(Circulation. 1998;97:1997-1999.)
© 1998 American Heart Association, Inc.
Summary of Cardiovascular Health Conference
Ruth SoRelle, Circulation Newswriter
The current chaotic
healthcare environment blocks improvements in the care of people with
cardiovascular disease, said Robert Brook, MD, ScD,
professor of medicine at the University of California at Los Angeles
and director of the Health Sciences Program for the RAND
Corporation.
"We are clinically practicing in a chaotic environment where some are
getting treatment they don't need and others aren't getting the
treatment they do need," said Brook during the first session of
Cardiovascular Health: Coming Together for the 21st
Century: A National Conference. To buttress his argument, he pointed to
the following findings:
A national study showed that only 35% of smokers were
advised by their physicians to quit smoking, and a second stated that
only 65% of adults had had their blood cholesterol
measured in the past 5 years.
Only 41% of fee-for-service patients and 54% of HMO patients had
their hypertension controlled in a study of 4 group practices in
Massachusetts.
In a study of Medicare patients, 17% of coronary
angiographies were deemed inappropriate, as were 14% of
coronary artery bypass surgeries.
A study of 5 California hospitals showed that 25% of those who
needed a cardiac revascularization procedure were
not offered one, but at the same time, hospitals were performing such
procedures on people who did not need them.
Similarly, another study of California hospitals found unnecessary
coronary angiographies and other surgeries were being
performed. In that study, Brook said, 50% of those individuals who met
the necessary criteria for a coronary angiography did not
receive one because there was no effective system to see that they
received one, he said. Forty percent of high-risk candidates for heart
attack did not receive aspirin during their first 2 days in the
hospital, 30% did not receive thrombolytics, 30% did
not receive heparin, and 24% did not receive
nitroglycerin.
"This is an example of chaos," said Brook. "You could do an
epidemiological study on the appropriateness of
cardiovascular procedures, and we did ... in New
York State. You could divide these procedures into 3 categories: things
that meet the definition of necessary, things that are appropriate but
not necessary, and things that are less than appropriate. You can add
them across for bypass surgery, angioplasty, and angiography. What you
find is there [is] a large percentage of procedures we could do
without and still meet the definition of necessary. In eliminating the
unnecessary services, funding could be redistributed to provide
services to those who are not receiving them now."
Improving the quality of care rendered to patients hospitalized for
heart disease is both possible and would improve overall
cardiovascular disease–related mortality rates, said
Brook.
A study of 400 hospitals randomly selected from across the United
States showed that there was a 6% difference in outcome when the
hospitals were grouped according to the best quality of care rendered.
"What caused the difference is a function of doctors' knowledge and
actions, nurses' knowledge and action, diagnostic methods,
and ICU use," Brook said. "These differences represent a
40% difference in death rate. It's safe to say that this variation
may represent 50 000 to 100 000 excess deaths a year."
The approaches to solving these problems could vary, he said. In a cost
approach, hypertension would be treated with the cheapest possible
medications in only those people at high risk. "If they express
dissatisfaction, suggest that another system might work better for
them," he said.
The "health-model approach" would involve a positive system in
which doctors would be provided with a list of all patients with
hypertension, and these patients would be treated with effective drugs
that have the fewest side effects and the best results. The healthcare
team would assess the patient's motivation and use the results to
ensure complete compliance and follow-up, said Brook.
"What we need is a change in the contract between physicians and
patients," he said. "We need to get more information from the
patients on a routine basis to find out what we do that works or what
we do that doesn't work."
He would also like to see quality indicators for
cardiovascular diseases that include yearly reports on
the proportion of science being implemented and developed, with
financial incentives to increase the likelihood and rapidity with which
such science is being used.
"We need a system where hospitals all have the same quality of care.
We have a system now that puts people at risk based on where they live.
Which way will we go?" Brook asked.
"We need to develop, in the next few years, a better knowledge about
the proportion of science that is implemented, and we need to have
real-time, useful data about quality so that we can practice better
medicine and guarantee to all Americans that they get necessary care
when they need it and that the care that they get is of a high level of
quality."
Adding her voice to that of Brook was Martha Hill, PhD, RN, president
of the American Heart Association. She addressed troubling trends in
hypertension. The recent report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
showed disturbing trends in detection and control of hypertension. In
that report, committee members found that three fourths of people with
high blood pressure do not have it controlled. Only one fourth of those
who know they have high blood pressure have it under control. Another
one fourth of those who know of their hypertension are taking
medication but do not have their hypertension under control. One half
are not on medication at all.
Medication is not the only answer, said Hill. It is not enough to know
what medications are useful in treating hypertension, she said. You
have to know how to convince patients that it is necessary and in their
best interest to take the medication.
"The background is that managing hypertension is very complex," she
said. "The factors that have to be considered are biologic,
psychological, and social. If we do not look at this broadly and
comprehensively, we will not improve the situation."
Such factors are both patient related, including such things as keeping
appointments and making lifestyle changes, and related to healthcare
professions and the healthcare system. "To look exclusively at the
issue of which drug is prescribed is only one piece of a very large,
complex series of decisions that have to be made and actions that have
to be taken," Hill said.
The patient-related factors are complex and sociological. Consider
where patients live, she said. Do they have homes or sufficient money
to buy medications? Are they on prescription plans or do they have
health insurance at all? Do they have a healthcare provider who can
provide education about the need for hypertension control that fits in
with the patient's beliefs and needs?
The system itself has to adapt, Hill said. Many managed care plans have
rules about how often a patient can have a prescription refilled. That
can interfere with the needs of a patient who must travel and has to
have prescriptions refilled ahead of time, she said.
Patients and physicians often have to be convinced that controlling
hypertension or any other chronic condition is important, she said.
"If providers don't believe there is benefit, no wonder we are
seeing some of the control rates we have," she said.
Popular culture is another barrier, said Henry W. Blackburn, MD, Mayo
Professor of Public Health (Emeritus), Division of
Epidemiology at the University of Minnesota in
Minneapolis. "[A] cultural backlash in North America exists, as
does New Ageism, which distorts health behaviors and commercializes
food, tobacco, fitness, and aging," said Blackburn. As the message
about the dangers of cigarettes and high-fat diets emerges, naysayers
arise, warning that such "puritanical" advice seeks to destroy
pleasure.
"We see these hedonists come to the fore. They label professionals
health Nazis and are hindering our way of life in the backlash against
health promotion," he said. The message is further garbled by the
changing message that further confuses a public seeking legitimate
health advice, said Blackburn.
"Junk science is a term now being used to derogate frivolous research
claims but also legitimate study results. Prevention researchers are
referred to as `turkeys' on the Web site `Junkman's Hall of
Shame.' It lists many of us epidemiologists in this country. Like
Nixon's hit list, you haven't arrived till you make the list!
"I don't mean to exaggerate, but this kind of source is dangerous to
science. It is symbolic of [the] backlash against effective health
promotion."
In other presentations at the 3-day conference, Margo Halm,
RN, and Sue Penque, RN, found that women arriving at the hospital with
myocardial infarction were more likely to have nonspecific signs and
symptoms. In women, back pain, loss of appetite, and paroxysmal
sleeplessness were seen more often than in men. Halm and Penque, in
their study at United Hospital in St Paul, Minn, also found that women
were more likely to deny the possibility that they were having a heart
attack. Women, on average, waited 5.3 hours before going to the
hospital, whereas men waited 4.2 hours.
Men were more likely to undergo revascularization
by PTCA and CABG than women, they said. For example, 19% of women
underwent PTCA compared with 33% of men. Eight percent of women
received bypass procedures compared with 11% of men. Twenty-three
percent of men received thrombolytics compared with
only 16% of women. Sixty-five percent of men and 40% of women
received intravenous nitroglycerin; 76% of
men received intravenous heparin compared with 40% of
women.
The study, although small (51 women and 47 men), has implications for
clinical practice, said Halm. Accurate cardiac assessment is crucial,
and doctors should expect to see nonspecific signs and symptoms from
their female patients, she said. A larger study is needed, she said,
but this one does point to the need to communicate better with women
and healthcare providers about women's risk of heart disease.
"There is indeed an enduring half-truth that heart disease is a
man's disease," said Millicent Higgins, MD, Professor of
Epidemiology and Internal Medicine Emeritus at
the University of Michigan School of Public Health. In fact, she said,
more women in the United States are suffering from heart disease than
men: 30 million women and 28 million men. Half a million women die of
heart disease in the United States annually, compared with just
slightly more than 450 000 men.
Then why has heart disease in men garnered more interest than heart
disease in women? "In men, cardiovascular disease
happened more suddenly and more often in middle age. In other words,
more dramatically," said Higgins. With more than half of all women's
deaths resulting from cardiovascular disease, it may be
surprising to learn that as late as 1994, the Reader's
Digest cover story was "Is Your Husband Headed for a Heart
Attack?" she said. "Clearly, in many minds,
cardiovascular health is still a man's issue," she
said. Yet >70% of all women have at least 1 risk factor for
cardiovascular disease, she said.
Physical inactivity is a major risk factor for heart disease, said
JoAnn Manson, MD, of Brigham and Women's Hospital in Boston, Mass.
"Sedentary lifestyles double the risk of heart disease," she said.
"We need to get the doctors and health maintenance
organizations behind this issue to the point where they are helping to
increase people's fitness levels.
"I think we need to work not only at the individual level but also at
the community level," said Manson. "We need to make physical
activity more accessible to certain segments of the population,
including socioeconomically disadvantaged groups."
Early studies indicate that homocysteine places people at increased
risk of heart disease and that folate consumption can reduce
homocysteine levels and thus the risk, said Manson. However, she said,
it will be 3 to 4 years before there is conclusive evidence of
this.
"At the present time, we recommend the 400 µg per day of folate
found in most multivitamins. But the major sources of folates and
vitamin B6 are fruits and vegetables. It comes
down to eating more fruits and vegetables," she said.
Antioxidants also may be important in the prevention of heart disease,
said Daniel Steinberg, MD, Professor of Medicine at the University of
California at San Diego. "I don't think antioxidants are ready for
prime time, but everyone else in the United States seems to think
so," he said. The probability is good that antioxidants will slow the
progression of cardiovascular disease, said Steinberg,
who is leading studies in that field. "But we still don't have
enough evidence at the clinical level to allow firm recommendations to
be made about what patients should do."
Equally tantalizing are reports indicating that some bacteria,
particularly Chlamydia pneumoniae, may play a role in heart
attacks, said Peter Libby, MD, of Harvard University Medical School and
Brigham and Women's Hospital in Boston. He theorized that researchers
looking for the cause of some myocardial infarctions should take their
cue from ulcer researchers who found the Helicobacter pylori
bacteria to be the cause of most peptic ulcers. H pylori and
C pneumoniae both cause infections that do not
immediately cause problems, he said.
Currently, studies are centering on the question of whether
patients who have had heart attacks and who carry the bacteria could be
helped by antibiotic treatment, said Libby. "We want to know if it
will reduce the probability of a second heart attack." But he warns
that such studies are crucial to understanding the nature of the threat
of such bacterial infections.
The easy solution probably will not be found, said Steinberg. "As
much as we would like an easy solution, the public will have to mind
its p's and q's," he said. "They will have
to follow recommendations for a healthy lifestyle."
But even that might not be as easy as it seems, said Ronald M. Krauss,
MD, senior scientist at Lawrence Berkeley National Laboratory in
California. He and his colleagues have found that extremely low-fat
diets can have a negative effect on a small portion of the population.
Krauss explains that even when individuals follow low-fat diets, the
level of LDL in their blood varies widely among individuals.
Genetics plays a role, he said, with specific variants, including those
affecting apolipoproteins E, A-IV, and B. His group studied the
response to reduced-fat diets in individuals with a common, genetically
influenced metabolic profile characterized by a
predominance of small, dense LDL particles (subclass phenotype
B). This profile is associated with a 3-fold increased risk for
coronary artery disease, said Krauss. It is found in one third
of men, 15% to 20% of postmenopausal women, and 5% of children and
premenopausal women.
Among 105 healthy men consuming a high-fat (46% of calories from fat)
diet, improvements in LDL and other lipoprotein risk measures on an
isocaloric reduced-fat (24% of calories from fat) diet were
significantly greater in the 18 men with phenotype B than in
the majority of men with predominantly larger LDL particles
(phenotype A). Moreover, among phenotype A subjects,
there was a shift from larger to smaller LDL, resulting in conversion
to phenotype B in 36 men. These results have been confirmed in
a second study of 133 men.
Krauss wants to see more studies done of the effects of such low-fat
diets. "What we are really saying is that we ought to be very careful
in extending our guidelines well below what we currently advocate for
the general population," he said.
Although the last 50 years of the current millennium have seen
tremendous strides in the treatment of heart disease, questions remain
unanswered—questions that will take >50 years in the next millennium
to answer.
