Download Cardiac Complications Caused by Polypharmacy

Event ID: 3017891
Event Started: 8/16/2016 3:44:19 PM ET
Please stand by for realtime captions.
Lee Pearce: So Dr. Yancey I appreciate you taking time to talk with us today and
share a little bit more information about some of the polypharmacy and cardiac
disease topics that you are familiar with. Before that I wanted to give a little
introduction for yourself. I know you are at Northwestern tell us what is your role and
how long have you been there?
Dr. Yancy: Good afternoon and I am delighted to visit with you about a very
important topic. I am Clyde Yancy, Chief of Cardiology and Professor Medicine here
at Northwestern University Feinberg School of Medicine.
Lee Pearce: Excellent, you have been there for a number of years?
Dr. Yancy: Six years here in Chicago.
Lee Pearce: You've got some ties to the south as well?
Dr. Yancy: I am originally from Louisiana, Baton Rouge to be specific. I have strong
ties to the heart association as well. I have formerly been President and I serve as their
official spokesperson.
Lee Pearce: Excellent. The research that we came across in our alliance, the atom
Alliance, we are specifically intrigued with this idea because it seems to affect just
about everybody, especially those were dealing with some cardiac disease, we did
notice that it is called a scientific statement. Can you tell us about this research and
what be scientific statement necessarily implies?
Dr. Yancy: I am happy to discuss this because I think it really sets a really great frame
of reference. The American Heart Association has a very long and incredibly valued
place in American science and American medicine as we have been evaluating doing
the research and implementing strategies to improve cardiovascular health and address
cardiovascular disease. One of the reason there is wise there is such gravitas for
initiatives about the heart association is there is a very strong conviction that science
has to lead everything that we do. If you look at the header of this article, you will
recognize that not only are the names of the individuals specifically articulated, as
contributors to the article, but importantly if valuation's within the organization are
highlighted. The organization divides its clinical components into councils, and the
councils all have an area of specific interest. So for example, I am a long-standing
member of the Council on Clinical Cardiology. But there might be someone else who
was a long-standing member of a Council on Cardiothoracic Surgery and
Anesthesiology or Epidemiology. Point being is that there are a number of parallel
councils that operationally use a different lens to see cardiovascular medicine. That is
a good thing because it helps us understand both the depth and breadth of
cardiovascular medicine. That preamble was necessary because it relates directly to
the construct of the scientific statement. There is a scientific advisory and
coordinating committee for the organization made up of leaders in the field of science
across the country. And from time to time, those is deemed leaders will make an
assessment that there is a subject matter, a topic, a concern, a new development that is
of sufficient importance to the medical community that it is necessary for a group of
individuals to come together, commissioned, if you will, to really summarize available
evidence and generate statements I can go forward to the practicing, prescribing,
treating community to recognize what are the prevailing best opinions that comes
from a dispassionate and partial -- impartial group of experts in different disciplines
working under the heart association. Truly give everyone a best guess. If I could give
you a very short statement, it is an authenticated document from a trusted resource,
the Heart Association, that addresses a topical issue. I thought the background was
import for you to understand.
Lee Pearce: Excellent. It is. I appreciate that. In general, what a scientific statement,
what were the major findings with this research on polypharmacy on cardiac disease?
Dr. Yancy: There are several findings that should come as no surprise, that should
also come as a statement of elevation. Increasingly, we live in a world where we have
many more treatment options for a given disease. Many more interventions, in this
case drugs, to which a patient might be exposed and the potential for drug/drug
interaction goes up exponentially. As well for other disease circumstances likewise
there has been a host of other new compounds developed and all the compounds that
are developed, some of the ones that are very novel, we'll have both known and
occasionally unknown and unrecognized consequences. So as a result, we have to
acknowledge that the first discovery is that there is quite a bit of substance here. It is
not just a handful of drugs about which the practitioner needs to be concerned when
treating a patient with heart failure but rather we should recognize that there is almost
an entire formulary which is otherwise known as a list of medicines, an entire
formulary that represents potential interactions with therapies for heart failure and/or
compounds that might uniquely affect the condition itself. The heart muscle, and the
attendant organ systems that work in concert to either exacerbate the condition or
improve the condition. So I think the first big statement again going from the more
detailed answer to the more pithy answer, the first observation is the complexity. Of
this space that we are dealing with. I think anyone who did not anticipate it would be a
complex space. Has probably fail to recognize the importance here. The second thing
beyond the complexity is just the sheer number of potential interactions. Across
almost all treatment classes for other kinds of drugs there are circumstances where a
drug may in fact exert a less than favorable or less than ideal effect on someone's
cardiac status or with regards to interaction with medicines being used, or that cardiac
condition and so that would be the second thing that it is a complex area, that there are
any number of drugs probably more than anyone can seem to remember that are
necessary when one contemplates this, and the third part about this is in fact
recognizing that we are following at a point in time where the notion that anyone can
walk around with these list, well demarcated in your mindset and can readily identify
drug/drug interactions is not a reality. And so I think the first issue is the complexity,
the second is the depth, if you will, the number of potential circumstances and the
third one is very important, is the necessity to have a process. One can no longer rely
on memory. There has to be a process to vet, to clear, to understand this complexity.
So as to avoid those kinds of consequences that may lead to negative outcomes.
Lee Pearce: Sounds like an enormous and important issue when treating cardiac
disease. Did you find that there was any one or two items that may be were more
surprising than others?
Dr. Yancy: There wasn't that discovery, but what I found fascinating is the notion
where we really don't have to remember all of these things. The suggestion that we
can put together templates using the electronic health record that can Pre-screen, preselect, pre-identify interactions or circumstances seemingly sounds like one of the best
utilizations of an electronic health record that we have yet identified. And so my own
sense is that this is a benefit I was curious to hear you describe it as an issue, an issue
usually means something that is not reconciled or on occasion not reconcilable and I
look at it as an opportunity because one looks at the summary recommendation, there
are well articulated, nine to be exact, that actually are intended to help the practitioner
avoid the pitfalls and one of the recommendations that I found fascinating is this
notion of using complexity tools. This notion of engaging the patient in patient
education circumstances that can help you have the patient as their own sentinel agent.
They notion of developing medication flow sheets is comprehensive and up to date. I
think it's very intriguing intersection of complexity tools to identify potential red flags
with it a medication regimen, the notion of a medication flow sheet which is
comprehensive enough to date which may also include laboratory tests and the ideas
of engaging the patient as a partner in the process, these are steps forward, these are
opportunities, these are things that can be operationalized. They are processed so that
the kinds unacceptable outcomes that come from drug interactions with the conditions
of the drugs can frankly be avoided, so in an area where we need to have precision
and accuracy in medicine, this is just managing information, this information being a
list of drugs, suite of drug, we should have this information solely to difference here.
Lee Pearce: I think this next question was answered with that response but if a
provider is out there and listening to this interview, what would you recommend he or
she do as a first step in trying to take some proactive steps towards ensuring they are
not actually overlooking or potentially harming one of their patients who is dealing
with a cardiac disease condition?
Dr. Yancy: I think a provider has a unique set of references ready. Providers have
access to health records. One of the basic functionalities of electronic health records is
they aggregate a list of medications the patients are currently taking; utilize that list,
keep it up to date, and then interfaced with either a resource that is electronically
available, one of these complexity tools, or better yet, form a relationship with a
pharmacist, someone with whom that practitioner works on a regular basis and says
here's my patient, with heart failure, here's a list of medications which the patient is
exposed, are there any concerns or red flags? I think the time has long since passed
where the physician is the king of the domain. I think it really is about a team now.
And there should be a nutritionist involved in a team, a pharmacist involved in the
team, yes a physician, but yes also a care provider like a nurse, a patient educator, or
something as compelling as heart failure. With so many consequences that are very
important. It would be less than ideal for the practitioner to assume the complete
responsibility and much better for the practitioner to put together the team and say
team, help me with home care services. Team, help me with polypharmacy. Team,
help me with shared decision-making when it is necessary to intervene. These are the
kinds of steps that I think reflect the future dynamic of medicine and especially the
future dynamic of care for chronic conditions like heart failure.
Lee Pearce: So as a quality improvement organization, we are subcontracted through
Medicare so all of our target audience is beneficiaries, on Medicare. And we
encourage them to also listen to these interviews. If you're a patient and you are
listening to this interview and you have coronary artery disease or congestive heart
failure or maybe even hypertension or atrial fibrillation, what do I do if I don't know
that my provider is taking some of the recommendations you just gave?
Dr. Yancy: We can take a step back from that even. In today's world, no patient, no
individual to whom a drug has been prescribed should accept that prescription and
take their medicine without having some understanding of the compound, the intended
purposes, the potential side effects, potential warning signs, potential advantages and
how it interacts with all the other medicines and how it influences not only the disease
but other organ systems. We are in a world today where if you know you are -- you
know your online passwords and cell phone number, you should know your blood
pressure, your weight, your cholesterol, and you should also know your medicines.
What they are, why you take them, how they work, how they will help you and how
they may harm you. It is just a part of the knowledge base that we should have. This
2016, the world is different, healthcare is different, this is an opportunity for the
patient to be a fully involved and engaged participant in their own care. We should not
just take a prescription out of a bottle because someone gave it to us. We should know
what is this medicine, why am I taking it, what should I anticipate, what should I fear,
how will this help me? Those are straightforward questions and answers. I applaud the
fact that one of the recommendations is to educate patients on over-the-counter
medications and on prescription medications. Avoid using over-the-counter
medications without having that preliminary conversation with someone in a
physician's office. I think these are the kinds of things going forward. Again, the
beauty of this whole discussion is that it is all about information. The patient should
be well-informed, the practitioner should be correctly informed. The system should
have information resources available whether that is IT systems or easily navigable
files. This is about information management, we should all on a piece of this. By
doing so, we can avoid some less than ideal situations.
Lee Pearce: That is excellent advice and information. What else? Is there anything
else that maybe we haven't discussed? About this topic in the future. What does the
future hold?
Dr. Yancy: I think the future takes this to the next level. Right now, we are talking
about drugs in a very crude way where there has been an already observed
consequence on cardiac performance, on interaction with drugs. The future is going to
allow us to begin to precisely select drugs according to the genetic profile of the
patient who is a candidate recipient. If you think about this carefully, it doesn't take
much of a leap of faith to recognize that even though we are human, some are older,
some are younger, some of different ethnicities, different races, some of other
conditions, the elements and lung disease, some of different family histories where
there is a family tendency towards her disease or family tendency towards a
neurological concern, when one takes all that into play, you realize that not every
human being is going to respond to every drug the same way. In fact, it would almost
be the more theoretical statement to think that everybody would and more realistic
statement to think there would be some variation. We believe going forward we will
eventually be able to predict drug response, to predict side effects, by knowing a
patient's genetic profile. When it happens we will make many fewer medication errors
because we will reduce the medicines which patients are exposed. We will give them
those medicines which are best for their condition based on their own genetic and
clinical profile and we will be able to use really sophisticated IT technologies to
interrupt potential conflicts for contradictory approaches that might harm someone
and with medicines becoming increasingly sophisticated, no practitioner can hold out
that their knowledge base is infinite and they have a walking encyclopedic knowledge
of all the drugs and all the different consequences. It just isn't likely, and so accepting
that and moving forward makes a lot more sense.
Lee Pearce: How far away? I know genomics is something that is been around for
several years. What would be your guess for the prevalence of that technology?
Dr. Yancy: If we were trying to predict when we will be able to use pharmacogenetics
which is what the field is called for clinical purposes, we are not there yet. But the
only reason we are not there yet is because we haven't done all the right research
initiatives. And we will, once we address these issues in a systematic way led by
science, we will get there. No one thought we would have gotten where we are now
with effective therapies for heart failure and atrial fibrillation coronary disease. Think
about what we have done with abnormal cholesterol levels and the benefit and
breakthrough of statins and now we have PCS canine inhibitors. We will get there.
We will become increasingly more sophisticated with our agents and importantly
increasingly more selective with our choices. Which necessarily means that we will be
doing the right thing for the right patient at the right time more and more often. That is
the future that we anticipate.
Lee Pearce: On behalf of the Centers for Medicare and Medicaid and the atom
Alliance, I still appreciate the time you have taken and share this information. We will
be keeping our eyes and ears open and hopefully you see some of these continued
discoveries and advancements in the Southeast. We are obviously keenly aware of
cardiac disease and again, just how pervasive it is any Medicare patients that are
served. If any of the providers that are listening as well as any of the patients who are
listening to this interview heedDr. Yancy's advice and I just put on the screen contact
information for each state within the atom Alliance. Reach out to us, where certainly
here to help. We have resources, and everything we do is free. All paid for through
our contract with the centers for Medicare and Medicaid. If there's not anything else,
Dr. Yancy a will let you go and thanks again for your time.
Dr. Yancy: There is one other thing. I can't overlook the personal reference to where
you are located in southeastern United States and my own state of origin, Louisiana. I
feel for my brother and in Louisiana, several of whom are without homes and some
have experienced loss of property and if you have even experienced loss of life and
my heart goes out to them. But it is exactly because the burden of cardiovascular
disease that I've seen firsthand in my own extended family in the deep South and
amongst my peers in my social network in the deep South that makes all of these kind
of conversations matter and matter greatly. We run the risk of losing more people
across the South do to just one consequence. One disease. Hypertension. We are the
stroke belt, heart disease belt for a reason because of our incidence of high blood
pressure. We need to know about these issues about polypharmacy. We need to treat
people aggressively for the conditions but we need to treat them smartly and so
understanding these drug/drug interactions in my own home region, my own home
state is incredibly important. I can't thank you enough Lee, for being sensitive to this
and bring this message to populations that really need this information and
practitioners who can take it and help a lot of people. Thank you for doing that.
Lee Pearce: Sure thing, we certainly want to do our part and our relationship with the
heart Association state and nationally is an important role to keep this topic on the
forefront of everybody's mind and again, just explaining how problematic it can be in
so many levels in something like awareness to polypharmacy can exist and we are
going to do everything we can.
Dr. Yancy: Outstanding. Well thanks again.
Lee Pearce: Thanks again, take care.