Tending broken hearts: How doctors handle the increase in heart disease survivors
■ Fewer people are dying of cardiac disease, but more people are living with it, creating significant challenges for primary care physicians.
By Victoria Stagg Elliott — Posted Sept. 5, 2005
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Over the past few years, Kevin Larsen, MD, a Minneapolis internist, has noticed that more and more patients pass through his office who are heart attack survivors.
"I have people in my practice who have died while they're out at the mall, and they are brought back to life," said Dr. Larsen, an assistant professor of internal medicine at the University of Minnesota Medical School. "Now they're a survivor of heart disease in a way that they wouldn't have been just a few years ago."
Still, no clear habits seems to emerge in the aftermath. Some patients become devoted to preventing a second event by changing their lifestyles and taking recommended medications. Others are not quite so dedicated, deferring secondary prevention either because of a lack of interest or money. They also might feel fine, making prevention seem less imperative.
"A number of them we'll see two years later, and they haven't been on any medications because they've felt well and didn't understand how sick they were," he said. "Some pay for it later and some don't."
Thus, what Dr. Larsen and many other physicians are increasingly facing is the downstream impact of the decreasing rates of mortality and increasing rates of morbidity associated with heart disease.
Heart disease is still generally considered the No. 1 killer in the United States for the population as a whole.
But according to "Cancer Statistics 2005," published by the American Cancer Society in the January/February issue of CA: A Cancer Journal of Clinicians, heart disease has been surpassed by cancer in those younger than 85. This statistic heralds the long-predicted shift in which cancer eventually takes over the top spot -- depending on how the numbers are crunched and diseases are defined.
It also underscores the notion that "more heart disease patients are living longer," said Alice Jacobs, MD, immediate past president of the American Heart Assn. and professor of medicine at Boston University Medical Center.
Meanwhile, according to Deaths: Preliminary Data for 2003, issued in February by the Centers for Disease Control and Prevention's National Center for Health Statistics, deaths from all diseases of the heart declined 3.6% from 2002 to 2003, continuing the descent that began in 1950. This trend is due in part to an aging population benefiting from improvements in heart care. More people survive because of the increased availability of automatic defibrillators in public places or new developments in medical technology that keep them alive long enough to make it to the hospital.
"As more people are surviving myocardial infarction due to improvements in treatment, we have a reservoir of people in the community who have heart damage who are at risk for recurrent heart attacks or congestive heart failure and for other medical problems," said Daniel Levy, MD, director of the Framingham Heart Study at the National Heart, Lung, and Blood Institute.
While physicians welcome this situation because it means more patients are living longer, it also has created significant challenges -- particularly in primary care.
Primary care pressures
"There are a lot of issues when you are taking care of a patient with heart disease," said Haney Wahba, MD, a family physician in Indiana, Pa. "It's a burden, but I'm glad to take it."
Nearly all heart attack patients see a cardiologist at least initially, but whether they continue to do so after the acute episode varies. As a result, they often land in the primary care setting, where doctors are time-squeezed. Thus, patients with this and other chronic conditions take up a lion's share of appointments.
For example, a study in the May/June Annals of Family Medicine found that physicians would need 3.5 hours per day to provide care for patients with 10 common chronic conditions, including heart disease, if providing care in line with current practice guidelines. This calculation applied only if patient conditions were well-controlled. If all the patients with these chronic medical conditions were unstable, physicians needed 10.6 hours a day.
"There is a big time crunch," said Truls Ostbye, MD, PhD, lead author and professor in the community and family medicine department at Duke University in Durham, N.C.
And while physicians have difficulty addressing the needs of patients with chronic conditions, providing preventive services sometimes can be even harder. This same group of researchers also published a study in the April 2003 American Journal of Public Health finding that physicians needed 7.4 hours a day to provide preventive services in line with guidelines.
"If there is a lot of time that is required to look after the more acute issues and even the chronic issues, then there's little time left for prevention," said Dr. Ostbye, one of the paper's authors. "Trying to fit it all in is an increasing problem."
In light of the ballooning aging population and their numerous chronic conditions, many experts say, the medical system is going to have to change radically.
"These older patients who are survivors of heart disease are taking multiple medications -- all of which they need. They'll have associated hypertension, diabetes, hypercholesterolemia, in addition to non-cardiac problems. Physicians are going to have to address all of them rather than do crisis interventions," said Nanette Wenger, MD, a cardiologist and professor of medicine at Emory University School of Medicine in Atlanta. "We're going to have to develop some kind of system that will allow us to take care of these patients with multiple medical problems on multiple medications."
In addition to squeezing both chronic and preventive care into a short visit, doctors need to help their patients juggle numerous medications both to prevent a recurrence as well as to treat conditions that might not be directly related to their heart disease. Multiple meds, though, increase the risk of drug interactions, and few drugs are extensively studied in patients who are also on one or more other drugs.
"The danger is that patients will get care from multiple physicians -- their cardiologist, their rheumatologist, their gastroenterologist -- and there may be potentially conflicting advice, even though each physician tries to take into account the entire picture," said Marc Sabatine, MD, MPH, associate physician in the cardiovascular division at Brigham and Women's Hospital in Boston. "Having a primary care doctor who knows the patient well and is able to weigh all this is critical."
Numerous medications also make compliance particularly challenging, either because patients can't keep track of so many pills or get tired of taking them.
"People who have had an event tend to be a little less complacent, at least initially. They're scared, so they're motivated," said Erica Swegler, MD, a family physician in Keller, Texas, and a member of the state's Council on Cardiovascular Disease and Stroke. "Some of that wears off. The question is two years from now, three years from now, five years from now, are they going to continue to be as motivated for the long term?"
Additionally, patients usually will not experience any adverse events if they stop taking their medications, at least not at first. They might not experience the consequences until much later.
Care can be incredibly expensive for the patient and the health care system.
According to an American Heart Assn. report, direct costs for the care of those with heart disease alone already costs $139.5 billion annually -- and this amount is expected to increase.
"[Patients] are doing well and fine and are thriving, but the cost to them and to the system has been huge," Dr. Larsen said.
There are, however, significant efforts to address some of the challenges of caring for the growing number of heart disease patients. A select group of family physicians and internists are increasingly focusing on providing care for the heart along with traditional primary care. In recognition of the increasing role of primary care physicians in the post-heart attack years -- which can be numerous -- in 1999 the University of Maryland School of Medicine launched the Coalition for the Advancement of Cardiovascular Health, which provides education to speed the translation of new science into clinical practice and boasts more than 5,000 members, many of whom are in primary care.
But while there have been changes and improvements in heart disease care, experts say there is still much to be done so that everyone can benefit. For example, there exists a persistent gender gap, with men benefiting far more from the decline in heart disease deaths than women.
According to the heart association report, 25% of men but 38% of women who have a myocardial infarction will die within a year. This difference is not fully understood, but many blame it on the fact that women tend to develop heart disease later in life than men and are less likely to exhibit what are considered the traditional symptoms, thereby sometimes causing delays in diagnosis. Women also are less likely to receive all the interventions that men do and might not consider heart disease a serious health threat.
"We're seeing underrecognition and undertreatment of women," Dr. Wenger said. "Women must be taught that they are vulnerable. If you don't think this is a problem for you, you're not going to address it."
But although secondary prevention and the care of heart attack survivors have become quite sophisticated, physicians would like to see the same thing happen to primary prevention. Many experts suspect that improvements in heart disease care might have reduced the mortality statistics as much as they can. The next step will be to reduce the rate of people who develop heart disease in the first place.
"The real action, if you want to make a change in coronary disease, is to change people's lifestyles before they get it," said Allan Abbott, MD, family physician and associate dean at the Keck School of Medicine of the University of Southern California, Los Angeles.