Expert Perspectives on Managing Polyvascular Disease and Coronary Artery Disease - Episode 3

Provider Engagement and Screening

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Dr Sahil Parikh and other experts discuss engagement of cardiologists in patients diagnosed with polyvascular disease and challenges in screening patients.

Deepak Bhatt, MD, MPH: Sahil, let’s say you’re in the catheterization lab, and you’re treating somebody for CAD [coronary artery disease] but you happen to come across the fact that they have PAD [peripheral artery disease]. Maybe you’re using routine ultrasound, which is good practice. You see a bunch of femoral plaque. Is it your job then to take care of the PAD aspects of that patient? What do you do with that? Do you then own that issue?

Sahil Parikh, MD: Yes. In my practice, I’m usually the patient’s cardiologist and vascular specialist wrapped in 1. If they have a cardiologist, then I do only the vascular job.

Deepak Bhatt, MD, MPH: It’s 1-stop shopping with you.

Sahil Parikh, MD: Yes. It’s incumbent upon us to identify a polyvascular patient for whomever the referring physician might be in my own practice or someone else. Clearly, we’ve all already emphasized that this is a marker of high risk. My antennae are always up when it’s clear that there’s a polyvascular patient. The staff does rock, paper, scissors to not be in my room because we tend to have the highest burden of atherothrombosis systemically in all our patients, and they have the most complex disease. We tend to do some of the most complex procedures as a consequence of that. It’s very important to give that feedback to not just the referring doctor but the patient. And to demonstrate to them that they you have a systemic illness that’s clearly present in a lot of places, perhaps in places they didn’t realize. For us, that means we need to be more aggressive about your secondary medical prevention. It seems like a lot of different categories of medical therapy. That’s critically important.

Eric Secemsky, MD: Deepak, 1 thing that’s interesting about our conversation is we’re talking about screening and identifying polyvascular. I think labeling the patient with this disease and saying, “This is what have,” is important to engage them and obviously our entire health care team. But why is that you should get a colonoscopy at age 45? Nobody questions the value of that. The most common condition in medicine leaves the most burden of events. We’re still a little hesitant to push for studies and things that identify athero. If we want to eradicate the most common thing killing people, we want to bend the curve of cardiovascular disease. Why are we saying that if you came to the cath lab, we shouldn’t know if you have PAD? We shouldn’t know if you have carotid disease. That’s a little on the edge. I get it. But I’m saying that because for cancer screening, we do all kinds of things. To highlight, we haven’t changed cancer mortality in 50 years despite amazing therapies. But they’re very personalized. We’re changing cardiovascular mortality, yet we’re scared to go look for more vascular disease.

Deepak Bhatt: MD, MPH: That’s a really interesting comment. It makes me think deeply about a lot of issues. Part of the hesitancy in cardiovascular medicine is that we’re so evidence based. If there isn’t a trial proving that a screening technique works, we say, “We can’t do that.” But what will change things isn’t necessarily doing to do a bunch of large trials. Maybe we will. I hope we do. But patients, even healthy people, are going to change it. It’s the cost and availability of screening, which is just there for the masses. People can get a carotid ultrasound without the doctor even being in the loop, for example. Or a CT scan of their coronaries. They’re going to do it whether there’s evidence or not. Many times, we’ll be left with the question of what we do with those data in the absence of clinical trials showing that strategy. It’s happening with wearables—maybe it’s a good idea for patients to detect A-Fib [atrial fibrillation] on their own. Maybe I don’t think it’s a good idea. But it doesn’t matter what I think. It’s probably better. I’ll help, as a community, to steer that technology so they’re providing value to patients and, more broadly, the health care system.

It’s been a great discussion on polyvascular disease. I hope the audience enjoyed that.

Transcript Edited for Clarity