Cardiology Magazine — Spring 2014
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Thinking Globally To Transform Cardiovascular Care

Cardiovascular disease is a burden shared by every country around the world. Although huge strides have been made in treating cardiovascular disease and reducing mortality over the last several decades, cardiovascular disease continues to remain the number one cause of death on every continent. According to the World Health Organization (WHO), 3.8 million men and 3.4 million women globally die each year from coronary heart disease. Countless others are living with or at risk of heart disease — of which the total costs to individuals, families, governments and others are unquantifiable.

These statistics are only being magnified as the result of an aging world population, the global obesity epidemic and the related growth in the prevalence of diabetes and other risk factors. To date, more than 300 risk factors have been attributed to cardiovascular death, leaving no country immune. In developed countries like the U.S. and many European nations, at least one-third of all cardiovascular disease is linked to one or more major risk factors, including hypertension, high cholesterol, smoking, alcohol use, and/or obesity. Developing countries face an even greater burden, in that they are not only contending with the same risks as developed nations, but must also deal with additional factors like malnutrition, communicable diseases and/or varying access to basic health care. According to the NCD Alliance, a global coalition that advocates for non-communicable disease (NCD) prevention and treatment, more than 80 percent of deaths take place in low- and middle-income countries, with this number only projected to rise by 2030 if current trends are allowed to continue.

While the statistics are sobering, there are increasing opportunities to fight back. Ever-growing access to and use of digital technologies is causing major shifts in how information is communicated, learned and received at both the health care provider and patient/ consumer levels. In addition, more and more unique global partnerships targeting prevention and treatment of specific risk factors are forming and being led by unique teams made up of medical societies, industry, government agencies, consumer companies and others.

On the communications front, mobile and digital technologies are allowing for easier access to education, training, scientific advances and patient care. At the ACC, online access to the Journal of the American College of Cardiology, clinical guidelines, self-assessment tools, point-of-care tools like the CardioSmart Heart Explorer and ASCVD Risk Estimator, and expert commentary and latest news, have increased the ability for international members to stay up-to-date in the field. The ability to stream educational programs, including key presentations from the Annual Scientific Session and live cases from hospitals around the world, has also led to increased international participation in educational activities. Patients and their families also have access to a wealth of information and resources about lifestyle choices and heart disease, such as those available on ACC’s website, previously not available to such a wide audience before — let alone at the touch of a finger.

On the scientific front, the ACC is also delivering on its goal to increase international participation in practice standards and quality efforts. Ongoing international adoption of the College’s clinical data registries is allowing local physicians and care team members access to crucial information about the care they are providing in their specific facility and how it compares to other hospitals in the U.S. More importantly, international registry participation is in the beginning phases of building a rich source of clinical data for research, post-marketing surveillance and quality improvement. To date, hospitals from the United Arab Emirates, Saudi Arabia, Brazil and India are pioneering registry partners, with more expected to join over the next few years. Quality programs like the ACC’s Door-to-Balloon Alliance and CardioSmart are also facilitating worldwide improvement in guideline-recommended cardiovascular care and patient education. “Science knows no country, because knowledge belongs to humanity, and is the torch that illuminates the world,” said Louis Pasteur.

The ACC is also at the forefront of global partnership efforts. In 2008 the ACC’s International Council (now the Assembly of International Governors) inaugurated a new era in the College’s international outreach with the formation of International Chapters. These Chapters, which now number more than 30, are in partnership with the relevant national society in each country and include benefits ranging from joint sessions at annual meetings to complementary Fellow-in-Training membership for all cardiovascular trainees. These partnerships have also resulted in novel educational programs, as well as leadership and networking opportunities, previously only available via in-person meetings.

With nearly one in four cardiologists in the U.S. being foreign medical graduates, it is natural to reach across national borders to improve cardiovascular care through education programs, formal training and exchange programs. Some recent examples of Chapter efforts include international “Twinning Programs” between U.S. ACC Chapters and International Chapters resulting in shared education and training of cardiology fellows. Started by the ACC’s California Chapter and the British Cardiovascular Society, these programs have expanded to include Pennsylvania and Italy, and Florida and the Spanish Cardiology Society. The College’s Cardiovascular Leadership Institute program has also been tailored for international audiences and following each year’s Annual Scientific Session, a condensed “Best of ACC” program has attracted large audiences when presented in countries overseas.

On a broader scale, the ACC continues to collaborate with the NCD Alliance and other organizations, to tackle non-communicable diseases. Since the first United Nations Summit on NCDs two years ago, the WHO has approved the goal of reducing premature deaths from NCDs by 25 percent by 2025 and the ACC and others are currently working with governments and non-governmental organizations to move from discussion to action in addressing modifiable risk factors, specifically tobacco, poor diet, insufficient physical activity, obesity, hypertension and high blood sugar. The College is also exploring ways to work with other industry and government partners around public education campaigns targeted at smoking cessation, blood pressure and cholesterol management, and aspirin use, similar to U.S. public/private initiatives like Million Hearts (of which the ACC is an original partner).

On the registry front, the U.S. Food and Drug Administration last April brought together various stakeholders from across the globe to establish the International Consortium of Cardiovascular Registries. The ground-breaking initiative, comprised of the ACC, the Society of Thoracic Surgeons, industry and others, aims to enhance the way device registries are used across the practice of cardiology and around the world.

Of course several key challenges remain. For one, there is still much to learn about the treatment of cardiovascular disease, given that disease type, occurrence and treatment vary with many factors. Despite widespread access to new technologies, there also remains an absence of standardized data, communication networks and both human and financial resources, especially in developing countries. Cardiovascular disease is projected to cost governments $20 trillion in the next 20 years if current trends continue, yet less than 2 percent of global funding is currently going toward NCD prevention and treatment. A lack of research capacity is also an issue. Less than 10 percent of published research is from the countries shouldering approximately 80 percent of the disease burden.

The stakes for success could not be higher. Addressing these challenges and continuing to make advances in both care and prevention will require all parties — medical societies like the ACC, governments, industry, patients and others — to come together in ways they haven’t before. However, in this age of globalization and ever faster communication, there is no better time to look beyond lines on a map and forge stronger personal and professional relationships that ultimately will help the world population live longer, healthier lives.

Improving Population Health in China

ACC’s China Chapter has been an exemplary chapter in the space of patient education. In China, smoking and hypertension are alarmingly prevalent. According to a recent World Health Organization report, 53 percent of Chinese men smoke and 40 percent of Chinese adults aged 45 or older have hypertension. Moreover, awareness and control of these two risk factors is limited. Only 40 percent of hypertensive patients are aware of their condition and only half of these patients receive medication.

In response to the lack of patient awareness regarding these modifiable risk factors, the ACC’s China Chapter has increased information available to the public regarding smoking cessation and hypertension management. For the last two years, the Chapter has hosted a patient education event during the Great Wall Congress of Cardiology that informs the general public about the impact of a healthy lifestyle and curbing cardiovascular risk factors. These events have been successful, with approximately 1,000 attendees each year. The Chapter has also translated CardioSmart fact sheets on various cardiovascular disease risk factors which are distributed to attendees at these events.

To build on these successes, the ACC and the Chinese Society of Cardiology are planning a major new initiative to combat hypertension in China. This project, due to launch in September 2014 at the Chinese Society of Cardiology Congress in Hangzhou, will include the release of a Mandarin language website, distribution of essential educational materials for nurses and patients, and a public health event where blood pressure screening will be conducted to raise awareness around hypertension management.

Expanding Data, Information and Knowledge Globally

In 2010, ACC’s registries were deployed internationally when the Sheikh Khalifa Medical City in Abu Dhabi implemented the ACTION Registry — GWTG. Since then, 13 additional international facilities have adopted NCDR registries. Current international NCDR participants include facilities in Brazil, Canada, India, Saudi Arabia and the United Arab Emirates.

Recently, ACC has partnered with a group of these participants to pilot a new program: International Centers of Excellence. This program recognizes hospitals outside of the U. S. for high performance standards and the provision of quality cardiovascular care. Among other criteria, pilot institutions are asked to demonstrate their commitment to quality services by actively tracking their performance and closing performance gaps based on registry data. The program is scheduled for a formal launch in 2015.

In addition, at ACC.14 the NCDR Management Board approved a new pricing structure for international hospitals that will be rolled out in 2014. The ACC is poised to partner with institutions from its 31 International Chapters and beyond in order to better understand the global burden of cardiovascular disease.

Building Programs to Increase Purposeful Education in India

The ACC recognizes that in order to maximize its mission to transform cardiovascular care and improve heart health, education needs to reach practitioners where they live and work. There is no country where ACC has had more success in this endeavor than India, where educational programs in 2013 reached thousands of cardiologists and physicians treating cardiovascular patients. The premier event held for the past four years is the ACC Cardiovascular Symposium chaired by Valentin Fuster, MD, PhD, MACC. The program regularly draws over 1,000 leading cardiologists and provides a comprehensive two-day update across all cardiovascular competency areas. In addition to this program, ACC extended the reach of its Annual Scientific Session with an ACC.13 Update Roadshow across eight cities in India that reached over 2,000 cardiovascular professionals. Perhaps the most unique offering from ACC in 2013 was a new electrocardiogram (EKG) training program. This was also a city tour that provided training to cardiologists and primary care doctors on how to utilize and interpret EKGs. These programs and others represent the impact the ACC has had on building purposeful education in India.