Video Presentations of the "1st Conference on Integrating Early Detection of Heart and Lung Disease through Low-Dose CT": Day 1 - Opening Remarks: CVD Burden in 2050 without New Prevention Strategies
- miguel65063
- Dec 23, 2024
- 28 min read
Updated: Dec 26, 2024
Cardiovascular Disease Prevention: Key Insights from Dr. Robert Harrington on Early Detection and Public Health Strategies
Thursday, September 19, 2024 | New York Academy of Medicine (NYAM)
1216 5th Ave, New York, NY 10029
After a warm welcome and introduction by Dr. David Maron, Dr. Robert Harrington delivered an insightful talk on the importance of early detection and aggressive treatment of cardiovascular risk factors. Dr. Harrington, who serves as the Provost for Medical Affairs at Cornell University and is a leading expert in cardiology and cardiovascular medicine, praised the American Heart Association's century-long contributions to cardiovascular research and highlighted trends in the prevalence and mortality of cardiovascular diseases.
Watch the Introduction by Dr. David Maron Below:
Watch Dr. Robert Harrington's Presentation Below:
Watch the Q&A Below:
Expand to Read the Text Transcript
Introduction by Dr. David Maron:
[Dr. David Maron] [0.08s] It's my honor, an unexpected honor to, introduce, doctor Bob Harrington.
[Dr. David Maron] [10.48s] Bob is one of the great thought leaders in cardiovascular medicine, and I would say in medicine at large.
[Dr. David Maron] [20.34s] I met Bob when, he was the director of the Duke Clinical Research Institute, and, then when he became chairman of medicine at Stanford.
[Dr. David Maron] [34.62s] And I was glad that he did because it enabled me to return to Stanford.
[Dr. Robert Harrington] [41.02s] And
[Dr. David Maron] [43.27s] Bob's leadership is exemplified by his, election to be the president of the American Heart Association.
[Dr. David Maron] [51.75s] David looked at at Bob when he said the Stanford gang.
[Dr. David Maron] [55.28s] I wish he were still there, but he's, dean of Weill Cornell and, provost of medical affairs for Cornell University.
[Dr. David Maron] [68.08s] And I'm gonna get off the podium so you can hear from Bob Harrington, a true visionary in medicine.
Dr. Robert Harrington's Presentation:
[Dr. Robert Harrington] [77.52s] Well, thanks, David, and thanks to the organizers for having me.
[Dr. Robert Harrington] [80.88s] When I first got invited to give the talk on, cardiovascular prevention by, my friend, Mike McConnell, I said, Mike, you do know that I'm an interventional cardiologist.
[Dr. Robert Harrington] [91.24s] And, so but over the course of the years as I've, been more and more involved in cardiovascular medicine, my attention actually has turned more and more to the early detection, the establishment of risk, and how do we get more aggressive about, about treating patients at risk for cardiovascular disease in addition to those who have documented cardiovascular disease.
[Dr. Robert Harrington] [115.72s] I hope my talk does 2 things for you.
[Dr. Robert Harrington] [118.76s] One of which is I hope it depresses you a little bit.
[Dr. Robert Harrington] [122.28s] And the reason I hope it depresses you a little bit is for my second point, which I hope it will spur you to action.
[Dr. Robert Harrington] [129.35s] When I first read the papers that I'm gonna reference that came out as part of the 100th anniversary celebration of the Heart Association, I was deeply depressed, because as as more has shown, the stats at one level look pretty good and in another level, they look pretty horrifying.
[Dr. Robert Harrington] [146.33s] And so I hope that in a group like this, we can actually bring together, different constituencies who were interested in the early detection of disease, I would say, in the early detection of risk for disease and, and really help us all do something about it.
[Dr. Robert Harrington] [165.15s] Here are my research and consulting relationships.
[Dr. Robert Harrington] [167.87s] Probably most relevant for this is I sit on the board of directors for the American Heart Association.
[Dr. Robert Harrington] [173.87s] Well, as I noted briefly, the American Heart Association in 2024 is celebrating its 1 100th anniversary, and I'll and I'll talk about why that's relevant.
[Dr. Robert Harrington] [183.59s] But maybe for the non cardiologist and the non cardiac researcher in the audience, I point out all the time that since the late 19 forties, the American Heart Association has supported almost $6,000,000,000 worth of cardiovascular and stroke related research.
[Dr. Robert Harrington] [200.43s] And so after the NIH, the American Heart Association is the largest supporter of cardiovascular and cerebrovascular research in the country.
[Dr. Robert Harrington] [210.13s] And so what I'm gonna try to walk you through is about a 100 years of progress, but give you the latest heart and stroke statistics.
[Dr. Robert Harrington] [217.08s] And so you can start to think about the challenges that we as a community have ahead of us.
[Dr. Robert Harrington] [221.67s] We'll talk about research, and we'll talk about some of the things that I think are coming.
[Dr. Robert Harrington] [226.79s] Over the course of, the last year, the journal Circulation, which is the main journal for the American Heart Association, it has a series of, of related journals under the banner of Circulation, but the main journal of Circulation has published a, series of papers.
[Dr. Robert Harrington] [242.90s] And in that series of papers, we've really reflected on as a group, our progress of, of science.
[Dr. Robert Harrington] [249.38s] And it really is science that's driven a lot of the changes in, cardiovascular health in the country.
[Dr. Robert Harrington] [255.07s] But, also, what does the future look like?
[Dr. Robert Harrington] [257.07s] And what we as an organization and by extension, what we as a group of stakeholders interested in the health of the country need to be doing?
[Dr. Robert Harrington] [268.83s] It was founded by these 6 gentlemen in 1924.
[Dr. Robert Harrington] [272.43s] They signed the articles of incorporation at the Drake Hotel in Chicago.
[Dr. Robert Harrington] [276.35s] We recently celebrated the 100th anniversary and the signing of the, articles of incorporation at the Drake Hotel.
[Dr. Robert Harrington] [282.51s] I suspect it looked a little better in 1924 than it does in 2024.
[Dr. Robert Harrington] [287.07s] But I also include this picture.
[Dr. Robert Harrington] [288.75s] This picture is, of Lewis Connor.
[Dr. Robert Harrington] [291.39s] And I put this in here because it has both a New York City and a Weill Cornell Medicine connection.
[Dr. Robert Harrington] [296.36s] Lewis Connor was one of the 6 founders of, of the American Heart Association.
[Dr. Robert Harrington] [301.09s] He was also the 1st president of the American Heart Association.
[Dr. Robert Harrington] [304.77s] And at the annual scientific sessions, the presidential session where the president has an opportunity to give an address to the, to the audience, It's the Lewis Connor session.
[Dr. Robert Harrington] [315.00s] Lewis Connor was also the 2nd chair of medicine at what was then known as Cornell Medical College, and I learned this from one of our, senior faculty members who's written extensively about Lewis Conner, his contributions to American medicine.
[Dr. Robert Harrington] [329.68s] And then with his help, we found in the archives at Weill Cornell Lewis Conner's portrait, which had hung for many years, but it had been relegated to, the archives at this point.
[Dr. Robert Harrington] [339.60s] And so this is hanging outside my office now for the, for the anniversary year, and I use it as an opportunity when people visit to reflect upon a couple of things.
[Dr. Robert Harrington] [348.54s] One of which is that the work continues after a 100 years, and secondly, that it does have a strong New York City, connection.
[Dr. Robert Harrington] [355.90s] And if you look, several of the founders of, of the resided and worked in New York City at the time of, of the founding of the organization.
[Speaker 3] [366.96s] And this is the, the graph that, that a variant of this that Mort showed,
[Dr. Robert Harrington] [372.38s] and he correctly pointed out the issue of age adjustment, we have seen marked improvements from 1950 to 2021.
[Dr. Robert Harrington] [381.65s] But look what we're starting to see at the tail end of that.
[Dr. Robert Harrington] [384.91s] At the tail end of that, we're seeing not just a plateauing, but we're seeing a reversal.
[Dr. Robert Harrington] [390.91s] And we're seeing a reversal in the progress that we've made across the landscape, whether we look at heart failure or coronary artery disease.
[Dr. Robert Harrington] [400.02s] Things are getting worse.
[Dr. Robert Harrington] [401.46s] And they're getting worse for a lot of reasons that I'll talk about, but I want you to keep in mind that the progress that's been made has largely been made from 2 perspectives.
[Dr. Robert Harrington] [411.23s] One of which was public health implementation.
[Dr. Robert Harrington] [413.69s] And the surgeon general report in the early 19 sixties around the dangers of smoking was a big part of that.
[Dr. Robert Harrington] [418.65s] And a large focus of the American Heart Association has been on tobacco control, since the 19 sixties, and we've made enormous progress.
[Dr. Robert Harrington] [426.96s] As many of you know, with the vaping epidemic and, the switch from vaping to combustible cigarettes, there's also been a reversal in some of that, particularly amongst the young people.
[Dr. Robert Harrington] [436.81s] And so it's something that we have to be vigilant in.
[Dr. Robert Harrington] [439.38s] The second big public health implementation, is around blood pressure control.
[Dr. Robert Harrington] [443.70s] And, the Heart Association has been vigilant in terms of, working to control population level blood pressure.
[Dr. Robert Harrington] [450.26s] But since about 2020 in the pandemic, blood pressure control in this country has gotten considerably worse.
[Dr. Robert Harrington] [456.51s] And so while major public health advances have occurred over the last 50 to 70 years, we're at danger of losing ground.
[Dr. Robert Harrington] [467.40s] One of the most important papers that comes out for the cardiology and stroke community every year is something called heart disease and stroke statistics.
[Dr. Robert Harrington] [475.08s] It comes out annually in the winter, and it really is a fantastic compilation of more data than you can imagine about split by various subgroups, split by different diseases, different diagnoses.
[Dr. Robert Harrington] [487.91s] And it really is trying to provide researchers with one source of, of baseline data that's updated annually with highlighting of certain elements of, of that heart and stroke statistics that we can all take away.
[Dr. Robert Harrington] [504.68s] And one of the things I like about it, and maybe it's the the visual in me as an interventional cardiologist is great infographics.
[Dr. Robert Harrington] [512.26s] And if you look at the infographics here, what you can see is that there's some pretty humbling statistics.
[Dr. Robert Harrington] [518.66s] Somebody in this country is dying of cardiovascular disease about every 30 seconds.
[Dr. Robert Harrington] [525.14s] That's extraordinary, and, we should be able to do better at that.
[Dr. Robert Harrington] [529.21s] You can see every 3 minutes and 14 seconds with regard to stroke.
[Dr. Robert Harrington] [533.29s] So we have work to do.
[Dr. Robert Harrington] [534.97s] We've made great progress, but I don't want us to stop.
[Dr. Robert Harrington] [538.97s] We have a lot of work left to do.
[Dr. Robert Harrington] [542.00s] And a topic that we're gonna focus on and I suspect that David Marron and Mike McConnell and others will focus on, and that is the notion of behavior.
[Dr. Robert Harrington] [550.56s] Our sleep patents affect our cardiovascular health.
[Dr. Robert Harrington] [554.08s] Whether or not we exercise, what kind of diet we eat.
[Dr. Robert Harrington] [559.28s] All of these let, lend into an increased risk of cardiovascular disease, and these are things that we can talk about in prevention.
[Dr. Robert Harrington] [569.74s] Now here comes the really depressing part.
[Dr. Robert Harrington] [571.58s] I was actually one of the reviewers for these two papers that I'm gonna talk about today, and when I provided my review in the top line, I said these papers depressed me.
[Dr. Robert Harrington] [581.01s] Because what it is, it's a forecasting.
[Dr. Robert Harrington] [583.76s] It's a modeling exercise.
[Dr. Robert Harrington] [585.36s] So take that for those of you who, say, well, that's not real data.
[Dr. Robert Harrington] [589.04s] It's modeling the data.
[Dr. Robert Harrington] [590.88s] It is modeling the data.
[Dr. Robert Harrington] [592.32s] But this is what you have to do from a policy perspective, to look forward to see where might we be going if certain trends persist.
[Dr. Robert Harrington] [602.17s] Where might we be going and what might we observe if we don't make changes in some of the behaviors that we're seeing?
[Dr. Robert Harrington] [611.13s] So forecasting the burning of cardiovascular disease and stroke through 2050.
[Dr. Robert Harrington] [614.67s] And when I first saw the title, I said 20 50?
[Dr. Robert Harrington] [617.39s] That's a long time away.
[Dr. Robert Harrington] [619.63s] Actually, it's not.
[Dr. Robert Harrington] [621.31s] 25 years from now.
[Dr. Robert Harrington] [622.99s] And if we're going to make policy change, and that's what a lot of this is gonna take, policy change.
[Dr. Robert Harrington] [628.77s] It's gonna take that long to exert an effect.
[Dr. Robert Harrington] [631.58s] So take a look at the paper, Karen Joynt Maddox.
[Dr. Robert Harrington] [633.82s] She works at Washington University in, in, in Saint Louis.
[Dr. Robert Harrington] [637.01s] She's one of the great policy investigators in the cardiovascular community, and it's built around this concept.
[Dr. Robert Harrington] [644.55s] I said that behavior matters.
[Dr. Robert Harrington] [647.83s] Heart association talks about this concept of life's essential aids.
[Dr. Robert Harrington] [652.87s] In fact, if you look at the risk of having a heart attack, it's not in your genes that's predicting that.
[Dr. Robert Harrington] [662.43s] It's in how you respond
[Speaker 3] [665.47s] to
[Dr. Robert Harrington] [665.63s] a variety of behavioral aspects of your life, diet, exercise, sleep, whether or not you use tobacco, controlling your blood pressure, controlling your blood sugar, how much exercise do you get, what's your weight.
[Dr. Robert Harrington] [676.44s] This explains about 90% of the risk of having a heart attack at the population level.
[Dr. Robert Harrington] [682.92s] And, and that's been well worked out by the McMaster Group through a series of large international epidemiologic studies, but the burden of cardiovascular disease is largely built here.
[Dr. Robert Harrington] [692.76s] I also put this up here as we begin to think about prevention.
[Dr. Robert Harrington] [696.61s] Coronary artery disease is actually preventable.
[Dr. Robert Harrington] [699.73s] Is that is it completely preventable?
[Dr. Robert Harrington] [702.06s] Probably not.
[Dr. Robert Harrington] [703.58s] But if we had perfect adherence to life's essential aid, we would have a lot less global burden of coronary artery disease and by extension, other cardiovascular diseases.
[Dr. Robert Harrington] [714.06s] So life's essential aid.
[Dr. Robert Harrington] [717.79s] Here's the model data that I find, both interesting and really disturbing.
[Dr. Robert Harrington] [722.43s] This is the prevalence of disease, all cardiovascular disease, and then some individual things which really drive that accumulated, total cardiovascular disease, atrial fibrillation, coronary heart disease, heart failure, and stroke.
[Dr. Robert Harrington] [735.58s] Everything's going up.
[Dr. Robert Harrington] [737.42s] And, and if you look, we're talking about a prevalence in the adult population of about 11% today going up to about 15%.
[Dr. Robert Harrington] [747.24s] Think about that at the population level, given the size of our country, about 330,000,000 people, about 210, 220, 30,000,000 adults going from 11% of something to 15% of something.
[Dr. Robert Harrington] [760.01s] That's an enormous increase.
[Dr. Robert Harrington] [761.77s] This is not sustainable from a country perspective if this happens.
[Dr. Robert Harrington] [766.09s] And if you look at the individual numbers of people affected, look at the numbers here.
[Dr. Robert Harrington] [773.14s] Right now, we have a prevalence of about 27, $28,000,000 I mean, million patients of any cardiovascular disease.
[Dr. Robert Harrington] [780.75s] Look at what it'd be by 2050.
[Dr. Robert Harrington] [783.87s] Almost 45,000,000.
[Dr. Robert Harrington] [787.15s] Again, that's not sustainable from a care in the country perspective, and it's affecting all of us.
[Dr. Robert Harrington] [793.71s] If you look at some of the various subgroups here, some group that, it's affecting disproportionately given the size in the population.
[Dr. Robert Harrington] [800.62s] But look at the look at the increase here.
[Dr. Robert Harrington] [802.86s] It's across all groups within the United States.
[Dr. Robert Harrington] [807.25s] And so I think the conclusions here should be sobering to all of us that the prevalence of many cardiovascular risk factors and cardiovascular and cerebral vascular diseases will increase markedly over the next 30 years absent intervention to change these trajectories.
[Dr. Robert Harrington] [824.01s] And that's critical phrase, absent interventions to change these trajectories, and put that into the context of what you're gonna talk about for the next couple of days.
[Dr. Robert Harrington] [833.33s] And we need both clinicians, but also the public health enterprise to urgently try to figure out how are we gonna manage, even reverse these adverse trends, in cardiovascular disease and stroke, and this should be a priority on the national level.
[Dr. Robert Harrington] [848.19s] If you go around the globe, cardiovascular disease is the globe's leading cause of death and disability everywhere except for Sub Sahara Africa, and it's increasing in Sub Sahara Africa.
[Dr. Robert Harrington] [860.13s] So think about that.
[Dr. Robert Harrington] [861.17s] Everywhere in the globe, this is an issue.
[Dr. Robert Harrington] [865.82s] Rob Kalief, who's currently the, the commissioner of the US FDA, published this viewpoint paper in circulation, around the time that the pandemic was going on and really brought brought light to this notion of with the pandemic and beginning to understand other common diseases that we don't even see this coming necessarily.
[Dr. Robert Harrington] [891.89s] And the increase in the burden of cardiovascular disease, he's called the tsunami of chronic disease.
[Dr. Robert Harrington] [898.29s] Again, this will overwhelm us as a country if we don't think about how to manage this better.
[Dr. Robert Harrington] [905.17s] Commissioner Kalief will actually be at Weill Cornell on October 15th to spend the day talking about the burden of cardiovascular disease and other chronic diseases in the country.
[Dr. Robert Harrington] [914.42s] It's going to be a New York City wide event with health system leaders, and public health leaders from around the city coming to spend the day on campus with commissioner Caleb.
[Dr. Robert Harrington] [923.23s] And if any of you are free, we will have some public events throughout the day.
[Dr. Robert Harrington] [928.58s] Okay.
[Dr. Robert Harrington] [928.82s] I gave you the medical data.
[Dr. Robert Harrington] [931.70s] Now if you wanna be really depressed, let's look at the economic data.
[Dr. Robert Harrington] [935.46s] And this is the same group of individuals, Karen Joy Maddox and, Dhruv Kazi, were really the leaders of these efforts.
[Dr. Robert Harrington] [942.84s] And this is, again, forecasting, modeling the economic burden.
[Dr. Robert Harrington] [948.51s] And if we look at hypertension, diabetes, hypercholesterolemia, you can see the requisite increases that are going on as a population level.
[Dr. Robert Harrington] [958.70s] And look what this is doing.
[Dr. Robert Harrington] [960.22s] Look at the cost here.
[Dr. Robert Harrington] [961.90s] Whether you're talking about total cost, health care cost, productivity losses because of mortality, productivity losses because of morbidity, this is not sustainable.
[Dr. Robert Harrington] [972.68s] If you think about we're already spending about 20% of gross national product for health care costs, look at this.
[Dr. Robert Harrington] [979.09s] This is just not sustainable from a economic perspective, and we have to be able to bend this curve.
[Dr. Robert Harrington] [986.40s] Not surprisingly, it predominantly affects the Medicare population given the aging of the population and the age for which Medicare largely serves.
[Dr. Robert Harrington] [995.20s] But we also see increases across other types of insurance, private insurance, the Medicaid insured population.
[Dr. Robert Harrington] [1001.45s] So this is gonna affect the entire population, all of society, unless we do something about it.
[Dr. Robert Harrington] [1008.57s] There's things that are gonna be more from a policy perspective than they are from an individual perspective from the heart association.
[Dr. Robert Harrington] [1014.40s] We've written a lot about the disparities in care that are in rural America.
[Dr. Robert Harrington] [1019.32s] We see this in New York state, in some of the rural areas of New York.
[Dr. Robert Harrington] [1022.84s] We saw this in California, some of the rural areas of California.
[Dr. Robert Harrington] [1026.36s] We also see this from a global perspective as we think about as well with migration across the globe and the, disproportionate burden of cardiovascular disease across that, that migration population.
[Dr. Robert Harrington] [1040.94s] We also see from other policy perspectives some of the things like air quality that are affecting the burden and the risk of particularly atherosclerotic disease and heart failure.
[Dr. Robert Harrington] [1051.66s] And so these are other things that you need to begin to think about.
[Dr. Robert Harrington] [1055.02s] How do we affect at a policy level things like air quality that are contributing to this burden of cardiovascular disease?
[Dr. Robert Harrington] [1062.46s] So it's behavioral issue at the individual level, but there's also issues at the public health issue level that we have to take, note of and begin to think about how can we impact that.
[Dr. Robert Harrington] [1076.04s] From a heart association perspective, we really think that science and research is what's gonna drive progress.
[Dr. Robert Harrington] [1080.76s] And one of the great series of papers that you can access all available this year as the 100th anniversary celebration are all of the what's been called the centennial collection of where is where science been in these key areas and where is science going.
[Dr. Robert Harrington] [1098.44s] And how do we really begin to understand things like clonal hematopoiesis as a science topic, but how there might be areas for therapeutic intervention as we begin to understand the association between clonal hematopoiesis and coronary artery disease.
[Dr. Robert Harrington] [1116.83s] And there's gonna be a lot of new types of science that are gonna drive where we go from discovery, and this is fantastic for what I would call the secondary prevention of cardiovascular disease.
[Dr. Robert Harrington] [1129.04s] But we really also need to move things towards the primary prevention.
[Dr. Robert Harrington] [1132.88s] And I included here one of the papers on policy strategies, and I'd encourage you all to take a look at this because you say, what can I do?
[Dr. Robert Harrington] [1141.15s] Here's the most important thing you can do.
[Dr. Robert Harrington] [1142.84s] You can vote, because who we vote for matters in terms of the policy arena around health.
[Dr. Robert Harrington] [1151.92s] So I'm gonna make 4 points about how do we bend this otherwise depressing curve.
[Dr. Robert Harrington] [1157.84s] Because I went from sort of through the Kubler Ross stages when I read these papers.
[Dr. Robert Harrington] [1161.92s] I went from depression to acceptance, and now I'm dealing with how are we gonna get active and how are we gonna really address this.
[Dr. Robert Harrington] [1170.23s] Number 1, for those who have established cardiovascular disease, as a community, we continue to need to focus on discovery, on clinical research, but an area that's woefully underused is and and and what talked about this?
[Dr. Robert Harrington] [1185.46s] Implementation.
[Dr. Robert Harrington] [1186.98s] We need implementation of new approaches to acute care.
[Dr. Robert Harrington] [1190.34s] How do we continue to lower case fatality rates in these these diseases like heart attacks and stroke?
[Dr. Robert Harrington] [1197.65s] For those with established cardiovascular disease, in addition to the research arena, we need to focus aggressively, and this is something that Mike McConnell's book addresses, aggressive secondary prevention, both at the individual and population level.
[Dr. Robert Harrington] [1212.77s] And I would include improving air quality as an important part of the population aggressive secondary prevention.
[Dr. Robert Harrington] [1220.91s] 3rd, and this is really getting into what you're gonna be talking about the next 2 days.
[Dr. Robert Harrington] [1224.76s] We need to improve risk assessment and screening using both clinical and technology tools, including imaging and artificial intelligence that can really allow us to focus on prevention, primary prevention, primordial prevention.
[Dr. Robert Harrington] [1242.41s] At the Heart Association, we're very interested in maternal health in part because it predicts long time health for both mother and baby with regard to cardiovascular risk.
[Dr. Robert Harrington] [1252.72s] And finally, policy.
[Dr. Robert Harrington] [1255.20s] We really need to as a community, and this is a great thing to talk about that last slide that David showed on all the groups that are coming together to really push for policy changes around physical activity, sidewalks and neighborhoods that need it, safe places to exercise, tobacco control.
[Dr. Robert Harrington] [1271.55s] You wanna make the biggest difference in public health, get rid of tobacco.
[Dr. Robert Harrington] [1276.40s] At the at the heart association, we call this the tobacco end game, and we're completely committed to this.
[Dr. Robert Harrington] [1282.00s] Air quality, insurance covers expansion, and other issues related to policy.
[Dr. Robert Harrington] [1287.52s] I I didn't know that David was gonna push the books of Bush of of Mike and Bruce, but I'll do the same.
[Dr. Robert Harrington] [1292.91s] These are 2 fantastic books that really address what I've been talking to you about today.
[Dr. Robert Harrington] [1296.83s] More aggressive treatment in Mike's book, fight heart disease like cancer.
[Dr. Robert Harrington] [1301.94s] And in Bruce's book, we gotta detect these diseases earlier.
[Dr. Robert Harrington] [1304.90s] So early detection.
[Dr. Robert Harrington] [1305.79s] Bruce talks about cancer, but it really pertains to cardiovascular risk as well.
[Dr. Robert Harrington] [1310.59s] Thank you for having me.
[Dr. Robert Harrington] [1311.55s] I'm happy to answer questions or just move to the next section.
[Dr. Morteza Naghavi] [1317.20s] Bob, if you know now you are not only a cardiovascular leader, you've been for 20 years.
[Dr. Morteza Naghavi] [1323.52s] You're also an executive in charge of policy making.
[Dr. Morteza Naghavi] [1328.12s] How can we make a difference in terms of reaching people who are asymptomatic?
[Dr. Morteza Naghavi] [1333.63s] You know, these people, they they don't feel anything as you know.
[Dr. Morteza Naghavi] [1337.63s] There is no pain for coronary calcium or even long nodule.
[Dr. Morteza Naghavi] [1341.95s] And so what we're trying to get, some brainstorming done here is in implementation.
[Dr. Morteza Naghavi] [1347.07s] Because if we implement what we know no no need discovery.
[Dr. Morteza Naghavi] [1351.23s] If we just implement what we know, we can break the back of our disease, lung cancer.
[Dr. Morteza Naghavi] [1356.67s] What are your thoughts on implementation?
[Dr. Morteza Naghavi] [1359.48s] Yeah.
[Dr. Robert Harrington] [1359.63s] So on your same point, we've written extensively about this over the years.
[Dr. Robert Harrington] [1362.36s] If we just implemented what we know, what would be the incremental add in in particularly my area of interest has been coronary disease.
[Dr. Robert Harrington] [1369.81s] It's enormous.
[Dr. Robert Harrington] [1370.53s] In fact, it it it outweighs new discoveries if we can just implement what we know.
[Dr. Robert Harrington] [1374.21s] So your point's really well taken.
[Dr. Robert Harrington] [1375.89s] On the other part, I think that there's an opportunity to do what David and Claudia did years ago, which is to launch new programs which deal with screening as a tool to detect previously undetected or unknown disease.
[Dr. Robert Harrington] [1389.38s] I'll mention 2 things that we have underway in, in Weill Cornell.
[Dr. Robert Harrington] [1393.14s] One of which is a, a clinic dedicated to cancer risk detection, in particular, GI cancers and, breast and ovarian cancer run by 2 early career faculty members who are trying to understand based on family screening, based on genetics, based on a variety of other risk characteristics, How do we just identify people at risk?
[Dr. Robert Harrington] [1415.48s] And then how do we apply therapies like imaging therapy, technologies, etcetera, to be able to really drive that point home of early detection?
[Dr. Robert Harrington] [1423.16s] So kudos to the pioneers of doing that.
[Dr. Robert Harrington] [1426.43s] 2nd, we have a research project getting ready to start on whole body MRI imaging as a way also to detect disease, not as the tool you sometimes see it online advertise.
[Dr. Robert Harrington] [1437.39s] Hey.
[Dr. Robert Harrington] [1437.55s] You wanna find out if you have anything funny going on?
[Dr. Robert Harrington] [1439.87s] Get your whole body MRI.
[Dr. Robert Harrington] [1440.91s] We're gonna do that as a research project.
[Dr. Robert Harrington] [1442.76s] So I think we can do more and more things like that.
[Dr. Morteza Naghavi] [1444.99s] Thank you.
[Dr. Morteza Naghavi] [1446.52s] Hey, Mike.
[Speaker 4] [1448.84s] Yeah.
[Speaker 4] [1449.15s] Thanks so much for coming and setting the stage for this.
[Speaker 4] [1453.15s] I really wanted to dive a little bit more, and and more already started around this that, you know, I think the you know, has been amazing around Life Central Aid and and laying out both for cardiologists and the general public around the importance of prevention.
[Speaker 4] [1469.90s] You As you indicated, I think we're not doing well enough on then treating it as aggressively as cancer, and trying to learn from that community.
[Speaker 4] [1483.07s] But know, a lot of what we're talking about here is that screening phase.
[Speaker 4] [1488.64s] So I, you know, I talk about sort of trying to implement the prevention when detected, more aggressive treatment.
[Speaker 4] [1497.63s] But I think there's still this disconnect in the cardiovascular community, which is very different from the cancer community that, yes, you can try to do your best with prevention, but between age and risk factors catch up with us, and many of us are not perfect on on the prevention side that and we have these tools for early detection.
[Speaker 4] [1521.39s] So I think really a lot of what this conference is about is learning from the experience of Claudia and David or all the work they've done and really leaning into screening.
[Speaker 4] [1531.88s] Right?
[Speaker 4] [1532.12s] If you even if you just look at Mesa, if you go on to the Mesa website, put in your age, etcetera, you know, most 1 in 4 men in their forties and 1 in 4 women in their fifties will have a positive coronary calcium scan.
[Speaker 4] [1548.23s] And most people are just not aware of that.
[Speaker 4] [1551.83s] So I think trying to uplift the screening element is probably another key message that I tried to convey, and this is a great opportunity to to work with the lung cancer screening community to to uplift that on the cardiovascular side.
[Speaker 4] [1568.42s] So, you know, I think how do we get that more in the conversation?
[Dr. Robert Harrington] [1573.46s] Yeah.
[Dr. Robert Harrington] [1573.70s] I I I'd say 2 things.
[Dr. Robert Harrington] [1575.30s] One of which is we who were involved with the educational aspects of, training next generations also have to do a better job at the at the aggressiveness with which prevention is, is needed to be implemented.
[Dr. Robert Harrington] [1588.22s] You know, one of the one of the great advances in cardiovascular medicine, for example, has been things like bypass surgery and coronary stenting for certain conditions.
[Dr. Robert Harrington] [1596.16s] And yet the words you know, it's interesting in David's slide about the word choice.
[Dr. Robert Harrington] [1599.60s] We use terrible word choice.
[Dr. Robert Harrington] [1600.88s] If you ever sir heard a surgeon go talk to a patient after they've had coronary bypass, well, I fixed you.
[Dr. Robert Harrington] [1606.12s] It didn't fix anything.
[Dr. Robert Harrington] [1607.39s] You you you know, you went around the problem, hence the name of the operation bypass.
[Dr. Robert Harrington] [1612.28s] And so what and how many times have we all seen patients go home?
[Dr. Robert Harrington] [1616.36s] Oh, you can stop that.
[Dr. Robert Harrington] [1617.32s] You can stop this, like, no.
[Dr. Robert Harrington] [1619.57s] We we need to get more aggressive because we know you have the worst form, most advanced form of the disease.
[Dr. Robert Harrington] [1623.65s] So I think we have to do a better job with that, Mike, and and and that has to be really from day 1.
[Dr. Robert Harrington] [1629.97s] The second, I think I do think at the policy level, we have to be imp we have to be pushing for changes.
[Dr. Robert Harrington] [1634.34s] We have to be pushing for expanded coverage of certain imaging technologies that we know are gonna save lives.
[Dr. Robert Harrington] [1639.78s] And, we we so as an advocacy group, the Heart Association has all of this on its advocacy platform.
[Speaker 4] [1647.73s] Yeah.
[Speaker 4] [1647.97s] I mean, I think I use the concept that if we're treating just end stage disease, you're you're taking out the the tumor that you see, but you're, 1, you're getting it when it's already quite advanced, and 2, you're sort of underplaying the the broader chemotherapy for what's really a systemic disease that's just gonna keep coming back unless you
[Dr. Morteza Naghavi] [1671.34s] Yeah.
[Speaker 4] [1671.58s] You know, treat it more like cancer.
[Dr. Robert Harrington] [1673.58s] Agreed.
[Dr. Robert Harrington] [1673.82s] And for those who wanna hear more Mike and I talking, you can go to my podcast on Medscape and see Mike and I talking about this topic.
[Dr. Robert Harrington] [1680.27s] Just a shameless plug for my podcast.
[Dr. David Maron] [1684.43s] My question has to do with randomized controlled trials.
[Dr. David Maron] [1687.39s] You mentioned the surgeon general in their early sixties who made a proclamation without the the benefit of a randomized controlled trial to show that, cigarette smoking causes cancer.
[Dr. Morteza Naghavi] [1698.52s] Yeah.
[Dr. David Maron] [1699.88s] We have so much evidence with coronary calcium.
[Dr. David Maron] [1703.49s] And we have the US Preventive Services Task Force saying, can't recommend it.
[Dr. David Maron] [1708.37s] There's no clinical trial.
[Dr. David Maron] [1710.61s] How do we move forward without I mean, I'm hoping that we'll do a a randomized controlled trial, but how do we move forward without that evidence?
[Dr. Robert Harrington] [1720.65s] Well, as you know, David, I'm a clinical trialist.
[Dr. Robert Harrington] [1722.82s] So, so so so I I do think that for some things, the randomized clinical trial is the gold standard.
[Dr. Robert Harrington] [1728.26s] You know?
[Dr. Robert Harrington] [1728.58s] If you wanna compare a with b, there's no better way than to randomize a versus b.
[Dr. Robert Harrington] [1733.45s] But there are other questions where observational nonrandomized data is quite appropriately used.
[Dr. Robert Harrington] [1738.33s] And, you know, sir, Richard Doll, who was one of the real leaders in the Oxford group that really put forward the notion of the relationship between smoking and and human diseases.
[Dr. Robert Harrington] [1752.06s] He talks a lot he talked a lot in the in in his papers in sixties seventies about when do you have sufficient evidence from nonrandomized data to, to to really drive home a point of certainty.
[Dr. Robert Harrington] [1766.38s] And, and it's things like, you know, biologic plausibility and what are the exact associations.
[Dr. Robert Harrington] [1771.18s] And he goes through a whole series of steps and the relationship between smoking, tobacco use, and, cancer is pretty clear when you go through all of that.
[Dr. Robert Harrington] [1779.63s] And I think we have to remember that that there are times that the observational data is sufficient to make the point.
[Dr. Robert Harrington] [1786.23s] I I know that you know that JAMA has recently made a decision that it will allow causal language in certain cases of publication of observational related research and group of biostatisticians and epidemiologists who are writing a lot about when is it to use causal language.
[Dr. Robert Harrington] [1807.01s] I was at a conference last year at the Harvard School of Public Health on causal language and what does it take in cardiovascular medicine to be able to use causal language.
[Dr. Robert Harrington] [1816.21s] Bobby Yeh's group at the BI has done a lot of this work in trying to understand how you do that.
[Dr. Robert Harrington] [1820.22s] So I I I think the community is coming along, and we have to do a better job of using good observational data with appropriate analytical techniques to be able to make those pronouncements.
[Dr. Morteza Naghavi] [1831.90s] Thanks.
[Dr. Morteza Naghavi] [1833.42s] Last part,
[Speaker 5] [1837.66s] is the public is inured to this, partially because they talk to this person about this in medicine.
[Speaker 5] [1846.65s] They talk to that person about this.
[Speaker 5] [1848.61s] And the message is so fragmented that the totality of what you're talking about gets diluted by the structure in which we approach this problem.
[Speaker 5] [1859.09s] How do we get over and and Bruce Pianton's gonna get into this.
[Speaker 5] [1862.92s] How do we overcome the balkanization of health care?
[Dr. Robert Harrington] [1868.61s] Now that I'm a dean, I'm not supposed to give sarcastic answers, I've been told.
[Dr. Robert Harrington] [1873.69s] But one of the things I would say to you, number 1 is you're right.
[Dr. Robert Harrington] [1877.77s] Number 2 is that our insurance and payment system really drives all of this.
[Dr. Robert Harrington] [1883.53s] And there will I I've said this from the stage before, so I can say it again.
[Dr. Robert Harrington] [1887.37s] There will be no change in the practice of American medicine until we figure out a better way to pay doctors.
[Dr. Robert Harrington] [1893.96s] And because right now, it's the payment system to get paid piecemeal that drives the balkanization that you're talking about.
[Dr. Robert Harrington] [1901.77s] And one of the things that I think really has to happen is wholesale policy change that allows doctors to get paid differently so that maybe, and I won't say definitely, but maybe we'll behave differently.
[Dr. Robert Harrington] [1914.55s] And, but but I but I agree with you, and I'd love to chat more that we're we're thinking about what is it that we can do to try to help with that.
[Dr. Robert Harrington] [1922.30s] And, because it's a mess.
[Dr. Robert Harrington] [1924.87s] It is a mess.
[Dr. Morteza Naghavi] [1928.61s] Well, I said that was the last question, but Bruce seems so eager
[Speaker 6] [1933.37s] to Yep.
[Dr. Robert Harrington] [1934.77s] Yeah.
[Dr. Robert Harrington] [1935.09s] So we have
[Speaker 6] [1936.13s] Thank you, very much, and I really appreciated, you know, the the inflection that you demonstrated.
[Speaker 6] [1946.03s] As we know, socioeconomic drivers overwhelm medical drivers, including medical prevention.
[Speaker 6] [1955.03s] And so I I think your your call to vote is is very important.
[Speaker 6] [1960.47s] But, I I I point out that there's when we look around the world, and this is international, doctors get paid lots of different things ways across the world, and, and there's lots of different ways of doing it.
[Speaker 6] [1976.12s] Outcomes in the US are worse despite much, much, much higher spending.
[Speaker 6] [1982.12s] So I think if we we, look at the this is some of the socioeconomic drivers and, and focus on those, I think we'll find ways forward.
[Speaker 6] [1996.35s] I'm afraid that medicalizing we're not gonna solve this with with medical solutions, not that we should push ahead as fast as possible.
[Dr. Robert Harrington] [2006.83s] You're a 100% right.
[Dr. Robert Harrington] [2008.03s] And when I talk about this in what I'll call in a more expanded way, I talk a lot about the social determinants of health.
[Dr. Robert Harrington] [2014.11s] I talk about structural racism and its effect on, on health.
[Dr. Robert Harrington] [2017.55s] The Heart Association has written a lot on both of these.
[Dr. Robert Harrington] [2019.79s] And if you look at the essential 8, there's nothing fancy there.
[Dr. Robert Harrington] [2024.65s] Right?
[Dr. Robert Harrington] [2024.89s] It's it's pretty straightforward things.
[Dr. Robert Harrington] [2027.13s] But if you look as well as the disproportional impact of all of those on different populations, we see worse outcomes even when you account for the fact that, you know, the blood pressure is only modestly different, for example.
[Dr. Robert Harrington] [2038.66s] So, yeah, we that that to me is falls into the policy realm, and, we we have to figure out ways as a society to be better about this.
[Dr. Robert Harrington] [2048.42s] Yeah.
[Dr. Robert Harrington] [2048.66s] I your point is really well taken.
[Dr. Robert Harrington] [2050.58s] Thank you.
[Dr. Morteza Naghavi] [2051.54s] And the final question.
[Speaker 7] [2053.84s] So I started a model that you're discussing in 2010, tobacco related diseases and lung cancer screening program.
[Speaker 7] [2062.64s] Taking that opportunity of lung cancer screening to identify emphysema and heart disease.
[Speaker 7] [2068.14s] Patients are very motivated by that.
[Speaker 7] [2070.06s] In fact, they're, I would say, arguably more motivated when they see coronary artery disease.
[Speaker 7] [2075.98s] I'm with you.
[Speaker 7] [2076.62s] We need policy change, but often when we're thinking about policy change, we think about coverage and reimbursement.
[Speaker 7] [2081.82s] And I would say that a program like that didn't have a chance to survive because from the top down, we also didn't we we suffer from structural racism within our health systems.
[Speaker 7] [2093.89s] And we have some we we need buy in from leaders within our health systems as well to have the courage and the boldness to flip this paradigm and endure the tough times that we will face when we are flipping from a fee for service to a value based, arrangement with payers.
[Speaker 7] [2111.88s] I mean, it's gonna take everyone, including the purchasers of health care, the the the folks that are on the front lines of delivery, and those who are responsible for that.
[Speaker 7] [2122.05s] And our health systems and our leaders don't have an appetite for that.
[Speaker 7] [2126.61s] So we all have to really kinda move forward with a total shift in what our priorities are and what we're willing what the cost is going to be on from every aspect in order to save lives, particularly for those who are the most marginalized and at the highest risk.
[Speaker 7] [2144.04s] I know I'm speaking to the choir here, but, it it's gonna take everyone.
[Dr. Robert Harrington] [2149.95s] Yeah.
[Dr. Robert Harrington] [2150.19s] I I agree with you.
[Dr. Robert Harrington] [2151.39s] You know, the the the group at, Intermountain, you probably know, in Salt Lake City has talked a lot about waste and health care and has written a lot about it.
[Dr. Robert Harrington] [2158.99s] And as you know, they've moved a lot of their system towards a value based, system.
[Dr. Robert Harrington] [2163.07s] And in part, they can do it because of the captive nature of the population that they have there.
[Dr. Robert Harrington] [2168.59s] And and they really believe that health systems won't make the change until you have somewhere in the range of 25 to 30% of your patient population in value based contracting.
[Dr. Robert Harrington] [2181.53s] That's when it starts to make sense for a system to really wholesale go all in on value based care.
[Dr. Robert Harrington] [2187.61s] They also have estimated that somewhere between 30 50% of what we do is wasted.
[Dr. Robert Harrington] [2193.97s] And part of, I think and this gets to the gentleman's question who asked about the balkanization and the payment system.
[Dr. Robert Harrington] [2200.14s] Part of what we, as the profession, need to do is get that out of what we do every day.
[Speaker 7] [2207.27s] Well, it's also economies of scale.
[Speaker 7] [2209.03s] Right?
[Speaker 7] [2209.35s] And thinking about our efficiencies of workflows and care delivery models, and it's really it's it's really looking at things from a population standpoint, really thinking about group counseling, modeling where you can bring volumes of people in to address issues.
[Speaker 7] [2226.05s] But, again, it's, you know, it's a workflow, and it's also optimizing everyone, all of your workforce, not just loading this on the front end of a doctor's plate.
[Dr. Robert Harrington] [2237.94s] Could could could not agree more.
[Dr. Robert Harrington] [2239.38s] When I leave here, I'm actually on my way to do my epic training because I I I just got my privileges at, at Weill Cornell.
[Dr. Robert Harrington] [2249.46s] I'm a start seeing patients at the end of the month, and I have an hour and a half dedicated to EPIC training.
[Dr. Robert Harrington] [2254.82s] So I I get it.
[Dr. Morteza Naghavi] [2256.11s] Thank you so much Thank you.
[Dr. Morteza Naghavi] [2257.63s] Bob.
The presentations were hosted by I-ELCAP – The International Early Lung Cancer Action Program.
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