This post was authored by Robert Beekman, MD, FACC, chair-elect of the Adult Congenital and Pediatric Cardiology Section Leadership Council.

A new scientific statement recently published in Circulation points out that children and adults with congenital heart disease (CHD) need physical activity as much as individuals who do not have heart disease. The statement lays out the rationale for increased physical activity in persons with CHD and guidelines to help direct clinicians in their exercise recommendations.

The statement, authored by Patricia Longmuir, PhD, Hospital for Sick Children, Toronto, and colleagues, explains that there is almost no research on physical activity in populations with CHD, but there are clear physical and psychosocial benefits gained from increased physical activity in groups in which activity has been studied. With the possible exception of some individuals with rhythm disorders or severe LV outflow obstruction, there is no indication in the literature that recreational physical activity among CHD patients should be restricted. At the same time, many CHD patients are relatively sedentary and at risk for exercise intolerance, obesity and psychosocial morbidities. Encouraging patients to engage in appropriate levels of physical activity can improve their overall medical condition and quality of life.

However, health care professionals must tailor exercise recommendations to each patient’s clinical status. Competitive sports may or may not be appropriate, but few CHD patients have disease that significantly restricts physical activity with family and friends. Only a very limited number of diagnoses, such as risk of ventricular arrhythmia or severe LV outflow obstruction, necessitate a priori activity restrictions in CHD patients.

The authors also note that existing physical activity guidelines for CHD patients are seldom evidence-based, and are typically directed at adolescents and adults engaged in intensive training for competitive sports. Training for competitive activity typically involves near-maximal exertion, a very different scenario from recreational activities that typically involved 50 percent to 60 percent of maximal exertion.

The statement underscores the need for promoting physical activity in CHD patients, and because many clinicians are limited in both time and knowledge of exercise and exercise physiology, providers must be prepared to refer patients to physical activity professionals, similar to the way they routinely refer patients for dietary counseling or therapy.

Check out the Congenital Heart Defects condition center on CardioSmart.org for more information on the importance of heart healthy habits for CHD patients.

This post was authored by Payal Kohli, MD, fellow-in-training at the University of California San Francisco.

Despite a growth in female physicians, there are as few female cardiologists as ever. Statistics from ACC membership as well as nationwide censuses has shown that the percentage of women in cardiology has unchangingly remained within the 10-15 percent range over the last several years, dashing our hopes that this number may be slowly creeping upwards.

So what seems to be the problem? Why are women continuing to go into fields like pediatrics and dermatology, while turning their backs on exciting fields like cardiology and surgery?  And, there are fewer women cardiologists going into academics than men. Don’t we need more estrogen to balance out all that testosterone?

There is the obvious challenge that female cardiologists face: achieving a work-life balance that remains compatible with societal (and sometimes marital) expectations.  It is quite impossible to be doing stat echoes on call and taking STEMI call while being seven months pregnant (although I do have some amazing colleagues who somehow manage to pull it off), who also get home in time to put dinner on the table every evening. And the ever-growing length of cardiology fellowship, compared with other disciplines even within internal medicine, is not helping matters.  Granted, a fellowship doesn’t last forever, but it still continues to pose a significant stumbling block for many female medical residents who, if they are contemplating child-bearing, often have to wait until they are no longer on call every other night before even thinking about becoming pregnant.

There is also the less obvious barrier, which I think is much more paramount for many women – the lack of strong female role models.  At every major crossroad in our lives, we look to our mentors to help guide us and get a sneak preview into our own future.  If our specialty has only a small percentage of females, then who do we turn to for this type of guidance?

Now, don’t get me wrong, I have been privileged to have some amazing male mentors in my life, but there continues to be professional and personal challenges that are unique to women, which I cannot fully comprehend from interacting with my male mentors. The old saying goes, men are from Mars and women are from Venus!

As I stand at the crossroads of academic medicine and private practice, I feel much less confident making a decision, with the majority of my uncertainty coming from the lack of women within my field who I can look to see how it’s done.  Unfortunately, I haven’t had the opportunity to work some of the amazing women in our field, like JoAnne Foody, MD, FACC, or Roxanna Mehran, MD, FACC, who have somehow overcome all barriers and demonstrated that we as women, can actually have it all – family, career, academic cardiology and even fashion (in case you hadn’t noticed, they are both very sharp dressers).  They do give me hope that it is possible.

The question becomes, what are we doing to try to fix it?  Personally, I have decided to take a more active role as a preceptor for young medical students and residents, encouraging more of them to become cardiologists.  I have also joined the ACC’s Women in Cardiology Council and hope to promote awareness and networking opportunities amongst female trainees. But else what do you think we can do to increase the number of women in cardiology and increase the opportunities for women to interact with other women?

*A version of this article also ran in the May issue of CardioSource WorldNews.

Not so subtle subliminal messaging is a common advertising and political foil with which we are all familiar. Inundated by messaging “below the surface” of the proffered material, we find it mostly harmless, sometimes comical and occasionally wildly satirical.  I have often wondered why, when drinking expensive Tequila, I don’t seem suave and debonair like the guy in the commercial… but I digress.

When used in other arenas, it can very effectively sway public opinion, influence the course of debate and even shape governmental policy.

In that vein, I share with you a New York Times blog that appeared earlier this week related to the relationship between pharmaceutical companies and physicians. The article states that even the casual relationship is viewed as beneficial by the pharmaceutical and device industry, each encounter subliminally altering our behavior. This is without question true, irrefutable education and social sciences research serving as proof, demonstrating unequivocally such an effect exists. You see, it’s not the pen with the name on it that induces a particular product usage; it’s the smile, the brief friendly chat and the bagels that engender positive feelings and subtly influence behavior.

In a similar way, albeit perhaps unintended, articles such as this have a subliminal effect on legislators, on patients and on the public. The “below the surface” message is not positive but sinister; one of greed, of excess, of influence peddling. And with each, we lose just a bit of our most powerful weapon, the non-medical world’s overwhelmingly positive impression of our trustworthiness and altruism. For you see, each time we lose a bit of that positive impression, with each little chink in the armor,  it becomes easier for those outside medicine to paint us with a broad brush, to convince others we all stent phantom lesions, to imply “inappropriate” really means “did it for the money” and to have that messaging believed.

As health care payment reform convulses forward, as value moves to center stage, as our David faces the hospital and payer Goliath, we can ill afford to dull the polished shield of trustworthiness or blunt the sharpened sword of altruism.

I would like to hear your thoughts.

This post was authored by Bonnie H. Weiner, MD, FACC, board chair and chief medical officer of ACE.

The debate over the Accreditation for Cardiovascular Excellence (ACE) process has shifted significantly, changing cath lab accreditation discussions from “should we?” to “when will we?” I am encouraged by the data generated from cath labs that are accredited by ACE, pushing the swing of the pendulum toward better documentation and improved patient care that is driven by clinical guidelines and appropriate use criteria (AUC).

The study, “Effect of ACE Catheterization Laboratory Accreditation on Hospital NCDR CathPCI Registry Reports,” was presented at the Society for Cardiac Angiography and Interventions (SCAI) 2013 Scientific Sessions, and assessed data from nine ACE accredited cath labs by comparing CathPCI Registry reports from their initial applications, at the beginning of the ACE accreditation process, to findings from two recent quarterly reports.  This preliminary data showed that, as a result of improved documentation, selected metrics in clinical records were more likely to show that angioplasty and stenting patients at these institutions met high-risk criteria, as determined by increased medication use, a greater number of high risk stress tests and the ability to evaluate a greater number of patients by AUC.

Several trends were noted in the findings. There was a clear trend (p=0.06) towards a higher percentage of STEMI patients treated within six hours of symptom onset. In patients who had percutaneous coronary intervention, the percentage with a fractional flow reserve determination 0.75 increased (p=0.003), as did the success rate among stented lesions (p<0.03) after accreditation.

Our clients tell us they believe in the ACE process.  “There is rigor in it.  It either will validate what you're doing as a standard of care in your cardiac cath lab or it will be an educational process,” said one ACE accreditation client. I encourage you to hop on the pendulum and join ACE in its quality journey.

This post was authored by Morton J. Kern, MD, FACC, professor of medicine and associate chief of cardiology at the University California Irvine.

In the current digital age, groups of interested individuals are now able to communicate in unique ways that weren’t previously available except at large in-person meetings.  Recently a listserv comprised of cardiac cath lab experts generated several interesting conversations regarding simple questions which evolved into complex, controversial and highly informative exchanges of opinion, facts, conventional and unconventional wisdom.  We have published several of these “Conversations in Cardiology” in Cath Lab Digest, Catheterization and Cardiovascular Interventions, and now on CardioSource.org.   

Recently, Peter Block, MD, FACC, associate editor of Science and Quality Video News on CardioSource.org, asked, “What are the antianginals that a PCI operator can list to support moving ahead after ‘maximal medical therapy’?”  While working on a quality review he noticed the appropriate use criteria (AUC) for PCI state that patients need to be on “two classes of antianginal medications” before intervention. The AUC criteria carefully define “two classes of antianginals.” Does this mean that one always needs two of the four true antianginal meds – calcium channel blockers, beta blockers, nitrates, or ranolazine – to be in compliance with the AUC?  If a cardiologist reports his patient received statins, ACEIs and ARBs as well, does this constitute maximal medical therapy?  While there is evidence that statins and ACEs may decrease angina, is this approach in keeping with the spirit of the AUC?

This simple question blossomed into a large and wide ranging discussion among the distinguished contributors that questioned whether any medication that improved the patient’s ischemic symptoms should be considered ‘anti-ischemic’ medication, as well as the following:  What was the basis for or studies used by the writing committee to form their particular recommendations? Are the AUC recommendations in keeping with common sense and daily accepted practice?  Several of the contributors, including members of the writing groups, chimed in and pointedly enlightened us on their deliberations of these issues.  It was a truly enlightening discussion.

At the end of the day, the ultimate value of exchanging these views among ourselves and now to the greater cardiology community is the understanding of the utility and limitations of rules, recommendations, guidelines, and how they contribute to the better care of our patients.  

I hope you find the “Conversations in Cardiology: How do the AUC Define Antianginal Medications?” as interesting as my colleagues and I did.  

Also, read more about a recent AUC usability survey that identified benefits and opportunities for improvement in the spring issue of Cardiology magazine.

This post was authored by Chittur A. Sivaram, MD, FACC, chair of the ACC Fellowship Training and Workforce Committee, and chair of the ABIM Competency-Based Pilot in Cardiology-Internal Medicine.

Many new hot button issues concerning the delivery of cardiovascular care are slowly finding their way into the curriculum for future cardiovascular professionals. This is inevitable since academic programs and their curriculum need to adapt to the changing health care needs and priorities of the populations they serve.  One such emerging area of emphasis in graduate medical education is training in areas of quality, safety and cost-effective care.

The call for enhanced focus on quality and safety began with two important publications: “To Err is Human” and “The Quality Chasm,” both from the Institute of Medicine (IOM). The Accreditation Council on Graduate Medical Education (ACGME) subsequently incorporated specific expectations regarding quality and safety education and competencies in their institutional as well as program-specific requirements.  These requirements apply both to internal medicine residency as well as cardiovascular fellowships.  Fellowship training is now required to prepare a cardiovascular specialist to advocate for quality, work within inter-professional teams, ensure safety in patient care, identify system errors and engage in effective transitions of care. In addition, ACGME’s annual fellow and faculty surveys now include questions related to education in the areas of safety, quality and inter-professional team based care. Compliance with such requirements is essential for continued accreditation of fellowship programs.

These new changes have placed unique responsibilities on cardiovascular fellowship training programs, and the programs are responding slowly, but deliberately. Two potential pathways exist for educating fellows in the areas of quality and safety. One option is experiential learning through actual participation by fellows in their own medical centers’ quality and safety operations. Many training programs are modeling processes of cardiovascular operations after the safety checklist principles already adopted in the surgical suites. Such checklists can be easily implemented with robust involvement by the fellows in many areas where patient care is delivered e.g. cardiac catheterization lab, echocardiography lab and EP lab. In my institution, such checklists have also incorporated another highly topical item – appropriate use criteria (AUC) for procedures. Moreover, the checklists are called out with the collaboration from nursing and other ancillary laboratory staff, thus allowing the fellows the experience of harmonious functioning within an inter-professional team. Fellowship training programs are also adapting their morbidity-mortality conferences to serve as opportunities for fellows to identify and resolve systems issues. Participation in ACC’s registries such as the PINNACLE Registry® also allows fellows to engage in practice-based learning and improvement.

The second option is formal instruction in quality and safety. Several training programs are slowly starting to make use of online resources such as the Institute for Healthcare Improvement (IHI) Open School, a free service that offers several training modules. The superiority of experiential learning over formal instruction alone cannot be overemphasized.

Now more than ever is the time to focus on quality and safety since cardiovascular training programs are rapidly aligning their structure to prepare our fellows to deliver patient care as defined by the IOM – safely, effectively, timely, equitably and efficiently with a patient-centered focus.
 

Over the last several years, there has been a plethora of discussion swirling around the appropriate use criteria (AUC); some of it reasoned but most, simply vitriolic. I have led projects attempting to use the AUC to extract data from electronic health records for quality improvement purposes, been witness to efforts to use the AUC in place of radiology benefits managers, and participated in numerous conversations related to the terms used to describe the categories and even the techniques employed to organize the classification for each scenario discussed. 

I have learned a tremendous amount… but mostly I’ve learned that we really don’t know squat about what we are doing!

1. Medically, we don’t really know the correct treatment most of the time.  Although it might seem obvious to us in reflection, it is certainly not clear to the public that the great majority of what we do is rooted in best guess, we think it will work, expert consensus type evidence, not in “proven fact.”  More significantly, we have a history of being wrong, occasionally famously.  Examples such as “bypass surgery will prevent heart attack”, “antibiotics make a difference in otitis media”, and “frequent stress testing helps predict outcome” dot our historical landscape.  There are numerous others.  They all have in common the fact that we thought we knew what we were doing when we didn’t.
2. We do a very poor job of keeping ourselves up to date as to the changes in the current practice of medicine.  The reasons for this appear to be multiple; mostly we simply do not have time. We seem to spend far more time as a profession publishing cutting edge research than publishing practical consensus documents about what physicians should do in the care of their patients.
3. We resist change that has a negative impact on our belief system.  Let’s face it, it is human nature to protest being told “you’re doing it wrong” (but I would point out we do not mind being told “to do more”).  The recent discussion regarding angioplasty is an excellent example of that.  No interventional cardiologist wants to be told they are doing too many angioplasties or that they are unnecessary, however virtually every interventional cardiologist would like to be told “you can do twice as many as you are doing now and it is medically justified.”  
4. We have a vested interest in enhancing our incomes.  Everybody does.  In the environment of a reduced physician fee schedule it is a difficult sell to convince a practicing physician to reduce their utilization (which they universally feel is appropriate) in the absence of good information. 

So what shall we do, as individuals and as an organization? 

1. We should encourage appropriate, evidence based care in as many situations as we can.  It is incumbent that organizations such as the ACC lead in developing those documents and standards on a timely basis and in a fashion that is easily available to all.  This might also mean that we admit we are not sure as to what the best strategy is in many circumstances. Transparency demands that admission of truth.
2. We should encourage a conservative approach in those areas that we do not know the correct answer. The concept of “less is more” certainly applies here. 
   
3. We should, individually and as an organization, diligently work to continuously educate ourselves not only by maintaining relationship with  the current literature but also by striving to understand those far more basic principles that are often left behind.  The Million Hearts initiative is an excellent example of the fact that we need to provide the most fundamental level of education to our patients.  This means that we must embrace those fundamental tenets of care, basic though they may be, and strive to achieve them.  

Finally we must be receptive and embrace change, even if it is uncomfortable for us personally, in order to provide that which is the best for our patients. Self-sacrifice is difficult, admitting you do not know is uncomfortable and recognizing that change occurs, inevitable. 

In doing so, we strive to do what is best for our patients and our country. 

I recently traveled to Israel for the 60th Anniversary Conference of the Israel Heart Society (IHS) in Jerusalem. The two-day conference gathered about 1,300 cardiologists from around the globe, including world-renowned leaders like Douglas Zipes, MD, MACC, and Eugene Braunwald, MD, MACC.

While there, I co-chaired the ACC/IHS Joint Session with Chaim Lotan, MD, FACC, president of IHS, and Basil Lewis, MD, FACC, governor of the ACC Israel Chapter. Updates were given on the management of aortic dissection, pulmonary embolism, clinical trials in PCI vs. CABG, mitral regurgitation, and the role of the autonomic nervous system in arrhythmogenesis presented by stellar ACC faculty from the U.S.: Kim Eagle, MD, MACC; Samuel Goldhaber, MD, FACC; Craig Smith, MD, FACC; Robert A. Levine, MD, FACC; and Douglas Zipes, MD, MACC.

I also had the unique honor of meeting with Shimon Peres, president of Israel and recipient of the Nobel Peace Prize. We had a discussion on democracy following a visit from U.S. Secretary of Defense, Chuck Hagel who our group was able to acknowledge.

The growth of cardiac services in Israel is nothing short of extraordinary. In an interview with The Jerusalem Post, I noted that Israeli cardiologists have had great bench-to-bedside developments, and that Israel is one of the safest parts of the world to have a heart attack. The country has also always had a knack for cardiovascular innovation and at the conference they commemorated three postage stamps featuring these innovations: a stent, an implantable defibrillator, and a percutaneous heart valve. The Director of Israel’s Philatelic Service, Yaron Razon, who unveiled the stamps, noted “the new stamp series is meant to increase Israeli awareness of the country’s world-class achievements in combating heart disease.” (CV stamps appear to be a growing trend, since the Republic of San Marino also recently issued a stamp to raise awareness of cardiovascular disease.)

Overall, it was an exciting trip for me, and a wonderful opportunity for the ACC to continue to foster relationships globally. To date, the ACC’s Israeli Chapter has more than 60 FACC’s and growing. Earlier this year at the ACC’s annual Middle East Conference as part of ACC.13, we discussed the importance of showing the world that cardiologists can transcend divisive issues and come together to benefit all. This meeting provided another opportunity for us to sit at the same table and discuss hearts – leaving politics at the door.

You can see more photos from my trip on ACC’s Facebook page. Click on the photo album “ACC Around the World.”

Pictured: Douglas Zipes, MD, MACC, and John Gordon Harold, MD, MACC while visiting Israel President Shimon Peres.

This post was authored by Michael S. Emery, MD, FACC, co-chair-elect of the ACC’s Sports and Exercise Cardiology Section Leadership Council.

On Monday, April 15, tragedy struck one of the oldest and most revered marathons in the world – the Boston Marathon. I was there as a medical volunteer in the ICU section at the finish line. It started off as a beautiful day, which was evident by the rather light use of our medical services (whereas the previous year, heat was a major factor). This was my first time volunteering, and I was there not just to help but to learn and experience marathon medicine at its finest.

At 2:50 p.m., while caring for a dehydrated athlete in the medical tent, I heard and felt the two explosions. The nurse helping me asked if the sound was thunder, but the sky was clear. I quickly began to realize that something bad had just happened and even before we were informed of anything, I immediately sent a text message to my wife letting her know that I was alright. The medical tent was about 100 yards from the finish line blast. Word came quickly that a bomb had exploded at the finish line and we were instructed to move all athletes to one end of the tent, to start hanging IV bags, and for all physicians to head to the finish line area.

Several of us then sprinted out of the tent towards the finish line. One of the first things I saw was the now famous spectator missing both legs with bones protruding being wheeled off the sidewalk towards the medical tent. The carnage, blood, smoke and injuries were a visual image that I will never forget.  One of the first sites I went to was a local running store located at the finish line, as I heard there were injured people inside. At that time, I had no idea whether the bomb had exploded inside a building or outside, nor did I know of the potential for secondary devices. It was smoky inside the building but there did not appear to be any more injured persons inside, so I made my way back to the sidewalk outside.

Once outside, the sidewalk was now covered in blood and there was so much, it was actually pooling in spots. There were injured bodies everywhere with multiple Boston Athletic Association physicians, bystanders, and EMS personnel doing what they could. Victims that could be put into wheelchairs were done so with volunteers wheeling them to the medical tent. Others were performing CPR, holding pressure on wounds, stabilizing compound fractures, applying tourniquets and as quickly as possible loading victims into waiting ambulances or wheelchairs.

While it was chaotic, there was a definite sense of purpose to rapidly stabilize and clear that sidewalk. As we loaded people into ambulances, the police were trying to get us out of the area as quickly as possible since there was a concern of secondary devices. At the time, I was not overly concerned about my own safety as adrenaline and my medical training took over. Even though I’m a cardiologist and not trained to handle trauma, it really was about the basics of care – stabilize and evacuate!

As I made my way back to the medical tent after helping to clear that initial blast site, the tent had turned into a triage center with areas setup for level 1s and level 2s. It didn’t take long to clear the medical tent of victims before they started dismissing volunteers from the tent so the police could sweep it.
 
Our next concern was for the several thousands of runners who did not make it to the finish line. We had worried about their medical needs with regards to the more typical marathon-related injuries. A small group of us, led by the marathon medical directors, made our way to the Boston Common where the runners on the course were instructed to meet. However, by that time I think most had found family and did not want to be in the area.

Obviously, marathon medicine took a back seat to mass causality that dreadful day. As a sports cardiologist, I spend a lot of my time assessing athletes and in particular answering questions about potential cardiac complications related to sports and the risks of sudden cardiac death. That all became irrelevant that afternoon. I am so very thankful to all of the physician and support staff that were on hand that day to respond to this tragedy. There were several other cardiologists, sports medicine physicians, emergency medicine physicians, residents, and fellows-in-training in the tent who put fear aside to run towards “ground zero.” While there were three fatalities and 260+ causalities with many limbs lost, undoubtedly, our combined and rapid response saved lives that day. I am proud to call all of them colleagues and friends.

Beyond the care for the athletes and victims, the emotional support that day and beyond has been a testament to the human spirit. I am not from Boston, do not have any family connections there, never trained or went to school there, and have never run the Boston Marathon; but the city, the Boston Marathon and Patriot’s Days will forever be a part of me. Next year, you can find me volunteering again at that finish line caring for the athletes! #bostonstrong

There have been some great conversations lately on the BOG listserv. I am always amazed by how much we can learn from one another through collaboration and sharing of ideas.

The question was raised if the world of cardiology is going flat, and an example of the number of STEMI programs being higher than the true demand for STEMI care was given. In my opinion, this is driving to the core of the issues we will face in the next several years.

The basis of the "competition" for STEMI and “market share” in general is unregulated fee for service medical care, the business of medicine.  In an environment in which there was "plenty of fee" being paid, the traditional model of care was sufficient. Attempts at capitation and other managed care models were in general frowned upon and in some cases, derided openly.

As more downward reimbursement pressure has been placed on the health care sector in general and hospitals and providers specifically, a "peeling back of the layers" of civility has occurred, with an unfettered drive to garner more service, the goal is simply to acquire more fee, usually with thinly veiled lip service to "quality" or "access." Most systems are poorly organized, each physical plant viewed as a stand-alone institution in which the most common metric is comparative sales. These systems are simply not able to move to a regional model due to the institutional coefficient of inertia.

Five years ago, all of our practices competed for the top trainees, often signing prize recruits 18 months before they finished training. Our training programs bought in, generating board after board, subspecialty after subspecialty, perversely driven by a fifty year old doctrine that “medical care was about the science,” the thinking that founded the National Institutes of Health and was hugely successful in bringing medicine from the barber shop to the bench. Those training programs are not wrong in the scientific sense, but we are no longer discussing that scientific underpinning. We are now, as they say in Texas, "talkin' bidness."

Directly- and indirectly-related problems now abound.  PCP's doing echo on their office desk, PCI programs on every corner, spiraling costs of insurance so insurance companies can be profitable, the unusual situation of over 450 EHR vendors, the lack of jobs for many of our new trainees.

I believe we are seeing the bifurcation of U.S. medicine; the distinction into the scientific complex and that part that delivers care. I sense we are standing at the front door of the most significant change in U.S. healthcare since penicillin. I anticipate we are witness to, and living, the conceptual shift of medicine from a commodity to medicine as a right of citizenship. And with it will come monumental shifts in our lives. Other less advantaged countries made that choice outright. Some had it thrust upon them by world circumstance. We stand at our Rubicon by virtue of bloated cost, of hidden expense, of lack of perceived value to the country.

And we must respond. The question is how.