Wednesday, December 12, 2012

My Grand, Sweeping Cardiovascular Predictions for 2013

Cardiovascular predictions for next year are always fun to contemplate this time of year.  So much is happening to the practice of medicine as we've known it that it can be helpful to highlight some of those changes, both good and bad, as our medical world continues to evolve.  While these predictions contain pure guesses, they also contain one doctor's observations of our new evolving medical world.  Many of these changes will profoundly shape how doctors interact with their patients. 

So grab some coffee and strap in.  Here are my 2013 predictions of life as a cardiologist in 2013.  (Please feel free to add your own predictions in the comments section.)

Valvular Heart Disease

  • TAVR for critical aortic stenosis will be applied to progressively younger and healthier patients. 
  • As smaller delivery systems for percutaneous heart valves gain widespread acceptance, government payers will look for new and inventive techniques to restrict patient access to these devices.  No heart valve will remain untouched as creative uses of the approved devices are attempted in non-surgical patients. 
  • Innovations valve design will improve the safety and effectiveness of this therapy.

Ischemic Heart Disease

  • The push for more drugs and less stenting will continue in stable ischemic coronary disease. 
  • Acceptable (payable) door-to-balloon times will shrink from 90 to 60 minutes as payers give the most reimbursement for centers with the faster times.   
  • Radial artery catheterization and interventions will grow in acceptance and CABG will continue to have a more prominent roll  for severe 3v disease (continuing the "reduced stenting" theme) compared to multi-vessel stenting.
  • Lipid therapy recommendations will remain unchanged.


  • Pressure on AF ablation to prove its superiority over medical therapy will continue, especially given ablations re-do requirements, up-front cost of therapy and uncertain utility compared to medical therapy.  Still, until enrollment of the multi-center NIH-sponsored CABANA trial completes, catheter ablation of atrial fibrillation will remain a mainstay of therapy for symptomatic patients with paroxysmal atrial fibrillation.
  • Novel oral anticoagulants (NOA) will see an expanding role the management of AF patients over aspirin and warfarin.  Apixaban will be FDA approved and quickly command the largest market share of the available agents based on clinical data.  Antidotes for reversing these agents will continue development and once developed and proven effective, NOAs will completely change the standard of care for management of stroke-prevention in non-valvular atrial fibrillation. 
  • Subcutaneous ICDs will show a slow growth in acceptance as doctors insist on a smaller device with fewer early battery depletions before adopting the first-generation devices more widely.  Also, look for other companies to enter the  subcutaneous ICD market with devices of their own.
  • Standard pacemaker and ICD implant rates will remain flat.

Heart Failure

  • Readmission rates will be reduced by increasing admission rates to extended-care facilities when heart failure relapses (at least it's not a hospital!) 
  • LVADs will see a slow increase in utilization, but expenses will limit wide-spread adoption at lower-volume centers. 
  • Ultrafiltration will die its slow, inevitable technological death. 
  • Biventricular pacing might see a slight uptick as hospitals seek every possible opportunity to prevent readmissions while maximizing revenues with the first heart failure admission.

Patient Care

  • In 2013, physician computer screen time will officially far exceed all direct patient care time.
  • The Electronic Medical Record will look more like Microsoft Office as basic features of letter writing, e-mailing, scheduling assume higher priorities for communication and coordination in patient care. 
  • Reliance on Big Data to shape proper medical care will consistently be shown to be a poor surrogate for carefully constructed prospective randomized trial due to the inability to code physician logic from progress notes.  Furthermore, associated widespread diagnosis and procedural coding flaws will continue to plague the field.  The implementation of ICD-10 will only make this problem worse.  More data does not mean better data.  Despite these facts, the heavy marketing of Big Data to doctors and hospital administrators will continue.
  • Speaking of guidelines: New guidelines recommending the appropriate guidelines to use will emerge (Should a doctor use guidelines from the AMA, American Heart Association, European Society of Cardiology, American College of Cardiology, American College of Chest Physicians or the Society for Cardiovascular Angiography and Intervention?  Oh, and which year?) 
  • Physicians will tire of completing data entry field for such random and byzantine criteria like appropriateness criteria, safety checkboxes, and quality measures.  But because these criterias' completion will be increasingly insisted upon by Central Planners, administrative employees in medicine will continue their brisk hire rates in 2013.  Doctors will then be forced to complete these fields at home. 
  • The smart phone (and its apps) will officially supersede the stethoscope in importance to practicing doctors of all types (even cardiologists).  Guidelines for appropriate app use will be developed.  The FDA will require their tentacles to extend to this space and stifle innovation here.
  • Patients will be responsible for a higher and higher portion of their health care costs which will lead to a rising voice for price transparency.  This push will be in direct opposition to large medical center/insurance industry efforts to shield their privately-negotiated pricing arrangements. 
  • Look for online health care pricing to grow in popularity. 
  • Appointment availability will dwindle as more patients enter the system.
  • Patient expectations for continued relatively immediate, exceptional care will persist despite the reality of more bureaucratic requirement for physicians. This will continue to grow the sense of hostile dependency toward physicians and their staff.
  • Finally, the push to pay only for outcome-based care will create incentives for facilities to tacitly triage the sickest patients away from some hospitals to their competitors.


  • Doctors will get increasingly tired of attending administrative meetings - especially those that generate more meetings. 
  • Doctors will assume more administrative responsibilities as business policy foot soldiers as they join forces with hospital systems. 
  • The tendency for administratively-minded doctors to clash with clinically-minded doctors will be an inevitable consequence of this new administrating physician prototype. 
  • Despite the outward appearance of more involvement with decisions, administrative physician decision-making autonomy will dwindle as payers exercise their growing sway over drug and device choices and pay only based on clinical outcomes. 

Health Care Terrain

  • Rich hospitals will get richer as poor hospitals get poorer. 
  • Indigent patients who will soon qualify for care will have to travel further for that care. 
  • Emergency rooms will continue to experience larger volumes of patients as the full effects of health care reform have yet to be implemented. 
  • The building spree that has consumed many of the larger health care facilities will taper as financial pressures mount.
  • Employers will seek ways to cut health care costs by negotiating their own prices directly with hospital systems without insurance company intermediaries.

Education / Research

  • Clinical cardiologists (who are increasingly employed) will find less time and money for educational pursuits compared to the time and money required for licensure requirements. Since most employed cardiologists will have expense allotments that cover both endeavors, higher licensure and credentialing fees will limit professional meetings doctors can attend.  The long-term effects of this reduction of continuing education as it pertains to patient care is uncertain.  Doctors are likely to turn to online courses rather than meeting attendance to fulfill CME education requirements.  As such, abstract submissions to meetings is likely to fall. 
  • Clinical research opportunities will continue to concentrate at the largest centers with the largest clinical volumes.
  • Academic cardiologists will have growing pressures to become more clinical as the prospect of expanding patient access looms in 2014. 
  • Academic cardiologists will also find research funds in shorter supply as medical device companies and pharmaceutical companies wean expense items like research protocols.  Government grants, too, will be more competetive than ever.

Summary for 2013

  • Patients will continue to get sick. 
  • Patients will continue to die. 
  • Each of the above will continue to occur despite millions of dollars spent on prevention initiatives and early-detection programs.
  • Despite all of the changes, the hassles, and the headaches coming next year, doctors will continue to care for their patients. 
  • Doctors will continue to have sleepless nights worrying about their patients. 
  • Doctors will still enjoy the reward of seeing their patients improve.
  • And when the dust settles in the years ahead, doctors will remain the only ones ultimately (and yes, still legally) responsible for their patients' health and well-being.
  • Some things, you see, never change.



Anonymous said...

Huge Disappointment.

No mention of Renal Denervation. How can you forget this?

RDN will change the management of afib, VT/VF/SVT, IST, HTN, CHF.

Have you looked at any of the European studies showing an increased EF in CHF, 50% reduction in CHF readmission, reduction in afib recurrence, 30 bpm reduction in HR with afib and RVR, 10 fold reduction in occurrence of PVCs, treatment of refractory VT/VT?

Why is this not mentioned? The University of Chicago is doing the Symplicity HTN 3 trial in your own backyard. Have you asked Dr. Bakris about his results not only on blood pressure but also on cardiac arrhythmias?

RDN will be the biggest breakthrough technology since the ICD which will subsequently become obsolete accept in extreme cases.

How about this for a prediction? RDN cures Takotsubo cardiomyopathy. Pulmonary artery denervation cures pulmonary hypertension.

Anonymous said...

Almost forgot best prediction of all...Ben Scherlag is credited with the discovery of RDN.

Anonymous said...


I predict that in 2013 you will be required by administration to assist in the completion of, as part of a group team building project, a macaroni and glitter poster that welcomes your patients into your lab :)


Anonymous said...

Smaller ICDs & no early battery depletions? This technology has existed for 4 yrs with BSC. However Docs, hospitals & CMS don't view these advances as important healthcare advances.
You have to ask yourself WHY?
The only person that benefints from these advances is the Patient, who has no say in the process.