A Cardiac Surgeon’s Path to Digital Health

I knew I wanted to become a cardiovascular surgeon when I was thirteen years old. Everything about the heart fascinated me—the anatomy, the physiology, the fluid dynamics of blood flow, the function of the heart valves, and the different disease states that caused things to go wrong. At the time, I didn’t have a full understanding of the global burden of cardiovascular disease: that it was the leading cause of morbidity and mortality in the United States for both men and women, or that more people died from cardiovascular disease than from all forms of cancer combined. But I did know of the burden in a different way when my family was touched by cardiovascular disease. Fortunately, my father underwent successful bypass surgery at a relatively young age. I knew at a very personal level what the impact a career in cardiovascular medicine could have. I also knew beyond any doubt that this was the impact I wanted to have.

As I embarked on my educational and post-graduate training path, the more that I learned, the more certain I became of my career choice. Most interesting to me were the incredible medical and surgical advances that had been made in a relatively short period of time. Within the long course of human medicine, cardiac surgery and interventional cardiology were relatively recent disciplines. The current era of cardiac surgery began with the advent of the heart lung machine by John Gibbon in 1953. Cardiac angioplasty and stents would not be performed until the 1970s and early 1980s. When I had the opportunity to observe a heart transplant as a first-year medical student in 1996, I was awestruck and could hardly sleep for days thinking about what I had seen. Since these early pioneering times, once incurable diseases are now routinely treated every day.

I have experienced first-hand the challenges that come with taking care of some of the sickest patients we see in our health systems and have seen how powerful these life-saving therapies are.

In my years of practice, my clinical areas of focus have been in the treatment of end-stage heart failure including heart transplantation, minimally invasive valve surgery, repair of diseases of the aorta, and coronary artery bypass grafting. As the surgical director of one of the busiest heart transplant programs in the country, I have had the opportunity and privilege of being able to operate on thousands of patients. I have experienced first-hand the challenges that come with taking care of some of the sickest patients we see in our health systems and have seen how powerful these life-saving therapies are. The gratification and joy of saving a patient is at times tempered by the burden of loss of life and complications when patients succumb to their disease.  As we often say, the high points are high, but the low points are low.

Many patients that suffer from end-stage heart disease will never receive any advanced therapies.

There is also a sad reality—many patients that suffer from end-stage heart disease will never receive any advanced therapies. Scarcity of resources, rising costs, and lack of access to specialty care limit the number of patients that can be treated. For advanced heart failure requiring transplantation in particular, numerous patients pass away every year while on the waiting list for an organ. Just over 3,000 heart transplants are performed in the U.S. annually. Yet, there are over 6 million patients suffering from advanced heart failure in our country, with over 500,000 new cases diagnosed annually. The demand for donor hearts far outweighs supply. One of my surgical mentors described heart transplantation as “highly effective but epidemiologically trivial”. The need only continues to grow. More and more patients suffer the terminal effects of ischemic heart disease, the leading cause of heart failure, from decades of poorly managed chronic disease such as hypertension, diabetes, and high cholesterol. Despite all the expenditures going to healthcare in this country, it certainly doesn’t seem that we are making much headway in improving the overall health of the population.

A misaligned fee-for-service healthcare system has focused incentives and resources to providing high levels of acute care, but not enough towards preventative care and lifestyle modification.

One afternoon, which extended into the night and spilled into the morning, I emerged from the operating room after a particularly arduous cardiac transplant case. While the patient did well, I was certainly feeling and showing the fatigue more than usual. It was in this haze of exhaustion that a realization worked its way to the front of my mind: maybe I had been asking the wrong question in my career. The question was not only how we can provide lifesaving therapies to more people; but also, how do we construct a healthcare system and engage patients in earlier preventative care so that fewer people end up needing these end-stage therapies in the first place.  We as providers were diligently focused on furthering and increasing treatments for end-stage disease, but were we doing enough upstream to prevent so many people from needing these therapies? More visits to the heart doctor was not the answer. Providing more care when patients got sick wasn’t the answer. It nagged at me; were we doing enough to promote “healthcare” and prevent disease, rather than just providing “sick-care” for acute end-stage patients? The answer was self-evident, we were not. A misaligned fee-for-service healthcare system has focused incentives and resources to providing high levels of acute care, but not enough towards preventative care and lifestyle modification.

The numbers are sobering. Despite the US spending over 19% of GDP on healthcare, far more than any other nation in the world, the health of our population ranks amongst the lowest along a variety of metrics including life expectancy and chronic disease burden. Hypertension is one of the leading drivers of cardiovascular disease, which accounts for the most deaths among men and women annually. Hypertension is one of the major risk factors for heart disease, stroke and kidney failure. These diseases drive enormous morbidity, mortality, loss of quality of life, loss of productivity, and health care costs. Unfortunately, the majority of people with hypertension do not have adequate control according to evidence-based guidelines. I know the importance of why things must change, the question is how?

Heart attack, stroke, heart failure, and kidney disease do not have to be the inevitable ends for those suffering from hypertension.

Hello Heart is fixing this problem and doing so in the most powerful way possible—by empowering people in their own care and giving them the tools to change their own health trajectories. Hello Heart is building a new world of preventative care through digital engagement. Heart attack, stroke, heart failure, and kidney disease do not have to be the inevitable ends for those suffering from hypertension. But, for too many patients, these are the tragic endpoints from years of uncontrolled blood pressure. We need to do better. I feel very fortunate and proud to be joining this incredible team, allowing me to be part of a journey that is having an impact with a scale and scope greater than what can be done from the operating room or clinic alone. The mission of Hello Heart to help people have better lives could not be more important, and the stakes could not be higher. It is the same mission that motivated me as a young teenager to become a physician in the first place.

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Footnotes:

1.  Dharmavaram N, Hess T, Jaeger H, Smith J, Hermsen J, Murray D, Dhingra R. National Trends in Heart Donor Usage Rates: Are We Efficiently Transplanting More Hearts? Journal of the American Heart Association. 2021;10:e019655. https://doi.org/10.1161/JAHA.120.019655. 
2. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation. 2020;141(9):e139-596.
3. Bozkurt B, Hershberger RE, Butler J, et al. 2021 ACC/AHA Key Data Elements and Definitions for Heart Failure: A Report of the ACC/AHA Task Force on Clinical Data Standards. J Am Coll Cardiol. 2021 Apr, 77 (16) 2053-2150.
4. National Health Expenditure Data. Centers for Medicare and Medicaid Services Web Site. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical. Published December 15, 2021.
5. Ahmed FB, Anderson RN. The Leading Causes of Death in the US for 2020. JAMA. 2021;325(18):1829-1830. https://jamanetwork.com/journals/jama/fullarticle/2778234. Accessed February 3, 2022.
6. Estimated Hypertension Prevalence, Treatment, and Control Among U.S. Adults. Million Hearts Web site. https://millionhearts.hhs.gov/data-reports/hypertension-prevalence.html. Published March 22, 2021. Accessed February 3, 2022.