Packing Up 2013: Hacking the Future
Best of, countdowns, and naughty-or-nice lists circulate widely at year’s end, but who better to take a look at cardiology in terms of recent past and coming future than CardioSource WorldNews? We have assembled highlights of 2013, as well as predictions of the next big things in matters of the heart as we unpack 2014 and beyond.
Driving Ms. Data: Better Health Care Through Hacking
A new book, ePatient 2015: Surprising Trends Changing Health Care, explores how digital technologies, history, legislation, and culture are combining to transform health care. The Pew Research Center defines “ePatients” as individuals who have searched online for health content for themselves or on behalf of another person. Already, nearly half of ePatients have used the Web to “care-hack” the convoluted US health care system; that is, they have successfully used the internet to get treatment faster or improve their care.
Through original research and individual patient stories, the authors illustrate the future of health care via 15 surprising health-care trends. Two major themes:
- Health Hyperefficiency: Innovations in computers, software, and mobile technology are helping to make health and medical care more efficient, safe, and effective for all patients. Moreover, big data and powerful computers will help facilitate cost-effective clinical trials. In some cases, patients will use social media to find one another, prep for trial participation, and maybe even recruit scientists to conduct the research. Caveat: As more data are collected, hard questions are arising regarding the ethics and privacy of these new tools.
- Personalized Health Movement: Genetics, behavioral methods, and digital tools already are being used to personalize health treatment. Medical genealogy will help predict disease and drive medication selection. Rewards (and punishments) will be used to persuade consumers to engage in healthy behaviors. Real-time data and advice will help them take better care of themselves. Caveat I: As the volume of health data from wearables, sensors, and more increases, patients will struggle to act on all this information. Caveat II: Financial barriers, as well as a lack of appreciation for cultural and socioeconomic variables, threaten to blunt the effectiveness of digital health technologies.
Don’t Discount Patient Interest
If you’re ready to dismiss all this as eNonsense, may we remind you of the Mayo Clinic’s recent iPad trial for cardiac surgery patients? David J. Cook, MD, who led the study, says the real innovation of the study was the unprecedented level of patient engagement—in patients he repeatedly described as “70-year-olds on morphine.” For the study, 149 cardiac patients were given iPads preloaded with a specially created app that interacted daily with patients through a customized to-do list and assessments of their mobility and pain. Mobility was both self-reported and reported via a wireless activity monitor. (Note: patients were outfitted with a wireless accelerometer [Fitbit, Inc; San Francisco, California], which was placed on a patient’s ankle after transition from the intensive care unit.)
The app also embeds educational modules through each step of the process. During the surgery, the app is designed to help families follow along and understand what’s happening to the patient. In the study, the app helped reduce hospital stays for some patients, because the app alerted doctors when patients weren’t meeting recovery expectations.
Patients completed 98% of the 1,418 self-assessments the investigators threw at them and finished 85% of their educational modules. While patients ranged in age from 52 to 85 years, there was no discernible link between age and engagement. Mayo has subsequently developed an app for the iPad that includes prescription refills, secure messaging, and a portal for accessing their patient information.
2013 NIH Research Highlights
In 2013, all three recipients of the Nobel Prize in Physiology or Medicine and all three awardees of the Nobel Prize in Chemistry received National Institutes of Health (NIH) funding during their careers. Here are CSWN’s picks—from a much longer list—of annual highlights from the NIH:
- Medical Management Best to Prevent Second Stroke
After a stroke, guideline-based secondary prevention typically involves blood-thinning medications and control of blood pressure and cholesterol. In hopes of improving the odds, doctors over the past decade have used an intracranial artery stent. While stenting is standard therapy in the coronary arteries, an NIH-funded clinical trial confirmed earlier findings that intracranial stenting adds no benefits over aggressive medical therapy alone for most of these patients. (Derdeyn CP, et al. Lancet. 2013 October 26. [Epub ahead of print])
- Genetic Testing Doesn’t Improve Warfarin Dosing
Determining the best dose of warfarin can be tricky. Too much can cause excess bleeding; too little can lead to dangerous clots. Past research suggested that adding genetic data to clinical information would improve initial dosing, but this was from small trials or observational studies and with equivocal results. A study reported in late 2013 contradicted earlier results, highlighting the importance of using clinical trials to assess the role of genetics in optimizing treatments. (Kimmel SE, et al. N Engl J Med. 2013;369:2283-93.)
- Duration of Obesity May Affect Heart Disease
Evidence of heart disease is being seen in younger and younger patients; a new study offers a reason why. NIH researchers found that how long a young adult is obese may affect that person’s heart disease risk in middle age. With obesity rates soaring among the young, the study suggests that not only preventing but also delaying the onset of obesity can help reduce heart disease later in life. Similarly, if we can’t get a handle on curbing obesity rates in this country, expect to see an ever-growing population of younger patients seeking help for ischemic heart disease. (Reis JP, et al. JAMA. 2013;310:280-8.)
Promising Medical Advances
- Stem Cells Coaxed To Create Working Blood Vessels
In an NIH-funded study, scientists used a synthetic matrix to help direct human stem cells to form networks of tiny blood vessels that can connect to the existing circulation in mice. These self-organized vascular networks might assist future efforts to repair and regenerate tissues and organs, which need an adequate blood supply to grow and survive. Kusuma S. Proc Natl Acad Sci U S A. 2013;110:12601-6.)
- The Human Microbiome
The human body hosts trillions of microbes and we’re gaining a better understanding of the many roles these microbial communities and their genes—collectively known as the microbiome—play in human health and disease. NIH-funded scientists surveyed all the fungi living on human skin and uncovered links between gut microbes and rheumatoid arthritis; discovered interactions among diet, gut microbes, and both heart disease and obesity; and found that microbes may also influence the effectiveness of cancer therapy and gastric bypass surgery. (Findley K, et al. Nature. 2013;498:367-70.)
- Strategy May Improve Survival after Shock
Shock is a life-threatening condition, and past studies have drawn an association between inflammation and shock, mainly through the digestive system. New research using a rat model found that blocking digestive enzymes in intestines increases survival, reduces organ damage, and improves recovery after shock. The approach may lead to innovative therapies to improve patient outcomes. (DeLano FA, et al. Sci Transl Med. 2013;5(169):169ra11.)
- Structure of a Potential Diabetes Drug Target
People with diabetes have difficulty maintaining healthy blood glucose levels. The hormones insulin and glucagon help keep blood glucose in a safe range. An international team of researchers, funded in part by NIH, determined the structure of the human glucagon receptor. The results may aid in the development of drugs for diabetes and other metabolic disorders. (Siu FY, et al. Nature. 2013;499:444-9.)
Top Cardiology Stories for 2014
Want to have your finger on the pulse of cardiology? According to ACC leaders, keep your eye on these developments this year:
The ACA’s individual mandate for health insurance coverage: The new health plan took effect January 1, so watch for payment model changes and more patients, some of whom will be seeing a cardiologist for the first time as they gain access to care through the Affordable care Act.
Sustainable Growth Rate (SGR) permanent fix: While often painfully slow, Congress seems closer than ever to finally passing a fix to the flawed formula for calculating physician pay under Medicare enacted almost 2 decades ago. A permanent repeal would be good news for Medicare patients, as many physicians would be unable to continue to see Medicare patients if payments for physicians were cut so dramatically.
Development of PCSK9 inhibitors: Multiple trials are in progress for this anticipated new class of drugs that dramatically decrease LDL cholesterol. Early data are already emerging, with more reports due soon.
Implementation of new ACC/American Heart Association (AHA) prevention guidelines: Guidelines for obesity, lifestyle management to reduce cardiovascular risk, blood cholesterol management, and risk assessment were released in November based on NHLBI efforts. The guidelines will continue to be discussed and debated, and education programs will be developed to help physicians incorporate them into daily practice. The ACC and AHA, with support from NHLBI, will start work on a guideline for the management of hypertension.
Rollout of mitral valve clip: In October 2013, the FDA approved a transcatheter procedure for treating prohibitive-risk patients with severe degenerative mitral regurgitation. The ACC and the Society of Thoracic Surgeons will add a mitral module to the National Cardiovascular Data Registry® TVT Registry™ and begin reporting data in 2014.
Expanded use of novel oral anticoagulants: These new medications began to get traction in the market in 2013, but still lagged behind warfarin, which was the only anticoagulant available in the United States for decades. While they cost more per dose than warfarin, these new medications do not require extensive monitoring or dietary/medication restrictions.
Results of the Dual Antiplatelet Therapy (DAPT) Study: Release of the phase IV study results are imminent and may impact the duration of such treatment following coronary stenting across a wide spectrum of patients.
A potential new therapy for refractory hypertension: The results of a phase III trial of renal denervation for hypertension are expected in early 2014 and could eventually lead to FDA approval for a renal denervation device.
Continued growth of cardio-oncology: This subspecialty focuses on the cardiovascular manifestations of cancer and complications of its treatment. Look for it to expand rapidly to more hospitals across the country.
United We Stand
The ACC’s innovative new Quality Improvement for Institutions program brings together under one umbrella all of ACC’s proven hospital quality improvement offerings, enabling hospitals to access a comprehensive suite of cardiovascular registries and quality improvement tools that support quality clinical care, deliver improved patient outcomes, and offers national recognition for participating in ACC quality initiatives.
This program unites the NCDR® and established quality initiatives including Hospital to Home (H2H) and the Door to Balloon (D2B) Alliance, and new initiatives such as Surviving MI. Participating hospitals and institutions also have access to clinical toolkits around key conditions and opportunities to participate in innovative quality improvement pilot programs.
Look Closely (You Have to—It’s Tiny)
At one-tenth the size of a conventional pacemaker, and comparable in size to a large vitamin, the world’s smallest pacemaker made someone’s holiday happier: in late December Medtronic announced the first-in-human implant of the Micra™ Transcatheter Pacing System (TPS). It is delivered directly into the heart through a catheter inserted in the femoral vein. Once positioned, the pacemaker is securely attached to the heart wall and can be repositioned if needed. The miniature device does not require leads; rather, it attaches to the heart via small tines, delivering impulses that pace the heart through an electrode at the end of the device.
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