Life and Times of Leading Cardiologists With Rob Califf. Guest: Sidney Smith

Robert M. Califf, MD; Sidney C. Smith, Jr., MD


December 11, 2013

In This Article

The American Heart Association

Dr. Smith: Yes, it does. About that time, I became the President of the AHA. For my presidential talk, I had written a paper on the contributions of invasive cardiology. At that time, if you remember, the 4S study came out around 1994,[2] showing for the first time that lipid-lowering with statins reduced mortality. In the early 1990s, there were prominent cardiologists who did not believe in cholesterol or lipid-lowering therapy.

This was not "the truth," and it was debated hotly. I found for the first time that we had a way of significantly reducing mortality and treating atherosclerosis. I tore up that talk. My life had come full circle from lipoproteins at NIH to the cath lab to being an interventional cardiologist all of my life. Now I was back, and this whole lipoprotein thing was making sense. So I wrote the talk on risk-reduction therapies, and the need to change.[3] And I challenged the community to think about the use of these medical therapies.

I also said that I thought that an interface between the academic medicine and the pharmaceutical and device community was essential to progress. After I said that, at the end of my talk, someone came up and said, "You are going to get into trouble for saying that." But I don't know how we could have made progress without it. Now we live in the days of conflicts of interest in relationships, but I tell you that without that dialogue between academic medicine and industry, I don't think we would be where we are today.

Dr. Califf: You know how I feel about it, so I'm glad you have been a consistent, rational voice about how things should work. You have been a major player with the AHA and continued after your presidency to play a major role in AHA. How did you get started on that? Most basic cardiologists haven't been all that focused on the AHA.

Dr. Smith: It started when I was at Colorado. I chaired the local research committee reviewing grants. Then when I went to San Diego, I got involved with the California Research Committee as a way for me to stay in touch with academics, which I really wanted. Then I became the president of the affiliate there, and then the national president.

Get With the Guidelines

Dr. Smith: Right before that, they had a programs committee. I challenged the AHA on the fact that we are telling people and schools to do things, but where was the evidence that any of this really changes behavior? How are we really thinking about it? So I became much more interested in how the AHA could become a force for change.

After the presidential address, I wrote the secondary prevention guidelines. I had been involved with the percutaneous coronary intervention guidelines, which was interesting. But the secondary prevention guidelines were just a table. It's still the shortest guideline; it's about 5 pages of what to do. Then we got the guidelines going, and I began to see that the AHA offered an opportunity for people to come together in a neutral place to begin to look at how you could interact with the community and get some good programs going.

Dr. Califf: And that has continued on to more of a global presence. You spend a lot of time in China, right?

Dr. Smith: Yes. The AHA led me to meet such folks as Philip Poole-Wilson, who was President of the European Society of Cardiology. The work with guidelines became what I could do academically. It seemed to fit my interest. I became interested in the lack of evidence outside of North America and Europe and different healthcare delivery systems. That led to my involvement with the World Heart Federation and getting projects going in China (which we are now expanding to 400 hospitals) and setting up a "Get With the Guidelines" project in China. But more interesting is how we interface with traditional Chinese medicine and how they begin to change their practice there, doing it with the Beijing Institute of Heart, Lung and Blood Vessel Diseases; the Chinese Society of Cardiology; and the China National Health Heart Programme. So, yes, I like that, and I am of course tied up with the NIH guidelines, and still involved clinically.

A Review of the Evidence

Dr. Califf: Can you say a few words about that? Tell us about your views on the guidelines. A lot of people were startled that the NIH said that they are going to turn this back to the professional societies.

Dr. Smith: It goes back to a paper that you and I worked on. When it first came out from the Institute of Medicine, it said that you have to have evidence if you are going to write guidelines. I looked at 5 of our most recent guidelines, and only about 10% were based on level-A evidence. Another 35% were maybe level B, and the rest were level C.

Most of what we are recommending is based on the experience and the opinion of respected cardiologists, but we need more evidence to make these recommendations. And of course, when that paper came out in JAMA,[4] you and I did not alert any of the societies that we were writing this.

I received calls saying, "How could you be doing this?" I said that what we are doing, going back to the HERS study, is telling the public the truth. We have a problem on our hands. We need more evidence. So the NIH has now undertaken to spend more than $20 million to do a systematic review of the evidence on hypertension, lipids, obesity, lifestyle, how much sodium should we be eating, risk, where we stand with coronary interventions, and whether we should be doing anything more than Framingham scores. And of note, what do we really know about the science of implementing guidelines?

During this period, I have never been through anything like it in my life in terms of a guideline that has gone on for 4 or 5 years. The NIH has decided, for a variety of reasons, that they don't think they should be making recommendations to doctors. When the mammography recommendations changed, everybody was very upset. Now we have sequestration, and so there has been a shift in thinking that they don't want to be involved. They will gather the evidence, but they don't want to be involved in making recommendations.

By the way, it turns out that when it comes to making recommendations, we don't have the evidence that we need to answer all of the questions that we have, which is something that you and I wrote about back in 2008 or 2009. And sure enough, we were right. So now we have a situation in which the professional societies are looking at and working with this evidence and turning out guidelines. Hopefully they will be out soon.

Dr. Califf: We will follow that with interest.


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