This post was authored by Vera Bittner, MD, MSPH, FACC, chair of ACC’s Prevention Committee.

Cardiovascular disease prevention is central to the mission of the ACC, and many entities within the College, including the ACC’s Prevention Committee, have contributed to this important mission through advocacy, education, and patient-centered care initiatives. However, previous coordination between these efforts was limited, and in May 2012, the Prevention Committee was challenged by the ACC’s Clinical Quality Committee (CQC) to rethink its role and mission within the College. Through tireless ACC staff efforts and discussions with multiple internal and external stakeholders, a new committee charter was developed and subsequently approved by both the CQC and the ACC Executive Committee.

Key goals of the ACC Prevention Committee include:

• Act as a liaison to – and a voice for – preventive cardiovascular specialist members within and on behalf of the College
• Mentor Fellows in Training, early career members, and CCA members interested in prevention
• Serve as ACC’s “access point” for collaborations with other societies and government entities on projects related to prevention including but not limited to:
  • Assuming coordination of the ACC’s partnership with the Million Hearts Initiative
  • Coordinating the dissemination of the upcoming prevention guidelines within the College with the College's representative to the National Institutes of Health-led National Program to Reduce Cardiovascular Risk
    
  • Maintain communications and collaborations with key professional societies active in the field of prevention (e.g. American Association of Cardiovascular and Pulmonary Rehabilitation, American Diabetes Association, American Heart Association, American Society of Hematology, and more)
• Provide input on ACC guidelines and performance measures relating to cardiovascular disease prevention, as appropriate
• Serve as a resource to the Advocacy department and other entities within the College
• Serve as a resource to address disparities in cardiovascular risk factor incidence, prevalence, awareness and treatment
• Serve as a resource to CardioSmart.org for patient-centered initiatives
• Support dedicated resources for prevention specialists, including but not limited to, access to guidelines, point of care reference tools, and quality improvement tools
• Create specific practical and clinical programming and content geared towards cardiovascular disease prevention at the ACC’s Annual Scientific Session and at Chapter meetings, as appropriate
• Work toward recognition as a Council within the ACC

The ACC Prevention Committee will only be successful in fulfilling its goals with the help and input from a wide cross-section of ACC physician and non-physician members, including those who are still in training. For those interested in or focused on preventive cardiology, please let us know who you are and consider volunteering to participate in projects coordinated by the committee. Let us know what gaps need to be addressed and how the committee can assist you in prevention efforts, be it in your own practice and community or at the chapter or national level. We welcome suggestions for educational programming and development of toolkits to facilitate implementation of prevention into daily practice. Let us know what you would like to see on CardioSource.org and collaborate with your patients to develop new ideas for CardioSmart. Help us develop relationships with prevention-focused organizations to facilitate joint prevention initiatives. Please direct all questions, comments and ideas, to Eva Grace, ACC Prevention Committee staff, at egrace@acc.org.

Check out the new CardioSmart Community on CardioSource and stay up-to-date on the latest CardioSmart features that can improve your practice.

This post was authored by William J Oetgen, MD, MBA, FACC, ACC's senior vice president of Science and Quality.

A recent study using data from the NCDR’s® ICD Registry™ found that the likelihood of receiving cardiac-resynchronization therapy with defibrillation (CRT-D) is mediated by community wealth and hospital resources. The study looked at 22,205 patient stays and found in the full hierarchical model, average median household income (P<0.001) and implantable cardioverter-defibrillator implantable volume (P<0.001) remained significant predictors of CRT-D receipt. Further, patients treated at hospitals in affluent communities were more likely to receive CRT-D than patients treated in poor communities, despite accounting for other patient and hospital characteristics, including insurance status.

Since health care disparities are complex issues, and it has been shown that “variations by race and ethnicity exist in the use of medical devices for the treatment of advanced heart failure,” the study attempted to address the “relative impact of patient-, hospital-, and community-level factors on the likelihood of CRT-D receipt.”

The lead author noted that the analysis demonstrates that the wealth of the community in which patients live impacts the care they receive, and the relationship between median household income and receipt of CRT-D persisted regardless of the patient’s insurance status. The authors also note that their findings have important implications for efforts to address healthcare disparities and that health policy targeting insurance coverage alone will be ineffective in resolving inequities in care.

The ACC has been working on several initiatives to address gaps in care like the example above. ACC’s credo initiative seeks to help clinicians better serve all of their patients, regardless of race, ethnicity, gender, primary language, or other factors that may impact care. The ACC has also been working with groups like the National Minority Quality Forum on the CardioMetabolic Health Alliance, to improve cardiometabolic risk factor control in diverse populations.

In addition, this past year the ACC and its CardioSmart initiative has partnered with the Association of Black Cardiologists on a series of community events aimed at increasing awareness of heart disease and promoting better heart health, particularly in high-risk communities. The next event, called Spirit of the Heart, will take place this weekend in Harlem, NY (read more about Spirit of the Heart and view photos from the event in a previous blog post here).

We know the complex problems related to health care disparities cannot be solved overnight, but it is our hope that these initiatives will slowly but surely help close the gaps in care.

This post is authored by Keith C. Ferdinand, MD, FACC, chair of the Minority Cardiometabolic Disease Alliance.

Over the last several decades, the U.S. has made substantial progress in overall cardiovascular health and reducing health disparities, but ongoing racial/ethnic, economic, and other social disparities in health are both unacceptable and correctable. Combating diabetes is an example of one such issue.

Diabetes is an urgent public health issue, especially for African Americans, Hispanics, American Indians and Alaskan Natives, and certain other minority populations. National data from 2007-2009 revealed that the prevalence of type 2 diabetes mellitus in non-Hispanic black adults was the greatest at 12.6 percent, with Hispanics closely following at 11.8 percent, followed by Asian Americans at 11.1 percent and non-Hispanic whites at 8.4 percent, respectively. Other groups with high rates of diabetes include American Indians, South Asians and Americans of Middle Eastern descent.

Race and ethnicity are not anthropologic or scientifically based designations, but instead sociocultural constructs of our society. Therefore, disparities in diabetes prevalence observed in racially and ethnically distinct subgroups of the U.S. population may not only be based on attributable, intrinsic factors (e.g., genetics, metabolism), but more prominently extrinsic factors (e.g., diet, environmental exposure, sociocultural issues). These social determinants of health are clearly major considerations in preventing and controlling diabetes and the associated cardiovascular morbidity and mortality and are the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics. For instance, steps to improve communication for patients who have English as a second language, and positive means to assist with culturally competent communication and care, include utilizing bilingual staff, an on-site professional medical interpreter, a telephonic medical interpreters, or professional interpreters, either on-site, telephonic, video. Using a patient’s bilingual minor relative is not recommended.

The ACC has taken innovative approaches to culturally competent diabetes care and CVD risk reduction. The purpose of CardioSmart.org is to provide comprehensive, thorough, and authoritative informational and educational resources as well as interactive management and compliance tools for heart disease patients and their families. It includes a Diabetes Education Center, with culturally appropriate and literacy level correct language on understanding diabetes. Novel tools include text messaging for adherence reminders and Spanish-language educational materials. In addition, the College’s credo initiative is dedicated to reducing racial/ethnic and other disparities in cardiovascular outcomes, while the new CardioMetabolic Health Alliance includes a focus on diabetes as a way of stemming the outbreak of cardiometabolic disease.

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.

As a female cardiologist in a field of predominantly men I am aware of the challenges and opportunities faced by my female colleagues. An age-old issue has been potential gender salary disparities.

A study published this week in the Journal of the American Medical Association (JAMA) answered the gender salary disparity question and found that gender differences in salary exist among a group of physicians who perform similar work.

The disparity is still apparent after adjusting for a number of variables which authors hypothesized may be the cause for the difference. The variables include medical specialty, characteristics of the institution in which they work, work hours, and academic productivity and rank.

The findings show that if the salary disparity is constant over an entire 30-year career, a woman in the study group will earn $350,000 less than a man in the same group. Authors emphasize that the “cumulative difference” would be significantly larger if not controlled for the variables like specialty, rank and leadership.

The study authors suggest that additional research is needed to investigate why these gender differences in compensation develop and how to diminish their impact, due to their continued presence and “difficulty to justify.”

The ACC’s Women in Cardiology Member Section is also a great resource for women cardiologists with opportunities to strengthen their professional support system and skills through networking events, professional development and mentoring programs. These findings are sure to be a topic of discussion in the section.

In addition to gender salary disparities, there are also gender differences in cardiovascular outcomes. To look at this further, the College, in partnership with SCAI, has been participating in a Gender Data Forum series, which bring clinical trialists together from around the world to address these disparities.  The first forum, held this past December, focused on acute coronary syndromes (ACS) and acute myocardial infarction (AMI).  A white paper containing the findings and recommendations is expected later this year.  A second forum, which will address DES, revascularization and complex PCI is planned for September.

Awareness of women and heart disease also continues to be a major issue. I wrote in a previous blog post that according to WomenHeart, heart disease is the leading cause of death of women in the U.S. Nearly five times as many women will die from heart attacks alone this year than will die from breast cancer and women have a 28 percent increased risk of dying as compared to men to die within the first year after a heart attack. The statistics are staggering.

CardioSmart.org has a plethora of information for patients on women and heart disease, which was “once considered largely a man’s disease.” It has been said that once women place the same importance on preventing and detecting CHD as they do on their annual mammogram, we will be a much healthier nation.

I am proud to be a female cardiologist in a leadership position with the ACC. As these issues become increasingly important we must continue to support one another and encourage the up and coming female stars in the field.

This post was authored by Boisey O. Barnes, MD, FACC, founding member and trustee of the Association of Black Cardiologists and Andre Williams, CEO of the Association of Black Cardiologists.

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Racial and ethnic minorities continue to lag behind in many health outcome measures and patients are less likely to get preventative care, translating into more instances of heart disease, stroke and cancer.

During a recent Capitol Hill briefing, several groups, including the Association of Black Cardiologists (ABC) gathered to discuss ways to create awareness and help eliminate health disparities among minorities. ABC is dedicated to eliminating the disparities related to cardiovascular disease in all people of color and to no longer have cardiovascular disease as the leading cause of death.

The National Institutes of Health (NIH) has identified three contributors to continued health disparities -- gaps in minority health research, minority participation in clinical trials and lack of cultural competence and investments in the health care workforce, including clinical investigators.

While these contributors are indeed true, and should be addressed, we as physicians – as cardiologists – must also reach out to our minority communities and talk to our patients face-to-face about the simple changes they can make at home to lead healthier lives. As we observe National Minority Health Month in the U.S., there needs to be a new understanding of race and health not just this month, but every month. Why do African Americans live sicker and die younger than other races? There is still a lot of racial segregation in the U.S. – something many African-American cardiologists see each day in their practices. Many patients are living in different environments and have different exposure to health risk. Where you live and what your risk factors are determine your health.

We have what has been called the “deadly quartet” in the African American population – hypertension, high cholesterol, diabetes and tobacco – and we need to redirect our forces to where the needs are and focus and push for prevention.  First Lady Michelle Obama said “We can make a commitment to promote vegetables and fruits and whole grains on every part of every menu. We can make portion sizes smaller and emphasize quality over quantity. And we can help create a culture - imagine this - where our kids ask for healthy options instead of resisting them.”  But before that can happen, for children and for adults, we have to address prohibitive factors such as the “food deserts” in many of our poor and more often than not, minority neighborhoods where no grocery stores exist and there is an abundance of fast food restaurants.

The conversation continues as we look to help people of all races live longer, healthier lives. Together with the ACC’s Coalition to Reduce Disparities in Cardiovascular Outcomes (credo) we hope to make a difference sooner, rather than later.

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Please note that statements or opinions expressed herein reflect the views of the contributor, and do not reflect the official views of the ACCF, unless otherwise noted.

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The good news in the 2011 National Healthcare Quality Report and National Healthcare Disparities Report released Friday, April 20, by the Agency for Healthcare Research and Quality (AHRQ) is that there have been significant improvements in cardiac care, in areas including reduced hospital admissions for congestive heart failure and fewer hospital deaths due to heart attack.

Unfortunately, the less good news in the reports is that overall improvements in the quality of health care continue to progress at a slow rate – only 2.5 percent a year, and the majority of disparities based on race and ethnicity, socioeconomic status and other factors are either not improving or are heading in the wrong direction.

Working together we can overcome the challenges to future successes and improve the quality rates overall. Chief among the challenges is that health care providers are increasingly being asked to do more – and do it better – all while trying to make sure we guide our patients to the latest credible, evidence-based information and encouraging them to become more engaged with us in their own health and health care.

In our work to improve quality and access to care, AHRQ is building a much-needed resource of comparative clinical information on a variety of priority health conditions, such as cardiovascular disease. The work is being conducted by the Agency’s Effective Health Care Program, the first Federally mandated initiative to support patient-centered outcomes research. As part of this effort, AHRQ is establishing a national network of partners including ACC.

Patient-centered outcomes research, also known as comparative effectiveness research, takes a comprehensive look at the evidence, comparing the effectiveness and risks of various treatment options, and presenting bottom-line results to help you work with patients to answer the question, “What is the best treatment for this individual?”

Data in the quality and disparities reports show strides have been made in answering some of these questions in cardiac care. Along with advances involving congestive heart failure and hospital deaths, racial and ethnic disparities in cardiovascular care were less common than those in other conditions and, in fact, minorities often received better quality care than whites.

Through the Effective Health Care Program, AHRQ conducts systematic reviews of available research to compare the effectiveness, benefits, and potential risks of different treatment options: drugs, medical devices, tests, surgeries, or delivery methods. These evidence-based findings are synthesized into comprehensive reports and translated into plain-language clinician and patient summaries on topics such as effectiveness of self-monitored high blood pressure, combination therapy for high cholesterol, and ACEIs, ARBs, or DRI for high blood pressure. Continuing education credits and slide libraries on cardiovascular patient-centered outcomes research are also available. These resources are designed to encourage and support shared decision making between the patient and clinician, resulting in better care.

As an advocate for evidence-based research and informed decision-making, ACC has joined AHRQ’s national network of partners to share the Agency’s growing inventory of free research reports and tools to help clinicians educate patients about cardiovascular disease, and work with patients to make informed decisions about care. You can view these tools on the AHRQ Effective Health Care Program website, or order free copies of the summary guides, including the consumer guide AHRQ recently cobranded with ACC titled “Measuring Your Blood Pressure at Home: A Review of the Research for Adults” by calling 800–358–9295 and using code C-01.

Together we will increase awareness of patient-centered outcomes research and encourage patients to use this kind of research to help them make the best treatment decisions.

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Please note that statements or opinions expressed herein reflect the views of the contributor, and do not reflect the official views of the ACCF, unless otherwise noted.

This post was authored by Dipti Itchhaporia, MD, FACC, chair elect of the ACC’s Board of Governors.

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According to WomenHeart, heart disease is the leading cause of death of women in the U.S. Nearly five times as many women will die from heart attacks alone this year than will die from breast cancer. Women have a 28 percent increased risk of dying as compared to men to die within the first year after a heart attack. Unfortunately, the vast majority of cardiovascular research has been performed on men and/or data have not been separated out based on gender.  Where men and women have been studied separately, some important differences have been identified.

Yesterday the ACC co-hosted a Gender Data Forum with the Society for Cardiovascular Angiography and Interventions’ (SCAI’s) Women in Interventions, to explore the information and statistics that are available. The forum featured primary investigators from major clinical trials who discussed gender data differences in their trials that specifically looked at anti-platelet and anti-thrombolytic therapies in Acute Coronary Syndrome (ACS). Studies included PLATO, TRITON, CURRENT OASIS, GRAVITAS, HORIZONS/ACUITY, ATLAS ACS, Fondaparinux, Integrellin, Abciximab, CHARISMA and CURE, and FRISC II.

By examining and discussing the results from these studies and commenting on the comparative effectiveness, the goal was to hone in on the differences in these studies that we could further explore and better understand as we think about future research and trials examining differences in gender. A further goal is to increase gender specific data in future studies.

Overall the forum was successful and there were several ideas that resulted from the discussions as we look to impact regulatory agencies, industry, physicians and patients to reduce health disparities.  Our hope is to compile our learnings from the forum into something that can be useful and more widely distributed, so stay tuned for more information. In the meantime look for upcoming ACC educational sessions on women’s health disparities, including the Heart of Women’s Health meeting in January and hot topics at ACC.12 in Chicago.

I am in San Francisco today and speaking about the state of cardiovascular medicine at the CRF's TCT 2011 conference. Here is a snapshot of what I will be discussing:

The trend in U.S. health care is simple: spending is drastically rising. U.S. health care expenditures total more than $2.5 trillion. In the past few decades, hospital, physician and prescription drug expenditures have also been steady to rise. Medicare spending for cancer and heart disease varies greatly – with heart disease still almost double cancer spending even though new hope to someday become take second place in morbidity, mortality and spending. Heart disease spending Medicare alone is projected at about $220 billion in 2011 and will rise to well over $300 billion or more by 2020. Health care spending in the U.S. is more than double that of other developed nations – and health care is the primary driver of future federal spending and the accumulating deficit. With more than 35 million U.S. citizens and 15 million non-citizens uninsured, 50 million on Medicare and 40 million on Medicaid, it is clear that the spending incurred by the American health system is a heavy burden to the nation unless the profession moves in to reduce unnecessary spending.

Baseline demand of physicians is sharply outpacing the baseline supply as medical school enrollment and choice to practice a medical specialty decline. Practices are changing as more than 38 percent surveyed by the ACC in 2010 are either already integrated or considering hospital integration and 14 percent are merged or considering a merger with another practice. Well over 50 percent of CV private practices have sold to hospitals or other employment venue and the trend continues.  It is clear that this is a time of change for CV medicine and health care at large. Practice transformation will be affected by the bullish forces promoting integration, payment reforms, delivery system reform that requires team practice and advanced health information technologies, more informed patients who will engage in shared decision making, public reporting on quality and efficiency, and pressures to use clinical data and feedback to systematically improve quality and value, and to reduce variation and disparities.

Socioeconomic Trends and Imperatives

Stunning technology and infrastructure, a superbly trained workforce, excellent academic institutions, leading innovation – these are hallmarks of the U.S. health care system which currently covers more than 84 percent of Americans with private or public health insurance. Unfortunately, that also means that 16 percent of Americans are uninsured, and the nation is saddled with skyrocketing costs, great variation in quality of care and lack of needed care coordination. Clearly our non-system is in great need of mending. While the embattled Affordable Care Act offers new opportunities to promote access, insurance reform, and prevention, while also adding new funding to stimulate innovation, research,  public health and work force development, it’s fate is uncertain. In this chaotic environment, CV medicine  faces major uncertainties in terms of the impacts of system reform and deficit reduction on the future attractiveness and viability of CV physician practice,  the availability of primary care, and the affects of delivery system reforms and funding changes on patient care.  

While uncertainties abound, the future of health care and CV medicine can be positive influenced by the use of registry data and quality improvement programs which more consistently deliver best evidence at the point of care. ACC’s NCDR® and PINNACLE registries; Hospital to Home, Door-to-Balloon,  and Imaging in FOCUS initiatives, and other quality improvement programs will greatly improve outcomes and  reduce unnecessary spending if they can diffused more widely and include primary care. The ACC is poised to help the nation solve the problems of uneven quality, poor care coordination, and skyrocketing costs in health care through these and other efforts and partnerships.

To emulate management guru Peter Drucker, “The best way to predict the future is to create it.” Let’s get on with it. 

For more information on ACC’s quality initiatives, visit http://www.cardiosource.org/qualityprograms.

This post is written by President-Elect William Zoghbi, MD, FACC.   

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Yesterday and today, I am in New York City representing the ACC at the landmark United Nations (UN) Summit on Non-Communicable Diseases (NCDs).  ACC CEO Jack Lewin, MD, is accompanying me in advocating for the inclusion of cardiovascular disease (CVD) in the UN’s eight Millennium Development Goals, an imperative step to combating NCDs in the developing world. Driving leaders around the world to address this issue are the astonishing statistics surrounding NCDs: 82% of the 17.1 million deaths caused by CVD occur in the world’s poorest countries -- that’s 14 million deaths per year. Despite this, only 3 percent of global funding is allocated towards NCDs.  

The General Assembly kicked off the meeting by unanimously approving without a vote a political declaration that creates a plan of action for combatting NCDs. Although the declaration does not contain specific targets for reductions in morbidity and mortality, it does contain an agreement to develop a comprehensive global monitoring framework for NCDs in 2012, as well as a set of voluntary global targets and indicators. Other commitments included in the declaration are to:

• Accelerate the implementation of the Framework Convention on Tobacco Control
• Eliminate industrially-produced trans-fats in foods, and implement interventions to reduce consumption of salt, sugars and saturated fats
• Curb harmful use of alcohol
• Restrict the marketing to children of foods high in fats, sugar and salt.

While imperfect, the declaration has galvanized the focus on this pandemic and is critical a first step to improving the health conditions of people worldwide.

• Tobacco control/elimination
• Sodium reduction
• Promoting healthy diet and exercise (low fat, sugar and alcohol intake, increased physical activity)
• Generic multidrug treatment for patients with high risk of NCDs

While significant attention has been paid to the above areas in developed nations, little education exists on these issues in the developing world. Worldwide, over 1.3 billion people smoke, 600 million have hypertension, and 220 million battle diabetes. These risk factors contribute to the estimated $500 billion per year NCDs cost in low-income and middle-income countries. Community programs -- such as Let’s Move, which was mentioned by U.S. Surgeon General Regina Benjamin, MD, during a lunch session as a program that could enable people to adopt healthier lifestyles -- are reported to have a 5-year return on investment of $5.60 for every dollar spent.

The Holmes, et al., paper is very clear on the need for worldwide unity and collaboration among leaders from the UN, World Health Organization (WHO), global and local governments, foundations, non-government organizations, and pharmaceutical companies, among others.

As a member of the Partner’s Group of the NCD Alliance, the ACC is epitomizing this collaboration by working with organizations such as the World Heart Federation and the Global Health Council to maximize international efforts to reduce the impact of NCDs. Given the success of NCDR in the U.S., Middle East and Asia, there is potential for developing nations to engage these tools to track their progress on CV care, ultimately improving their patients' outcomes.

Stay tuned for developments in the coming days as we continue to participate in the UN NCD Summit. Follow @ACCinTouch on Twitter for live updates and visit the American College of Cardiology Facebook page for photos and conversation revolving around the Summit.