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 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

 This post was authored by Chris Simpson, MD, FACC, Ontario ACC Governor and president-elect designate of the Canadian Medical Association. 

Canadian Medicare was born in Saskatchewan; its roots dating back to the Depression era. In 1949, Saskatchewan became the first political jurisdiction in North America to introduce public coverage for all hospital services. In 1959, Premier Tommy Douglas announced that the government intended to implement universal and comprehensive medical insurance. Saskatchewan doctors were apoplectic. Douglas won the 1960 election with a mandate to proceed, but the doctors went on strike.

Negotiation eventually led to an agreement. The doctors could still bill patients directly, but patients would just be reimbursed by government. Very shortly afterwards, doctors started billing government directly, having quickly realized that by doing this, payments always came promptly. Doctors’ incomes went up, and opposition to government “control” melted. Further advancing the rate of acceptance was that professional autonomy, if anything, was enhanced. No one told doctors what to do, whom they could see, or what tests they could order.

The Saskatchewan experiment was a success, and by 1972, all provinces and territories in Canada had provincial publicly funded health care. Then, in 1984, the Canada Health Act (CHA) was enacted into law, cementing the universal health care culture in the national political consciousness. The now iconic “Five Principles of Medicare” in the CHA are: public administration, comprehensiveness, universality, portability, and accessibility.

However, Tommy Douglas did not foresee that spending would grow faster than both government revenues and economic growth. In 2010, Canada’s spending on health care was $4,445 per capita (U.S. dollars); one of the highest in the OECD (not counting the U.S., which spends almost twice as much). Our health care spending as a percentage of GDP was 11.4 percent in 2010, fifth highest amongst 34 OECD countries (the U.S. was highest at 17.4 percent).

It is widely accepted that this growth is not sustainable at current tax rates. The question has now become: how do we both preserve the benefits of our system (high life expectancy, high levels of health equity, low infant mortality rates, etc.) and fix the weaknesses (long wait times for some elective treatments and overcrowded emergency rooms) in a fiscally sustainable way?

This is where doctors can help to lead. We can lead by helping our health care organizations find efficiencies. We can lead by helping to transform our health care culture from a hospital-centric (expensive) one to a community and patient-centered one. We can lead by proactively defining what constitutes medically appropriate diagnostic testing and treatment. We need to be on the right side of history.

In essence, we can protect our long-held professional autonomy and our ability to advocate for our patients by also embracing our civic professionalism – our duty to protect and enhance our country’s health economy. I passionately believe that Canada’s doctors can help lead the transformation of our health care system into one that is truly worthy of Canadians’ confidence and trust.

This post was authored by Joseph G. Cacchione, MD, FACC, chair of the CQC Partners in Quality (PIQ) Subcommittee and chairman of Operations and Strategy for the Cleveland Clinic Heart and Vascular Institute.

The promise of payment reform to rescue the growth in health care expenditures is central to fundamentals of the Affordable Care Act (ACA). A 2010 study by RAND showed that only two things will bend the cost curve:  more financial risk for consumers and provider risk. Provider risk is not a new concept as the 1990’s version of “managed care” transiently muted health care spending increases but there was little attention to quality. The managed care/capitation era of the 1990’s gave way to an era of significant growth in health care spending with predominantly a fee-for-service (FFS) reimbursement system. The proposed novel payment changes ushered in by the reform movement are an expansion of provider risk and now include pay-for-performance, bundle/episode payments and total global payment. 

As stated in a Health Affairs article by Robert E. Mechanic and Stuart H. Altman: to be successful, payment reform options must include the following criteria: 1) Potential for reducing unnecessary utilization, 2) Encouraging high quality, 3) Supporting provider integration and 4) Operational feasibility.

The U.S. government has chosen to pilot bundled payment programs. Bundles are one claim for an event of care whereas episodes are time sensitive bundles and include both a hospitalization and some post-acute period.  Several health care organizations entered into pilot agreements around bundling services for a specific diagnosis and in many circumstances episode payment. As part of these bundle pilots, there are required commitments in cost savings to CMS. These pilots are just underway and the results will fuel further CMS programs.  In addition, pilots with bundling using the Prometheus grouper tool are underway. These programs have had limited penetration due to the inability to implement the new payment methodology in what has traditionally been a system that is dominated by FFS claims systems.

The constituents of any payment system include the insurers, patients and providers; and each will have challenges with the conversion away from FFS. The vast majority of health insurers’ systems are designed exclusively for FFS payments and adding in a bundled/episode claim program will be administratively challenging. As an example, related claims that should be inside a bundle may be paid as an individual FFS claim, thus causing rework and duplication. The operations of bundling will require modification of the insurer’s existing work flows and systems. In most cases the providers have little information about utilization patterns once patients leave the acute care setting. Many providers are entering into the pilots described above with CMS and other private insurers based on small amounts of claims data. It is hopeful that the experience they gain will allow them to take on the intended financial risk successfully. 

In addition to cost data, there will be the need for longitudinal clinical data registries with outcome measures at timed intervals that are coterminous with the episode period.  This is one of the major differences with the latest iteration of the risk programs compared to the 1990’s version, the addition of quality outcomes. 

Last but not least, patients don’t live in episodes nor do they understand how their financial responsibility may be impacted by these new payment methodologies.  Clearly the constituents of the health care system are on a very steep part of the learning curve for the new payment system.  Providers will need to garner far more information about longitudinal cost and quality measures before going at significant risk for bundled payments.  

This post is authored by Michael Scherlag, MD, FACC, governor of the Oklahoma chapter of the ACC.

As a pious devotee to evidence-based therapies, forgive me for reciting the (unproven in large trials) litany of diseases which have been benefited from renal denervation (RDN): hypertension, congestive heart failure, diabetes, sleep apnea, ventricular tachycardia, atrial fibrillation, PVCs, SVT, rapid ventricular response with atrial fibrillation, diastolic dysfunction, anxiety, depression, etc. Whenever it is shown to regrow hair, you can count me in. However, it is quite clear that resistant hypertension is dramatically reduced following RDN.

The procedure is easy to perform and assuming the Symplicity HTN 3 trial is positive, and assuming that the U.S. Food and Drug Administration approves it, and assuming that Centers for Medicare & Medicaid Services will reimburse it...our patients will no longer be subjected to drugs that are unproven/difficult to take. Irrational exuberance aside, as with any new therapy, it must be carefully evaluated, tested, analyzed and distributed in a standardized fashion. The ACC is in the best position to develop a registry to ensure that appropriate patients are being treated and these patients are followed for side effects which may in some cases be beneficial and hopefully not detrimental.

The science sounds pretty simple. An electrode catheter is placed against the wall of the artery and radio frequency ablation heats the nerves leading to their inactivation. In essence, disconnecting the sympathetic afferents/efferents of the kidneys from the brain thereby decreasing blood pressure. This would be simple, but it is also probably incomplete. There is still a lot to learn about the basic science. The ACC will encourage the dissemination of this science as it is uncovered.

Indulge me with some predictions for RDN. If my understanding of the physiology is correct, this should be effective for inappropriate sinus tachycardia, possibly neurologic movement disorders, or even Takotsuboʼs cardiomyopathy. Could RDN or an offshoot of this procedure supplant a significant number of implantable cardioverter-defibrillators? Will this be the first time a new technology actually lowered the cost of health care? Could reflex sympathetic dystrophy be treated with denervation of blood vessels to the affected limb? With this potential, one thing is certain: it is an exciting time to be a cardiologist.

Check out a recent article in CardioSource Interventional News: “Resistance is Futile: Renal Denervation Takes on Hypertension.”

This *post is authored by Andrew M. Freeman, MD, FACC, chair of the ACC’s Early Career Professionals Section, and editor of the Patient-Centered Care CardioSource Clinical Community.

We’ve all been there – a busy clinic with a patient who has lots of questions and can’t quite make sense of your chicken-scratch, grade-school level coronary tree drawings. If you’re not in the medical field, it’s often very hard to wrap one’s head around the fact that someone is going to stick a balloon in the artery that supplies your heart. Of course, you’ve been working diligently to make sure that your patients are truly in the know, understand what’s going to be done to them, and that they are “captaining” their own health-ship. Being patient-centered in your delivery of care means involving your patients in their decisions about medications, intervention, and the overall disease processes. But, as we all have experienced, getting a patient up to speed quickly can be a daunting task.

This is where your ACC steps in. With the CardioSmart Explorer App for the iPad 2, you can select from many common health conditions and “bring to life” for patients what these conditions mean and what their treatments can look like. With a wave of your fingers, you can show a patient their heart muscle, its coronary anatomy, and the processes of a stent implantation. You can also mark up an anatomically and functionally correct digital model of the heart, and email this image directly to your patient. If your patient has atrial fibrillation, you can now show them how the electrical system of the heart works and how it can go awry.

The power of this application lies in its user friendliness, availability on the iOS (Apple) platform and its ability to show disease states and treatments with animations and pictures. Really, a picture is worth thousands of words. The concept of coronary disease and PCI with stenting can now be explained in 2 minutes instead of 20 – and can be instantly rewound, forwarded, and played in slow motion until all can grasp what this means.

Ultimately, this means your patient no longer comes to you with the “I don’t know what they did to me 5 years ago, but it involved a hole in my leg” phrase. Instead, you have a well-informed patient who understands exactly what has been done and why. Discussing procedures is now easier, and the risks and benefits of those procedures can be more clearly explained when the patient understands just how the procedure works.

As you can tell, the excitement behind this powerful application is tremendous – and for good reason. This kind of technology is the future of patient-centered medicine and no longer relies on “back-of-the-napkin” line drawings. Your ACC is proud to have brought this project to fruition, for you, our valued members.

This week is National Public Health Week, check out CardioSmart.org and the Patient-Centered Care CardioSource Clinical Community for additional tools and resources available to help prevent, treat and manage cardiovascular disease, while facilitating patient-centered care.

*A version of this article also ran in the CardioSmart Tech column on the Patient-Centered Care CardioSource Clinical Community.

This post was authored by William Bommer, MD, FACC, governor of the California chapter of the ACC.

The ACC was founded by dedicated physicians who wanted to improve professional education and cardiovascular health. Subsequent generations have continued to foster optimal cardiovascular care and disease prevention through professional education, promotion of research, leadership in the development of standards and guidelines, and the formulation of health care policy. The development of future leaders requires education, training, and mentoring. In comparing the nurturing, growth, development, and success of our leaders, it is interesting to compare this process to the management and culture of grape vineyards. 

A grapevine starts as a grape-seed that requires light, heat, water, air and soil. With the proper nutrients and climate, the seed can germinate and develop shoots that reach out to the sun. With continued cultivation, nurturing, vine training, and pruning, the vine can flourish and produce valuable fruit. The fruit can ultimately provide food and drink to its caretakers. The new seeds can be sewn and produce new vines for future generations.

Similar qualities can be found in our ACC leadership development program. Our leaders begin by starting as Fellows in Training, graduate to become Fellows in the College, and then become involved in College Committees, Chapters or Councils under the tutelage of former leaders. They develop into leaders themselves with their own unique flavor, color, and qualities. At that point they bear fruit to sustain the membership and ultimately the patients that we serve. This fruit will also produce the seeds that will generate new members that will become the future of the College.

Much like the agricultural process, leadership in the ACC depends on the guidance of previous leaders, and requires just the right amount of nourishment.  If you are a leader, I encourage you to reach out to your Fellows in Training to develop a relationship and to help mentor. If you are a Fellow in Training, I encourage you to get involved in the ACC and in your local state chapters, and get to know your leaders.

Together we can ensure that the ACC continues to produce the best of the best.

This post was authored by William Zoghbi, MD, MACC, immediate past president of the ACC.

Over the last few years, and especially last year during my tenure as ACC president, I had the opportunity to become greatly involved in the United Nations (UN) Summit on Non Communicable Diseases (NCDs). The ACC has partnered with the World Heart Federation, the European Society of Cardiology and the American Heart Association through the NCD Alliance to collectively advocate to the World Health Organization for inclusion of essential cardiovascular prevention and treatment targets after the first UN Summit on NCDs commenced in September 2011. All of the proposed targets were approved in late 2012 and a Global Action Plan that reflects these targets will be finalized at the World Health Assembly meeting in May 2013 in Geneva. 

Recently I was reminded of how much our actions, even few words, affect others. I was contacted by Carlo Dall'Olmo, MD, a vascular surgeon in Michigan who is originally from the Republic of San Marino (an enclaved microstate surrounded by Italy), who was inspired by a statement I made regarding the lack of public awareness of NCDs and related issues. Dall’Olmo agreed this lack of awareness is an important component of the overall problem, as it is something that he and his colleagues experience every day.

In an effort to increase public awareness about cardiovascular diseases, and unbeknown to me, Dall’Olmo approached Marino Manuzzi, MD, the director of the Filatelic Agency in the Republic of San Marino, and suggested that his agency take a lead role in public education by creating a stamp with a simple story line that would be dispersed throughout the world. Thus, the “cardiovascular diseases” stamp will be released on April 3 by the Republic of San Marino. It is their hope that the stamp will help to raise public awareness about cardiovascular disease in the campaign to combat NCDs. 

This is truly amazing and inspiring. I applaud Dall’Olmo on his resolve and Manuzzi on his appreciation of the weight of this issue. Public education actions like these are helping us achieve the overarching goal of a 25 percent reduction in preventable morbidity and mortality by 2025. With every step we take, we make our way closer to the goal. The ACC stands strongly behind this vision and will continue to advocate for the importance of achieving this important target.

This post was authored by Gerard R. Martin, MD, FACC, immediate past chair of the ACC’s Adult Congenital and Pediatric Cardiology Council.

“For the first 20 years of my son’s life, I felt as though I was driving with my eyes closed. My son was born with CHD, but during those first 20 years there was very little information available and very few support groups,” said Barbara DeMaria, a parent ambassador for the Adult Congenital Heart Association (ACHA), during the recent Congenital Heart Advocacy Day reception held at the ACC’s Heart House.

DeMaria is one of more than 100 patients, family members and health care stakeholders who attended the 7th Annual Congenital Heart Advocacy Day in Washington, DC, on March 18 and 19. The two-day event is designed to bring together congenital heart disease survivors, their families and health care providers to help educate Congress about the need for increased research and programmatic funding to help better understand the disease.  

This year, in particular, attendees met with lawmakers seeking support for National Institutes of Health research funding and Center for Disease Control and Prevention surveillance efforts. In addition, they sought to recruit additional members of Congress to join the Congressional Congenital Heart Caucus.  I had the honor of speaking to and hearing from DeMaria and others the day prior to them heading to Capitol Hill.

This lobby day, of which the ACC has been a long-time partner, is one of the key ways we continue to keep up the drum beat for continued advances in treatment and care for children and adults living with the disease. Not only is congenital heart disease still the nation’s number one birth defect, there are currently more than one million adults living with congenital heart disease thanks to advances that have already been made.

It’s events like this that showcase just how far we have come, that make me encouraged about the future of care for adults and children with congenital heart disease. For me, this lobby day symbolizes the coming together of physicians, patients and families in recognition of the need for collaboration with and among each other. It is this collaboration that I believe members of Congress and others are now beginning to appreciate, understand, and reward through programs, research and initiatives that can (and in some cases already are) not only save lives, but help those with the disease live longer, healthier and productive lives.

There is still much work to do – and more Advocacy Days to be had – but working together I am confident that we can continue to make progress in the treatment of congenital heart disease patients, like DeMaria’s son, all along the care continuum.