Ralph Brindis and I just got back from 4 days in Stockholm, Sweden, for the European Society of Cardiology’s 2010 annual meeting (view the CardioSource coverage). ESC is one of the biggest CV meetings in the world because it’s a very good scientific meeting. It’s also easier and cheaper to get to than the USA from not just Europe, but the Mideast, the Balkans, northern Africa, and much of Asia.  

That said, the ACC was a mega-presence at ESC. I’d guess nearly a thousand US cardiologists attend. Our officers and spokesmen were quoted in almost all of the news coming out at this year's ESC meeting. The ACC was everywhere there. Our CVN (CardioSource Video Network) video production team was incredible in proving nearly live coverage back to US members, and ACCEL recorded many live interviews. Brindis presided over a truly grand reception and dinner honoring CV leaders from around the world in the grand room at which many Nobel dinners have been held. JACC journal editors (Tony Demaria, Jagat Narula, Spencer King) were also omni-present.

Mega Coverage!
Moreover, Brindis, and President-elect David Holmes, immediate past president Fred Bove and many other ACC leaders and past presidents were on hand to help the press with their stories. We got mega-coverage! Here are some highlights in which ACC was specifically named as a source:

• Wall Street Journal, Race On to Prevent Clots, Sept. 1: "We are getting pretty close to the Holy Grail of finding a replacement for warfarin," said Ralph Brindis (“ACC President”)
  
  
• Wall Street Journal, Plavix Rival Gains From Studies, August 30: "You can't do a genetic test on an acute patient and get a result in time to change your mind," said Spencer King (“ACC past president”).
  
  
• Bloomberg, AstraZeneca’s Brilinta Doesn’t Require Gene Testing, Study Says, August 29: “While its low price may make the generic version, known chemically as clopidogrel, the treatment of choice, confirmation that newer medicines don’t require gene testing may also influence doctors,” Alfred Bove, immediate past president of the American College of Cardiology, told journalists…. “Doctors may decide against genetic tests anyway, especially for patients who need to take a drug immediately and can’t wait weeks for test results, said David Holmes (“president-elect of the American College of Cardiology").
  
  
• Reuters, No clear winner in 3-horse anticoagulant race, Sept. 1: "Patients and physicians have been begging for a warfarin replacement," according to Ralph Brindis, president of the American College of Cardiology.
  
  
• Reuters, Novartis, Portola heart drug moves to final tests, August 30: Doctors said the rapid reversibility of elinogrel and its availability in intravenous form was attractive....  "This is definitely worth pursuing," said Douglas Weaver ("past president of the ACC").
  
  
• MedPage Today, ESC: ECG not much help for screening athletes’ hearts, August 28: While hypertrophic cardiomyopathy is the most common cause of sudden death in competitive soccer players, when pro players were screened ... the positive results all turned out to be false positives....  Alfred Bove, MD ("past president of the American College of Cardiology") told MedPage Today in an interview that the findings are plausible but at the same time pose a conundrum for clinical practice.

With Congress back in session today, the party’s over in terms of bipartisan planning, and the POTUS will address a semi-reluctant joint session of Congress Wednesday evening to lay out what the “at minimum” health reform agenda needs to be.

Gang of Two
The Senate Finance Committee is hurrying to get their proposed bill out before the big speech Wednesday. Chairman Baucus has apparently lost the support of the Gang of Six, except for Senator Snowe (R-ME), who’s still talking with him. He’s going to put the bill out anyway. He has leaked some details of his proposal, including that it will provide access for all Americans, and cost about $900 billion over 10 years.

Families and individuals earning less than 133% of the federal poverty level ($29,000 for a family of four) will be covered in the expanded Medicaid program at government expense; those who earn more than 133% of the FPL but less than 300% ($66,000 for a family of four) will get subsidies on a sliding scale to help buy private coverage through new insurance exchanges. Those above 300% of FPL must purchase it themselves through the exchanges, or be covered through their employer, or face some kind of tax penalty. Employers will be encouraged to cover all their employees, but not forced to do so. However, if they don’t, they must pay for part of the coverage costs by contributing into state insurance exchanges that will help uninsured persons get affordable coverage, have a choice of plans, and have portability of coverage if they change jobs or move within the state.

He will not include a “public option” in the exchanges, but will promote insurance reform and publicly owned insurance coops (such as Group Health of Washington State, which is organized and owned by its beneficiaries). He has trimmed back the mandated minimum benefits to try to keep costs down and premiums more affordable (and interestingly, Snowe apparently thinks he has cut benefits back too far). He raises some of the funding through a new tax on insurers who offer coverage that is over the average costs of family coverage (about $13,000 per year for a family of four). This is a clever switch from taxing people with coverage over that amount, as proposed by others. I don’t know if he will have ‘MedPAC’ on steroids “federal reserve’ body to oversee health policy decisions for Congress (with less politics and more expertise). That’s all I know. 

It’s somewhat strange to me that how we’re going to pay for reform isn’t the headline issue being debated: Instead, the controversy is all about the public option, the base closure commission idea (MedPAC on steroids), death panels, whether federal money can be spent on abortion, and other matters. It does seem like most of Congress and most Americans are still prepared to support expanding access to all Americans, to propose needed insurance reforms, and to figure out a way to put the brakes on rising costs to ensure that health care and health care spending remain affordable. (We would add with respect to the latter goal that improving quality is the proven means of reducing the cost curve, and that there is no effective way of doing that in the bills proposed thus far. So, it will be interesting to see if Mr. Baucus includes any of the pilot ideas we have proposed to incentivize and improve quality.)

Socialistic Europeans?
There were quite a few chuckles at the European Society of Cardiology about the incessant bashing by some members of Congress of the National Health Service (NHS) and other allegedly “lefty strategies supposedly diminishing the lives of those socialistic Europeans.” Most European cardiologists I talked with at ESC felt this is almost humorous, even though they recognize that cardiologists and physicians in this country in general are the most highly compensated on the planet, and that our hospitals often have much more technology and money to spend than theirs. The difference in outcomes are not great, and clearly Europe is ahead of us in some areas. And, despite problems in every country, Europeans have a lot of pride in the progress their nations are making as they should.  Incidentally, I was interested recently to see income comparisons between compensation of American versus European physicians based on ‘purchasing power.’ When that comparison is made, American physicians aren’t doing much better than many of their European counterparts.

Next Steps
So what happens now that the Congress is back?  The House will start entertaining amendments to HR 3200, similar amendment discussions are ongoing with respect to the Senate HELP bill, and when this week the Senate Finance is announced, the Senate has to put its two bills together into one proposal, which will be no easy task. Once that happens, the House and the Senate will appoint a conference committee to take the amended House proposal and the amended and combined Senate proposal and try to craft a unified proposal to be passed by both the House and the Senate, and that the President will be willing to sign. That has to happen between now and the New Year.

So, despite Congress still being out -- this has been quite a month! This month of September and the two months following are likely to be one hell of a rollercoaster ride. More on the Baucus bill below.

*** Image from Flickr (peve.de). ***

ESC’s Congress is just one meeting of the many international meetings the ACC leadership team and I attend each year that foster relationships with other international societies, although it is certainly the largest. In the five brief days we'll be in Barcelona, we’ve met with 14 international cardiovascular societies, along with Huon Gray, Chair of our new International Council, and that's not counting the informal conversations we've had along the way. This is a reflection of how strongly the ACC feels about working with international societies.

As mentioned at the start of the Congress, cardiovascular disease is not just a problem in the U.S. – it’s a problem across the world. And if all the countries across the world work together to find what works best for treatment CVD, then patients everywhere benefit.

One area in which this is particularly evident is comparative effectiveness research. Comparative effectiveness research has the potential to do so much: from informing the practice of medicine to improving care. Not only do we need to work together with international societies to collect comparative effectiveness data to improve care, we also need to work with other societies to disseminate these best practices. It’s not good enough that the information stay within the U.S. or the originating country; the information needs to be spread as far and wide as possible. By keeping the lines of conversation open at meetings like ESC’s, hopefully we’ll be able to increase our collaborations to benefit patients around the world.

*** Image from Flickr (katmere). ***

Even more impressive science out of the ESC meeting. Peter Block, F.A.C.C., and Chris Cannon, F.A.C.C., from CVN have more on ISAR TEST 4, TIMI 38 and TRIANA trials, and complete coverage is available from Cardiosource.

Sunday night I attended a charity event for “European Heart for Children,” a humanitarian initiative launched on Saturday by Roberto Ferrari, current President of ESC with his wife and others. The program’s purpose is to improve treatment of pediatric congenital heart disease in third world and emerging economy countries where treatment of this condition is inadequate. The program will offer training to health care providers to help them improve the care they offer, as well as educate physicians and politicians on CHD. Says Ferrari:  

“To me it's completely shocking to see first-hand that in some countries...the only hope for a child born with congenital heart disease is to go to another country for an operation otherwise they'll die. We hope that our initiative will give some hope to the children of Europe.”

Other CHD Issues
Treatment of pediatric CHD is a serious problem, not only because of the inadequate treatment in some countries, but also because of the lack of research. As a recent Wall Street Journal article put it: “Hardly any of the myriad drugs and devices developed for ... cardiovascular disease are designed with kids in mind.” Because of this, when treating pediatric CHD, “physicians often must rely on instinct, back-of-the-envelope calculations and anecdotal case reports swapped at medical meetings, instead of the more rigorous clinical evidence.” I heard from various European pediatric cardiologists and physicians here engaged in CHD diagnosis and treatment that Eastern European and some European countries have challenges in the CHD and adult CHD that still need attention locally.

Clearly, this lack of knowledge about best evidence and therapeutics regarding CHD is unacceptable. This is why the ACC two years ago began laying the ground work for a registry to look at outcomes and treatment for pediatric and adult CHD. The registry, called IMPACT (For Improving Pediatric and Adult Congenital Treatment), is in pilot phase currently but will launch officially in 2010. It will be the first national registry to provide data relating to demographics, acute management and in-hospital outcomes for patients undergoing diagnostic catheterization or catheter-based interventions for congenital heart disease. Also, it will serve as the benchmark for comparing catheter-based interventions to the more traditional surgically-based interventions currently in place. Once it’s nationally rolled-out, the pilot is going to provide invaluable knowledge about what works in the treatment of CHD and what doesn’t.

*** European Heart for Children logo. From ESC's Web site. ***

There were some exciting late-breaking clinical trials presented here today and yesterday, and ACC leaders were widely quoted in the media on the implications of what was discussed. 

I took a little time out yesterday from the international scene to hold a panel with the American Heart Association to examine AHA and ACC’s vision for the future of U.S. health care. The panel featured me, Fred Bove, Clyde Yancy and Robert Califf.  Part of the purpose was to help cardiologists and CV professionals understand better the differences and areas of collaboration between AHA and ACC. We focused on the positives, which are numerous, rather than on areas on competition. As I’ve said before, the future of health care should be rewarding for continuous outcome improvement and providing patient-centered care.

The ACC has a health care reform campaign, called Quality First, which, like the name suggests, advocates for payment incentives for quality care, along with increasing the focus on patient value (which we define as transparent, high quality, cost-effective, continuous care), better coordination across sources and site of care and emphasizing professionalism to increase partnerships with patients. Reform would also provide universal coverage through an expansion of public and private programs. (You can read more about Quality First and specific examples of how to make it a reality in ACC’s “Blueprint for Reform.”)

Of course, making sure all of this is included in health care reform is quite a tall order, which is why the ACC is working with lawmakers and the White House to make sure that they know what we feel is best and how best to achieve it. We’ll know soon enough if we’ve left an impact.

The science so far at ESC 09 has been quite impressive. Check out Sunday's daily wrap-up video from CVN, featuring RE LY, PLATO and CURRENT OASIS 7.

¡Saludos de Barcelona! The theme of this year’s ESC Congress is “Prevention of Cardiovascular Disease from Cell to Man to Society.” From the ESC 2009 program:

“Cardiovascular disease remains the main cause of mortality and morbidity [and] we felt that major advances in prevention and risk factor identification should be our scientific highlight.”

According to the World Health Organization, an estimated 17 million people die of cardiovascular disease – in particular heart attack and stroke – each year. In the U.S., over 860,000 people died in 2005 from cardiovascular disease, accounting for 35.3 percent of all deaths in the country. This is a very important topic, and ESC plans to address it through nearly 80 sessions focused on how to reduce the CVD burden.

At the ACC, one way we address prevention is through our patient education Web site, CardioSmart. CardioSmart is a place for people diagnosed with cardiovascular disease to learn more about their condition and how to improve their health. We like to consider it a “safe space” for patients to come online and look for more information. Not only can they find more information, they can also participate in their health through the CardioSmart Blood Pressure Tool, which gives visitors a simple, secure and easily accessible way to enter their daily blood pressure readings and see their process. They can then take to their readings to their next doctor’s visit. The format of the site and the tools that it offers helps to make the patient a PARTNER with their physician, which in turn can help increase compliance and improve outcomes.

*** Image from Wikimedia Commons (Metamario). ***

Beginning tomorrow, I’m off for several days to the beautiful city of Barcelona for ESC (European Society of Cardiology) Congress 2009. I’ll be covering the event daily, so check back for updates. Also, follow the ACC on Twitter for more scientific coverage (@Cardiosource) and general news (@ACCinTouch) from the meeting.

Check out this preview video from Cardiosource: