This post is authored by Michael S. Emery, MD, FACC, member of the ACC’s Sports and Exercise Section.

Recently a diverse group of cardiologists, sports medicine physicians, pediatricians, athletic trainers, patient families, representatives of college and professional sports, researchers, military physicians, and others met for the first Sports Cardiology Think Tank, followed by the first Sports Cardiology Summit.

More than 200 participants joined the summit, a lively two-day educational forum that included interactive discussions of case studies; a debate about adding ECGs to screening; presentations about differences in athletes based on sports played, gender, age; and a presentation by the family of a 9-year-old boy who died from anomalous origination of a coronary artery from the opposite sinus after two years of failure to get an accurate diagnosis. It was truly a dynamic meeting, which I was honored to be a part of.

During the summit, I spoke on performance enhancing drugs (PEDs) and their cardiovascular effects and risks. This is a hot topic since there continues to be a lot of buzz in the media about PEDs, especially in baseball and cycling (particularly with the recent news that Lance Armstrong has been stripped of his seven Tour de France titles and has been banned for life).

It is highly probable that this topic is even more prevalent than reported. However, beyond the legal implications and questions of ethics, the question becomes what are cardiovascular effects and risks of using PEDs?

Unfortunately, not a lot is known as studies are typically small, observational studies, or case reports. The most common PEDs are anabolic-androgenic steroids (AAS), often taking multiple as a “stack” at supraphysiological doses for prolonged periods in “cycles.” Others include human growth hormone, erythropoietin (EPO) and blood doping, which all have even less data available. Cardiovascular effects can include systolic dysfunction, diastolic dysfunction, accelerated atherosclerosis, myocardial infarction, arrhythmias, hypertension and dyslipidemia (particularly low HDL).

Over the counter supplements are another diverse group of “performance enhancers” legal in the U.S. but are not controlled by the U.S. Food and Drug Administration (FDA) and may contain a number of different substances with varying names.  Knowing what an athlete may be ingesting with these and what role they may play with regards to any cardiovascular side effects is often difficult.

We as cardiologists also need to be mindful of the use of prescription medications for athletes as some are prohibited from use in competitive sports.

The bottom line is more data is needed but since studies are difficult due to the “black market/underground nature,” it is almost impossible to have a controlled study. This is indeed a conundrum that my colleagues and I are faced with, which we are striving to overcome.

For more information about the ACC’s Sports and Exercise Cardiology Council and Section, click here.  

Over the past few weeks the ACC has expanded its international reach even further and has launched the Spain Chapter, the Argentina Chapter and the Lebanon Chapter, which makes the international chapter count 23 total. We have also passed the 6,000 international member mark, which is an amazing accomplishment for the College. These successes are truly a testament to the efforts the College has put forward to focus on expanding internationally. We have much to learn from one another and our new international members will only help in these efforts.

Last month I attended the Brazilian Society of Cardiology (SBC) Congress in Recife, Brazil.  While in Recife I had the privilege of officially signing the agreement for the Second Annual ACC Cardiovascular Conference in Brazil featuring Valentin Fuster, MD, PhD, MACC, to take place in 2013. Anticipated attendance at this event is expected to exceed 2,500 cardiologists from across Latin America. You can see pictures of the signing ceremony with SBC President Jadelson Andrade, MD, FACC, here.

Earlier this month I traveled to Argentina where Jagat Narula, MD, FACC, and I attended the Argentine Society’s Annual Congress of Cardiology and participated in a joint session titled "What Is the Future of Cardiology?" The ACC Argentina Chapter was officially launched and Carlos Barrero, MD, FACC, was named as the new ACC Argentina Chapter Governor. Thank you Drs. Cesar Belziti and Walter Stoerman for your historical and important collaboration in making the Argentina Chapter a reality. Be sure to check out photos from the launch here.

Next up, BOG Chair Dipti Itchhaporia, MD, FACC traveled to Spain for the Spanish Society of Cardiology’s Annual Congress in Sevilla. Vicente Bertomeu, MD, FACC, president of the Spanish Society of Cardiology announced the ACC Spain Chapter at the opening ceremony.  Check out a video posted here where Dr. Bertomeu and Dr. Itchhaporia announce the Spain Chapter. We are truly excited for this new endeavor!

Also, just last week I was in my home country of Lebanon to officially launch ACC’s Lebanon Chapter with Samir Arnaout, MD, FACC, president of the Lebanese Society of Cardiology. This of course holds a special place in my heart since I grew up in Lebanon and most of my family still resides there. You can view photos from the event here. I was surprised and honored to receive two awards during my trip, an award from the Order of Physicians, and a special recognition Award: the National Order of the Cedar, Knight, given by the President of Lebanon General Michel Suleiman. It was such a great honor and a moving experience; we will continue to work with the chapter to advance cardiovascular health in Lebanon and the larger Middle East region.

I also traveled to Beijing, China for the 23rd Annual Great Wall International Congress of Cardiology meeting, which hosted the first-ever patient education event. The meeting, chaired by Professor Dayi Hu, MD, FACC, was an resounding success, with over 13,000 attendees, and featured a full day of joint sessions with the ACC. CardioSmart was an important part of the activities and our patient education materials were translated to Mandarin to teach attendees about exercise, smoking cessation, blood pressure and cholesterol management. An important message from the event focused on encouraging people to walk 10,000 steps a day since exercise is the best medicine. You can view photos from the event here.

In addition to our first foray internationally in China, this fall CardioSmart has really stepped up its community outreach events. Spirit of the Heart (which I had the pleasure of kicking-off in Houston and you can read about it in a previous blog post here) took place in Houston, Dallas and Austin, TX and will be coming to Harlem, NY in December, and Oakland, CA in March. This event touches hundreds of patients who might not have the resources available to check their numbers and to learn about cardiovascular health. CardioSmart also attended a NASCAR event in Charlotte a few weeks ago where hundreds of fans learned more about heart healthy lifestyles and watched CPR demos given by our NC Chapter.

These events are just a few of the activities the ACC has embarked on recently that are affecting the lives of patients nationally and internationally. Of course there is much more to come as we continue to expand and work with our partners. The sky truly is the limit.

Don’t forget to follow me on Twitter @WilliamZoghbi as well as the ACC’s account @ACCinTouch as they use #ACCIntl for the latest international news from the College. Also don’t miss all of the photos from the chapter launches on ACC’s Facebook page.

This post was authored by Mike Tempelhof, MD, cardiovascular disease fellow, Northwestern University Medical Center.

Beginning January 2013, the Affordable Care Act (ACA), the Budget Control Act of 2011, the Sustainable Growth Rate (SGR) formula and additional health care reform programs as proposed by the Center for Medicare and Medicaid Services (CMS) will be implemented. Unless modified, several provisions within these policies will have a detrimental effect on the quality of patient care, physician autonomy, reimbursement and the future of medicine in America. It is imperative that health care practitioners have an appreciation of the critical health care policy issues and how their implementation will limit our ability to continue to provide high-quality, high-value health care in the future.

If implemented, the SGR formula will cut Medicare physician payments by 28 percent starting Jan. 1, 2013, and budget sequestration targets as defined in the 2011 Budget Control Act will cut Medicare reimbursement annually by an additional 2 percent. The combined 30 percent reduction in physician reimbursement will limit critical investments in diagnostic and therapeutic equipment, ultimately threatening Medicare beneficiaries’ access to quality care. These reductions in Medicare funding will have a dramatic impact on Graduate Medical Education (GME) and research funding, which will likely reduce the number of trainee positions and de-incentivize trainees from pursing specialized medical training. At a time of growing physician shortages in conjunction with an aging population, these cuts would have a significant impact on the quality and availability of US health care in the future. Finally, sequestration is estimated to reduce federal funding of all scientific research by 8.4 percent. Any reduction to the already resource deficient medical research sector will further limit the innovation and development of new medical therapies that our medical system depends on. Such setbacks would stifle the recent gains made in the morbidity and mortality associated with cardiovascular disease.

The ACC is advocating to repeal the SGR, and stabilize sequestration payments until a new reimbursement system is in place. Juxtaposed to the current volume-based payment system, the ACC is strongly advocating for payment models that align payment incentives with evidence-based improvements in health care quality and outcomes. With a proactive approach to health care reform, the ACC has implemented quality improvement tools including clinical data base registries (NCDR, PINNACLE) and appropriate use criteria into clinical practice. This practice model affords the ACC the ability to hold cardiologists accountable for reaching benchmarks in standard of care. Evidence suggests that an evidence-based, incentive payment program modeled on similar quality improvement tools will improve the quality and cost-utility of health care in America. Therefore, the ACC strongly advocates for a quality and not volume-based payment system that aligns payment incentives with evidence-based medicine.

As our health care system evolves at this time of momentous reform, cardiologists and all practitioners must remain the patient’s strongest advocate by continuing to practice medicine with beneficence; delivering effective and efficient health care to all Americans. Collectively, we must act now to repeal the SGR and the sequestration cuts scheduled for January 2013. We must advocate for a meaningful medical liability reform and a sustainable payment system that incentivizes high-quality health care. Choosing not to act, would be the greatest risk to the future our patient’s lives and quality of their care.

By: Judy Tingley, MPH, RN, member of the ACC’s Clinical Quality Committee.

The Centers for Medicare and Medicaid Services (CMS) readmission payment penalties went into effect on Oct. 1.  Mandated by the Patient Protection and Affordable Care Act, this quality improvement initiative imposes financial penalties on more than 2,200 hospitals with Medicare readmission rates above the national averages.  The unintended consequence of these penalties is yet to be determined.

This new crackdown will have the greatest impact on the “safety net” hospitals that treat our poorest patients.  Current studies demonstrate that much of the variance in readmissions is due to factors beyond the hospital's control.  Many of these community hospitals have limited resources, antiquated medical records systems, serve late presenting and/or underinsured clients, and are at greatest risk for financially failing.  This reality reaffirms that quality metrics identification and measuring outcomes has never been more important.  As we move toward data driven reimbursement models, it is critical that the implementation of “patient centric quality metrics” does not get lost in the quagmire of financial and regulatory demands.  Quality needs to remain the focus of “quality metrics.” 

Of late, safety measure techniques used by the airline industry have been meaningfully translated to health care delivery systems.  Pre-operative checklists (modeled after pre-flight checklists) have significantly improved patient safety.  Just as regular and consistent communication between the crew and air traffic control helps thwart potential problems and keep the skies friendly, so should regulators, payers, hospitals, patients and practitioners communicate to keep patient safety at the forefront.  If not, we should brace for the impact of the unintended consequences of making worse a system that is very much in need of patient centric reform.  

Our population is changing and if you’ve seen one patient, you’ve seen one patient.  There will never be a one-size-fits-all model to eliminate readmission.  Therefore, the impact of demographic characteristics, co-morbidities, socioeconomic parameters, post-discharge environmental factors and regional health care delivery disparities all must be considered in strategically planning meaningful cost efficient care.  As our patient population ages the economic impact of this reality is yet to be seen:

• Half of older women 75+ live alone
• Persons reaching age 65 have an average life expectancy of 18.1 additional years
• The 85+ population is projected to increase to 9.6 million in 2030
  

Improved efficiency and reduction in avoidable readmissions is imperative.  Methods to better identify patients at risk for readmission, reduction of hospital complications, improvement in transitional care and overall communication between providers and patients are important ways of improving quality care.

There remains much work to be done in order to transform today’s health care into the efficient quality centric delivery system needed for the future.  The ACC has taken the lead in providing tools to help practitioners review and provide a transition of care plan.  Specifically, Hospital to Home (H2H) is a national quality improvement initiative developed to help hospitals reduce all-cause readmissions among patients with heart failure or acute myocardial infarction.  As health care providers, we must continue striving toward a coordinated multi-disciplinary strategy to effectively address improving quality of care in a fiscally responsible way.  If we fail, brace for impact!

This post is authored by Gary Puckrein, PhD, president and chief executive officer of the National Minority Quality Forum.

Physicians and the medical community have reached a fork in the road: we need to document that quality and reduced costs are related. By doing so, we hope to offer policymakers a new framework in which to measure the value of medicine. The conjectures:

• An avoidable mortality index can be an indicator of unnecessary acute events (disease, hospitalizations, disability and death) in a population. Such an index may have utility in localizing the performance of our health care system, thus enabling the investigation of gaps in outcomes of care. 
• There are signals that avoidable acute events are non-random occurrences. There is a possibility that they manifest at predictable frequencies within clinical and geographic sub-populations, and are sentinels of health care and health status disparities.
• Unnecessary acute events have financial implications. At least one study found that 36% of diabetes-related hospitalizations were avoidable. If that percentage holds true for Medicare beneficiaries, the savings could well be over $10 billion per year.
• By reducing unnecessary acute events, we may be able to establish an association between improved quality and bending the cost curve, thereby offering a counterpoint to those who believe reducing provider reimbursements is a desirable cost savings device.
  

The American College of Cardiology, the National Minority Quality Forum (NMQF), and the American Association of Clinical Endocrinologists have joined forces to put our conjectures to the test and have formed the CardioMetabolic Health Alliance. The objective of the Alliance is to improve cardiometabolic risk factor control in diverse populations, including high blood pressure, elevated fasting blood sugar, dyslipidemia, abdominal obesity (waist circumference) and elevated triglycerides; and to provide more effective and coordinated care for people with established cardiometabolic disorders.

In pursuit of its mission, the Alliance will study the possibility that predictable patterns of unnecessary acute cardiac events occur in communities, and that these patterns are measurable and amenable within the context of current treatment modalities. By using the ACC’s PINNACLE Registry and CathPCI Registry, as well as NMQF’s Cardiovascular Disease Index and U.S. Diabetes Index, the Alliance will explore the possible correlation between cardiometabolic disease and unnecessary emergency room visits and hospitalizations; and how these findings can be used to design predictive models and quality improvement interventions targeted for providers and patients at high risk for an acute cardiovascular episode.

Members of the CardioMetabolic Health Alliance and ACC will be meeting at the 2012 Cardiometabolic Health Congress this week in Boston, Ma. Visit the Alliance’s website for more information www.cardiometabolicha.org. Also read more about CardioMetabolic Syndrome in an article in the July/August issue of Cardiology magazine.

Last weekend I had the privilege of kicking off the first of a series of community events targeted at the nation’s minority and underserved communities in my hometown of Houston, TX.  The program, called Spirit of the Heart is a partnership between the Association of Black Cardiologist (ABC) and ACC’s CardioSmart initiative and aims to increase awareness of heart disease and promote better heart health, particularly in high-risk communities.

The program began with a community leader’s forum on Friday evening, where ABC President, Ola Akinboboye, MD, MPH, MBA, FACC, and I presented opening remarks. After the dinner and entertainment, I sat on a panel discussion alongside Keith Ferdinand, MD, FACC, and other ABC leaders and community partners including Darrell Green, former Washington Redskins cornerback and founder and CEO of WalkFitHealth.  The discussion, moderated by Ryan Neal, MD, was both informative and educational and we heard from advocates of health, exercise and nutrition on how to better manage care.

Dr. Ferdinand gave a presentation on reducing cardiovascular disease risk in diverse populations, and mentioned his work on the executive committee of ACC’s Coalition to Reduce Disparities in Cardiovascular Outcomes (credo) initiative, which provides healthcare providers who treat or prevent cardiovascular disease with the tools to assure optimal care for their diverse patients. He also touched on how CardioSmart and its resources, including our text message platforms, mobile Apps, and more, can help educate patients and their families about healthy lifestyle choices as well as care options.

The audience was full of ACC and ABC’s partners in the community, and during the Q & A portion of the evening, they asked a lot of important questions, especially about personalized care and how we as leaders encourage our patients to live healthier lifestyles.  

In response, along with emphasizing patient-centered care, a style of care that is based on strong physician-patient relationships, I also explained how in the end, medicine is about a healing connection between human beings. We need to re-establish the idea of medicine as an art as well as a science, and restore the physician-patient relationship; patient-centered care is the right thing to do, both in principle and in practice.

The next day ACC and ABC conducted free day-long health screenings for area residents. ACC also gave out practical health information to the community. I heard from ACC staff that there was a great turnout for the screenings and the CardioSmart presence was strong and effective. This type of grassroots outreach in underserved communities is exactly what we are trying to do with CardioSmart: to get together with patients and the public to make a difference in their heart health.

The program concluded on Sunday with ACC and ABC representatives visiting local churches and presenting ABC's 7 Steps to a Healthy Heart:

1. Be Spiritually Active
2. Take Charge of Your Blood Pressure
3. Control Your Cholesterol
4. Track Your Blood Sugar and Maintain Ideal Weight
5. Enjoy Regular Exercise, Follow a Sensible Diet and Get a Good Night's Sleep
6. Don't Smoke
7. Access Better Healthcare, Get a Check Up and Faithfully Take Your Medication

This program will be replicated in Dallas, TX from Oct 5 – 7; Austin, TX from Oct. 12 – 14; Harlem, NY from Dec. 7 – 9; and Oakland, CA on March 7, 2013 (to coincide with ACC.13). If you live in any of these cities I encourage you to come out and help us spread the spirit of the heart!

Follow @CardioSmart on Twitter and search #SpiritHeart to join the conversations. Also be sure to visit CardioSmart’s Facebook page for additional tools and resources for patients.

Check out ACC video coverage of the Houston event.

 

By William J. Oetgen, MD, MBA, FACC, senior vice president of Science and Quality of the ACC.

The ACC’s NCDR® is comprised of six hospital-based registries and one ambulatory registry, known as the PINNACLE Registry®. These registries measure the application of clinical guidelines in the real world setting – which helps us target national opportunities for quality improvement.

The PINNACLE Registry currently has 5.3 million patient encounter records covering 1.5 million unique patients, submitted from over 550 office locations nationwide. Of those patients, nearly 320,000 have atrial fibrillation (AFib), which is the most common arrhythmia in clinical practice, and is responsible for 15-20 percent of all strokes. Due to the growing need for the understanding of treatments and practice patterns for AFib, last year we announced the expansion of the PINNACLE Registry to include a new platform focusing on AFib, and include the next generation of anticoagulants coming online.

As new treatments are introduced to the market, assessing shifts in care patterns – and the impact of these shifts on patients – is a top clinical and research priority. The Registry can provide a means to monitor practice pattern changes over time while we rigorously assess current practice patterns and provide feedback reports to help providers evaluate and improve adherence to established guidelines and performance measures. We are also interested to see if these new medications coming online change the way doctors think about stroke prevention, which will ultimately help us close a long-standing quality gap in anticoagulation.

PINNACLE-AF is already yielding powerful clinical insights, and a study published last year in the American Journal of Cardiology used the PINNACLE Registry to look at treatment rates with warfarin in outpatients with nonvalvular AFib who were at moderate to high risk for stroke, as well as the extent of patient- and practice- level variation in warfarin use. The investigators found that warfarin treatment in AFib was suboptimal, with large variations in treatment observed across practice, and noted that their findings suggest important opportunities for practice-level improvement in stroke prevention for outpatients with AFib and define a benchmark treatment rate before the introduction of newer anticoagulant agents.

Because global anticoagulation patterns, especially in emerging markets, are less understood, the ACC recently conducted a transnational survey of AFib patterns the U.S., U.K., Germany, Brazil, India, and China, in order to develop a broader understanding of the causes of gaps in anticoagulation. The October issue of CardioSource WorldNews details the results, so be on the lookout for your copy hitting newsstands in the coming weeks. As mentioned in a previous blog post, the College is currently in the early stages of developing a comprehensive initiative to address gaps in treatment and encourage compliance with guideline-recommended care.

The power of registries is immense, and we encourage the use of this quality improvement tool – all in the name of improving quality and outcomes for patients. Expect to see more data and research come to fruition in the coming months, especially in the topics related to kidney function and bleeding risk and events which are areas of clinical import with the next generation of anticoagulants.

This post was authored by Jorge Acuña Valerio, MD, member of the ACC Mexico Chapter and fellow-in-training at the Instituto Nacional de Cardiologia Ignacio Chavez.
 
This year I was fortunate to be invited by leaders of the ACC Mexico Chapter to attend the ACC’s Legislative Conference. What was most interesting to me was seeing how the ACC is present in other areas, not just the science and medicine. It is important for cardiologists, and any specialty, to move forward as a group and advocate before other people or organizations. I believe that often times the medical community doesn’t do enough to come together as a group, so it was satisfying to see how in a more developed social model, physicians indeed can come together to advocate before organizations, even government.
 
Physicians have always been leaders in society, and the weigh cardiologists have over any other specialist has always been quite particular. It is because of this responsibility why I think it’s very important for cardiologists to be involved in social activities besides their medical education and clinical formation. The principle of democracy lies when our representatives act in our favor, and to achieve this we need to have our issues exposed to them. If we, as physicians, have the support of such a powerful organization such as the ACC, it’s easier to execute.
 
The Congress in Mexico is comprised of Deputies and Senators. There are 500 Deputies total, and represent the citizens from each region called a “district.” The Senate members are elected by state, and we have 128 members. Even though they’re both Congress members, deputies have more power over the fiscal legislation and the senate has more power over the ins and outs of Mexican politics. Both are elected for three or six year terms, almost every one of them by voting. Although the US and Mexico differ greatly in government structure, there is still much to learn from one another.
 
In Mexico we have a saying: “God can’t hear the one who doesn’t speak.” I think this saying can be applied to the ACC’s Legislative Conference. If we want to move one step closer towards getting our work conditions improved, it’s necessary for us to expose these issues to our political leaders so that they can decide what contribution they can make, which will ultimately benefit patients. After seeing your model, I think in many cases this can be applied to every profession.

Visit the ACC’s International Center on CardioSource.org for more news and information about ACC’s International activities.