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Cardiology Care Advances in the VA

 

With heart disease the leading cause of death in the United States and the No. 1 reason for hospitalization in the Department of Veterans Affairs (VA) health care system, the importance of cardiac care cannot be overstated. Cardiovascular diseases involve a range of disorders including coronary artery disease, congestive heart failure, hypertension, stroke, and structural heart disease. Historically, the VA has demonstrated consistent focus on these problems, both clinically and with research efforts, and through an array of current advances and innovative approaches continues its commitment to delivering exceptional cardiology care to veterans.

“I would use the descriptive terms comprehensive, dynamic, exciting, and evolving,” said Sunil V. Rao, M.D., section chief of cardiology at the Durham VA Medical Center and associate professor of medicine at Duke University Medical Center in Durham, North Carolina, in portraying the current state of cardiology care for veterans. “I think that’s a credit to the providers, a credit to the current administration of the VA, and a credit to the veterans, because they’ve demanded better care, and I think the VA has responded to that.”

According to Richard Schofield, M.D., national program director of cardiology in the VA Office of Specialty Care, “Generally speaking, cardiologists in the VA are adopting new treatments in the same manner and along the same time lines as would be seen in academic medical centers and in the private sector. In this regard, the VA benefits from its close and ongoing relationship with over 100 academic medical centers, which allows for sharing of faculty physicians and trainees, and which promotes the early adoption of medical advances.”

In that time, large studies of 7,000 to 8,000 patients randomly assigned to either the traditional approach of doing cardiac catheterization through the groin, or the newer way through the wrist, showed the rate of bleeding and vascular complications from the radial artery approach was 70 percent lower, “with absolutely no sacrifice in the treatment efficacy.”

One example Schofield cited of the VA’s early adoption of cardiology advances is the radial artery access method for cardiac catheterization, a procedure in which a long, thin tube, or catheter, is inserted into an artery and threaded through the vessel to the heart for diagnosing and treating cardiovascular conditions. Rather than the traditional approach through the femoral artery in the groin, radial artery access is through an artery in the wrist.

Schofield noted that this method is increasingly recognized as a quality of care indicator in interventional cardiology, and that the VA has a higher rate of use, 44 percent, than the private sector at 25 percent, as reported in the 2014 American College of Cardiology CathPCI Registry.

Wilkes-Barre cardiac-1

Richard Weaver, registered cardiac invasive specialist (foreground) and Dr. Izzat Shah provide veterans advanced cardiac catheterization care at the Wilkes-Barre VA Medical Center. The majority of cardiac catheterizations performed at the Wilkes-Barre VAMC are radial catheterizations. The VA has a higher rate of use of this method than the private sector. VA photo

“The traditional approach to doing heart catheterization to diagnose and treat heart disease has always been through the femoral artery in the groin,” explained Rao. When cardiac catheterization was first developed, he said, the instrumentation was quite large, but since then, “the equipment has become significantly miniaturized; it’s much smaller now than it was 40 years ago when it was first developed.”

That change allows for catheter insertion through the radial artery in the wrist, a much smaller and more superficial blood vessel than the femoral artery in the groin, which reduces bleeding risk, the major complication from cardiac catheterization.

Schofield described another significant area of progress as the development of dedicated structural heart disease intervention programs across the VA.

Rao said the “golden era” for the radial artery approach has been in the last seven to eight years. In that time, large studies of 7,000 to 8,000 patients randomly assigned to either the traditional approach of doing cardiac catheterization through the groin, or the newer way through the wrist, showed the rate of bleeding and vascular complications from the radial artery approach was 70 percent lower, “with absolutely no sacrifice in the treatment efficacy.”

There are additional advantages to this method, which all contribute to increased patient satisfaction. Rao emphasized, “Patients tell us exactly why they prefer the radial artery approach.”

One reason, he explained, is that it eliminates the requirement for patients to lie flat on their back for four to six hours, necessary after the traditional femoral artery approach. This allows recovery in a more comfortable position post-procedure, especially helpful to those with arthritic conditions or back problems. It also facilitates early ambulation and use of the bathroom in a usual way, instead of the challenge of bedpans or urinals while lying flat. Patients also report much less discomfort at the insertion site using the radial artery, Rao said, so they’re able to ambulate more easily and recover faster at home.

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The Wilkes-Barre VAMC’s Cardiac Catheterization Suite features state-of the art technology. VA photo

Rao elaborated on the VA’s more rapid adoption of the method. “Some small pockets of practitioners started adopting the radial approach,” he said. “We were one of them here in Durham way back in 2006 because we read the literature and said, ‘This is a way for us to increase patient comfort, reduce complications, and increase patient satisfaction, and because the recovery process is so much faster, maybe we could even treat more veterans coming through our VA.’ So we adopted it, and we started teaching other people how to do it, and it turns out that in the last probably 10 years, there’s been an influx of cardiologists in the VA system who are very forward thinking and were already using this approach.”

Rao said that while the VA system as a whole is using the radial approach at a rate of 44 percent, the frequency at the Durham VA Medical Center is much higher at 96 percent.

Using the VA mechanisms for funding research, Rao said, “We’ve studied some of the barriers that physicians and programs may have to adopting the radial artery approach, and the biggest one, really, is lack of training. So the VA has supported a large-scale national program to train physicians and cardiac catheterization laboratories in doing the radial artery approach. And we’re hoping to launch that [program] this fall in an attempt to even further encourage VA centers to adopt the radial approach.”

“Now, we have an option where we can actually replace their valves through a non-surgical catheter procedure with a hospital length of stay somewhere between three and five days, and one that reduces mortality from valve disease by up to 50 percent … And the VA has embraced this as a way to treat our veterans.”

Rao said that the use data over time was further supported by studies, including a 2008 paper looking at just private-sector procedures. “There’s a large database of private-sector procedures housed at the American College of Cardiology, the professional society for cardiologists,” he said, “and we looked at over 600,000 procedures done between 2004 and 2007 in the private sector. It turns out that the rate of radial artery approach during that time period was only 1 percent. So 99 percent of the procedures done outside the VA were being done using the traditional femoral approach.

“So we then looked at it in the VA system a few years later,” Rao continued. “And while early on, again during that same time frame, the rate of radial artery approach in the VA was very low, around 1 percent, it has dramatically increased, I think because of the publication of these studies showing that it was so much safer. So we do have a time line of the adoption rates. Both the private sector and the VA started very, very low. If you say that time zero is 2008, here we are in 2017 and the VA is at 44 percent and the private sector is at 25 percent. So we’ve far outpaced the private sector, and I think it’s because the VA is very focused on a patient-centric approach to cardiology care.”

Schofield described another significant area of progress as the development of dedicated structural heart disease intervention programs across the VA. “These important programs allow for close collaboration between surgeons and cardiologists, and the performance of complex catheter-based interventions like transcatheter aortic valve replacement (TAVR) and mitral valve clip procedures,” he explained.

TAVR Surgeons

A surgical team carries out a TAVR procedure. Thanks to TAVR, many patients who are too high risk for traditional open-heart surgery now have an option for treatment of structural heart disease. Hospital stays for TAVR patients are shorter on average than those for traditional open-heart surgery patients, and recovery is faster. VA photo

In describing structural heart disease, Rao said, “This is not dealing with blockages in the blood supply to the heart muscle and the coronary artery. This is dealing with valvular disease, valves in the heart that either leak or don’t open well enough; for example, aortic stenosis, which is a very common disease among older patients, particularly in the VA population.

“The traditional way to treat that has always been through cardiac surgery that involves sternotomy, cutting the chest open,” he said. “Many patients are not candidates for that surgery because they have so many other illnesses.”

Rao said that about 10 years ago, a technology was developed to enable valve replacement through a catheter. “These catheters are very large, so we still have to use the groin for those,” he said, “But this does avoid the patient having to get their chest cut open, and very large studies have shown that doing the catheter-based valve replacement improves survival over just medical therapy.”

Previously, patients who were not candidates for surgery could only be treated with medication, Rao said. “Now, we have an option where we can actually replace their valves through a non-surgical catheter procedure with a hospital length of stay somewhere between three and five days, and one that reduces mortality from valve disease by up to 50 percent … And the VA has embraced this as a way to treat our veterans.”

Currently, eight VA sites perform TAVR procedures, with that number expected to double over the next one to two years as additional VA facilities upgrade their operating rooms to make them compatible for complex procedures like TAVR.

Rao said there are other procedures coming up very rapidly in structural heart disease, one of which is left atrial appendage occlusion. “This is for patients who have atrial fibrillation, an abnormal rhythm of the heart where the risk is stroke,” he explained. “Because the blood is not flowing through the heart normally, it pools in the heart. It can form blood clots, and those blood clots tend to ‘live’ in the left atrial appendage, where they can break off and cause strokes.

Heart failure is a very common problem, not just for Americans in general, Rao said, but for veterans, adding, “The No. 1 Medicare diagnosis in cardiology is congestive heart failure,” a condition resulting from the heart’s inability to maintain adequate blood circulation.

“We’ve traditionally treated those patients with blood thinners,” Rao continued. “Some patients are not candidates for blood thinners because of a variety of different co-morbid conditions. There’s a new technology now that allows us to actually non-surgically, again in the cath lab, using a catheter without a surgical incision, to tie off that left atrial appendage and basically seal off that area that gets blood clots. That’s a structural heart disease intervention that’s being introduced into the VA.”

The VA has also been a pioneer in the area of cardiovascular clinical data registries through its development of the VA Cardiovascular Assessment, Reporting and Tracking (CART) program. The CART program features real-time patient data entry of all VA patients undergoing cardiac catheterization procedures in a process that is fully integrated into daily workflow in the Computerized Patient Record System, the VA’s electronic health record. This allows rapid and ongoing assessment of quality of care in all of the VA cardiac catheterization laboratories. It also has contributed a number of important research findings in the cardiovascular scientific literature.

Heart illustration

A medical illustration of the left side of the heart shows the left atrial appendage, the cul-de-sac-shaped area protruding from the left atrium (upper chamber). Left atrial appendage occlusion is a procedure in which a catheter is used to tie off that area, which can harbor blood clots that can lead to strokes in patients with atrial fibrillation. Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist

Additionally, the VA administers one of the world’s largest remote monitoring programs for cardiac implanted electronic devices. The National Cardiac Device Surveillance Program (NCDSP) maintains a database of all veterans with implanted pacemakers and defibrillators followed in the VA system, coordinating remote monitoring of 45,000 patients. Remote monitoring has been shown to increase access to timely cardiology care and improve clinical outcomes in patients with these devices. The NCDSP also tracks implanted devices or leads that are subject to Food and Drug Administration (FDA) or manufacturer recall or clinical safety alerts.

Another new development is the rollout of hemodynamic monitoring programs for chronic heart failure, made possible by the recent FDA approval of an implanted pulmonary artery pressure sensor that wirelessly transmits pulmonary artery pressure data on ambulatory outpatients with this diagnosis. Schofield explained, “Use of this ambulatory pressure data is increasingly believed to be advantageous in the titration of oral heart failure medications, and by doing so, the rates of heart failure re-hospitalization may be reduced.”

Heart failure is a very common problem, not just for Americans in general, Rao said, but for veterans, adding, “The No. 1 Medicare diagnosis in cardiology is congestive heart failure,” a condition resulting from the heart’s inability to maintain adequate blood circulation.

He explained that in congestive heart failure, the pressure inside the heart builds up to the point where the blood, rather than flowing smoothly through the heart, pools and causes fluid buildup in the lungs. That pressure can be measured, traditionally with a procedure done through the arm in the cath lab. Medications can be adjusted based on those measurements.

Cardiology va

Navy veteran Danny L. Henderson visits William Jennings Bryan Dorn VA Medical Center, in Columbia, South Carolina, to strengthen his heart after surgery while award-winning cardiology nurse Yvette Twum-Danso, RN, MSN, CCRN, tracks his progress. Such cardiac rehabilitation treatment for veterans has typically taken place in VA facilities, but the VA has instituted home-based cardiac rehabilitation programs so that more patients can experience the benefits of the treatment. Dorn VA photo

“This technology now allows us to implant a monitor inside the heart, in the pulmonary artery, that will continually monitor that pressure and relay that information back to our clinic, allowing us to actually preempt patients from having to come to the hospital,” Rao said.

If the monitoring system relays information that pressures are increasing, he added, “we can call the patient and say, ‘Your pressures are starting to go up. It looks like you probably need to increase your diuretic medicine,’ and we can keep an eye on that pressure to make sure that it comes back down. That allows patients to stay at home, in a state that we call euvolemic, or avoiding having fluid build up in their lungs.”

Rao stressed that the VA has been proactive about getting this technology into its system. Currently, the VA has more than 15 sites that are implanting this device in heart failure patients.

Rao pointed to one more example of the VA’s innovative approach to cardiology care. “This is a new spin on an old reliable treatment, cardiac rehabilitation, which has been shown to be very beneficial for patients who have heart failure or a recent heart attack,” he said. “The challenge in the VA system has been that because the infrastructure, the number of VA hospitals, is relatively constant, we have not had an opportunity to prescribe cardiac rehabilitation to as many patients as we’d like.”

So the VA has instituted home-based cardiac rehabilitation programs, he said. “There are several centers now that have a program, including Durham, where we identify patients who are candidates for cardiac rehabilitation, do their evaluation before they’re discharged from the hospital, and send them home with a pedometer and a tablet that allows us to videoconference with them. This allows them to do their cardiac rehabilitation at home, through monitoring from the VA facility.”

Regarding the VA’s resourceful approach, Rao said, “I think that’s a very creative way of introducing a simple, and yet incredibly effective treatment.”