Heart to Heart
Kalb, Claudia, Newsweek
Byline: Claudia Kalb
Four leading cardiologists open up about how to combat America's No. 1 killer.
For all the strides we've made against heart disease, it still accounts for 26 percent of all deaths in the U.S. This year alone, it will cost $316 billion in health care, medications, and lost productivity. A push for better preventive care hasn't solved the problem. And advances in the field aren't being incorporated into practice routinely or quickly enough. NEWSWEEK gathered four cardiologists to discuss the future of the field. Senior writer Claudia Kalb spoke with Dr. Elizabeth Nabel, president of Brigham & Women's Hospital and former director of the National Heart Lung and Blood Institute; Dr. Paul Ridker, director of the Center for Cardiovascular Disease Prevention at Brigham & Women's Hospital; Dr. Eric Topol, director of the Scripps Translational Science Institute and chief medical officer of the West Wireless Health Institute; and Dr. Clyde Yancy, president of the American Heart Association and medical director of the Baylor Heart and Vascular Institute. Excerpts:
Why isn't prevention working? Or is it working and, if so, where? Yancy: What we've seen over the last four decades has been a steady reduction in deaths due to heart disease and stroke, especially in the last 10 years. This is clearly a function of better systems of care, new devices and technologies. But there's some very provocative research that demonstrates that about half of the reduction has in fact been due to prevention strategies. The real question is, how can we do more with prevention? It's not sexy, it doesn't generate a lot of dollars, but it certainly generates some benefits that may be far-reaching and real.
Nabel: We had a pretty steady rise in heart-disease rates up until about 1965 to 1970 or so. Since then, there's been a really marked steady decline. So instead of men dying in their 50s and 60s in the 1940s, '50s and '60s, people are now dying of heart disease in their 80s and 90s. As Clyde alluded to, studies have suggested that about half of that steady decline is due to prevention measures and about half to improved medications and technology improvements, such as bypass surgery and valve replacement.
Topol: I think the point has been well made that there's been progress. But I think it's worth emphasizing that heart disease is still the leading cause of death and disability. Beyond the things that have already been cited, part of the problem is we're not able to characterize things very well for prevention. For example, [high] blood pressure, which is notoriously underdiagnosed and inadequately managed--we rely on spot blood-pressure checks rather than continuous assessment, which is now possible in the era of wireless medicine. That's something we can do a much better job on.
What are the challenges we're up against? Ridker: We know a lot more about the root causes of heart disease than we did 20 years ago. But it's still about going to the gym, exercising regularly, throwing out the cigarettes, and changing lifestyle.
Yancy: We're beginning to understand that there's a certain ecology of health that may predispose [you to] disease in ways which we didn't consider before. The density of fast-food restaurants in certain neighborhoods, the availability of recreation, the ability to purchase fresh fruits and vegetables. I think we have to consider the totality of everything--not just risk factors and genetics, but other very intriguing considerations.
How can we encourage prevention? Nabel: One of the pieces that I found to be quite difficult and frustrating from a policy perspective is the notion of behavioral change. We can put into place all sorts of guidelines [and] recommendations, but at the end of the day, unless that body of knowledge is fully implemented, that knowledge goes nowhere. Policymakers have responsibility for this; the physician community has a big responsibility for this. …