In his last book, Haider Warraich, MD, focused on modern death. Now, the young cardiologist has gone boldly into the land of the living. His new book, State of the Heart: Exploring the History, Science, and Future of Cardiac Disease (St. Martin’s Press, 2019), traces the twists and turns that cardiology has taken up to, and even through, the field’s golden age. Warraich tells the story of the specialty’s leaps forward alongside its missteps and wrong turns. With compelling storytelling, he reveals cardiology’s journey in the contexts of both real patients whom he has treated and the news of the day. More than once he notes the impact of attention-grabbing but sometimes flat-out wrong media coverage, long before “fake news” was a thing. He predicts a challenging future, where cardiologists will need to grapple with widening disparities, an intensifying “war on facts and science” and technologies that are changing “what it means to be human.”
Warraich and I spoke by phone as CVB was finalizing the related story about the small increases the U.S. has seen in cardiovascular death rates since 2016 (see cover story). We talked for over an hour, despite the fact that he was busy packing a U-Haul to depart North Carolina, where he’d recently completed his cardiology fellowship at Duke University Medical Center. He and his family were heading to Boston, where he has since started work as the associate director of heart failure at the Boston Veterans Affairs Hospital, associate physician at Brigham and Women’s Hospital and instructor at Harvard Medical School. Here are excerpts from our conversation.
The cardiologists we’ve talked with about the cardiovascular disease (CVD) mortality trend line have been unfailingly optimistic. Not dismissive of the data, but enthusiastic about emerging innovations and opportunities to engage patients in ways that could transform healthcare delivery. Does that surprise you, considering the forthcoming challenges you outline in State of the Heart?
HW: I also believe that we are still very much in the Golden Age of Cardiology. But what history shows us is that only a few of today’s innovations will be around in 60 years. Our current appetite for innovation is such that we’ve come to expect revolutionary advances that will change the natural history of disease dramatically. We’ve had things like that—for example, TAVR. But in history’s arc, it’s good when even a few innovations live up to their promise. So, we shouldn’t expect that all of the medications, devices and developments being studied today will turn out to be effective. If we start seeing that, then we need to question the data rather than the idea that we are in the golden age.
You wrote about the furor around statins and patients’ reluctance to take them. Given the way science seems to flip-flop—think eggs, stents and carbs—is it surprising that laypeople are reluctant to get on board with lifestyle changes that aren’t that appealing anyway?
HW: No, it’s not. One day, you learn that coffee is great; the next, you’re told coffee gives you cancer. Or you hear that statins and lowering cholesterol are the best things for your health only to read in a credible publication that statins cause dementia. Where does that leave you?
It underscores that physicians need to communicate very strongly that science is an ongoing journey, where we travel from one tunnel to another. We need to tell the story of how, despite science’s incremental nature, there have been advances that are transforming the lives of patients with CVD. And we need to educate people more about how science works. If we help people understand the difference between an observational study and a randomized trial, then the next time they read a news story, they might get a sense of the limitations on that day’s claim. If we’re going to overcome the epidemic of fake news about medicine in our modern media, we need to give our patients the tools to understand the data themselves, so they can get the message themselves rather than relying on the messengers.
Have you had success educating patients or families?
HW: What has worked for me, for example, when talking with patients about statins, is a combination of explaining the evidence and storytelling. For example, I told a patient who was fearful of statins about my father who had a heart attack and why I’m glad he’s on the highest dose of the medication. It helped to humanize the situation far more than if I’d just shared numbers. It’s part of the reason I wrote my book—so I can share data and stories. As advocates for our patients and our field, physicians need to share both.
There’s something about building a relationship with someone who talks with you and listens to you. For me, the importance of listening was one of the messages of your book.
HW: That’s one of the advantages of medicine. Other professions are affected by disinformation as well, but clinicians actually get to be in touch with the people it affects. We need to make the most of those interactions. That means making sure that when patients leave our offices they’ve asked all of their questions and they trust what we’ve told them. We need more training in how to engender trust.
Let’s turn to some of the predictions you make in State of the Heart. How do you think cardiologists’ daily work will be the same or different a decade or more from now?
HW: LVADs are a great case study for exploring this question. The LVAD is the first device that almost completely replaces the function of one of our key organs. It’s a huge advance, it evolved right in front of our eyes and it gives us insights into a future where physicians will be connected to patients’ bodies in an even more intimate way than we are today.
Look at how we remotely monitor our patients now. We are able to know the different fluctuations in our patients’ circulation, the actual pressure inside their heart, their heart rhythms and so on. It’s going to increase, which will change the nature of clinic visits. We may have an engineer in every clinic to focus on all of the technology our patients will have.
I hope that this also will change how our tools are designed. Look at the iPhone. Its ergonomic design takes into account what the device is all about. That’s what we need to do for new medical technology. We need to realize these devices will be part of our patients’ bodies in ways much more personal than iPads or iPhones are. New technology needs to reflect what the technology means and how we’ll interface with it. And it should feel like it’s a part of your body, because from a functional point of view, it is. The ultimate goal of any durable cardiovascular technology needs to be that it will become forgettable, that the patient will actually forget that they have this foreign thing inside of them that is keeping them alive. It will be organically designed and melded into their daily lives so that it doesn’t feel like an intruder in any way.
Another of your predictions is that heart disease will be “increasingly divided along financial, racial and ethnic lines.” Isn’t this in contrast to the historical trend where CVD grew in prevalence as countries westernized? Who will be your future patients?
HW: When we entered the Industrial Age, the first people to access mass-produced foods and goods were the affluent. Smoking and being overweight were signs of being financially secure. The kings and queens of England weren’t sporting six-packs. They didn’t have knowledge of the consequences. The knowledge that these things were doing more harm than good went first to the people with the most resources. Naturally, they became the first people to change their lifestyles to live longer and better.
Today the situation has reversed. Especially in the U.S., heart disease is now densely prevalent among people who are poor, live in rural areas and are in the racial and ethnic minority. I don’t think it’s science fiction to say that heart disease might become the tuberculosis of the next century. Heart disease could become even more overlooked than it is today because the people with it will increasingly become those who don’t have resources or access to advocate for themselves.
This is the direction that heart disease could take, as it has taken for the past many years. And that’s a real, serious threat to the pace of innovation. I worry that if heart disease continues to increasingly affect people who are dispossessed in one way or another, then it won’t have the cultural footprint to support the development of new discoveries.
We’re already starting to see this with PCSK9 inhibitors, which are more effective than statins for reducing cholesterol. The fact that the vast majority of patients can’t access PCSK9 inhibitors is a troubling sign of things to come.
How will this reality impact cardiologists’ ability to do their work? What does it say about the need for them to become advocates?
HW: During my training, I didn’t know a single patient who could afford both a NOAC and insulin at the same time. They have to pick one or the other. If our goal is to have our patients in good health, then our responsibility cannot end with writing prescriptions. That’s just a surrogate marker. In the end, what really matters is whether patients can afford medications and access them in a way that doesn’t hinder them. Equitable access to medications should not be reserved for certain groups. I absolutely believe that we need to advocate for new innovations but also that our patients can actually access them. If they can’t, that’s a real travesty.
One of the ways physicians can do this is to educate ourselves about the policy questions surrounding medical care. Traditionally, health policy has not been something physicians are trained in, which is why we feel surprised when sweeping changes are enacted. It’s a sphere where we’ve never had strong representation. Unless that changes, there’s a huge part of the physicians’ mission that we are leaving on the table. How physicians should take on advocacy is a complex question but, really, advocacy should come naturally to any physician who takes care of patients and wants them to get the best care.
You wrote that heart disease’s language needs to be told “in heart disease’s language, using heart disease’s metaphors.” Was writing State of the Heart an act of advocacy?
HW: Heart disease has become the forgotten disease of our time. That’s an ironic thing to say about the disease that kills more people than any other. But I stand by it because heart disease does not have the same place in conversation as other conditions like breast cancer. We need to tell the story of heart disease well.
Many people think that getting heart disease is the patient’s fault, which is why we need to tell the stories of the many patients who have heart disease but no risk factors. All they had was really bad luck. We also need to correct the idea that heart disease just happens as you get older. That’s why it’s important to tell the stories of women with CVD, for example, because their stories often disprove the misconceptions about heart disease.
In your chapter on women’s heart disease, among others, you stress the need to break down the silos between cardiology and other specialties. Speak to that idea—how do you envision that happening in the fast-paced world of modern patient care?
HW: We talk a lot about the evolution of medicine, yet how we see patients is still ancient. You get really sick, you call 911, you come to the emergency room, you get admitted, you get medical care, you get a bit better, you go home. If you’re not that sick, you wait for an appointment, find parking, see a physician for a few minutes and then you’re back out in the world again. It tends to be either very intensive or very hands-off at least for many people in the outpatient world.
We’ve seen so much innovation, but how we see patients and how we track them has not changed. That’s where a lot of the innovation needs to occur to address the silos and the fact that we don’t have a great way of taking care of patients with chronic disease. Our health system has been designed for acute presentations. I hope that the layer of disruption that’s coming with digital health, information technology and telemedicine will help with care delivery: knowing if our patients are healthy, targeting therapies, supporting behavior changes, engaging patients and making them the captains of their ships.
We still adhere to the traditional view that the physician is in charge, and that’s a real challenge. The body doesn’t know that it’s being seen by a specialist. When the body is sick, it speaks for itself in an interconnected way. The task for us is to beat it at its own game, which will require integrating all of our knowledge and expertise in a multipronged way.
Some health systems are better at integrated care than others, but in the end it’s going to come down to how we pay for care. I believe we need to move away from the fee-for-service model. There are many things that we do in medicine that people will look back at in 50 years and say were a disservice to our patients. One of those things is the idea that people today are paying for healthcare as you would buy services in a hotel. We need to tie payments to the health outcomes of patients—what we’re able to achieve for them, not just what we do to them. And that should include the heart attacks we prevent.
Are today’s cardiologists ready for this model?
HW: Change is coming. Payers and insurance companies are on board. Our patients are up in arms. If we just wait on the sidelines, hoping and praying for the status quo to be maintained—because we have benefited from the status quo—then we’ll wind up with the changes that are imposed on us instead of changes that will lead to good outcomes for patients and that we had a voice in.
We’ve reached a breaking point. I don’t think that physicians can continue to observe as bystanders because we will get railroaded.
To win the war of the heart, you wrote, “we will have to win over the mind first.” What does that prediction mean for cardiologists?
HW: The polls show that people trust their physicians much less than they did 30 years ago. When my wife had a toothache, she didn’t ask me. She Googled it. You could argue that she made a smart decision. Google is readily available, it doesn’t care about her gender or what she looks like, it delivers jargon-free information. And it’s free. Take those two things together—patients trust their doctors less and have alternative means to get information that have advantages—and it’s clear why people are going to those other sources and are being lured by misinformation. We must address this.
Recently, Washington State declared an emergency because so many parents—well-meaning parents who want the best for their children—were refusing to get their kids vaccinated. We’re starting to see ripples of this in cardiovascular care. I cannot tell you how difficult it is to convince many patients to take statins, which are some of the best-studied medications in our arsenal. Unless we take this challenge seriously, gain back our patients’ trust and push back against alternative sources of information by matching its advantages, then it’s going to become a modern-day epidemic. I hope that cardiologists are not just swept along by this, but rather that we are part of changing it.