From the Chairman - March 2016

March 2016 - Volume 20, Issue 3
March 1, 2016

Usually when we talk about helping people or saving lives we talk in large numbers (populations). Many would say that Vaccines were the most life-saving therapies that were ever developed. Some would tout antibiotics, although it is rapidly appearing that the overuse of antibiotics may end up costing more lives unless this resistance problem is overcome. Many believe that Penicillin was the first Miracle drug (although if you google ‘miracle drugs’ the first thing you get is the top ten erection pills. Miracles are clearly in the eye or other organ of the beholder.) But my choice, or at least a leading contender, would be Insulin. The story of the discovery of Insulin from Langerhans in the 1860’s to its purification by Banting and Best in the 1920’s is an amazing story that saved millions of lives. I should admit that I once claimed tPa to be a miracle drug for acute MI, on live TV. I don’t think we have used it for that purpose in the last 20 years. But it sure sounded good.

It is possible that statins will surpass all of the above given that the #1 killer is heart disease. I believe that every cardiologist who began practicing before the days of statins has been in awe at the decrease in incidence and mortality of coronary artery disease. However, we may be treating too many patients/ or is it too few? We are obviously over treating some patients who will never developed coronary disease and not treating others who will. Guidelines are far from perfect. They try to include as many patients at risk as possible but not everyone. Why not? A few years ago I touted the pollypill of which statins were one ingredient. Other than the side effect of muscle aches would it be so terrible to just treat everyone? We give everyone measles vaccine even though not everyone before the days of vaccines acquired measles. Just watch Apollo 13 if you don’t believe me. Overusing statins isn’t like over using antibiotics. Cholesterol isn’t as smart as bacteria; it hasn’t become resistant to statin use (or maybe cardiologists are just smarter than infectious disease docs.)

But this week I am blown away by a simple statistic in an email I received. At GW we have performed 51 TAVR’s (transcatheter aortic valve replacements) or replacement of the Aortic Valve done minimally invasively without surgical incisions. That means that 51 patients who had no alternative other than to live a short time with a major disability such as class 4 heart failure had a chance and most survived! These were patients who were not surgical candidates and there was no medication that could help them. And just a few short years ago they would have died soon after developing symptoms. These were elderly or debilitated patients that may not have survived surgery but could and did survive TAVR and went on to have some additional time in their lives. TAVR patients live longer and better than patients who do not undergo the procedure (and it appears that woman do better than men.

Now, each TAVR probably cost well over $100,000. Can we afford this type of therapy especially for the sickest and oldest? Of course not. However, when you look at cost in regard to quality of life improvement TAVR is within the cost structure that society already accepts. It compares favorably to other expensive procedures such as bypass surgery or heart transplant. When you think of treating Patients and not Populations you can’t get better  than this.