Tag Archives: heart failure

VA Adopts Innovative Project Nationwide

An innovative medical project that we reported in April has made the big time — a nationwide pilot program in the immense Department of Veterans Affairs system, the nation’s largest integrated health care system.

Project ECHO (Extension for Community Healthcare Outcomes) has been working wonders in New Mexico, Washington State, and a few other locations to bring specialty care to thousands of people who previously had little access to this care. Created by Dr. Sanjeev Arora of the University of New Mexico, Project ECHO connects primary care physicians with specialists in weekly case-management and educational teleconferences to give primary care physicians the support they need to manage complex patients with hepatitis C, asthma, chronic pain, rheumatic or cardiac disease, HIV, substance abuse, mental illness, high-risk pregnancy, childhood obesity, and more.

Dr. Arora (center, back turned) leads a Project ECHO videoconference. (Courtesy Project ECHO)

The U.S. Department of Health and Human Services awarded Project ECHO an $8.5 million Health Care Innovation grant in May 2012 to expand its operations in two states.

Impressed, the Department of Veterans Affairs cloned Project ECHO and tomorrow will launch a nationwide pilot program in the VA system that could help veterans get care in the local communities instead of traveling to specialists for treatment of heart failure, chronic pain, hepatitis C, etc. In our April 2012 video interview with Dr. Rollin M. Gallagher, deputy national program director for pain management in the Veterans Health Administration, he explains why Project ECHO is so appealing to the VA

The VA’s version, called Specialty Care Access Network-ECHO (or SCAN-ECHO), will kick off officially with a briefing by a panel of experts in Washington, D.C., that also can be viewed by Webcast (how appropriate) on Wednesday, July 11, 2012 from 10 a.m. to 11:30 a.m. Eastern time. Register here to view the Webcast.

The panel will feature Dr. Arora with Dr. Robert A. Pretzel, under-secretary for health in the V.A. system, Dr. John R. Lumpkin, director of the Health Care Group for the Robert Wood Johnson Foundation, which has funded much of Project ECHO’s work, and both specialty and primary care providers from the Cleveland VA Medical Center.

With any luck, the success of Project ECHO will echo across the country as this model of care expands.

–Sherry Boschert (@sherryboschert on Twitter)

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Filed under Cardiovascular Medicine, Dermatology, Endocrinology, Diabetes, and Metabolism, Family Medicine, Geriatric Medicine, IMNG, Infectious Diseases, Nephrology, Rheumatology, Uncategorized

The Funny Thing About Ivabradine and Heart Failure

The report earlier this week by cardiologists of results from the SHIFT trial, a major advance in treating heart failure by slowing patients’ hearts with the drug ivabradine, came complete with a funny, fascinating footnote. 

The footnote literally is funny, a myocardial mechanism know as the “funny” current and written as “If”–f as in funny–that supplies the “I” in the trial name SHIFT and also provides the physiologic sweet spot where ivabradine works its therapeutic magic. 

image courtesy Flickr user The Capt'n

The funny current is an ever-recurring movement of sodium and potassium ions across membranes in the sinus node of a beating heart, the trigger for each heartbeat, the heart’s spontaneous pacemaker, which means the lifespan of each funny current is less than a second. Chemists formulated ivabradine as a highly specific and selective inhibitor of the funny current, an action that slows the heart beat without any other clinical effect. This produced ivabradine’s impressive reduction in heart failure deaths and hospitalizations in the SHIFT results, reported August 29 at the annual congress of the European Cardiology Society in Stockholm. 

The story of how the funny current got found and named comes from the source, Dario DiFrancesco, Ph.D., professor of physiology and biochemistry at the University of Milan, who a few years ago recorded a charming, brief reminiscence about the episode. As Dr. DiFrancesco recalls, he began studying the heart’s pacemaker current as a postdoc junior researcher in 1976, first in Cambridge and then, starting in 1977, in Oxford. He made ex vivo preps of rabbit sinus-node tissue, which he stuck with microelectrodes and treated with voltage clamps. 

This led, in 1979, to his discovery of “a very unusual current,” an inward current that activated on hyperpolarization. All other known, inward currents in heart muscle activate on depolarization. “We termed it funny because of its odd properties,” Dr. DiFrancesco said. “We realized this was landmark data that established a new dogma for pacemaker activity. Funny current is responsible for the heart beat and for controlling heart rate. It is an essential mechanism in initiation of the heart beat.” According to his vignette, Dr. DiFrancesco’s discovery rested on his chance treatment of the rabbit-tissue prep with a hyperpolarizing current. 

He and his collaborators, Hilary Brown and Susan Noble, reported their discovery and coined the funny current, If name in a 1979 Nature paper

Somehow funny current became evolution’s solution to how hearts beat, and somehow the Oxford group stumbled onto the current’s existence. Developing ivabradine and showing its efficacy in a major trial with 6,500 heart failure patients turned funny current into serious medicine. 

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Cardiovascular Medicine, IMNG, Internal Medicine

The Surgery Was a Success, But the Device Died

From the annual meeting of the American College of Cardiology in Atlanta. 

When a medical device tests safe and works well enough to cut patient mortality in half  it usually has a rosy future. But not when the small-company developer falls victim to the recent financial crisis, an economic calamity that led to bankruptcy  more than a year before the promising trial results were known. 

Coapsys device, a cord threaded through the left ventricle and attached to two external pads. (photo by Mitchel Zoler)

The device was called Coapsys, and it had an unusual design: A piece of cord threaded through a patient’s left ventricle and tethered with two pads on either side of the heart (see photo). The idea was that the tension the cord exerted on the pads could reshape an enlarged heart to improve its function and partially correct mitral regurgitation, a leakage of blood through the valve that separates the left atrium from the left ventricle. 

At the American College of Cardiology meeting last week, Dr. Eugene A. Grossi, a cardiothoracic surgeon at New York University, presented results from a multicenter, randomized trial that included 165 patients with enlarged hearts, heart failure, and functional mitral regurgitation. The device was safe, with none of the 81 patients who received it having a peri-operative complication. The device recipients also had significantly fewer adverse events during 3 years of follow-up. And their overall mortality rate was about half that of the 84 control patients, who had conventional surgical treatment of their mitral regurgitation. 

After the company that developed the device and started the trial, Myocor, closed down in late 2008, a viable medical-device company, Edwards Lifesciences purchased the rights for the Coapsys device and all of Myocor’s other intellectual property. But a query today to a spokeswoman for Edwards revealed that the company had no specific, immediate plans for further development of the Coapsys device, or at least no plans that they were willing to reveal. 

Despite Edwards’ suprising lack of enthusiasm, or at least expressed enthusiasm, Dr. Grossi remained optimistic that the new results will not be overlooked. “With something as concrete as a mortality benefit, I think we’ll see a lot of equivalent devices that focus on treating the ventricle and not the mitral valve,” he said. 

—Mitchel Zoler (on Twitter @mitchelzoler) 

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Filed under Cardiovascular Medicine, Drug And Device Safety, IMNG, Internal Medicine, Surgery, Thoracic Surgery

Emergency Docs Seething Over New Heart Failure Guidelines

from the annual meeting of the Society for Academic Emergency Medicine:

The dirty little secret about the recently released ACC/AHA 2009 Focused Update on the Diagnosis and Management of Heart Failure is that even though the guidelines proudly trumpet an all-new section on hospitalized patients with acute heart failure, the writing committee didn’t include any emergency physicians–the people expected to actually use the guidelines.

So much for lip service regarding the importance of taking a collaborative multidisciplinary approach to the nation’s number-one reason for hospitalization in patients over age 65.

“We had no representation whatsoever,” Dr. Judd E. Hollander fumed at the SAEM meeting.

That lack of input from emergency physicians is glaringly obvious in the weak quality of the new acute heart failure portion of the guidelines (Circulation Apr. 14, 2009; 119:1,977-2,016), according to Dr. Hollander, professor and clinical research director of emergency medicine at the University of Pennsylvania, Philadelphia. He noted that 13 of the 18 Class 1 recommendations are a mere Level of Evidence C.

“So what we have here are guidelines written by people not in emergency medicine about emergency medicine who could find no evidence for anything they concluded they should do, but who actually have no experience treating the acute heart failure patient in the emergency department,” he spluttered.

The affront was duly noted in the editorial offices of the Annals of Emergency Medicine, where Dr. Hollander is a deputy editor, and Academic Emergency Medicine. Last week the editors of the two journals created a new joint policy statement that the journals will not publish guidelines or guideline summaries unless they include input from representatives of organized emergency medicine.

—Bruce Jancin

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Filed under Cardiovascular Medicine, Emergency Medicine

Heart Failure Re-admissions Targeted by the ACC

From the 2009 annual scientific session of the American College of Cardiology in Orlando

The American College of Cardiology wants to cut  by 20% the current rate of hospital re-admissions for patients with heart failure by 2012, said Dr. Jack Lewin, the College’s CEO.

Dr. Jack Lewin, CEO, American College of Cardiology

Dr. Jack Lewin, CEO, American College of Cardiology

The ACC is motivated by both a desire to help patients and the opportunity to piggyback on what they predict will soon be a hot health care issue: cutting unneeded hospital readmissions. The 2010 U.S. budget introduced in late February cited hospital readmissions during the first 30 days after discharge as a multibillion dollar dead weight targeted for reduction through a combination of reimbursement incentives and penalties. Four of the six most common causes of readmissions are cardiologic: heart failure, acute myocardial infarction (MI), coronary artery bypass grafting, and percutaneous coronary interventions (PCI), Dr. Lewin said. The ACC’s initial target is heart failure, followed by acute MI.

With a bullseye drawn on hospital readmissions by the government, it’s clear the ACC wants to be ahead on this issue and lead the effort rather than wait and let bureaucrats do the job. 

The culprit in heart failure patients is often a botched hand-off of patients from the hospital staff to community cardiologists and primary care physicians.  Poor communication means patients don’t get on or stay on the medications they need as outpatients, and also results in  redundant testing. Another step that might cut readmissions is keeping patients hospitalized the first time for an extra  day or two until they’re completely stable. The ACC will also collect new data on what’s causing readmissions and what’s succeeding in stopping it through its National Cardiovascular Data Registry.

The ACC will recruit several other professional societies and their members in this  “Hospital-to-Home” program, including hospitalists and nurses. Dr. Lewin cited the success of the recent program aimed at reducing door-to-balloon times for treating acute MI patients by PCI as a model for the new initiative. He estimated that perhaps $2 billion a year is now wasted on preventable hospital re-admissions out of the roughly $37 billion spent annually on heart failure treatment in the United States.

—Mitchel Zoler @mitchelzoler

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Filed under Cardiovascular Medicine, Practice Trends