Heart of the Matter

The Cardiology Big Tent


Two comments in the President's Page of the Aug. 7 issue of the Journal of the American College of Cardiology raise some concern about the future course of the ACC.

We all understand the problems of keeping each of the cardiac specialties under the “big tent” of cardiology, and we applaud the efforts of the college to prevent the balkanization of our discipline. The advances in interventional cardiology, imaging, molecular biology, treating heart failure, and arrhythmia therapy, to name just a few, make it even more difficult for practicing cardiologists to obtain and retain familiarity with the therapeutic options available to our patients. The college, through its journal and meetings, has been a platform upon which new therapeutic concepts can be presented and older ones challenged. Peer review, which has been the hallmark of the determination of what and when this information is offered for reporting and examination, has been a well-worn, if not occasionally flawed, process.

The President's Page outlines the extensive attempts made by the college to accommodate the needs of the interventional community for representations to the public and to the medical community (J. Am. Coll. Cardiol. 2007;50:558–9). In spite of these efforts, it appears that a few restless members of the interventional community have been critical of ACC leadership for the way new and controversial data have been released at national meetings and to the press.

They have been particularly concerned about the manner in which the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial and the data on late thrombosis risk with drug-eluting stents were presented. The President's Page referred to the “public confusion generated by the results of the COURAGE” trial and outlined the extensive attempts made by the college to accommodate the needs of the interventional community for representation to the public and to the medical community. However, the media circus that occurred as a result of the premature release of the COURAGE outcomes at an industry sponsored symposium should be separated from the results of the COURAGE trial.

The message—that percutaneous coronary intervention does not decrease death or myocardial infarction rates when added to optimal medical therapy in patients with stable coronary artery disease—was clear. Learning more about the benefits and risks of implanting drug-eluting stents in stable patients who seem to do quite well with optimal medical therapy is a critical issue. The result has been a rapid decrease in the use of PCI (percutaneous coronary intervention) by both the interventionalists and clinical cardiologists.

The statement by the authors that “we are concerned about the most significant risk to the profession and our patients, which is health care reform,” is particularly puzzling. It is clear that the college must walk a thin line between its physician advocacy and its quality initiatives. However, many of us see health care reform as an opportunity to effect better care for our patients and a more equitable distribution of our health care resources. The ACC in fact has been well ahead of other specialties in the effort to establish guidelines, which have been specifically directed to this goal.

The membership has acted on the premise that in order to provide an informed and science-based approach to the use of health resources and in order to avoid either over- or under-treatment, guidelines are necessary. Every physician is well aware of the wide variation and often inappropriate use of resources in cardiology. Although we may modify their use in an individual patient, we all fall back on those guidelines to provide a frame of reference for care. Health care reform, if done correctly, can be an instrument to provide an informed homogeneity of care to our patients; it should not be viewed as a risk but as an opportunity to participate in changes that are long overdue.

It is hard to see how the ACC can be a productive participant in the future form of health care if we are driven by a concern about protecting our risks.

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