COMMENTARY

John Mandrola's Top 10 (er, 11) Cardiology Stories of 2013

John M. Mandrola, MD

Disclosures

December 20, 2013

In This Article

The Top 3

1. Obamacare/Affordable Care Act

The reforms that sweep in with the tidal waves of Obamacare will transform the landscape of cardiology. Things look differently already, but even more change is coming. Optimism is healthier than pessimism, so my assessment is: Obamacare will be associated with better heart disease outcomes.

Here's why: What single factor limits improvement of outcomes in heart disease? It's surely not a lack of access to echocardiograms, or new antiplatelet drugs, or LAA occlusion devices. Rather, it's the lack of patients' adherence to healthy lifestyles choices. Cardiologists have reached a therapeutic threshold. Gains in the treatment of heart disease have become and will likely stay incremental. The next big jump in heart disease outcomes will require patients' actions -- not doctors'.

The chief strength of Obamacare is that it ushers in the era of cost-shifting to patients. People will pay more for care. This, I believe, will favor the adoption of healthy lifestyles. Skin in the game, will, on the whole, do great things for heart health. The car analogy: We get our oil changed in our car because preventative maintenance is cost-effective. If you never had to pay for a new car, there'd be little incentive not to trash your current one.

I can hear the naysayers. Placing more of the costs on patients will keep them from getting care. Yes, in isolated cases, which will surely be amplified -- this might be true. But overall, 3 arguments refute this thinking: First is that in the past decade, both deaths from heart disease and number of cardiology procedures have declined. Patients are doing better while we do less. Second is the observation that countries that do far fewer procedures boast better CV outcomes. Third, you don't really believe that doctors control outcomes, do you?

2. The George Bush Stent Case

More than 2 decades ago, a mentor at Indiana taught me that squishing a high-grade coronary lesion did not reduce the risk for heart attack or death. I still remember where I was when I heard that. It was that counterintuitive. The notion that the vulnerable plaque is not the one that looks like a baddie on an angiogram has been proven time and time again. What's truly remarkable is the resistance of the cardiology community to accept it. Perchance, our visceral reactions to angiograms have clouded our interpretation of science.

Cynics would believe that the overuse of stents -- in the face of contrary clinical evidence -- is due to financial incentives. They point to examples of outrageous behavior on the part of a tiny few outliers behaving very badly. I can't deny that incentives don't play a role, but I think this story has more to do with the cognitive bias stemming from the success of acute primary angioplasty. It's tempting to merge the stunning benefits of intervening in an acute MI situation to the nonacute situations.

The George Bush story is big because the media attention forced us to look again at the science of the COURAGE trial.[1] What's more, this story gave strength to those who question the entrenched paradigm of ischemia-guided revascularization. Imagine the implications for cardiology if there was little reason to look for asymptomatic ischemia.

3. Cholesterol Guidelines: Who Decides the "Need" for a Statin?

The cholesterol guidelines[2] had some obvious practice-changing revelations: (1) the end of nonstatin cholesterol-lowering drugs; (2) cessation of treating to numbers; (3) the notion of using statins as cardiovascular risk reducers, rather than cholesterol-lowering drugs; (4) the fight over where CV risk warrants statin intervention.

These are big issues, but I don't see them as the biggest part of the 2013 cholesterol guideline story. I think what makes this a tipping point in clinical cardiology is the notion that the ultimate decision to take a statin falls with the patient.

Writing to patients in Forbes, Dr. Harlan Krumholz says:

It is your decision. Your doctors can guide you, but you deserve to be informed about the decision and make the choice that feels most comfortable to you. You do not know if you will be the person who avoids a heart attack or will suffer a side effect. You should have the information about what you are likely to gain by taking the medication -- and what risks you are incurring. The decision to take the drug should mean that you believe that you are more likely to benefit from the drug than to be harmed by it. And even if a drug has a benefit for you, you have a right to decide whether it is right for you.

This is huge because it brings patient-centered, shared decision-making to the mainstream. Before the cholesterol guidelines, shared decision-making was something you read about in academic journals. But now, across doctors' offices throughout the United States, low-risk patients will have to decide whether their 1-in-100 chance of preventing a heart attack is worth the 1-in-100 chance of developing diabetes or other statin side effects. Getting patients to see tradeoffs, NNTs, and aligning care with their goals isn't just a story of 2013; it's a story of the decade.

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