Monday, March 11, 2013

What others missed about heart failure

Every research medical center markets itself as interdisciplinary, with brochures proclaiming that University X is breaking down barriers between research specialties to solve medical mysteries.

Perhaps it started in 2002 when Elias A. Zerhouni, M.D., then newly appointed director of the National Institutes of Health (NIH), began crafting his "road map" for the agency. He concluded that the quickest way to deliver more breakthroughs would be to put multidisciplinary teams on the case, and with the institutions best suited to do so winning more grants. I could argue that UAB has done this better than most, but that's another story.

My point is that I have a high threshold for getting excited about the "interdisciplinary" aspect of anything. It has to be "real," and I think a study, led by UAB's Ali Ahmed, M.D., and making news today, fits the bill.

The study found that an old heart failure drug digoxin, used less and less since it “failed” its clinical trial 16 years ago, may do something no drug has achieved since: dramatically reduce the chances that heart failure patients check into the hospital within 30 days of first taking the drug.

Who cares you say?  The nation's hospitals and Medicare care a great deal. Medicare penalized thousands of hospitals millions of dollars last year for admitting too many heart failure patients too often. The agency leveled the penalties with the rationale that many admissions and readmissions are preventable if care is handled properly, and because frequent admissions cost the agency $17 billion each year. Digoxin is known is reduce scary symptoms of acute heart failure like shortness of breath that send people racing to emergency rooms.

The current study is a re-analysis of the 1997 DIG study in which digoxin failed to lower the risk of death (all-cause mortality) in patients with chronic heart failure. The treatment did reduce the risk for hospitalization, but that fact was largely overlooked. After it failed to reduce mortality, digoxin went from one of the most prescribed heart failure drugs to an afterthought. In the meantime, newer drug classes like beta blockers and aldosterone antagonists came into vogue after successfully reducing both mortality and long-term hospitalization in pivotal trials. And yet, they don't appear to fully address the acute symptoms driving readmissions.

The current analysis found that digoxin could reduce admission for heart failure within 30 days of first taking it by 34 percent. But what made Ahmed check on whether it could do this in the first place? Marketing effort aside, it looks like it was an interdisciplinary approach. Let's look at his titles.

Within the School of Medicine:
  • professor in the division of Gerontology, Geriatrics, & Palliative Care
  • profession in the division of Cardiovascular Disease
Within the School of Public Health 
  • professor in the Department of Epidemiology
  • director of the Advanced Illness, Multimorbidity and Heart Failure (AIM-HF) program in the UAB Center for Aging
Comparing problems faced by heart failure patients, understanding the mechanisms of drugs old and new,  and sifting through public health and policy trends, Dr. Ahmed and his team were able to frame a useful question, and answer it - potentially and in part, with a solution overlooked by the field.

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Here is some media coverage of the digoxin ACC presentation:







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