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Continuum of care a challenge in interventional cardiology
Interventional cardiologists should become preventive cardiologists, according to Spencer King III, MD.
Spencer B. King III, MD, wants to improve long-term outcomes for patients undergoing interventional coronary procedures. He intends to achieve that goal by supporting development of advanced prevention methods that could decrease the need for multiple, repeat interventions.
Part of that plan involves a new program at the Fuqua Heart Center, part of Piedmont Hospital in Atlanta that King and colleagues designed. The program coordinates the efforts of a large, metropolitan heart center with a university.
“We’ve been working on projects that involve care delivery,” said King, chair of interventional cardiology at Fuqua, “and we have created an organization called the Center for Health Care and Learning, which is a joint effort between Piedmont Hospital and Mercer University.
“It’s taking a private hospital and integrating it with university programs in pharmacy, nursing and medicine,” said King, also
Cardiology Today’s Section Editor for Interventional Cardiology. “The primary goals are not basic discovery or bench research but more in delivery of care methods. The nursing and nurse educator shortage are being jointly addressed, and a new physicians’ assistant program has been established.
“How do you develop preventive cardiology programs, which is a major effort of Robert Superko, MD, and Szilard Voros, MD, at this center — to develop 21st century methods to identify patients and families with genetic predisposition for vascular disease?”
Interventional cardiologists can play a pivotal role in developing these programs because they see the patients at a critical time, according to King.
“We stress that the interventional cardiologist must also become a preventive cardiologist — meaning controlling the currently known risk factors and becoming knowledgeable about medical advances that are going to be revolutionary in the next several years. Interventional cardiologists are becoming expert medical interventionalists as well,” King said.
Challenges for specialty
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Fuqua Chair of Interventional Cardiology, Fuqua Heart Center, Piedmont Hospital, Atlanta Chairman of the American Board of Internal Medicine’s subspecialty board in interventional cardiology Editor, Cardiology Today: |
Interventional cardiologists face many challenges and understanding the safety of drug-eluting stents continues to be one of them.
“Drug-eluting stents have clearly been an advance in interventional cardiology for many patients. In others, there are rather marginal improvements over bare metal stents,” King told Cardiology Today.
“For patients who need drug-eluting stents, you have to balance the reduction in restenosis and reintervention events with the small potential for late thrombosis and the need for long-term dual antiplatelet therapy. Initially, drug-eluting stents were adopted almost universally by a lot of people figuring that there was only an upside.”
With concerns about long-term antiplatelet therapy, however, physicians have become more selective about using drug-eluting stents, according to King.
“We have advocated a selective approach to drug-eluting stents all along,” he said.
Lingering questions
Questions linger about antiplatelet therapy and how long patients should be on it. King is uncertain about the answer to this question because current trials have been time-limited.
“We have pretty good evidence that taking antiplatelet therapy permanently in some form is worthwhile for all patients with coronary disease.”
As far as dual antiplatelet therapy is concerned, King said the studies on aspirin and clopidogrel (Plavix, Sanofi Aventis; Bristol-Myers Squibb) indicate this combination is useful for up to one year after PCI.
“But truthfully, we don’t have any good data that tells us how long you should use dual antiplatelet therapy, and it’s a risk–benefit [relationship] that varies from patient to patient,” King said. “Some patients have a greater risk for bleeding than they do of late thrombosis, and for others, it is the other way around. New methods for identifying which patients need long-term dual antiplatelet therapy are needed. Treating everyone to prevent a very rare event should not be the answer.”
Promising future, growth
During the next several years, use of coronary interventions will probably level off for two reasons: first, is the aging population and the increasing surveillance of patients with tools like CT angiography. As a result, more people who are candidates for interventional procedures will be identified, according to King.
“On the other hand, there is an increasing awareness that medical therapy may be adequate for some patients who are mildly symptomatic or asymptomatic. Therefore, referring physicians may be somewhat less enthusiastic in referring patients for interventional procedures,” he said.
There will be a lot of growth in peripheral interventional work, particularly as more physicians are trained in grafting for aortic aneurysms and treatment of leg and carotid artery diseases. Structural heart disease will be another growth area, according to King.
“The potential for artificial heart valve implantation percutaneously is quite interesting and exciting,” King said. “There are many other areas of miniaturization that are going to take place during the next several years that are related to structural heart disease.”
Creating a specialty
King was a key player in establishing interventional cardiology as its own specialty. He successfully advocated for the development of a formal specialty approved by the Accrediting Council on Graduate Medical Education and the establishment of a board exam by the American Board of Internal Medicine. The first exam in the new specialty was given in 1999. To date, approximately 5,500 people have been certified in interventional cardiology through this process.
Among his many other achievements, King and his colleagues at Emory implanted the first coronary stent in 1987 to prevent acute artery closure during angioplasty. This led to their research on restenosis, which revealed that restenosis was largely a wound-healing process. The group developed a coronary brachytherapy method that inhibited restenosis. Their findings influenced drug-eluting stent development.
In addition, King and his co-investigators conducted the first National Institutes of Health-sponsored trial that compared angioplasty with bypass surgery. The Emory Angioplasty Surgery Trial began in 1987. He is currently co-director of the Atlanta TIME project, a collaborative effort of PCI-capable hospitals and the EMS services to reduce symptom-to-balloon time in patients with STEMI.
Training
King attended the Medical College of Georgia and completed his internship at the Walter Reed General Hospital in Washington. He did his internal medicine residency and cardiology fellowship at Emory University. King was a 30-year faculty member at Emory, where he remains a professor emeritus.
He has been a member of the Society for Cardiac Angiography and Interventions since its inception and was president of the organization in 1990. King was president of the American College of Cardiology from 1998 to 1999. – by Colleen Owens