Finding middle ground on heart health

Medicine is a strange mix of the preventive and reactionary. Some of the greatest public health initiatives come from knocking out disease before it hits — vaccinations are a prime example of this.

However, much of routine medicine comes from treating illness after it already  has surfaced, like the emergency care given to a heart attack patient.

Heart health is an area where physicians and insurance companies are attempting to find middle ground when it comes to the preventive and the reactionary. Heart disease is still the nationÂ’s No. 1 killer, and itÂ’s obvious that catching disease early can save lives as well as have a huge economic impact.

The problem lies in how much attention needs to be given to people who may not have any symptoms or only a few risk factors and how to pay for sometimes more expensive screening procedures and tests.

Medicare and the companies that manage its coverage usually do an excellent job of covering tests and screenings for seniors, said John Nelson, a registered nurse who works as the administrator for the Heart Center of North Texas. If a patient sees a primary care physician during a routine physical and mentions that he is having some chest pain during exertion, then the physician can refer him to center for a stress test or some other test to assess heart function.

The stress tests or comprehensive lipid tests like the Berkeley HeartLab are not necessarily considered screening, though, because the patient did mention a problem to his physician, Nelson said.

“That whole screening thing is really nebulous,” he said.

ItÂ’s considered Medicare fraud to do a screening like an ultrasound and then add a diagnosis afterward, but presenting with a complaint means that tests can be done, he said.

Insurance as a whole and Medicare in particular are often thought of as being slow to encouraging preventive medicine, said Kristine Lykens, assistant professor of health policy at UNT Health Science Center School of Public Health. It wasnÂ’t until relatively recently that Medicare started covering screenings like mammograms, she said, but it is making strides in monitoring heart health through primary care physicians.

“Medicare will pay for, and in fact really encourage them, to get annual exams,” she said.

Annual physicals and comprehensive patient and family histories may be the most important screening tool for heart health, said Dr. Roberto Cardarelli, director of the Primary Care Research Institute at the UNT Health Science Center. Cardarelli, an associate professor of family medicine, is also the principal investigator of the North Texas Healthy Hearts study, which has funding through the National Institutes of Health.

The study uses CAT scans to look at how stress impacts the heart, but he said sometimes there is a gap between what may give interesting data for research purposes and what is appropriate for routine clinical use.

“A lot of these tests are estimates,” he said, which can only tell if a patient is at a higher risk of heart disease but can’t gauge for sure what will happen in the future. Getting a good history on a patient can also offer significant insights into whether a patient is at an increased risk of heart disease, he said.

Insurance companies and physicians often use guidelines, such as those set by the U.S. Preventive Services Task Force through the U.S. Department of Health and Human Services, to determine what tests should be administered and when. The problem, Cardarelli said, is that almost every professional organization and advocacy group has its own set of guidelines, and the opinions about what is appropriate can vary. The American College of Cardiology, for example, may give information on how an emerging test can be used but may not have research about it lowers the risk of preventable disease or morbidity, he said.

“It may be just as good to do the things that we’re doing now,” he said.

Integrative cardiology is a movement by cardiologists to take a more holistic approach to treating heart disease, said Dr. Stephen Newman, a cardiologist who does diagnostic and preventive medicine at the Heart Center of North Texas. Newman said the approach, which looks at stress, diet, exercise, mental wellness and more, can have benefits when it comes to screening — for example, checking and finding that a patient has depression can be an indicator of heart health.

The movement is also focused on finding future heart patients before they have their first heart attack or stroke, he said. Patients who may seem at their prime — like 30-something year old marathon runners — may have chest pain and ignore it. However, those patients may already have partially-blocked arteries and are merely being spared worse symptoms because of their youth, and the majority of heart attacks occur without any prior symptoms, he said.

“A lot of us feel if you wait until a patient has symptoms, you’ve really failed the patient,” he said.

Getting the word out about heart disease risks to younger people means that some of them will seek screening, Newman said, and then he can refer them to the appropriate radiology group or other testing facility. Sometimes a patient has several risk factors and a family history that prompt Newman to encourage more tests, and sometimes those tests have to be paid for out-of-pocket, either by the patient or by the Heart Center, he said.

Paying several hundred dollars for a test may be a small expense when one considers the money spent on keeping a car running smoothly, Newman said.

“Most people spend that much at least to get their car serviced,” he said, and keeping one’s health is much more important.

“Heart disease is the No. 1 killer for men and women, and yet we’re not given the ability to go early and do things for those folks,” he said.