The Piedmont Heart Institute Addresses Heart Disease & the Family
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| Piedmont Heart Institute, Atlanta |
Each year, roughly 700,000 Americans die from heart disease and 325,000 of those die suddenly without any prior symptoms. In an effort to thwart this scourge, the Piedmont Heart Institute (PHI) in Atlanta initiated the Family Heart Disease Program, which “reaches out to people in the community, identifies those at risk and crafts a treatment plan to mitigate those risks,” says Michele Molden, president and CEO of PHI.
The pilot Family Heart Disease Program, which ran from February to September 2009, was offered free of charge and funded by an anonymous donor. Initially, the program included only family members of patients diagnosed with heart disease. Today, it has expanded to include all patients and residents of the community. Participants pay for the services via insurance or out of pocket. The program integrates CT scans to detect calcium build-up, a medical history review, blood tests to detect genetic markers for heart disease and a cholesterol analysis to create an overall picture of a person’s health and potential risks. The tests take approximately one to three hours.
“We really wanted to invest in the health of our patients,” says Molden. “We set this up as a facility where people can come in, get assessed for risk and begin early intervention. If a person needs treatment, we can start the process sooner rather than later and hopefully never have to perform open heart surgery, put in a stent or see any of the other downstream impacts of cardiovascular disease.”
Auto pilot on
Under the direction of Szilard Voros, MD, medical director of cardiovascular MR and CT, the pilot program enrolled 50 patients hospitalized at PHI for cardiac procedures, along with two of each patient’s immediate family members, for a total of 150 participants. There were three important findings.First, 22 percent of first-degree family members recorded a positive calcium score with significant plaque buildup that warranted aggressive drug therapy. Comparatively, in the general population, only 7 percent of people without a first-degree relative with coronary heart disease will test positive for plaque.
“This means that having a relative with heart disease triples a person’s risk for calcium or plaque buildup in his or her arteries, which is staggering,” Voros says.
Second, the researchers found that the Framingham Risk Score (FRS) did not correlate well with findings on calcium CT scans. All but one of the family members who tested positive for plaque were classified as “low risk” by FRS. “These results highlight the importance of more sophisticated screening tests beyond the traditional methods,” Voros says.
Third, Voros and his team found a very strong correlation between genetic variances in specific genes related to blood pressure regulation and positive calcium scores. Investigators tested 15 gene variances, and while the results are preliminary, Voros says: “This is a big finding because a new pathway of blood pressure regulation may contribute to a calcium deposit in the arteries.” The research also may help tailor blood pressure medication to a specific genotype.
Knowledge is power
Piedmont includes a 481-bed hospital and 31 ancillary care locations. The non-profit institute with 85 cardiologists uses community partnerships, such as with the Atlanta Falcons football team, to promote awareness and advertise the Family Heart Disease Program. In September 2009, PHI employees offered Falcons fans at each home game the opportunity to take a free online risk assessment test and blood pressure screening. Depending on the score of the seven-minute risk test, patients could then be eligible for admittance into the Family Heart Disease Program. “The risk assessment gives the patient an opportunity to connect with PHI, make an appointment and see a physician,” Molden says.The total risk assessment package, including blood tests and calcium scan, can be completed in a few hours and results can be returned the same day, says Joseph I. Miller, MD, a PHI cardiologist. After assessment, patients undergo a consultation by physicians to determine the next steps.
People can self refer for a calcium CT scan, says Miller, but the Family Heart Disease Program is different as it extends the focus onto families at risk for heart disease. “The program offers blood tests to evaluate cholesterol and hemoglobin A1c levels, which are often markers for diabetes and inflammation,” he says.
Next step: Roll out results
“Family history is one of the most important risk factors for heart disease,” says Miller, and beginning this month, PHI will begin its iCARE (individualized Comprehensive Atherosclerosis Risk Evaluation) program to study patient genotypes, which involves screening 700 individuals using pharmacogenomics to detect dangerous plaque.Looking at specific genetic variances can create a customized approach to medicine, says Voros, the study’s principal investigator. The team will study two groups of patients: one managed with pharmacogenomics and the other with traditional guideline-driven approaches. Rather than using the 15 genetic variances studied during the pilot program, iCARE will look at more than one million variances. “We are hoping to determine which of these genetic factors are actually helpful in managing patients,” he says.
The apolipoprotein E (APOE) gene variant, for example, could help determine which lifestyle changes, such as a low-fat or low-carbohydrate diet, would most benefit a patient to fend off heart disease. “The study’s combination of factors such as family history, genetics and plaque build-up allows for more sophisticated therapeutic recommendations, compared to a broad, universal guideline-driven approach, where everyone receives the same therapy,” says Voros.
“When we see a specific genotype, it doesn’t necessarily mean that a patient will have heart disease, but it does mean that he or she will have a very high probability of getting heart disease,” Voros says. “Through programs like this, we are able to start interventions and therapies earlier, which is the first step.”
Cost-benefit analysis
While early detection programs such as the Family Heart Disease Program are fairly easy to implement, smaller, private facilities may have overhead costs and limited return on investment that might impede implementation. “We talk to hospitals across the U.S. almost every day about what we are doing at PHI,” says Molden. The program provides a unique model that could be replicated at other provider settings, she says.The overall costs for the risk assessment package vary, but it generally runs about $650—with costs ranging from $300 to $400 for genetic testing, $100 to $200 for metabolic testing and $150 for a calcium CT scan. However, the benefits outweigh the costs, which are miniscule compared to those associated with heart surgery and hospitalization rates associated with the treatment of coronary heart disease, Voros says.
Most importantly, the program has positively impacted patient outcomes. “We are already seeing that we are doing fewer interventions on people since the implementation of this program,” says Molden. “We want to take this a step further so we are not just prolonging the time before people need intervention, but actually preventing the disease altogether.”