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Friday, May 24, 2024

Medical: Heart & cancer care

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SAVING LIVES
With technology and careful planning, healthcare providers are making heart and vascular care more accessible.

Whether delivering life-saving equipment directly to patients in cardiac arrest, bringing cutting-edge therapies to prevent strokes, or using technology to allow open-heart-surgery patients a way to recover more quickly at home, health systems are making heart and vascular care more accessible and convenient, and saving lives.

Football fans across the country were shocked to witness Buffalo Bills safety Damar Hamlin collapse on the field after a seemingly routine tackle in a nationally televised game against the Cincinnati Bengals in January.

In July, Bronny James, the teenage son of NBA player LeBron James, suffered cardiac arrest during basketball practice at the University of Southern California. A medical team was on hand to quickly treat him and get him to a local hospital where he recovered.

In Hamlin’s case, a blow to his chest during a tackle stopped his heart, and thanks to on-field medical personnel who immediately administered CPR and applied an automated external defibrillator (AED) to restart his heart, Hamlin lives to play football again.

The remarkable recovery of both athletes is far from the norm. Out-of-hospital cardiac arrest claims the lives of nearly 350,000 people in the United States each year, according to the American Heart Association.

And the Mayo Clinic reports sudden cardiac arrest is the leading cause of death in young athletes. Estimates vary, but some reports suggest that about 1 in 50,000 to 1 in 80,000 young athletes die of sudden cardiac death each year.

Inspired by Hamlin’s recovery from a potentially devastating event, Duke cardiology researcher Dr. Monique Starks is developing a drone network to deliver AEDs to people who suffer sudden cardiac arrest in their own communities.

Last January she received funding from the National Institutes of Health
to explore development of the network and in June the American Heart Association included her drone project among five programs sharing a $20 million grant to develop the infrastructure. The drone project received $3.5 million, Starks says.

“In cardiac arrest, time is of the essence, with only 10 minutes before the patient dies,” she says.

“And really five minutes is the optimal time for using an AED effectively,” she adds.

As a co-investigator with Duke’s ongoing Randomized Cluster Evaluation of Cardiac Arrest Systems program, Starks has been working on strategies for reducing response times to meet that five-minute window. One way is to make sure all first responders are equipped with AEDs. Adding a drone network can further reduce the response time to under five minutes. She has been conducting tests with the Institute for Transportation Research and Education at North Carolina State University with a goal of integrating AED delivery by drones into 911 calls. Pilots would be standing by to dispatch drones and ensure they arrive to the patient in need. Users receiving the AEDs will depend on the 911
operator for instructions on how to use the device.

“We discovered that counties need, on average, five to eight drones to substantially move the median response time for cardiac arrests from eight to 10 minutes to a median of five minutes,” she says.

Recently, Starks aligned her testing procedures with Forsyth County Sheriff Bobby Kimbrough, who is using drones as part of a Drones as First Responders program, the first of its kind in North Carolina.

“It’s a dream come true, and an incredible opportunity to have a hand in bringing this technology to our current cardiac arrest standard of care,” she says.

Bringing cutting-edge care to rural North Carolina, cardiologists at CarolinaEast Heart Center in New Bern are now offering a minimally invasive procedure to treat people with atrial fibrillation (AFib) who are at risk of ischemic stroke.

Dr. Josh Kramer successfully performed the first procedure at the hospital last June using the new Abbott’s Amplatzer Amulet Left Atrial Appendage Occluder, a catheter-based therapy to close the left atrial appendage and alleviate the patient’s need for blood thinners, says CarolinaEast CEO Michael Smith.

CarolinaEast serves the rural northeastern part of the state and has been recruiting specialists like Kramer to help local patients avoid having to travel to distant cities for lifesaving procedures. “We’re proud of the work our folks do here,” Smith says. “They’re incredibly talented.”

AFib occurs when the upper chambers of the heart (atria) beat out of coordination with the lower chambers (ventricles) and contract rapidly and irregularly. AFib can also increase the likelihood of a clot formation, which can travel to the brain and cause a stroke.

Smith says cultivating heart care gives CarolinaEast an advantage for a hospital of its size. “For us to accentuate what we do well, we want to grow that service line,” he says. “We’re recruiting more cardiologists and electrophysiologists, and we’re preparing to serve more patients across a wider region in this part of the state.”

At FirstHealth in Pinehurst, Dr. Michael Pritchett is using Immertec, a virtual reality technology that allows medical professionals in distant locations to observe procedures in a one-of-a-kind immersive environment.

“As soon as they put on the headset they are transported into our facility,” Pritchett writes in an email. This specialized technology uses video inputs from the hospital’s devices, including FirstHealth’s groundbreaking robotic bronchoscopy platform, and from cameras placed in strategic locations including the pathology lab, Pritchett wrote. The interactive technology also allows viewers to talk with FirstHealth doctors in real time. “This technology has been invaluable in training physicians from around the world on new innovative procedures being performed at FirstHealth,” Pritchett writes.

Adding a layer of convenience to heart care, Atrium Health is using technology to enable heart surgery patients to recover at home, thanks to its Perfect Care program launched in 2018 with a $1.1 million grant from The Duke Endowment.

The program relies on remote patient monitoring and virtual follow-up visits with doctors, and along the way, it collects data that can impact patients’ health and the health of others in the future.

According to articles in the Daily Dose, a newsletter published by Atrium Health, Perfect Care enlists technology – like smartphones, tablets, wearable devices, and digital scales – to help keep an eye on patients’ health and well-being.

“We set patients up with a digital toolkit, and then we monitor key health indicators such as weight, blood pressure, and heart rate remotely,” says Shannon Crotwell, clinical nurse navigator at Atrium Health’s Sanger Heart and Vascular Institute. “We also offer virtual visits on a weekly basis for up to 90 days after the patient has been discharged following cardiac surgery.”

Over the last five years, Atrium Health has expanded the use of this program to patients in treatment for diabetes, stroke, weight management and hypertension. The Perfect Care program, which is popular with patients and clinicians, may extend to other specialties soon.

Often the medical journey for heart patients is long and complicated, requiring them to visit multiple specialists in different locations and a variety of appointments.

In 2020, Novant Health opened its Claudia W. and John M. Belk Heart & Vascular Institute and Agnes B. and Edward I. Weisiger Cancer Institute. Though the name is long, the outcome is streamlined. The center consolidates all outpatient cardiac and cancer specialists, treatment services, and support programs in one location to improve the patient experience.

“The Belk Heart and Vascular Institute addresses the development of cardiology and its specialties,” says Mariane Carna, Novant Health Heart & Vascular Institute system administrative executive. “Our role as leaders is to ensure our patients have access to care, that we have the right physicians, and the quality is where it needs to be.”

The Institute is also focusing on prevention. “As our population starts to age, we’re seeing advances in heart care, more prevention, and predictive analysis around what our future holds for us,” she says. “If we course correct at an earlier age, I think in the future we can mitigate a lot of the mortality and devastating heart events.”

 

TREATING THE WHOLE PATIENT
Development of cardio-oncology is just one way cancer teams are treating the whole patient, not just the disease.

A cancer diagnosis can be devastating, both physically and emotionally. Even treatable forms of the disease often take months to stabilize, and depending on its stage, the treatment patients receive can diminish their quality of life, even if they ultimately survive.

Doctors today are finding ways to improve their patients’ experience by focusing on taking a more holistic approach to cancer care.

“We as oncologists have been focused on curing cancer and extending the life of our patients, but we haven’t focused the same degree on the consequences of the treatments or the impact of those treatments on other pre-existing conditions, like cardiovascular disease,” says Dr. Susan Dent, a medical oncologist at Duke University School of Medicine and co-director of the Duke Cardio-Oncology Program.

For the last 15 years, Dent has been making strides in developing cardio-oncology, an emerging subspecialty, recognizing that some cancer patients may have pre-existing heart disease, which may worsen during treatment.

And patients who are heart healthy before their cancer diagnosis, may be at risk of developing cardiovascular disease because of their treatment.

Dent began working in cardio-oncology in Ontario, Canada 23 years ago. She is the founder of the Canadian Cardio-Oncology Network and is president of the International Cardio-Oncology Society.

“I like to think of this specialty as moving away from a disease-centric approach to a person-centric approach,” Dent says. “We’re treating the person, not just the cancer, and we know the treatment they get affects their entire system.”

Dent has worked with cancer and cardiology specialists and primary care doctors to emphasize the importance of treating other conditions like hypertension, diabetes, or heart problems, which in some cases can shorten people’s lives more than the cancer itself.

At the Novant Cancer Institute in Charlotte, Dr. David Rizzieri is also exploring a multidisciplinary approach to cancer care, bringing physicians from different disciplines together under one roof, and aligning medical oncologists with radiation oncologists, surgical oncologists and other specialists.

“This approach to care recognizes that one person can’t do it all, and everyone must come together,” he says.

Rizzieri, is the senior vice president and system physician executive for the Novant Health Cancer Institute. He holds the Agnes B. and Edward I. Weisiger Endowed Chair for Cancer Research.

“Fifteen to 20 years ago you could have a generally trained oncologist up to date on all the latest information and treat everybody with every illness, but we don’t believe that’s the way patients receive the optimum care today,” Rizzieri says.

He adds that the multidisciplinary approach to care recognizes that one person can’t do it all.

“Research shows that patients access about 10 different services across their cancer journey, and here at Novant, we focus on bringing specialists together to provide patients a personalized plan,” he says.

FirstHealth Cancer Center in Pinehurst takes a similar approach to comprehensive care. Located on the campus of Moore Regional Hospital, the four-story, 120,000 square-foot-center opened last March to bring all FirstHealth’s outpatient cancer services under one roof.

In addition to state-of-the-art treatment facilities, the center includes palliative care services, research and clinical trials, navigation and support services for patients and caregivers, nutrition services, a dedicated wellness center, and a healing garden outside where patients and their families can connect and relax.

“We wanted our cancer center to be patient-centric,” Barnes says. “The building is designed for easier navigation from one department to another, and it is designed to be warm and inviting.”

Oncology services at FirstHealth once were spread across several different locations. In the new facility, scheduling appointments is now more streamlined, saving patients time and money.

“Patients that were seeing two or three providers over the course of two weeks can now be seen in a two-hour period,” Barnes says. “Decreasing the number of trips patients have to make improves their overall treatment experience.”

In addition to bringing local specialists under one roof, FirstHealth is taking its multidisciplinary services to patients in outlying communities. The health system draws patients from a 15-county area in the Sandhills region of the state.

“We’re bringing the physicians to the patients, giving them the opportunity to go to a local clinic and see two or three different doctors in one setting, as opposed to having to go to different areas on different days to see those specialists,” he says.

At Duke University, Dent and her team are also exploring ways to push cardio-oncology practices into communities and academic settings.

“We’re exploring ways we can support community centers, and use telehealth visits or video consults with local providers,” she says. “We’re just looking at alternative ways to get the expertise to the patient rather than requiring the patient to come to us, and that’s the challenge in an emerging specialty.”

Dent notes that because of the speed at which many new cancer therapies are developed, the average cardiologist would struggle to know the potential for cardiovascular toxicities they might contain.

“I think for patients who encounter cardiovascular problems while on novel or recently approved cancer therapies, it’s more appropriate for them to go to a dedicated, cardio-oncologist or a cardiologist that has more expertise in treating cancer patients,” she says.

At Novant, the concept of pairing the Cancer Institute with the Belk Heart and Vascular Institute in the same building is part of that same strategy.

“All these new technologies and new therapies are great, but we can’t forget the patients and making sure their whole heath is considered,” Rizzieri says. “So we focus on nutrition, physical therapy, survivorship, and optimize what we call ‘prehab’ to get them on a plan that’s going to help minimize heart damage while they go through cancer treatments.”

A cardiology clinic is located across the hall from Rizzieri’s office.

“We have a gym right here in my cancer building, and we have fitness classes for our cancer patients,” he says.

Before joining Novant, Rizzieri was the clinical vice chief of the hematologic malignancies and cellular therapy division at Duke University. He says his colleagues dubbed him “Dr. Walkamile” because he prescribed every patient in chemotherapy to walk a mile a day.

“The old ways of staying on bed rest are out the door,” he says. “You have to get up every day, consume healthy nutrition and get good exercise.” He adds that collaboration with cardiovascular colleagues is essential to patients’ continued good health and is one of the things that he wants to foster.

And Dent says that Duke’s cardio-oncology program is starting to see an increase in referrals of patients with compromised heart function, who need to continue their cancer treatments without causing further heart damage.

“We even see heart transplant patients,” she says. “I have had a few patients in my practice who have had heart transplants and then developed cancer.”

The International Cardio-Oncology Society has set a mandate to educate providers and works with individuals around the world.

“The Society has 1,000 members from 23 countries, and we are now working with cancer and heart organizations to bring awareness to them about cardio-oncology,” she says. “We’ve done a lot in 15 years, but there is still a lot to do.”

— Teri Saylor is a freelance writer in Raleigh.

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