Fighting heart disease with novel approaches to care

Fighting heart disease with novel approaches to care

Cardiovascular disease is the number one killer of people in the United States and worldwide. Yet physicians often do not prescribe evidence-based medicines that could change those statistics.

Neha Pagidipati, MD, MPH, wants to do something about that.

“There are therapies that have a ton of evidence [showing they] keep people from developing recurrent disease,” says Pagidipati, a cardiologist who specializes in prevention. “They are just not being used appropriately. That has to change on population level.”

In particular, there are three types of FDA-approved drugs that can reduce the risk of heart attack or stroke among the growing number of people who have both diabetes and cardiovascular disease, a combination often referred to as cardiometabolic disease. The three classes of drugs treat high blood pressure, high blood sugar and high cholesterol, which are all risk factors for both diabetes and cardiovascular disease.

“These are not fair diseases,” Pagidipati says. “They are inequitably targeting patient populations that don't have the resources to combat these chronic illnesses. That's part of what motivates me—it's a public health and a social justice issue.”

In a recent study called COORDINATE Diabetes, Pagidipati and her colleagues tested a strategy in clinics nationwide to encourage physicians to prescribe all three of these types of drugs to their patients with both diabetes and a specific type of cardiovascular disease called atherosclerosis or hardening of the arteries.

In the randomized controlled trial, the clinics that followed the multifaceted strategy successfully increased the percentage of patients who were prescribed all three medicines. Half of the participating medical centers received the intervention and the other half were business-as-usual. At the beginning of the trial, less than 3% of the 1,000 patients were prescribed all three drugs. By the end of the trial, that percentage had risen to 37.9% in the intervention group.

“It has major implications about what methodologies we can use to improve the way clinicians are providing care to this very high-risk population,” Pagidipati says. “That care promotes resilience.”

The intervention was designed to encourage coordination among the multiple specialists who see patients with diabetes and heart disease. In the absence of such coordination, it can be difficult for a cardiologist to prescribe a drug targeting blood sugar or for a diabetes specialist to prescribe a drug targeting blood pressure. The strategy called for health systems to create multidisciplinary teams to identify and remove barriers to coordinated care.

The intervention also provided educational materials to both physicians and patients, and gave the clinics regular feedback about how well they were doing in prescribing the drugs.

The study was designed to measure an increase in prescriptions, not cardiac events such as stroke or heart attacks. However, the investigators did find fewer cardiac events (23) in the intervention group compared to the business-as-usual group (40). While that difference was not statistically significant, it was encouraging.

Pagidipati hopes the results of the study will inspire more health systems to adopt the strategies to improve the health of their patients.

At Duke, Pagidipati is taking coordinated care to a new level. She started a clinic a few years ago where patients with advanced cardiometabolic disease see a team of multidisciplinary specialists, including cardiologists, endocrinologists (diabetes doctors), nephrologists (high-blood pressure experts), hepatologists (liver doctors), and pharmacists. “The goal is to provide coordinated, state-of-the-art comprehensive preventative care for the highest risk patients in the health system,” she says.

Pagidipati's ultimate goal is to improve care not just for patients at Duke, but for patients everywhere. She is planning a randomized trial to measure the effectiveness of the strategies used in her clinic. If her multidisciplinary team helps patients stay healthier longer, she'll be looking for ways to spread the word and influence the standard of care nationwide and beyond.

“At the end of my career,” she says, “I would really like to say that we did something to help people combat cardiometabolic disease, both locally—at Duke—and at large—regionally, nationally, internationally.”