September 3rd, 2013
Hearts and Minds
Several Cardiology Fellows who are attending ESC.13 in Amsterdam this week are blogging for CardioExchange. The Fellows include Paddy Barrett, Louis Handoko, and Amanda Vest. For more of our ESC.13 coverage of late-breaking clinical trials, interviews with the authors of the most important research, and blogs from our fellows on the most interesting presentations at the meeting, check out our Coverage Headquarters.
Some years back, a good friend of mine continued to smoke despite the persistent requests by his wife that he stop. Being a psychologist, she understood that conventional requests were unlikely to be successful, and she adopted a slightly alternative strategy: She started smoking. Every time he smoked, she did too. She would only quit, when he did. Needless to say, my good friend no longer smokes.
Although successful in its outcome, this strategy clearly can’t be adopted on a larger scale, but it does highlight a very important point. Management of cardiovascular disease is as much a behavioral challenge as it is a basic science one.
There is no doubt that many of the clinical trials presented here will result in therapies that will significantly affect cardiovascular disease. But with the cost of taking a drug to market in the U.S. now estimated to be as high as US$1.7 billion, we must ask whether the degree of benefit justifies the cost.
The announcement of negative, and often staggeringly expensive, cardiovascular outcome drug studies is all too common at these meetings. Yet, we know that achieving most of the seven health metrics, including a normal weight and regular exercise, as outlined by the American Heart Association, substantially reduces not only cardiovascular mortality but also all-cause mortality. Still, the process of implementing them at a population level is costly and lengthy. But, surely, the cost and time benefit accrued must be in favor of behavioral modification.
When increasingly expensive drug trials fail to result in mortality reductions, and behavioral interventions repeatedly do so, maybe we need to rethink our strategies.
This year’s ESC has emphasized behavioral approaches, ranging from the provision of dedicated cycle lanes to and from the conference center, to the presentation of findings of provocative mortality reductions in Tour de France riders.
However, more than anything, we the delegates must first act as advocates and adopters of these behavioral interventions. For the most part, I believe we do. However, with incredulity I have witnessed several delegates avail themselves of the health-conscious option of cycling to the Congress, walk to the main entrance, and promptly light a cigarette. I’m pretty confident that the Tour de France riders studied didn’t celebrate the completion of their stage with a pack of Marlboro Lights.
Achieving the most effective and economical reductions in cardiovascular morbidity and mortality is a much a challenge of the mind as it is of the heart. But as delegates of the Congress, to achieve these benefits of the heart, maybe we need to start by changing our own minds.
How do you see the relative value of behavioral and pharmaceutical approaches? Do you avail yourself of the best “health-conscious options”?