Moving Forward

A new year of research and clinical accomplishment is ahead of us in 2017. The National Institutes of Health (NIH) has approved new funding for research, while many of the new discoveries of 2016 have been approved for general use and show promise in making significant clinical improvements in health. In the heart failure field, advancements in new medications have provided a gain in heart failure outcomes with the new sacubitril/valsartan combination, but its widespread application appears to be getting a slow start due to cost and the usual habit of clinicians to go slow and see what the real-world application of the medication accomplishes. However, many of the other clinical trials in heart failure management did not accomplish their stated goals, providing no justification for those of us who manage heart failure patients to abandon current established care. This is particularly true in underserved, poor communities where the newest drugs are too costly, but standard heart failure medications are affordable.

The hope is that extremists in health care reform who want to abandon government-funded health care will reach a balance that provides continuing health care to these communities. We have experienced many patients who fail to take heart failure medications, decompensate and require acute hospitalization, thereby increasing rather than reducing health care costs. Our role in providing care for cardiac patients will require support for health care systems that can provide the usual medical care, and access to new therapies and medications by working with their clinicians and investigators to optimize care delivery through use of care teams and population health methods. Non-physician providers and team-based care will be essential to this effort.

"The hope is that extremists in health care reform who want to abandon government-funded health care will reach a balance that provides continuing health care to these communities."

This past year also saw more data that strengthen the hypothesis that achieving LDL levels well below the previous aggressive target of 70 mg/dl will further reduce risk of coronary disease. Long-term clinical trials assessing outcomes are not yet completed, but current data continue to support LDL targets below 50 mg/dl.

To reach these low levels, increased statin doses with the addition of ezetimibe will likely be needed in many more patients. Additionally, given the current data on PCSK9 inhibitors, the easier way to a very low LDL level is likely to be use of these agents. Many patients already express concern over muscle injury and dementia related to statin use, and PCSK9 inhibition would be a desirable alternative if cost was not a factor. Here again affordability of therapy becomes an important issue in advancing care. Many patients with insurance have high out-of-pocket costs for brand-name medications, and use of a PCSK9 inhibitor might be rejected by the patient if the therapy is unaffordable.

Insurers also commonly deny a higher cost drug unless the caregiver can demonstrate intolerance or ineffectiveness to the low-cost generic medication. Clinical outcome data from use of PCSK9 inhibitors should appear sometime in mid-2017, and if they show a significant reduction in coronary disease risk, they will provide strong support for wider use of these medications to manage atherosclerotic risk even when risk is intermediate.

Telemedicine has been a particular interest of mine over the past 20 years, and for many of those years, in spite of encouraging clinical trials in heart failure, diabetes, and hypertension management, the technology has not been widely adopted. Part of the reason is economic as chronic care using remote monitoring and electronic communications has not been reimbursed, but things are changing. Many health care systems are finding value in remote monitoring and telemedicine communication for chronic disease management.

For an integrated health system where the system takes some financial risk for care, particularly in the new outcome- and quality-based reimbursement models under the Medicare and CHIP Reimbursement Act (MACRA), remote monitoring and other telehealth methods will likely increase in value. In spite of the advances in telecommunication technology with smartphones and wireless connections, the greatest impediment to success of such systems is getting the patients to participate. Motivation for health improvement was emphasized in data presented at the American Heart Association’s Annual Scientific Sessions this past fall, and methods to improve patient participation in their care through use of modern telecommunications is an important priority for all cardiovascular professionals.

Team-based care is an ideal way to connect patients with their caregivers, and much of the effort is best done by non-physician providers who can handle the day-to-day care management for many of the chronic cardiac conditions that we encounter. Data emerging from clinical trials and registries support this type of long-term care.

As we expand our scope of care in cardiology, we are now seeing more demand to add management of cardiac patients who have diabetes. Newer diabetes medications show value in reducing cardiovascular risk in both patients with documented cardiovascular disease, and patients at risk due to diabetes. With the high incidence of diabetes in obese patients and in the elderly, a partnership with endocrinology appears to be an excellent model for providing this combined care.

"In spite of the advances in telecommunication technology with smartphones and wireless connections, the greatest impediment to success of such systems is getting the patients to participate."

A similar approach can be taken for patients with cancer. The complex medications used to treat various forms of cancer, and the cardiovascular side effects of many of the anticancer drugs, also are best managed by a team approach with a cardiologist and an oncologist involved in long-term care of these patients.

Essential to understanding the long-term outcome of our patients with multiple comorbidities and multiple caregivers, is the ability to analyze large databases to find trends that cross boundaries of care from multiple providers. We have seen several preliminary analyses of large-scale databases, using sources that include electronic records systems and social media to identify trends in population health that could not be detected by our usual clinical measurement systems.

Looking forward, it is evident that we will see important new clinical therapies emerging from clinical trials and data registries, but also expect to see a better understanding of population health and how it will affect our daily practice of cardiology in the future.

Cardiology Magazine, Jan. 2017

Alfred A. Bove, MD, PhD, MACC is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and a former president of the ACC.

Keywords: Cardiology Magazine, ACC Publications, Aged, American Heart Association, Cardiovascular Diseases, Caregivers, Comorbidity, Coronary Disease, Dementia, Diabetes Mellitus, Disease Management, Goals, Government, Habits, Health Care Costs, Health Care Reform, Health Expenditures, Heart Failure, Hospitalization, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Incidence, Insurance Carriers, Long-Term Care, Motivation, National Institutes of Health (U.S.), Neoplasms, Medical Oncology, Patient Participation, Registries, Research Personnel, Risk Factors, Social Media, Telemedicine, United States

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