John Mandrola


November 14, 2013

Two facts:

  • Over the past eight years, the death rate from heart disease has decreased.

  • Over the same time period, cardiologists performed fewer diagnostic and therapeutic procedures.

The idea for this intro came from a recent conversation I had with a practice manager. "Dr Mandrola, I've looked at the numbers; you were right. We are seeing more patients and working longer hours, yet procedural volume is way down. Not just in electrophysiology; stress tests, echoes, nuclears, caths, stents, and other devices are down too."

I repeat: death rates from heart disease have decreased.

How one feels about the fact that fewer people are dying from heart disease while cardiologists are doing fewer procedures turns on how you feel about doctoring. Doctors who love doctoring love this stuff. The basics are back. I learned at Indiana a long time ago, in a faraway rural hospital called Hendricks County Hospital, that good outcomes could be had with listening, examining, and practicing minimally disruptive medicine.

Here the means matter less than the ends. It matters not that it took appropriate-use criteria, regulatory scrutiny, and a crackdown on predatory practices. The days when patients referred to a cardiologist had an echo, nuclear, and Holter monitor before they saw the doctor are gone. Good riddance, I say.

I like the practice of cardiology much more now. I find myself trying not to interrupt a patient for more than 30 seconds. (It's not so easy.) I listen to heart tones more attentively; I study the nuances of ECGs, and I consternate more than usual on whether that test or procedure will improve outcomes. Although listening, examining, and thinking do not pay as well as procedures, they engender respect—which, for doctors these days, is almost priceless.

Basics aren't only back in medical decision making, they are also coming back in therapeutics. I asked a respected hard-working young cardiologist what made her most optimistic about cardiology. She texted this nugget:

"H  onestly, the thing that excites me most is the fact that we are getting back to basics. Realizing that sleep, exercise, dental care, laughter are keys to preventing bad outcomes, along with good old-fashioned generic meds that have shown their merit time and time again."

Cardiologists have grown more cautious of the unproven. More of my colleagues are asking questions like: how does AF ablation compare with achieving balance in life? (That's a tough comparison, but now you can find sessions on yoga at major AF conferences.) Should we add a third blood-pressure medicine, or is it better to lobby harder for one good food choice per day? Should we accomplish vasodilation with another afterload reducer or with an intensive-exercise prescription? And maybe ejection fraction would improve with therapy for sleep apnea?

Even thinking about asking these questions indicates major progress. But now we have more than just thinking. We have brand-new expert guidelines that address the role of lifestyle in prevention and treatment of heart disease. The rock of dogma has developed a crack.

Less Is More

Less is more pervades all aspects of cardiology, and no more so than in interventional cardiology. My plumbing friends deserve a hat tip.

Radial artery catheterization. Millions of patients still undergo coronary angiography; therefore, any improvement of the technique can have a major impact. Radial artery catheterization is such an advance. It allows patients to get off the table under their own power. Vascular complications have decreased dramatically, especially for interventions where antiplatelet drugs are required. Again, this is an innovation that appeals to doctors who love doctoring. The radial approach is a hard procedure to learn. It takes skill and dedication. Mostly though, it takes a little humility. Why? Radial cath doesn't look like much. It's not showy. It just works better for patients. If you are a cardiologist not learning radial techniques, I ask, why the heck not?

Less is more in drug therapy. Adding more drugs rarely improves health. A recent study showed combining ACE inhibitors with ARB agents worsens outcomes. Of course it does. Aggression with chemicals is fraught with problems. Heart disease is not cancer. In permanent AF, strict heart-rate control offers no benefit over lenient control. Digoxin use has grown more nuanced, and I hold out hope that the reflexive overuse of IV diltiazem for acute rate control of AF will give way to less disruptive means, like peace and quiet, reassurance, and metoprolol.

Less is also more when it comes to treating to surrogate markers. Finally, expert guidelines have jettisoned the idea that statin drugs be titrated to cholesterol numbers. Mainstream medicine now states unequivocally that statin drugs aren't just cholesterol-lowering drugs; they are pleiotropic risk reducers, whose benefit turns on the risks of the patient—as with all of therapeutics. What's more, nonstatin drugs are done. Moving a surrogate isn't enough. Now we accept drugs that improve hard outcomes. It's about time.

Mobile Information Technology

At Indiana (sorry to keep mentioning Hoosiers), the now-deceased former ACC president, Dr Suzanne Knoebel, used to beat into us that being a good doctor was about tracking down the right information. "Doctoring isn't complicated," she said. Get the old ECG or CXR; look at the labs; know the pharmacokinetics of what you prescribe. Nowadays, information is much easier to obtain and share. IT, especially mobile IT, has transformed our ability to care for patients. I can send a perplexing ECG across the globe for consultation in seconds. Recently, I looked at a jpeg of an incision that was taken and sent from a patient's smartphone. He lived many miles away in rural Kentucky, so this selfie saved him a long trip. Telemedicine allows experts to guide care for many more people than was possible years ago. Google Glass has the potential to transform surgical education. And don't think for a moment that IT is just for doctors. Information also empowers patients.

Decision quality. And what happens when both doctors and patients are better informed? Decision quality improves. This is a revolutionary concept. Until very recently, medicine was about the doctor prescribing the therapy. That was okay when infection was the leading cause of death. Now, with the increased prevalence of chronic disease and, in some cases, industry-created disease, patients encounter risk from both disease and disease treatments. Preference-sensitive decisions dominate the field of cardiology. Whether to take anticoagulation and statin drugs; whether to undergo ICD implant, valve surgery, or coronary-stent placement are all decisions that have changed verbs. We used to say the patient needed these things;now we say the patient can consider these choices. Love shared decision making.

The rise of team-based care highlights the importance of decision quality. In AF, nurse-directed care that centers on evidence-based practice and education can outperform doctor-based care. Valve clinics, in which multiple disciplines weigh in on a case, will lead to higher-quality decisions. (Just make sure there is a geriatrician on the panel.)

Why is decision quality so relevant? Think about the conflict in US healthcare most in need of resolution. It's inefficiency and wastefulness. We don't need to ration care; all we need to do is improve decision quality with knowledge. If patients and doctors have good information and multiple perspectives, and if care is aligned with the patient's goals, stupid wasteful medical decisions will plummet. Nothing makes me more optimistic than the thought of reducing the dumb stuff we do.

Three honorable mentions

Cardiac MRI. The sheer beauty of cardiac MR images begs to be mentioned. But it's not just the beauty of the images; it's that they are specific, sensitive, and radiation-free. The word that comes to mind is useful. Common examples of MR's utility include avoiding CABG in someone with nonviable muscle, ruling out (or in) conditions such as infiltrative heart disease, and determining myocarditis as the cause for troponin rise with normal coronaries. Electrophysiologists often turn to MR to sort out disease in the right ventricle. And in risk stratification, characterization of scar may aid both AF management and ICD choice in nonischemic cardiomyopathy. Sure, high costs, lack of access, and the dependence on expert interpretation are barriers, but these are surmountable.

Congenital heart disease. Few groups of patients have benefited more from innovation in cardiology and cardiac surgery than those with congenital heart disease. I don't follow many adult CHD patients, but the few that I do teach me a lot. Caring for patients with congenital heart disease underscores the importance of looking at the entire person, not just images. These young people teach you that youth—and the good condition of other organs—helps. (The converse of this is also a relevant lesson for cardiologists who care for the elderly.) Another observation: CHD patients teach you not to discount the value of grit, family support, and love. I've seen determined young people survive and flourish despite the odds. I can't help but wonder about the therapeutic benefits of love.

Social media. How else could I conclude a piece on transformation and optimism? It would be nuts to leave out the power of social media. Social media will make you a better doctor. Here are some reasons: social media informs. You don't miss important studies and news items. Social media forces thought. The 140-character limit of Twitter improves communication skills. Indiana University journalism professor Mark Land recently said that if you can't distill an issue down to 140-characters, you don't understand it well enough. Social media provides a platform for celebrating the joy of this job. Tell me that's not a good thing these days. Social media connects people. Luddites take note: success in social media comes from the same things that bring success in real life—candor, honesty, optimism, sharing, and mastery of the obvious. Cardiology is behind in social media, but not for long. We are not a bashful lot.

So, yes, despite a lull in innovative ways to treat established heart disease, it is indeed a great time to be a caregiver. Compassion, empathy, listening, nuance, shared decision making, and communication are making a comeback. We are on the precipice of good things. This I believe.



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