(Circulation. 2001;103:e9028.)
© 2001 American Heart Association, Inc.
50th Annual Scientific Sessions of the American College of Cardiology
President Bush Advocates for Budget and Tax Cuts and Promises a Patients’ Bill of Rights at American College of Cardiology Meeting
Calling the US healthcare system "the best in the world," President George W. Bush said that his proposed new budget funds many of the nation’s priorities, including health care. "We double funding for Medicare over the next 10 years and make sure that every dime that comes in for Medicare is spent only on Medicare," the President told his audience at the 50th Annual Scientific Sessions of the American College of Cardiology (ACC) in Orlando, Fla, on March 21, 2001.
Bush said that reform of Medicare is important at a time "when prescription drugs are often the treatment of choice for heart disease and many other illnesses, 99% of employer-provided healthcare plans offer some form of prescription drug coverage, yet Medicare does not. Often, Medicare does not cover new treatments and innovative technologies. The Medicare bureaucracy is rigid and difficult and too often treats doctors as if you have nothing better to do than fill out forms." He promised to bring new life and vitality to the program with the help of US Sen Bill Frist (R-Tennessee), US Sen John Breaux (D-Louisiana), and US Rep Bill Thomas (R-California). The President promised that every senior will have access to prescription drug coverage under his plan.
He also said his budget will include tax credits to help make health insurance more affordable to working families and will increase funding for community and migrant health centers in order to double the number of people served at such centers in rural and low-income neighborhoods. He said he has asked Congress to increase medical research funding, including an additional $2.8 billion for the National Institutes of Health.
President Bush promised to accomplish all of this and still implement the tax refund that was the core of his political campaign. He pledged to sign a patients’ rights bill that meets his criteria. "I want to sign a patients’ bill of rights this year, but I will not sign a bad one. And I cannot sign any one that is now before Congress. So enacting a patients’ bill of rights this year is going to require some different thinking, a new approach, based on sound principles."
Those principles include covering all patients in all private health plans and giving them the right to get emergency treatment in the nearest emergency center and the right to see a specialist when one is needed, including allowing a woman to see her gynecologist and children to see pediatricians without going through a gatekeeper. Bush said the bill of rights should also give patients the right to participate in clinical trials when standard treatment is not enough. When treatment is denied, patients should have the right to a fair and immediate review without going through a long legal process. The way to ensure patients’ access to care is a strong, binding, independent review process involving a panel of physicians, according to the President.
Patients who have been harmed, Bush said, should have a meaningful remedy—without encouraging frivolous lawsuits. "After independent review, if you have been harmed by our HMO’s refusal to provide care, you have a legitimate complaint, and you should have recourse in court." Another guideline of the bill he envisions would ensure that Americans have access to affordable healthcare coverage. "I want to sign protections that improve medical care, not make it impossible for patients to afford it, or employers to provide coverage." That would mean capping damage awards at levels lower than currently set by proposals in Congress, he said.
Clopidogrel Hailed as First Advance in Long-Term Antithrombotic Therapy Since Aspirin
Treating patients with unstable angina with clopidogrel in addition to aspirin reduced cardiovascular-related deaths, myocardial infarction, and nonfatal stroke by 20% in the CURE (Clopidogrel in Unstable angina to prevent Recurrent ischemic Events) trial, according to Salim Yusuf, MD, professor of medicine and director of the Division of Cardiology at McMaster University in Hamilton, Ontario, Canada. Dr Yusuf estimated that if the treatment using clopidogrel and aspirin were used widely in the United States, 50 000 to 100 000 people would benefit each year. Globally, he said, if use of the new form of treatment were taken up by only one fifth to one tenth of physicians, 250 000 to 500 000 patients around the globe would be helped.
A total of 12 562 patients with either unstable angina or non–Q-wave myocardial infarction were enrolled in the study in 28 countries and 482 centers, said Dr Yusuf during a press conference March 19, 2001 at the 50th Annual Scientific Sessions of the ACC in Orlando, Fla. In the study led by Dr Yusuf, patients were randomized either to a standard therapy of aspirin in doses of 75 mg to 325 mg daily or to the standard therapy plus clopidogrel. The antiplatelet agent was given at a loading dose of 300 mg followed by 75 mg each day for a mean follow-up of 9 months. At the 12-month mark, Dr Yusuf said that 11.5% of patients in the placebo arm and 9.3% of patients in the clopidogrel arm have experienced one of the primary endpoints. "That means a 20% reduction on top of aspirin," he said. "Each component of the primary endpoints—cardiovascular death, myocardial infarction, and nonfatal stroke—trended in the right direction."
Dr Yusuf noted that the positive effects became statistically apparent on day one and continued throughout the study. "The only side effect we saw was bleeding," he said. There was a 30% increase in major bleeds, a percent increase that was also seen in tests of aspirin. However, "The excess in major bleeds is less marked for life-threatening bleeds."
He estimated that the cost of the clopidogrel treatment would be $2 to $3 per day, an amount that might be prohibitive for some elderly patients who would have to pay for the drug out-of-pocket. Robert Califf, MD, of the Duke Clinical Research Institute at Duke University in Durham, NC, said, "If this treatment were free, it would be no issue. Society needs to find a way to pay for treatments like this."
ACC Debate Pits Advocates of Diet Extremes Against One Another
Robert Atkins, MD, creator of the Atkins diet and director of the Atkins Centers for Comprehensive Medicine in New York City, and Dean Ornish, MD, of the Preventive Medicine Research Institute in Sausalito, Calif, debated the merits of their approaches to risk reduction and weight control at a press conference at the 50th Annual Scientific Sessions of the ACC on March 20, 2001.
Dr Atkins’ diet restricts the intake of carbohydrates and emphasizes intake of meat and fats. "The government has been pushing a low-fat, high-carbohydrate diet as part of the food pyramid," he said. In doing so, he believes, it has created two epidemics—obesity and diabetes—that will increase the rates of heart disease in the nation.
In contrast, Dr Ornish favors a very low-fat, vegetarian diet accompanied by exercise, stress reduction, and smoking cessation. He said that the biggest difference between his approach and that of Dr Atkins is that he has published his results in peer-reviewed journals. "When people makes these changes [following his dietary and lifestyle recommendations], first they feel better, and within weeks, it is comparable to a bypass. They not only felt better, they were better," he said. He has published his results in a number of professional journals.
Dr Ornish admits that his diet is strict but said that a very strict approach is only necessary when patients seek to reverse established heart disease. "You don’t have to be strict" when seeking to prevent heart disease or lose weight, he said. However, the farther a patient goes toward the strict diet, the greater the benefit he or she will see.
Dr Ornish said that his studies, conducted over a 24-year-period, prove that heart disease can be reversed by changes in diet and lifestyle alone. However, Paul Thompson, MD, of the Preventive Cardiology and Cholesterol Management Center at Hartford Hospital in Connecticut, said, "There is a message I want to make sure gets out to the population. Certain groups of patients would make a major mistake if they ignored their cardiologists’ advice." He said that there are data showing that bypass surgery is of benefit in some patients and there are "unequivocal data" showing the positive effects of cholesterol-lowering drugs. "Not every cardiologist out there is nutty because they recommend lipid-lowering drugs," said Dr Thompson.
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