Heart Matters

Host: Jack Lewin, MD Guest: Regina Herzlinger, PhD The role of specialization in our economy dates back to the 18th century. Now fast-forward to healthcare in the present day: one application of specialization is the concept of a focused factory, where care providers focus on one or two specific organs or disease processes. Host Dr. Jack Lewin welcomes Dr. Regina Herzlinger, the Nancy R. McPherson Professor of Business Administration at Harvard Business School, for an interesting conversation about the potential role of focused factories in healthcare. We have seen this model take hold in a few areas of medicine, including cardiology, but is the time ripe for an expansion of the focused factory model? Dr. Herzlinger also explains where a specialty hospital or a general tertiary care facility would fit within this system.

Host: Jack Lewin, MD Guest: Nancy Brown Decisions our young patients make now can have metabolic consequences for the rest of their lives. It's hard to overstate, not only how crucial it is that we reduce the incidence of childhood obesity, but also how difficult it has been for us to turn the corner on this issue. These concurrent themes are central to a campaign put forth by the American Heart Association (AHA) that aims to make major progress on childhood obesity in the years to come. Host Dr. Jack Lewin gets the details on this campaign during his conversation with the AHA's chief executive officer, Nancy Brown. How is the AHA partnering with schools to empower kids to make healthier decisions about their consumption habits and lifestyle choices? How can we help fellow clinicians move beyond the feeling that their efforts to reduce childhood obesity aren't having the desired effect?

Host: Janet Wright, MD Guest: Joshua Hare, MD Cardiac disease was once thought to be both progressive and irreversible. As stem cell therapies emerge across many fields of medicine, our patients with cardiac disorders may be among the first to benefit from this translation of basic science into very valuable clinical applications. What do the latest findings tell us about our ability to tap into the promise of stem cells to treat, reverse or even prevent cardiac disease? Dr. Joshua Hare, director of the Interdisciplinary Stem Cell Institute and the Louis Lemberg Professor of Medicine at the University of Miami Miller School of Medicine, walks us through the most promising developments in this cutting-edge research and provides his insights on how you can talk with your patients about where they can expect to see benefits in the short term. Dr. Janet Wright hosts.

Host: Janet Wright, MD Guest: Salim Yusuf, DPhil, FRCPC Start with one part diuretic. Add one part ACE inhibitor, and sprinkle in one part beta blocker. Then add a dose of statins, and top it off with a portion of antiplatelets. Here we have the proposed recipe for a singular pill that some experts believe will eventually help us stick a fork in heart disease. Yet there are pharmacologic concerns and certainly clinical trials to pass before this drug comes to a practice near you. That said, it's fair to wonder: how close are we? Dr. Salim Yusuf, professor of medicine and the director of the Population Health Research Institute at McMaster University in Hamilton, Ontario, Canada, is the lead author of one of the most recent polypill clinical trials, presented at the American College of Cardiology's 2009 Scientific Sessions. Dr. Yusuf joins host Dr. Janet Wright to give us an update on the global effort to create a polypill that will improve compliance, increase convenience and reduce cost.

Host: Janet Wright, MD Guest: Noel Bairey Merz, MD Research tells us that more than 80 percent of American women have used hormonal contraception during their lives. Though evidence suggests hormonal contraception could offer anti-atheromatous effects, the verdict is far from in. Further, we have a lot to learn about the long-term risks for thrombosis, arrythmogenesis, vasomotion and beyond. As we study the potential links between contraceptive hormone use and cardiovascular disease, where should our priorities lie? Host Dr. Janet Wright poses this question as part of a fascinating conversation with Dr. Noel Bairey Merz, director of the Women's Heart Center and the Preventive and Rehabilitative Cardiac Center, and the Women's Guild Endowed Chair in Women's Health at Cedars-Sinai Medical Center in Los Angeles, and a professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles.

Host: Janet Wright, MD Guest: Rita Redberg, MD, MSc Does elective percutaneous coronary intervention (PCI) make sense for patients with stable coronary artery disease (CAD), or are some better off with optimal medical therapy? The answer may depend on our ability to document ischemia in these patients, but it also leads us to another question: are we doing enough, through stress testing or other means, to substantiate the need for PCI? Dr. Rita Redberg, professor of clinical medicine in the division of cardiology at the University of California, San Francisco, School of Medicine, talks with Dr. Janet Wright about the work-up and evaluation of patients with stable CAD.

Host: Janet Wright, MD Guest: Rita Redberg, MD, MSc It is increasingly recognized that symptoms of heart disease are different for men and women. But it appears we are often slower to recognize heart disease in women, resulting in important distinctions in early treatment and outcomes. What are these differences, and how can we, as providers, help narrow this gender gap? Host Dr. Janet Wright welcomes Dr. Rita Redberg, professor of clinical medicine at the University of California, San Francisco, School of Medicine (UCSF), and director of women's cardiovascular services at the UCSF National Center for Excellence in Women's Health, for an important conversation about where can we do a better job of encouraging women to be aware of cardiac concerns specific to women? Dr. Redberg also shares her approach to evaluating female patients with symptoms that are suggestive but not definitive.

Host: Janet Wright, MD Guest: Robert Hendel, MD We're seeing some progress in cardiac imaging toward this lofty goal, thanks, in part, to a system that combines online technology with science-based selection criteria. The system will help us track patterns of care, provide insights into variations in care across the country and ensure that patients get the test that brings the most value to their care. Host Dr. Janet Wright probes the areas where we can further develop our goals for providing the most appropriate care with Dr. Robert Hendel, clinical cardiologist at Midwest Heart Specialists, based in suburbs west of Chicago, and professor of medicine at Rush University Medical College in Chicago. Dr. Hendel also explores trends in the appropriate ordering of tests within a practice versus those referring to that same practice.

Host: Jack Lewin, MD Guest: Mark McClellan, MD, PhD It takes a substantial measure of time, money and manpower to bring a new drug from the bench to the marketplace. One key aspect of this sequence is the drug approval process, overseen by the Food and Drug Administration (FDA). Host Dr. Jack Lewin welcomes Dr. Mark McClellan, director of the Engelberg Center for Health Care Reform at the Brookings Institution, former commissioner of the FDA and administrator of the Centers for Medicare and Medicaid Services, to discuss a range of issues within the FDA's approval process: from essential boosts in funding, to more transparency about conflicts of interest, to the imperative need for comprehensive, real-time surveillance of long-term drug outcomes, how can the agency devote more attention to each of these areas of concern?

Host: Jack Lewin, MD Guest: Alfred Bove, MD The next year promises to be an important one in health policy, in cardiology and in many other areas of medicine, as we set our sights on significant transformations across our health care system. What improvements can you anticipate that will enrich your practice environment and enhance the care you provide to your patients? Host Dr. Jack Lewin welcomes Dr. Alfred Bove, the newly installed president of the American College of Cardiology (ACC), for a look ahead at key points of emphasis during the coming year, from more rigorous quality measurements, to patient empowerment and value of care, to the broader issue of health care reform and the ACC's role in furthering the priorities of cardiologists and care providers across the entire health care spectrum.

Host: Doug Weaver, MD Guest: Don Poldermans, MD, PhD For patients undergoing major non-cardiac surgery, perioperative management often focuses on recognition and treatment of cardiac risk factors and disease. Dr. Don Poldermans, professor of medicine and head of perioperative cardiac care at Erasmus Medical Center in Rotterdam, the Netherlands, joins host Dr. Doug Weaver to explain how medical treatment and testing should factor into pre-operative preparations. How should you proceed with patients who you suspect possesses some risk, but displays no risk factors? Does aspirin complicate our approach to certain surgeries for certain patients?

Host: Doug Weaver, MD Guest: John A. Cairns, MD Long-term anticoagulation is often viewed as inconvenient and somewhat risky, even for patients with atrial fibrillation who are at elevated risk for stroke. Are these factors overshadowing the evidence that demonstrates the effectiveness of anticoagulant therapy in preventing stroke? Dr. John Cairns, professor of medicine in the division of cardiology at the University of British Columbia in Canada, talks with host Dr. Doug Weaver about stroke prevention for patients with atrial fibrillation. Is it safe to stop anticoagulant therapy in this population, and if so, when should this decision be considered?

Host: Doug Weaver, MD Guest: Spencer King, III, MD The performance of percutaneous coronary intervention (PCI) without a surgical backup has long produced controversy. In recent years, off-site PCI has become more common, and clinical evidence demonstrates comparable outcomes for on-site and off-site procedures. How does this shift allow us to serve a broader patient population? Will guidelines change to reflect some of these new findings? For a look at these questions and more, Dr. Spencer King, president of Saint Joseph's Heart and Vascular Institute in Atlanta, professor of medicine emeritus at Emory University School of Medicine, and a past president of the American College of Cardiology, joins host Dr. Doug Weaver.

Host: Jack Lewin, MD Guest: Chris Jennings It seems we all work so much these days, we might as well get our personal mail delivered at work, or maybe even consider a hide-a-bed for the office. That may seem a bit far-fetched, but many of us do receive our health insurance coverage from our place of employment, and an increasing percentage of us are participating in so-called wellness programs at work. As we anticipate reforms in our health care system, what is the future role of the employer and the workplace in this movement? For a look at these questions, host Dr. Jack Lewin welcomes Chris Jennings, president of Jennings Policy Strategies, a health policy and advocacy consulting firm based in Washington, DC, and a former White House Senior Health Care Advisor during the Clinton administration. Mr. Jennings also compares the current efforts toward health care reform to those of the early Clinton years, and outlines what he sees as the key reasons why the present climate will be more receptive

Host: Jack Lewin, MD Guest: Robert Hauser, MD Because new cardiac technologies are often rapidly integrated into clinical practice, we must be mindful that these innovations can contain a level of risk. Regrettably, we've seen examples of this before with previous generations of implantable cardioverter-defibrillators (ICD), and some experts say the latest advances in ICD technology could pose similar problems. Host Dr. Jack Lewin explores this issue with Dr. Robert Hauser, senior consulting cardiologist at the Minneapolis Heart Institute and a founder and past president of the Heart Rhythm Society.

Host: Janet Wright, MD Guest: Mark Hlatky, MD Does the patient with few cardiovascular risk factors who displays little, if any, sign of heart trouble warrant a coronary CT scan? For patients who may not be best suited for a CT scan, is the coronary calcium measurement a reasonable risk-assessment alternative? Dr. Mark Hlatky, professor of medicine and professor of health research and policy at Stanford University School of Medicine, explores a range of issues related to coronary CT angiography: how the rationale for ordering can change in the emergent setting versus the clinical scenario, its merits as a ‘triple rule-out' test, and the frequency with which patients undergoing a CT scan subsequently undergo angioplasty, bypass surgery, or another coronary procedure. Dr. Janet Wright hosts.

Host: Janet Wright, MD Guest: Mark Hlatky, MD Measuring precise risks in medicine can be a tricky proposition. Factoring risk into cost-benefit analyses can make the situation even less clear. In many ways, this is where we stand with coronary computed tomography angiograms: a scan can be immediately helpful in emergent circumstances, but at other points in the clinical care spectrum, the value of that scan is more difficult to estimate. Dr. Mark Hlatky, professor of medicine and professor of health research and policy at Stanford University School of Medicine, juxtaposes the medical aspects of these tests with the money we spend on them. Dr. Janet Wright hosts.

Host: Janet Wright, MD Guest: Bob Graboyes, PhD Is your practice one of the growing number of small healthcare businesses that cannot afford to provide health insurance for its employees? It’s a startling reality for many medical employers and employees, and more broadly, for the entire small business sector, which, in some states, is the collective employer for upwards of half of the uninsured population. As Dr. Bob Graboyes, senior healthcare advisor for the National Federation of Independent Business, tells host Dr. Janet Wright, with new proposals for restructuring health care coming in droves these days, meaningful healthcare legislation would be welcome news for small businesses around the country.

Host: Janet Wright, MD Guest: Gregory Demske How can individual practitioners interact with industry in a positive, lawful and commendable manner? Are there regulations we can and should put on companies in this arena which fund initiatives such as continuing medical education? Industry certainly plays a major role in health care today, but one wonders whether we are managing these relationships to the best of our abilities. Greg Demske, assistant inspector general for legal affairs in the Office of the Inspector General for the United States Department of Health and Human Services, joins host Dr. Janet Wright to discuss a range of issues related to the role of industry in health care, as well as potential conflicts of interest that may arise.

Host: Jack Lewin, MD Guest: Elliott Antman, MD New treatment guidelines regularly make headlines in medicine, recommending advances in our approach to care. In recent years, we have accelerated the speed at which we can update our guidelines and welcomed more global input into the process. Will these trends continue? Where else can we improve our process for authoring treatment guidelines? Host Dr. Jack Lewin explores these questions and more with Dr. Elliott Antman, professor of medicine at Harvard Medical School, and past chairman of the American College of Cardiology and American Heart Association’s Task Force on Practice Guidelines.