, but it's not what leads me to the diagnosis most often. I discover this sinister tumor quite by accident and often in a patient who is largely ignored by the current guidelines for screening, which include: 

• Patients with end-stage renal failure on dialysis.
• Patients with Von Hippel Lindau (VHL) syndrome or tuberous sclerosis.
• Relatives of patients with VHL or with familial incidence of RCC.

A few years ago, a patient in her late 40s was referred for chest pain; at times more right-sided than left. Due to the atypical nature of her presenting symptoms, I asked for a RUQ ultrasound, and bingo, there the cowardly creature sat, staring back at us, perched upon her kidney, a serial killer of whom "Dexter" could be envious. It waits for an opportune moment to steal 30 to 40 years of quality life from the innocent and the unsuspecting. Due to the expertise of one wielding a Bard-Parker blade, that patient is now many years free of disease and likely a grandmother, no less. She stopped in a few years later just to tell me she had not forgotten my saving her life. I told her I really could take no credit for the accidental discovery. It was a blessing but I thanked her anyway.

I've followed a gentleman in his mid-60s for 15 years with known hypertension and an old CABG. He recently visited me because his previously well-controlled blood pressure was now problematic. Using the excuse of "recent exacerbation of previously well-controlled hypertension," a renal-artery Doppler was ordered, which forced a renal ultrasound that resulted in the discovery of yet another tumor. His wife phoned Friday to tell us his surgery, a partial nephrectomy, went well at Vanderbilt University. He is now resting comfortably at home with a good long-term prognosis. I celebrated my latest tumor "kill" with a big broad smile and a bike ride. 

Doctors, if you can't get your middle-aged hypertension patient's insurance company to pay for it, invite your patient to seek out a roving ultrasound unit where they can shell out $99 out-of-pocket dollars for a chance at life. Sherry would tell you it's worth it. Do it in honor of Sherry and for all the "undiagnosed Sherry's" out there who deserve a chance. Guidelines for screening are inadequate, so it's up to us as cardiologists to develop our own. Together we can turn the hunter into the hunted. Make Hannibal proud. 

Published in 2007 in the New England Journal of Medicine, the COURAGE trial randomized just over 2000 patients with objective evidence of ischemia to medical therapy or PCI after a cath. Multivessel-disease patients too complex for PCI were excluded. At 2.7 to seven years of follow-up, there was no statistically significant difference in the composite end point of death, MI, and stroke or of hospitalization for ACS or MI. In other words, we tried to disprove the old CASS trial by providing a less offending method of revascularization, and it still could not beat good medical therapy. Don't get me wrong, I'm not a CABG hater. I sent two people to bypass surgery in an hour the other day. Their symptoms were progressive and their anatomy not suitable for PCI. One had leaking troponin and the other, poor LV function with significant MR. I thank God for bypass surgery and for our wonderful surgeons. As proof, I've sent hundreds to surgery in the past 20 years, but I confess I've sent far fewer to surgery in the last four. There are two main reasons of course: the advent of stents and the publication of the COURAGE trial.

As Paul Harvey used to say, "Now, for the rest of the story." When I returned from a medical meeting, my secretary Nikki caught me up on the week's happenings. It had been fairly uneventful. She had fended the phone calls well, scheduled overbooks into the coming week, and gave my partner who covers me plenty to do. "Oh by the way," she said, "Mr X is having bypass surgery tomorrow" as she handed me the chart. When I saw the progress note, I remembered fully the details of our conversation and was surprised by this change in events. I did take a mental note of the pained look on his daughter's face as we went over the results of the tests and the treatment options. I sensed general unhappiness during each office visit, but she never articulated any issues at any point, at least directly to me, and I gave her plenty of opportunities. I even recall her telling me how relieved she was that they were able to get in to see me. (I chalked it up to her general demeanor. I had treated other family members and she had always looked the same; a bit bewildered, uncomfortable, etc.) My secretary Nikki continued, "She came in and asked for his records and said she wanted a second opinion." Next thing we knew, in the social media, someone noted he was scheduled for coronary bypass surgery, at advanced age with no symptoms at least within a week of the last visit despite good LV function and a clean Holter with the recent addition of good meds.

Throughout the years, I've prided myself by being "first" to suggest a second opinion if patients aren't doing well. I can count on less than two hands the number of patients or families "that I know of" who have beat me to it. This particular case, however, was a bit concerning. I hope the reason he had to go to surgery was that he developed progressive symptoms, but I'd say he merely presented himself and got a cath out of it. It's a sure bet that in some regions of our country you will get a cath/stent/or CABG if you merely present to a system. It appears sometimes there is little thought that goes into the process. We hang our hats on the old caveman approach to coronary artery disease: "See blocked artery, do blocked artery," and for the life of me, with the data available, I'm not certain why.

I often wonder how many of us actually read the COURAGE trial. One might argue this patient is not a COURAGE trial patient because he did not undergo a cath first to define his anatomy. However, backward extrapolation from the results of COURAGE point to an excellent prognosis with medical therapy, and even if you think he wasn't a good COURAGE trial patient, he certainly would have fit nicely into the CASS study. You know . . . that old study all the way back in 1983 that surprised and wowed us with the fact that survival rates were similar for multivessel disease (except for reduced-EF patients who fared better with surgery) in both those treated medically and those treated with CABG. Hmm . . . wonder if they cathed him and hit the left main jackpot? I'll probably never know.

I cautioned a surgeon once who was challenging me about the COURAGE trial when I made the point that his patient would do just as well medically. His rebuttal reminded me very much of a religious argument. Throughout the ages, wars have been waged, cities plundered, and soldiers killed in battle for defending the validity of religious documents like the Bible. Entire populations have been annihilated by those who challenge their customs and teachings, although the aggressors often have never read the very thing they are fighting against. Same for the COUARGE trial. Those of us who try to practice risk having their reputations martyred in the name of trying to do what is evidence-based. Oh well, if the patient survives to tell about it, is it merely a case of no harm, no foul? Only the patient could really answer that question, but I'd wait about eight weeks before I asked him his opinion.

Today, my "former" patient has a brand-new median sternotomy incision. His Pandora's box was opened with around 120 cc of contrast. He went in presumably with no symptoms and came out with what was likely a three- to four-vessel bypass procedure. He risked stroke and other complications to make his daughter feel like she had done something for her dad. He risked infection so the surgeon could say he saved him from certain disaster. The disappointed interventionalist likely had to relinquish another opportunity due to complex or multivessel long segment disease and likely stared at the floor in reverent silence when the anxious waiting room full of family members asked, "What on earth would have happened if we hadn't brought him to you"? Everyone who was involved with this patient to this very moment is telling and retelling the story, "Oh my gosh, If I hadn't taken him to this other doctor, he would have been a ticking time bomb!" Makes for a good story, but the thing that should have been done had been done already. His new medication regimen consisting of a beta blocker and amlodipine is cheap, effective, but not glamorous enough for the many who never heard of the COURAGE trial, never bothered to read the COURAGE trial, or who are not brave enough to practice COURAGE trial medicine. Furthermore, you'd never convince anyone in his party, now that the surgery is over, that the patient could likely have coexisted peacefully with those "terrible" blockages and likely could have gone on for years or maybe even a lifetime without an event. Thank goodness the family is relieved and the second-opinionaters are heroes!

Practicing "COURAGE trial style" works great for most patients, but unfortunately for this patient, not this time. 

 See also:

New data show COURAGE findings are not being implemented

Single bout of spinning exercise increases troponin in healthy subjects. Just when you thought you'd had it with the dilemma of equivocal troponins, it gets even worse. In this study, healthy subjects underwent blood work at one hour following a 45-minute session of vigorous spinning and again at 24 hours. Troponin T levels almost doubled the normal range, myoglobin increased up to three times the normal level, whereas creatine phosphokinase (CPK), CK-MB, and N-terminal pro-brain natriuretic peptide (NT-proBNP) remained normal. This poster by Drs Mats Borjesson and Smita DuttaRoy, from the University of Gothenburg, Sweden, gave surprising results. I would have sworn the findings would be just the opposite and would have expected elevated CPK and MB levels as a result of extreme physical exertion. We discussed the impact these new troponins have on systems. It seems we've traded specificity for sensitivity and agreed we have sacrificed a bit of common sense for biochemical curiosity.

TAVI dual source CT of the aorta, the ascending aorta, and the iliacs to predict flouro angles. For those cowboys and -girls who are leading the world by expanding indications for transcatheter aortic-valve implantation (TAVI), there was an interesting poster on reduction of contrast media required for the procedure. In this study, 75 patients with a mean age of 82 years underwent a set protocol by ECG-triggered spiral CT. The group who underwent CT had a significant reduction in contrast utilization. 72 cc vs 106 cc. This reduction was seen in 84% of the patients without significant increase in radiation. The poster moderator was Dr Annika Schuhbaeck, and the lead author for this study was Dr Stephan Achenbach from Erlangen University. Simple and practical just the way I like it!

RV dilation in iron-man athletes. Are endurance athletes really the picture of health? Dr Alain M Bernheim moderated this poster. He invited 39 athletes, age 38+9 to undergo an echocardiogram the day prior to an iron-man competition. The images were compared with 23 controls. Five athletes had a right ventricular end-diastolic dimension (RVED) of 22+3 mm vs 17+3.4 mm in normal controls. All underwent signal-averaged ECGs and were normal. The RV characteristics looked very much like RV dysplasia by echo, yet the patients had no symptoms, were otherwise healthy, and had competed on numerous occasions without difficulty. When I inquired of Dr Bernheim as to whether or not the patients had been informed of their results, he stated he had related to them their echos were not normal, but no further testing was offered or discussed. If this study had been conducted in America, they would have all had two MRIs, a plethora of cardiology consultations, stress exams, and ECGs, and we still wouldn't likely know if it was RV dysplasia. One thing is for sure: their careers as "iron men" would pretty much be over.

Cataracts and cardiologists. Is that your interventionalist over there squinting at the morning paper? It might not be new news, but the point is worth emphasizing. I don't know what was more concerning, the fact that of 58 coronary interventionalists, 38% had lens opacities compared with 12% controls or that almost 40% of 106 cardiologists in this study were smokers. Anyhow, this new study also found that interventional radiologists, cardiologists, and electrophysiologists are getting higher-than-recommended amounts of exposure and have an increased number of lens opacities. Jeepers creepers, put on those ugly, heavily leaded peepers, guys!

Hope for metal-valve patients everywhere. From Dr Anja Kaeberich from Martin-Luther-University Halle-Wittenberg, Germany, came this very interesting poster. Rivaroxaban at a dose of 600 mmol/cc, when placed in a THIA II Thrombotester with a bileaflet St Jude mechanical valve—in in vitro testing, of course—prevented thrombus formation. I am aware there are studies with other anticoagulants gearing up to look at this, but this is the first real proof I've seen that it just might work! This is great news for those who have already undergone valve replacement, but maybe the carbon onyx valve guys will be successful in their endeavors to alleviate the need for anticoagulation in those who remain in sinus rhythm.

Put some teeth into it. If this one doesn't get you running to the dentist, nothing will. Finnish researchers performed scanning electron micrographs on coronary aspirates in those who underwent cath for STEMI. They found DNA of bacteria in the coronary aspirate in 78%, 90% of which was strep viridans. Hmm . . . maybe there really is something to that dental-to-vulnerable-plaque link. Furthermore, on panorex films, over half of the patients exhibited abnormalities that created the perfect opportunity for bacterial growth with lesions and bone pocket. Floss anyone?

A systematic approach to high-risk valvular surgery patients. From Dr Mercè Cladellas, from the Hospital del Mar in Barcelona, Spain, was a prospective study on 301 patients from 1998 to 2010 who were scheduled for high-risk valve surgery. They all underwent pulmonary function tests, carotid ultrasound, and correction of anemia preoperatively with iron and EPO. Two underwent carotid stenting. Study patients were compared with elective controls from 1998 through 2003. The results were impressive: mortality in the control group was 10.5% vs 4.7% in the treatment arm. Prolonged ventilation: 13%. vs 8%; infection: 12% vs 7.6%, renal failure 21 vs 15%. P values were 0.01–0.07, except for stroke, which was only 0.73. Impressive results, especially if you were the one going under the knife.

Birth of Venus
by William Bouguereau

The intentions of the artists and physicians whose creations we viewed on our last day in Paris are essentially the same: To promote well-being, improve quality of life, communicate thoughts, explore theories, or demonstrate opinions. Hippocrates said, "Wherever the art of medicine is loved, there is also a love of humanity." Obviously, if Hippocrates could have spent the last day of the ESC 2011 meeting with theheart.org team, he would have witnessed many joyful displays, from posters to Picassos, of the love of humanity.