November/December 2017

Ask cardiologists to name the big advances of the past decade, and many point to transcatheter aortic valve replacement (TAVR) and other breakthroughs that are allowing cardiologists to treat structural heart disease with minimally invasive procedures. Looking ahead, some believe that even bigger, broader changes are coming.

The recently reported CANTOS trial represents an enormously important development in cardiovascular medicine. For the first time, an anti-inflammatory drug (canakinumab) given by injection every three months has been shown to reduce morbidity and mortality. Trial entry criteria required a hsCRP level >2 mg/L and stable coronary heart disease. The 150-mg dose reduced the risk of nonfatal myocardial infarction, stroke and cardiovascular death by 15 percent with no effect on lipids. These benefits were observed in patients already treated with the best available therapies, including high-dose statins and antiplatelet drugs. The importance of these findings extends far beyond the CANTOS trial. Now that we know that treating inflammation can reduce cardiovascular morbidity and mortality, the search for other anti-inflammatory regimens can proceed with the high likelihood of successful clinical trials.

This has been such an exciting time in cardiology—although the lens we use is often cloudy. Why? Because the pace of change is truly unparalleled. From massive changes in the physician fee schedule resulting in a rapid migration to employment to a total transformation in cardiovascular care delivery models, our practices are not what they were a decade ago. Cardiovascular service lines, dyad leadership and payment for quality and patient outcomes were unheard of in 2007. Yet I find our world invigorating and inspiring. We have successfully reduced mortality related to cardiac events!

With physicians and administrators ever more focused on high-quality medicine and the financial bottom line, what trends and strategies are shaping the future of the cardiovascular service line? Let’s take a look at the future forecast through the expert eyes of Brian Contos, an executive director of The Advisory Board Company. Is your program poised to take advantage of changing market dynamics such as outpatient care, reimbursement and payment policies? And what about implantables, MACRA patient-focused care and interventional procedures like Protected PCI?

As risk-sharing agreements become more common, hospitals and physicians are focusing on teamwork and attention to metrics.  

Are enough resources available to treat the growing population of adults with congenital heart disease?   

It would have to be providing basic universal healthcare for all. There is no other way to address healthcare in the U.S. short of this, as evidenced by the political reality in Washington D.C. Even with a Republican majority in the Senate and House as well as a Republican president, the Affordable Care Act hasn’t been repealed—despite multiple attempts. People want access to adequate healthcare. We, as a country, should move forward to modernize our healthcare delivery system and fix the current patchwork of programs. Very little of the current system represents the modern reality. Providing adequate healthcare for citizens is the only way to move the country forward on this issue. Anything else is a political excuse.

Due to advances in medical, surgical and transcatheter therapies, there are now more adults living with congenital heart disease (CHD) than children. Development of accessible integrated transition pathways from pediatric healthcare systems to specialized adult CHD centers will be essential to improve cardiac health, longevity and quality of life for children as they age. There are numerous potential barriers, such as inadequate self-understanding of the nature of their heart disease, separation from parental support, insurability concerns and lack of knowledge of available support resources, that can have a negative impact on the health of young adults living with CHD. Organized planning and access to centers with specialization in the management of adult CHD can prevent long periods of being lost to follow up and potentially irreversible decline in quality of life.

While the WannaCry cyberattack against hospitals, clinics and device makers was largely unsuccessful, future hacks might be used to imperil patients. Experts worry the U.S system is still too vulnerable and health IT departments are under-resourced.  

Physician burnout has been called a “silent epidemic” that not only overwhelms physicians but can impact the care they deliver to patients. A number of programs are starting to confront the problem head on—giving doctors hope that someone is listening.

As president of a community hospital in suburban Boston, and a practicing vascular medicine specialist myself, I am terribly worried about the deterioration in the morale of my physician colleagues. They feel devalued, overwhelmed by administrative burden and are permanently tethered to computer screens. This is particularly evident among the primary care physician workforce. My hospital employs over 270 physicians representing many specialties. I am focused and committed to restore joy to the professional lives of my medical staff. I am looking at creative ways to make interacting with our electronic health record easier. I am investigating novel compensation plans that promote behaviors that align physicians and our health system. I am regularly interacting with my medical staff, listening to issues and evaluating solutions. Most important, I am discussing the challenges facing U.S. physicians on a regular basis with colleagues around the country, hopeful that successful pilots elsewhere would be applicable to my colleagues.

The game has changed, the rules are evolving and winning has been redefined. Adopt a gaming mindset to get to the next level.

To my grandchildren, I would say…Are you insecure? Healthcare is recession proof and unlikely to be outsourced offshore.Are you financially worried? Healthcare jobs pay well, in some cases outrageously well.Are you adventurous? Healthcare is needed in exotic settings where few are bold enough to go.Are you innovative? Healthcare begs for innovation, from basic science research to global health policy.Are you good with your hands? The best place for skilled hands is on the handle of a scalpel.Are you intellectual? Daily your mind will be challenged by strange symptoms and insoluble problems.

Cardiology fellow Haider Warraich, MD, hopes his book about death will change how we live.