Experts' Perspectives: Top Issue Facing Cardiology in 2024

Key Speaker Timestamps

00:00 - Michelle Kittleson, MD, PhD

01:20 - James Januzzi, MD

02:45 - Laxmi Mehta, MD

03:43 - Deepak Bhatt, MD, MPH

05:06 - Ahmad Masri, MD, MS

07:04 - Tom Nguyen, MD

08:17 - Steve Greene, MD

10:17 - Viet Le, DMSc, PA-C

13:28 - Lauren Sykes Eyadiel, MMS, PA-C

Unlike any other specialty in medicine, cardiology has stood at the forefront of public health for more than a century. As time, decades upon decades, have passed, cardiology has maintained its role at the head of the table in public health discussions, yet the American Heart Association’s most recent heart disease and stroke statistics report highlights cardiovascular disease as the leading cause of death—a truth that has not changed for more than a century.

Despite being unable to dethrone cardiovascular disease as the leading cause of mortality, the cardiology community has welcomed an innumerable number of practice-changing breakthroughs, particularly in recent decades as an improved understanding of disease pathophysiology, pharmacotherapy, and technology have contributed to multiple discoveries and advances, including TAVR, SGLT2 inhibitors, wearables, and gene therapies.

With the month of February recognized as American Heart Month, the editorial team of HCPLive Cardiology sought to commemorate the month in a more untraditional manner by highlighting the top issues confronting cardiology as a specialty in 2024. Below, we have spotlighted the responses of 9 leading experts in cardiology, spanning the spectrum of subspecialties and the care team itself, to the question: What is the biggest issue confronting your specialty today?

Included in our esteemed panel of expert perspectives are those of Michelle Kittleson, MD, PhD, of Cedars-Sinai, James Januzzi, MD, of Massachusetts General Hospital, Laxmi Mehta, MD, of Ohio State University Wexner Medical Center, Deepak Bhatt, MD, MPH, of Mount Sinai Heart, Ahmad Masri, MD, MS, of Oregon Health and Science University, Tom Nguyen, MD, of Miami Cardiac and Vascular Institute, Steve Greene, MD, of Duke University Medical Center, Viet Le, DMSc, PA-C, of Intermountain Heart Institute, and Lauren Sykes Eyadiel, MMS, PA-C, of Wake Forest University.

Editor’s note: These transcripts were edited for grammar and clarity using artificial intelligence.

HCPLive Cardiology: What is the biggest issue confronting your specialty today?

Kittleson: I feel very fortunate to be a cardiologist because we have an extraordinary base of evidence to guide clinical judgment. We have a plethora of information ranging from aspirins to statins for coronary disease, blood pressure management, management of arrhythmias, anticoagulation for atrial fibrillation, and guideline-directed medical therapy for heart failure with preserved or reduced ejection fraction. We possess numerous tools in our armamentarium that can enhance people's well-being, keep them out of the hospital, prolong their lives, prevent heart attacks and strokes, and resolve their cardiomyopathy. However, our failure lies in implementation, which is influenced by various factors. These include patient-related factors, lack of access, financial constraints preventing medication affordability, and clinician-related factors such as inertia or lack of knowledge. Thus, addressing implementation requires a multi-pronged approach. It's not solely great science that saves lives; rather, it's the combination of great science and effective implementation that equals lives saved. Moving forward, our goal should be to implement the excellent science we've produced.

Januzzi: In the current landscape of cardiovascular disease, particularly in 2024, the most pressing issue appears to be the rising incidence and prevalence of risk factors such as obesity and type two diabetes, compounded by an aging population. This concerning trend has led to an increase in cardiovascular disease cases, despite the availability of effective and safe treatments to both prevent and manage its complications. The challenge we face is twofold: firstly, how to enhance prevention efforts amidst this growing prevalence of risk factors, and secondly, how to ensure the optimal application of available therapies for those already affected by heart disease.

Addressing these challenges will require a concerted effort, with a heightened focus on at-risk populations and underserved communities lacking access to quality healthcare. Additionally, there is a need to consider the affordability of healthcare treatments and interventions. By uniting our efforts and prioritizing the dissemination of advancements made in heart disease treatment over the past two decades, we can strive to reach those affected by the disease and effectively reduce their risk.

Mehta: In my opinion, the most significant issue facing cardiology is the shortage of healthcare professionals in our field. This shortage poses a significant challenge as we may not have enough clinicians to meet the growing demand from an ever-increasing number of patients, both now and in the coming decades. We are approaching a tipping point, and urgent action is needed to address this issue. Several factors contribute to this shortage. Firstly, the lengthy process required to become a certified cardiologist, particularly with hyper-specialization, can deter potential candidates. Additionally, burnout within the field is a prevalent issue that further exacerbates the shortage.

To overcome this challenge, it is imperative that we prioritize addressing the workforce shortage as a profession. This entails implementing strategies to streamline the certification process and alleviate barriers to entry into the field. Moreover, improving the well-being of our clinicians through initiatives aimed at preventing burnout is essential. Unless we take proactive measures to tackle the workforce shortage and enhance the overall well-being of our healthcare professionals, we will continue to face significant challenges in delivering quality care to our patients.

Bhatt: The pandemic has undoubtedly had far-reaching effects across various aspects of life, including the economy, supply chains, and mental health. Particularly concerning are the observed impacts on cardiovascular risk factors, which have seemingly spiraled out of control for many individuals. It is evident that significant numbers of people have experienced weight gain, with alarming rates of obesity, diabetes, high blood pressure, and suboptimally controlled cholesterol levels. This deterioration in cardiovascular risk factors is worrisome, as it has led to an increase in cases of decompensated heart failure and acute coronary syndromes, with even young individuals presenting with complex cardiovascular diseases.

It is disheartening to witness the apparent reversal of the gains made in cardiovascular prevention over the past decade or so, a trend that has been exacerbated by the pandemic and the peri-pandemic period. As a medical community, our collective hope lies in our ability to reverse this trajectory. However, achieving this goal will undoubtedly require concerted efforts and innovative strategies. Only time will tell if we can effectively address and mitigate the cardiovascular consequences of the pandemic and prevent further erosion of the progress made in cardiovascular prevention.

Masri: The issue of drug pricing, affordability, and access presents a significant challenge within the field of cardiology. While personalized therapies offer the potential for more targeted and effective treatments, they also cater to smaller patient populations, thereby diminishing the return on investment for pharmaceutical companies. This trend is particularly evident in the pricing of drugs aimed at treating specific subsets of conditions such as hypertrophic cardiomyopathy or amyloidosis. These drugs are often priced at a premium, making access challenging, especially for elderly Medicare beneficiaries.

Although there have been efforts, such as the Inflation Reduction Act, to address affordability concerns by potentially capping prices, the burden on the healthcare system is expected to persist and even grow as personalized medicine becomes more prevalent. Additionally, there is a risk of neglecting the development of therapies for rare diseases due to their limited economic viability. However, this approach would be ethically problematic, as it would leave certain patient populations behind solely based on economic considerations.

As we navigate these challenges, it is crucial to reassess our approach to therapeutic development and reimbursement. While rare diseases may individually affect a small number of patients, collectively, they represent a significant portion of the population in need of effective treatments. Therefore, finding innovative solutions to ensure equitable access to therapies for all patients, regardless of the rarity of their condition, is imperative for the advancement of cardiovascular care.

Nguyen: It's indeed an exhilarating time for cardiology and cardiac surgery, driven by the transformative potential of artificial intelligence (AI). The integration of AI technology is poised to revolutionize patient care in unprecedented ways. Already, notable examples from institutions like the Mayo Clinic showcase the power of AI algorithms in leveraging electrocardiograms to predict essential patient parameters such as age, gender, and ejection fraction. This capability is nothing short of remarkable and offers promising avenues for more precise and personalized treatment approaches. Furthermore, ongoing research and development efforts are harnessing AI to predict postoperative complications, which has the potential to significantly enhance patient outcomes and streamline surgical procedures. For cardiac surgeons, particularly those specializing in robotic heart surgery, AI holds the promise of improving surgical techniques and outcomes through data-driven insights and analysis.

The potential of AI to reshape the landscape of cardiology, cardiac surgery, and medicine as a whole is truly exciting. As advancements continue to unfold, the integration of AI technology stands poised to elevate the standard of care, optimize treatment strategies, and ultimately improve patient outcomes in profound ways.

Greene: The issue of implementing evidence-based therapies for patients with heart failure is a critical concern within cardiology. Despite the availability of proven medications, there is a significant gap in their implementation, leading to dire consequences for patients. Many individuals are experiencing adverse outcomes or passing away without ever benefiting from these life-saving treatments.

While cost and access are certainly barriers in some cases, they do not fully account for the widespread underuse of both branded and generic therapies. Even for generic medications like ACE inhibitors or beta-blockers, less than a third of patients typically receive the recommended triple therapy regimen. This underutilization underscores the urgent need for improvement in implementing evidence-based treatments.

Beyond cost and access issues, there are other challenges facing cardiology. Therapeutic inertia, wherein clinicians hesitate to initiate or intensify treatments, contributes to the underuse of medications. Additionally, fragmented care, characterized by disjointed handoffs between clinicians and inadequate communication systems like faxing in an electronic world, further compounds the problem.

To address these challenges, targeted education for clinicians and patients, along with improved implementation strategies within health systems, are crucial. Furthermore, efforts to streamline communication and coordination of care are essential for optimizing patient outcomes and reducing duplicative testing.

In summary, while cardiology has seen significant advancements in therapeutic interventions, there remain substantial barriers to implementing evidence-based treatments effectively. Addressing these issues requires a multifaceted approach encompassing education, system-level improvements, and enhanced communication and coordination of care. Only by tackling these challenges can we ensure that patients receive the life-saving treatments they need and deserve.

Le: The challenges facing cardiology, and healthcare in general, are indeed multifaceted and complex. Despite significant advancements in therapeutic interventions and medications in recent years, there are persistent issues that need to be addressed.

Firstly, the issue of cost and access to life-saving therapies remains a significant barrier for many patients. Prior authorization requirements, along with therapeutic inertia, contribute to delays in implementing new treatments, leading to disparities in care. To address this, targeted education for both clinicians and patients is necessary, along with improvements in the implementation of therapies within healthcare systems.

Secondly, fragmented care exacerbates the challenges faced by patients and clinicians alike. Disjointed handoffs between different healthcare providers, coupled with outdated communication systems like faxing, lead to inefficiencies and potential errors in patient care. Streamlining communication and enhancing interoperability among electronic medical records systems are essential steps in overcoming this obstacle.

In summary, the key issues facing cardiology include cost and access to therapies, the need for targeted education and implementation strategies, and the challenge of fragmented care. While these are complex issues, there are solutions available, and it is essential for the healthcare community to work together to address them effectively. By doing so, we can improve patient outcomes and advance the field of cardiology in meaningful ways.

Eyadiel: The burgeoning aging population coupled with the increasing prevalence of cardiovascular diseases presents a significant challenge for cardiology. There is a pressing need for a workforce equipped with the necessary skills and training to care for this growing patient population. However, there is a crisis in the availability of providers to meet this demand, leading to a shortage of hands-on deck.

To address this workforce shortage, the field of cardiology is exploring alternative approaches, including the utilization of AI and telehealth services. These technologies have the potential to enhance patient care and expand access to specialized services, particularly in areas like heart failure. The projected increase in heart failure cases from now until 2030 underscores the urgency of the situation. Currently, heart failure and transplant cardiology fellowship programs are filling at less than a 50% rate, highlighting the need for immediate action to address this crisis.

In response, there is an opportunity for a multidisciplinary approach to patient care, involving various healthcare professionals such as pharmacists, advanced practice providers, nurse educators, and nurse navigators. By leveraging the expertise of this diverse team, it becomes possible to provide comprehensive care for patients with cardiovascular diseases, including heart failure. Furthermore, community education initiatives play a crucial role in raising awareness and promoting preventive measures for cardiovascular diseases. By educating the community on how to care for patients with cardiovascular conditions, we can empower individuals to take proactive steps in managing their health and reducing their risk of developing cardiovascular diseases.

Addressing the workforce shortage in cardiology requires innovative solutions and collaboration across disciplines. By embracing alternative care delivery models and engaging a multidisciplinary team, we can better meet the needs of the growing population with cardiovascular diseases and improve outcomes for patients.

Kittleson has no disclosures of note to report. Disclosures of interest for Januzzi include Abbott, AbbVie, AstraZeneca, Bayer, and others. Mehta has no relevant disclosures to report. Disclosures for Bhatt include Amarin, AstraZeneca, Sanofi, Pfizer, Roche, and others. Relevant disclosures for Masri include Cytokinetics, Bristol Myers Squibb, Eidos, Pfizer, and others. Relevant disclosures for Nguyen include Edwards Lifesciences, CryoLife, and Abbott. Relevant disclosures for Greene include Amgen, AstraZeneca, Bayer Healthcare Pharmaceuticals, Boehringer Ingelheim Pharmaceuticals, and others. Le has no relevant disclosures to report. Eyadiel has no relevant disclosures to report.