In all of American medicine, there is no better example of the disconnection between what we know and what we do than in the case of women with coronary artery disease. While the different symptom patterns in women with abnormal heart arteries are receiving more attention, even women who properly engage the system very often receive medical care that is not appropriate and leaves them in great danger while adding layers of needless cost. The woman who is seen in the emergency room for chest pain or other symptoms suggestive of coronary disease will be evaluated under an outdated scientific paradigm aimed at finding blocked arteries. She will have a stress test done and /or a cardiac catheterization. If these tests are normal, the patient will be told that the symptoms are not related to her heart. Every other week, I see a woman who has had symptoms of coronary artery disease and has been told that the problem is her esophagus or worse depression. She is told in effect: “Go home, take your Valium and Prozac, you will be fine!” What she has been told is wrong-too often dead wrong!
The American taxpayer has already paid for a specific study looking at the unique nature of coronary artery disease in women. The findings of the NIH-sponsored WISE (women’s ischemic syndrome evaluation) study are extremely important and have very practical implications. Coronary artery disease in women is very different from coronary disease in men. This illness in men produces focal obstructions of the artery that cause chest pain with exercise that is relieved by rest. Most women produce diffuse cholesterol plaque that is distributed evenly throughout the arterial system producing arteries that are small and with less focal obstruction. Still, these plaques can rupture and produce clot. Most heart attacks are clotting events, which explains why the anticoagulant aspirin prevents heart attack and clot-busters will stop a heart attack already in progress. When clot blocks the artery, that produces a heart attack.
Not only is the plaque deposition in women diffuse, but it remodels the artery outward and plaques may therefore be very large before producing any obstruction. This diffuse, vulnerable plaque in women explains why women with repeated chest pain in the WISE study still had a high risk of heart attack and other cardiovascular events, even with a normal heart catheterization. What these women really need is optimal medical therapy for their vascular risk which has been shown to have a powerful effect on stabilizing plaque, relieving symptoms and preventing events. Optimal medical therapy consists of aspirin, blood pressure control, cholesterol management, and smoking cessation. Diabetic and prediabetic patients should be on metformin. Female patients who already have chest pain may benefit from beta blockers, nitroglycerin, and new medications like Ranexa.
Our current medical system continues to operate under the fixed blockage paradigm in coronary artery disease. If a patient does not have a fixed blockage, they are told that the problem is not related to the heart. What are the consequences of this diagnostic error?
These women do not have their real problem effectively addressed. A year after their catheterization only about 10% of these women were on any treatment for their blood pressure and cholesterol problems. Many women with repeated chest pain continue to have unnecessary pain and suffering. Many of them have heart attacks and too many of them die. The personal costs are devastating. Because the real problems are not addressed, these women frequently return to the emergency room, have repeated tests and hospitalizations, and seek second opinions. The lifetime cost of care for the woman with repeated chest pain and no obstructive coronary artery disease approaches $800,000.
While the gap between what we know and what we do may be most pronounced in women with coronary artery disease, this issue is just the best example of glaring problems in our health care delivery system. Our system still functions under the paradigm of the fixed blockage in coronary artery disease. We identify patients with chest pain, do a catheterization, and then relieve any blockages with coronary stents or bypass surgery. Most patients and providers believe opening obstructed arteries protects these patients from having a heart attack for 10-15 years. The landmark COURAGE trial conclusively showed that in stable angina patients adding a stent to optimal medical therapy provided no additional benefit. Seventy percent of patients who received optimal medical therapy were completely relieved of their chest pain within a year. Multiple studies have confirmed that result.
The results of optimal medical therapy for coronary artery disease extend far beyond benefits on the heart. In our clinic, most high-risk patients are somewhere on the path toward developing diabetes. They have high triglycerides or a low HDL (good cholesterol) indicating insulin resistance, their fasting sugar is over 100 indicating prediabetes, or they are frankly diabetic. All of these patients have elevated cardiovascular risk. The complications of diabetes begin decades before the sugar actually reaches diabetic levels. Optimal medical therapy in these patients has dramatic benefits in multiple chronic diseases. Applying optimal medical therapy to high-risk diabetic patients in the Steno 2 trial resulted in a reduction in all cause mortality by half while producing a 4-fold reduction in heart attack, a 5-fold reduction in stroke, an 11-fold reduction in coronary stenting, a 6-fold reduction in dialysis, and a 3-fold reduction in amputations and blindness in one eye. In our focused optimal medical therapy effort we have actually seen improvement in renal function in patients with stage 3 chronic kidney disease and none have gone on to dialysis. Optimal medical therapy is very inexpensive when compared to costly, largely ineffective local interventions done later in the disease process. New science and new systems-can dramatically improve the health of American women with heart disease and other patients with chronic conditions now- today. The most urgent need today is not developing new science. They most urgent need is to translate what we already know.
The obvious next question is: Why have we not made more progress? This question is further complicated by the fact that the prestigious Instituteof Medicineissued a call to action for comprehensive health system reform to better address priority chronic conditions more than a decade ago. The landmark document Crossing the Quality Chasm laid out a roadmap to better care. (see page 10) We have a plan for improvement, we just haven’t done anything with it. Health quality pioneer Michael Millenson chastised us all for not making more progress some years later in The Silence. Still we have done very little and good women continue to suffer needless pain, disability and death in a very expensive system poorly designed to meet their needs. Why have we done such a poor job of translating the needed new systems and science?
The answer is complicated. Effective change will require transformation of several different paradigms of care. The first very important obstacle is old scientific paradigms die hard. This is just a reality. Physician scientists are introduced to scientific paradigms in a dogmatic way that provides the structural form upon which they build their assumptions.. The scientific paradigm of the fixed blockage goes back to the days of the rotary telephone and has been drilled repeatedly into the mindset of physicians ever since. The fixed progressive blockage made perfect sense-but it is just not correct. More recent science has conclusively refuted that paradigm. A second important obstacle is siloed care. Most of our basic scientists are looking at a very narrow piece of the puzzle. Very few professionals are looking at the larger picture to bring together the best science to provide integrated, coordinated management of patients with hypertension, high cholesterol, diabetes, coronary artery disease, stroke, congestive heart failure etc, although all of these problems are related in their causation.
Thirdly, perverse financial incentives are the biggest obstacle. Patients with multiple chronic conditions generate most of the cost in health care and the most revenue to providers. Ten percent of the patients generate ninety percent of the costs. Health care represents 15-20% of GDP. There is so much money on the table that winners under the old paradigm are desperate to see that their advantages remain. In any paradigm change, the old guard will push back hard to prevent the transition to the new system. Under the old system, the big winners were hospital systems and specialists. The war against multiple chronic conditions will be won in the outpatient setting and focused, patient-centered primary care teams will have to play a much larger role in the coordination and integration of treatment.. Effective management requires a multi-system approach aimed at the whole person. Since expensive stents offer no advantage over very effective, inexpensive optimal medical therapy, taxpayers should not pay for stents in stable angina patients until the patient has received a good trial of best medical treatment. Unfortunately, we get what we pay for and the system produces the product it was designed to produce. Progress requires effective system redesign.
We cannot count on anyone else to do this. In spite of all of the evidence that I have just presented, insurance companies may present stenting in stable patients as an intervention that will prevent heart attack or death. Self insured employers may be our best ally. A major American corporation has engaged our team directly, outside of insurance, to provide aggressive team-based care for patients with high-risk diabetes or hypertension. The program provides financial incentives to employees to participate and pays our team to aggressively bring these patients to goal with multiple risk factors. We report performance to the employer directly and the whole program is entirely transparent for all parties. The program includes several high-risk subsets, including women with hypertension and repeated chest pain. This program will allow us to engage these high risk women and insure that every woman has aggressive treatment for their blood pressure, cholesterol and diabetes-that every woman gets aspirin and beta blocker as indicated-that every woman has effective advice on life-style management including diet, exercise and smoking cessation.
We can implement the recommendations of crossing the Quality Chasm now. Every woman in every community in Americacould receive care that meets her needs, keeps her safe, improves her health and sense of well-being. The best way to achieve this would be to develop a system of cardiovascular centers of excellence across the nation that manage IOM priority conditions in a focused integrated way. Many interventions in high-risk patients have been tried and have failed. Primary care-led teams in the centers are able ensure that every patient receives every element of needed evidence-based care every time. Equal vigilance should ensure that no patient receives in intervention that is not based on the evidence-ever. Governance of these centers shoud be completely transparent and include patients and multiple stakeholders. You should be able to engage this system inNew York orLos Angeles. You should be able to visit a center inBaton Rouge orBangor.
Women Heart should play a leading role in the transformation of our system. Since the problem of women with heart disease is the most glaring example of our failure to apply new science and systems for the benefit of our patients and the problem impacts so many women, this is a great example to focus on. Women Heart is well-organized with many capable individuals who can be effective advocates and leaders in the reform movement. This organization should join with other stakeholders to create the push to overcome the push-back from the old paradigm. We should not tolerate a system that leaves our sisters, mothers, daughters and wives in harms way.
See Dr. Bestermann’s PowerPoint presentation here on vascular disease in women
William H Bestermann MD is a preventive cardiologist at the Holston Medical Group in Kingsport, TN, and leads the Cardiovascular Center of Excellence program for the Consortium for Southeastern Hypertension Control (COSEHC).