Current CVD Prevention and Management Challenges

Peter Salgo, MD: Cardiovascular diseases represent a substantial portion of the current healthcare expenditure. Controlling lipid levels in at-risk populations remains an important part of prevention in management strategies. This AJMC^® Peer Exchange^® panel of experts in cardiovascular diseases and managed care will discuss the optimal management of cholesterol, including the role for newer, more expensive therapeutic options. I’m Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and an associate director of surgical intensive care at New York-Presbyterian Hospital.

Participating today on our distinguished panel are Dr. Seth Baum, president of the American Society for Preventive Cardiology, chief medical officer at Excel Medical Trials, and an affiliate clinical professor of clinical biomedical science at the Charles E. Schmidt College of Medicine of Florida Atlantic University; Dr Gary Johnson, a family physician and managed care medical director; Dr Jennifer Strohecker, director of Medicare pharmacy clinical operations at Molina Healthcare in Long Beach, California; and Dr Howard Weintraub, a clinical professor of medicine at NYU School of Medicine, clinical director of the NYU Center for the Prevention of Cardiovascular Disease, and the treasurer of the American Society for Preventive Cardiology.

I want to thank everybody here for joining us. We’ve got a lot to discuss. Why don’t we just sort of lay out the groundwork over here. What is the burden of managing cardiovascular disease in this country right now?

Seth J. Baum, MD: The burden is enormous. Cardiovascular disease still remains the No. 1 cause of death in the United States—and disability as well. We often look at cardiovascular disease as dying from heart disease, but there are other elements as well. People can have strokes, and then there’s a disability associated with a stroke, or an infarct, or an infarct at a young age, and it affects the entire family. It really is an enormous problem.

Peter Salgo, MD: Look, we’re in the age of the statins, right? We’re in the age of enlightenment. We’re in the age where everybody should be eating properly. And yet, if I get the numbers right, 1 in every 3 deaths in this country are cardiovascular-related in some way. That’s huge. What are we doing wrong?

Seth J. Baum, MD: We’re doing a lot wrong. For one thing, compliance is a problem. Patients are often prescribed medications and they don’t take them. Sometimes they’re not prescribed medications that they should be prescribed. And all things considered, if you look at, just simply, lipid levels. And let’s say we have a goal of less than 70 mg/dL for somebody with atherosclerotic cardiovascular disease; about 20% of Americans with that problem are at goal. That’s a major issue.

Peter Salgo, MD: Let’s put this in, if I may, a different perspective. Certainly, there’s the carnage out there. Simple death, disease, disability. But it costs money. That gets people’s attention. My number here, about 1 in every 3 healthcare dollars—is that a fair number?

Howard Weintraub, MD: It makes a lot of sense. The problem, to add to what Seth said, is that we’re late for the party when we deal with this. We’re attending to people who enter the healthcare system, maybe unexpectedly, in their 40s or 50s; or, kind of anticipatedly, in the 60s or 70s. When you take someone out of the cycle who should be earning money and instead is removing it from the system, this is a problem. So, that’s part of the unseen costs. But the rest of it comes down to the fact that medicine and the tests that we do to define the disease are also very costly. Doctor visits, emergency room visits, as well as the cost of putting a stent in someone’s coronary, from soup to nuts, is $50,000. You do a million of those a year, some of you. I think this is a very complex problem.

Seth J. Baum, MD: Right, exactly. But then it goes even deeper than that. It’s a societal issue, or social structural issue, in that people are not eating well, people are not exercising, people are getting heavier, and diabetes is increasing. There are so many things that are going wrong in the United States.

Gary L. Johnson, MD, MBA: And to that point, to answer your question about what are we doing wrong, you have to define “we”—what are “we” doing, as clinicians, wrong? What are “we” doing, as society, incorrectly or suboptimally?

Peter Salgo, MD: In what sense? What are you trying to say?

Gary L. Johnson, MD, MBA: In terms of lifestyle. In terms of eating properly, exercising, and those sorts of things.

Peter Salgo, MD: But is that surprising? Every time I pick up a newspaper, I would say 2 times a week, there’s some article about, “This is the diet that, now, is recommended so that you won’t get a heart attack.” And one week it’s, “Eat lots of meat,” and one week it’s, “No, no, no, only grains.” So, is it surprising the American public is confused?

Howard Weintraub, MD: What do consumers do when they’re overloaded? They do nothing, right? And so what ends up happening is someone who puts his/her name on a diet and it gets to be the “diet of the week” until someone smart gets up and says, “You’ve got to be joking with me. This is going to put you in a box.”

Seth J. Baum, MD: And then it creates another diet.

Howard Weintraub, MD: Exactly. Correct. If you take your dietary advice from a movie star, you deserve whatever you get as far as I’m concerned. And I think there comes a time in which, and here’s the real problem, the American Heart Association came forth with their diet: step 1 and step 2. And they put people that were prediabetics firmly into diabetes because they said, “Eat no fat, eat only carbohydrates and protein.” So, these people were munching pasta every day of the week and were bragging about it as they got fatter. Their bellies got bigger, and all of a sudden their sugar has just zoomed up and now they have something new to brag about. They’re going to die even sooner because they’ve now become diabetics.