Transformation of Cardiovascular Health
Presidential Address at the American Heart Association 2009 Scientific Sessions
Good afternoon, my name is Clyde Yancy. Welcome to the American Heart Association’s Scientific Sessions 2009. Thank you for being here. Today, you are part of the phenomenal tapestry of those attending this meeting.
As I look out in the audience, I see accomplished and new basic and clinical scientists, clinicians, clinical and research nurses, and allied health professionals. I marvel at the collection of AHA past presidents and chairpersons, leaders of our partner national and international professional and volunteer health organizations, and my colleagues here from the American College of Cardiology.
I embrace the volunteers, patients, and family members who are here today; and I appreciate the business professionals, innovators, and media who share our interest in cardiovascular diseases and stroke. Welcome. We have all come together at Scientific Sessions for a singular purpose: to share our interest, our curiosity, our passion, and our intent to “build healthier lives, free of cardiovascular diseases and stroke.”
Today, I will address the transformation of cardiovascular health. Health care is changing. One year ago, we realized the dawning of epic change—specifically, the potential transformation of American health care. Given the enormity of this moment, we were galvanized to contribute proactively to healthcare reform. Under the leadership of former AHA President Ray Gibbons, the American Heart Association outlined and published the following principles:
Access to care for all persons residing in the United Sates;
Enhanced focus on the prevention of disease;
Increased quality of care;
Elimination of disparate health care;
Advancement of research with sustained and consistent funding of the NIH and;
An increase in the healthcare workforce.
But healthcare reform per se is not the focus of my comments, as healthcare reform that is not accompanied by a true transformation will only shift the suite of problems. Thus, I will address the transformation of health care and will especially focus on transforming cardiovascular and stroke health.
I believe that a true transformation of cardiovascular health involves generating new science, applying best science, and continuing to improve the quality of care of patients with cardiovascular diseases and stroke with a targeted emphasis on prevention, attaining health equity, and advocating for better health for all.
Let’s turn our attention toward science. The AHA was founded in 1924 by visionary physicians, led by Paul Dudley White, Lewis Conner, and others—names that resonate within the history of American medicine. Their brilliance was eclipsed only by their humility. They were smart enough to know that our evidentiary science was woefully inadequate. Since those incipient moments of enlightenment, the AHA has held firm to its core: the generation of new knowledge; the promulgation of best evidence; and especially the nurturing of new scientists. Our resolve to support science has been relentless and will remain so.
You should know that, to date, the AHA has spent $3.2 billion—with more than $1.3 billion spent in the past decade—in our support of research on heart disease and stroke. And despite today’s precarious economic environment, we have continued to be second only to the National Institutes of Health [NIH] in the support of cardiovascular research.
The AHA, through its positive corporate partnerships and with the help of amazing private philanthropy, has established:
The AHA–PRT–Stevie and David Spina Outcomes Research Centers to pioneer outcomes science;
The AHA-Jon Holden DeHaan Foundation Cardiac Myogenesis Research Centers to create breakthroughs in cardiovascular regenerative medicine; and
The AHA-Bugher Foundation Stroke Prevention Research Centers to understand how best to preempt this debilitating disease.
We have not and will not lose sight of the discovery of new science, as nothing defines the depth and breadth of this organization more profoundly. This is our core strength and this is where the transformation of cardiovascular health begins.
Generating new knowledge, though laudable, is not, however, sufficient. We must apply this knowledge to our mission. With that in mind, this organization adopted a bold vision, and set an ambitious goal in the year 1998: to reduce coronary heart disease, stroke and risk by 25% by the year 2010.
Pause for a moment and consider the enormity of this goal. In 1998, we didn’t yet have widespread use of important evidence-based therapies, such as statins, ADP [adenosine diphosphate] platelet receptor inhibitors, PCI [percutaneous coronary intervention] for ACS [acute coronary syndromes], or lytic therapy for stroke care. Secondary prevention measures were still evolving. Yet, this organization moved ahead with conviction that the cardiovascular and stroke community would respond to the challenge—and indeed you did.
By 2008, we nailed a big part of our 2010 goal—deaths from coronary disease had fallen by more than 25%, and soon after, the goal for stroke was achieved. Hypertension control is at goal and cholesterol control is nearly there. Consider that the actual reduction in death due to CAD [coronary artery disease] has been 35.7% and for stroke, 32.5%. The process of discovery, implementation, and application of best practices has been so forthcoming, so profound, and so transformational, that tens of thousands more patients are alive and well now.
That, my friends and colleagues, is no small feat. But this is not the whole story. Importantly, we recognize that we have not achieved our 2010 goals for smoking, physical activity, obesity, and diabetes. Worse, we know that a recrudescence of mortality due to heart disease and stroke is already occurring in certain areas, and it’s likely to worsen even more if we don’t impact these important factors, and especially if there is not a significant change in the worrisome incidence of obesity in our younger population.
So, how best can we drive transformational change in cardiovascular diseases and stroke?
Quality. Such a simple word but a complex rubric. In health care, “Quality” is spelled with a capital “Q.” As outlined by the Institute of Medicine, a “Quality” system or a process must be:
This embrace of quality in cardiovascular medicine has become one of the truly transformational movements in health care, and raising the bar for quality is now a major effort of the American Heart Association. The quality movement has revealed to us what the German poet and philosopher Goethe suggested: “Knowing is not enough, we must apply; willing is not enough, we must do.” Without a process in place to help us define and improve quality, we rely too much on recall; even the best among us fails to do the simplest things perfectly and consistently.
Let’s think about heart failure. Even today, fewer than 90% of eligible outpatients with heart failure are treated with ACE [angiotensin-converting enzyme] inhibitors/ARBs [angiotensin receptor blockers] and only 85% are treated with β-blockers; we note that device therapy use is no better than 50% for ICDs [implantable cardioverter-defibrillators] and 35% for cardiac resynchronization therapy in suitable patients. I personally agonize that combined vasodilator therapy, that is, isosorbide dinitrate and hydralazine, a dramatically effective adjunctive heart failure therapy, is used in <10% of appropriate patients.
The problem is the absence of process. The solution is process of care improvement.
The American Heart Association, American Stroke Association, and others have pioneered process of care improvements that have had remarkable success. Our Get With The Guidelines initiative is arguably one of the most exemplary quality programs in health care.
To date, more than 2 million patient records have been entered from nearly 1600 US hospitals, some of which are participating in multiple modules. Get With The Guidelines is now represented in >35% of all US acute care hospitals. Thank you for the tremendous job that so many of you have done to champion Get With The Guidelines.
What’s been the result? Consider stroke. More than 1 million of the patient records in Get With The Guidelines represent stroke care. These participating Get With The Guidelines–Stroke hospitals have dramatically improved both performance and quality metrics. Case in point: Lytic therapy for acute stroke in participating Get With The Guidelines–Stroke hospitals has increased from ≈33% to 66%, a 100% improvement. Quality of life is being preserved through evidence-based quality-driven stroke care. This is transformational change.
Let’s return to heart failure, a theme to be embraced at this meeting and one that will be highlighted in the Paul Dudley White lecture to be given by Karl Swedberg. Get With The Guidelines–Heart Failure has now accumulated over 400 000 unique patient records from 638 hospitals. Heart failure metrics of quality care are improving and, especially in those participating Get With The Guidelines hospitals that have earned quality recognition, heart failure outcomes (specifically 30-day mortality rates), are significantly better than in other hospitals. This is yet another transformational change.
To further your efforts to improve heart failure care, the AHA has just this past month launched TARGET HF, which captures the entire suite of AHA heart failure–related resources in 1 repository to facilitate best care and quality. Get With The Guidelines–Outpatient, launched earlier this month, is a performance improvement initiative also intended to help you improve quality of care for your outpatients with heart disease or stroke.
As much as breakthroughs in science have yielded important new treatments, it has been the embrace of quality by healthcare systems that is driving those treatments and building healthier lives that are free of cardiovascular diseases, and stroke. However, despite the incredible new science and focus on quality-driven systems, the state of ill health persists. Being sick is a bad thing.
Targeting the prevention of disease and promptly intervening at the earliest signs of disease, even preventing risk itself, would represent a more potent objective, especially in today’s resource-sensitive environment. Stunning epidemiological research done by AHA volunteers revealed that for the 50-year-old male or female devoid of known risk factors for heart disease, including hypertension, diabetes, smoking, dyslipidemia, and a sedentary lifestyle, life expectancy free of heart disease and stroke is at least another 40 years. To date, it is estimated that only a fraction of the US population, perhaps as low as 1%, fits this mode of “ideal health.” But, the possibility exists that preventing the onset of risk factors represents the ultimate strategy toward attaining a longer life free of disease.
The thinking here is truly transformational. The implications go beyond secondary prevention and even beyond primary prevention. This new transformational thought process targets primordial prevention, which is the prevention of risk. This will require bold new science, new processes of care, and new metrics of quality.
With this new context, the AHA underwent an intensive review of relevant clinical and prevention research with a keen focus on the attainment of ideal health. After thoughtful deliberation, the AHA has now adopted an ambitious new goal, as visionary as its 2010 goal. I am pleased to announce this new goal: By 2020, we intend to improve the cardiovascular health of all Americans by 20% and further reduce deaths from cardiovascular disease and stroke by an additional 20%.
Think about this. Consider the potential benefit. Truly we will be creating a future of healthier lives free of cardiovascular diseases and stroke. Let’s not miss the transformation here—improving the cardiovascular health of all Americans, a new goal for the AHA.
In 1966, Dr Martin Luther King, Jr, spoke these words: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” I take this statement to heart.
Now more than 40 years later, this injustice remains. The stain of disparate health care is as evident in heart disease and stroke as it is in any other disease state. This is not in keeping with the most basic commitment in medicine, to provide care and to do so compassionately for all who are ill and are suffering.
The photo in Figure 1 is the “Yancy 9.” These are the sons and daughters of my grandmother, a devoutly spiritual, fiercely independent, driven Negro woman and my grandfather, a hard-working grandson of slaves from the southeastern United States.
Their character traits were passed on to their sons and daughters, and then passed on to my generation, which includes 4 physicians, 3 chemists, 2 teachers, 1 psychologist, 1 economist, and 1 accountant. But we also received our family history of heart disease.
In Figure 1, my father is fifth from the left. He and all of his siblings suffered from or succumbed to heart disease and stroke. Only 1 remains alive. And now my generation has hypertension—me included. That is both astonishing and sobering. Clearly my heritage predisposes me to heart disease but should it also influence how effectively I am treated?
Consider the plight of many African Americans in the United States: Rates of bypass surgery, PCI, statin use, and, as seen from this recent Get With The Guidelines database analysis, even ICD use—all class I recommended treatments for heart disease—are strikingly different (Figures 2 and 3⇓). Despite similar indications, an African-American woman is nearly 50% less likely to receive an ICD.
In part as a result of these examples of disparate health care, African Americans in this country suffer a greater toll of hospitalization and death due to heart disease and greater disability due to stroke. Similar issues are noted in other populations. Is this acceptable?
The complete explanation for the absence of health equity goes beyond the scope of today’s comments, but let me stand squarely with former AHA president Dan Jones, and share his belief that the absence of high-quality health care for any one of us should be unacceptable to every one of us.
The AHA is improving health equity; data derived from our Get With The Guidelines program now demonstrate that the racial/ethnic gap in quality metrics and outcomes is narrowing. Careful use of improved processes of care, more precise genomic or physiological characterizations of groups at risk, and better access to care may ultimately support the elimination of healthcare disparities. That would truly be transformational.
For many years the AHA was a sleeping giant, content to quietly push the boundaries of science and awaken only to trumpet new discoveries. But the vision of past leaders identified that the mission of the AHA would not be achieved without a more proactive position in the legislative process.
We are trusted; this allows the AHA to serve as the voice of authority on cardiovascular diseases and stroke issues. We truly advocate for best cardiovascular health for our nation. Advocacy can be a powerful vehicle of change. However, some will label those of us who advocate as supporting 1 political point of view or another. However, the AHA supports only 1 point of view: that of the patient.
Our advocacy efforts have supported increases in the NIH budget, greater uniformity in stroke care; availability of emergency cardiac care across the country including rural environments; women’s health; childhood fitness; and tobacco restrictions. This latter effort culminated in the Family Smoking Prevention and Tobacco Control Act signed this year that provides FDA [Food and Drug Administration] oversight of the tobacco industry and for the first time subjects the tobacco industry to full disclosure and greatly restricted advertising policies. This could be a transformational change affecting an important risk factor.
Many of you are aware that the AHA has been involved in the debates that are shaping healthcare reform. Importantly, we are at the table as a tireless patient advocate, understanding that any shift in focus away from the patient and the provision of ideal health is a missed opportunity. As an organization, we have heard the heartfelt stories of people who have reached the brink of bankruptcy due to healthcare costs despite good insurance; we have agonized over the plight of mothers with children who have congenital heart disease and the impossible task of staying ahead of their bills; and we have felt the anguish of people who know that they have seen loved ones suffer due to the lack of adequate, accessible, affordable health care. As Americans, we envision that the United States provides the best health care in the world, but wouldn’t we truly be one of the best healthcare systems if no Americans were left out?
The healthcare reform debate is complex, and even within the AHA we are no different than society at large: our volunteers have many points of view—all of which are respected. Components of healthcare reform such as funding, tort reform, and public options are all important issues and appropriately are being advocated passionately by many others, but any of these issues can easily obscure the quiet voice in this debate: the patient. It is the patient for whom the AHA is advocating.
Let us be indefatigable in our advocacy for the right changes and consider the challenge of immediate past AHA president Dr Tim Gardner to create a uniquely American solution for a uniquely American healthcare system. People, we can do this.
[Mohandas] Gandhi admonished us to “be the change we wish to see in the world.” Change of some sort in our healthcare system is inevitable. We can be passive and allow events to define us or we can shape events. The choice is ours: By moving boldly into new scientific arenas, we take the initiative to own and direct new science; by challenging ourselves with an audacious 2020 goal, we continue to embrace treatment but also put prevention more clearly in our prism.
As people who care, we know that the exclusion of any group or person from adequate health care is the exclusion of all from our best quality of life; we know that the mission of the AHA is best served by making certain that science, evidence, and the patient stay at the heart of healthcare reform. Thus, these initiatives represent the necessity for us, the AHA, to lead in the transformation of cardiovascular health.
In closing, let me be clear. We are grounded in science. We are driven by mission. We are focused on reducing death and disability due to cardiovascular diseases and stroke. We are committed to building healthier lives free of any disease. And we are charged with being transformational. That’s today’s message. Let us not lose this great opportunity.
Here is my call to action to you: If you aren’t a member of the AHA, join today and become a part of this extraordinary organization. Join a council; participate in Get With The Guidelines; sign up for our grassroots advocacy network “You’re the Cure.”
Exhale for a moment this week and enjoy your success, whether it’s a first abstract or a premier award—everyone matters and everyone’s work is important. This is an electric environment and this is where transformational change begins.
Thank you; have a great time at Scientific Sessions 2009!
Presented at the 2009 Scientific Sessions of the American Heart Association, November 14–18, Orlando, Fla.
The Appendix is available in the online-only Data Supplement at http://circ.ahajournals.org/cgi/content/full/121/25/2773.