Lown Forum

All in the family: Matters of the heart

Brian Bilchik, MD
Genetic susceptibility. Support. Learned lifestyle. Happiness. Shared environment. Stress. When it comes to heart health, family matters.

T HE

2010

NUMBER

LOWN CARDIOVASCULAR RESEARCH FOUNDATION

Families of all kinds and sizes have been part of the Lown Cardiovascular Center for generations. We care for brothers and sisters, husbands and wives, parents and children, grandparents and grandchildren. Our patients demonstrate the enormous variety of ways in which family sometimes inuences cardiovascular risk factors as well as the ways families can promote heart health. A patients family history reects his or her genetic susceptibility to a range of cardiovascular conditions such as premature coronary artery disease and stroke. On top of that, families share environments, eating patterns, and frequently adopt similar behaviors. People can react to their family histories in many ways. Some become crippled by anxiety, convinced that the heart attack that killed a parent will strike them at the same age. Or they may feel falsely reassured by the fact that grandmother lived to be 100 although she smoked like a chimney. Others respond with denial: Dad was diabetic because he was overweight, but I work out.

At the Lown Center, we pay careful attention to each patients family history in a way that incorporates the complex interaction between environmental, behavioral, and genetic factors. Our approach is in direct contrast to what today is called personalized medicine, which is a form of genetic proling that lumps people together based on inherited risk factors that may have signicant prognostic bearing but may actually depersonalize care. Personal medicine as practiced at the Lown Center, on the other hand, builds a relationship of trust and openness between physician and patient. It requires time, careful and unhurried listening, and searching out the uniqueness of each patient in order to understand him or her as a unique and complex person. Understanding family history can be a powerful tool for both physician and patient. It provides information and insight that is critical to identifying and preventing heart disease. When addressed proactively, a patients family history can become one of the best motivators in promoting healthy behaviors. Conversely, lack of family history is equally important, and should be sensitively considered in order to provide the best care possible for our patients.
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FAMILY ALBUM

Four generations of Lown Center patients: One familys history

We visit the Lown Center in packs, joked Tony Jarvis, Jr. during a recent visit with his mother, Carol. Tony Jr., as the Lown sta refer to him, is part of the 3rd generation of a family whose history with the Lown Center began over 40 years ago when Carols mother was a patient of Dr. Bernard Lown early in his cardiology career.
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Carol and Tony Jarvis, Sr. (front seat) with children Marcia, Barbara, Nancy, and Tony Jarvis, Jr. Four generations of Jarvises have been Lown Center patients.

INSIDE

2 3 4 5

Presidents message Lown Center updates Question from a patient A new renaissance in medicine NewsBeat

6 8 9 10 12

Patient guide to family and heart health ProCor at World Congress of Cardiology Training healthcares future leaders Family histories Contributing to the communitys health

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If you would prefer to receive the Lown Forum by email, send your full name and preferred email address to info@lownfoundation.org.

PRESIDENTS MESSAGE

The Aordable Care Act

Vikas Saini, MD, President
After saturation coverage in the media last year, the Obama health care reform has passed. The major thrust of the legislation is to expand coverage and end the burden of an uninsured population. Now 45 million uninsured in the US will have access to insurance, but aordability remains a big unknown. A mandate to purchase insurance raises a host of issues. Key to aordable pricing will be the ability to control medical ination, but there is much dispute about whether any of the measures in the bill will actually save money. Early discussion by the administration of cost-containment faded quickly, in part because of the ruckus over rationing and death-panels. This occurred despite wide acknowledgement that there is much overuse, overtreatment, and waste in the health care system, as the Lown Group has emphasized over many decades. What aspects of the bill might be of interest to the Lown community? Some economic elements are worth noting. In 2010, small businesses get tax credits to oset health insurance premium costs for employees and participants in the Medicare Part D donut hole in prescription coverage get a $250 rebate; in 2011 they receive a 50% discount on brand named drugs. Prevention is apparently acceptable to both sides of the aisle: the bill takes small but signicant steps in the right direction. Medicare co-pays for annual wellness visits are eliminated. Co-pays and deductibles for preventive services such as screening for cholesterol, diabetes, high blood pressure and depression are also eliminated in 2011. Buried in the details are items of potentially greater signicance. Medicare beneciaries will gain access to a comprehensive health risk assessment and creation of a personalized prevention plan and will have nancial incentives to change behavior. The government will provide grants to small employers that establish wellness programs and all employers will be able to oer rewards of up to 30%-50% of the cost of participating in such programs. Many details remain to be worked out. Increases in coverage will undoubtedly create crises of access and budgets as Massachusetts has discovered. What seems clear is that passage of the legislation marks the beginning of a long process of change. As the contradictions are sorted out, we believe that our way of practicing medicine will be seen as a valuable and necessary part of the solution we need.

Dear Readers: Please tell us what you think!

To make the Lown Forumthe newsletter you hold in your handas interesting and useful as possible, we are seeking feedback and ideas from you, its readers. We have embarked on a survey of what you think and what you would like to see in future issues. Our brief questionnaire should only take 5-10 minutes for you to complete. All answers will remain anonymous. Therst50peopletocompletethequestionnairewill receiveaFREEhearthealthygift! Howtorespondtothesurvey: Papercopies:Copies of the survey are available in the Lown Centers waiting areas. We are also happy to mail readers a copy of the survey with a stamped return envelope. Please call Jessica Gottsegen at 617-732-1318 x3805 to request a copy. Online:You can complete the survey online by visiting www.surveymonkey.com/s/lownforumquestionnaire. A link to the survey also appears on the Lown Foundations website, www.lownfoundation.org. Email:If you would like to receive the survey as a Microsoft Word document by email, please contact Jessica Gottsegen at jgottsegen@partners.org. The Lown Forum is published quarterly. Past issues are available on the Foundations website. Themes of past issues include: 2010#1: Guide to lowering cholesterol with lifestyle 2009#4: Stable coronary artery disease: A benign condition 2009#3: Atrial brillation: The importance of individualized treatment 2009#2: Addressing stress to promote cardiovascular health 2009#1: Honoring Dr. Bernard Lown

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LOWN CENTER UPDATES

QUESTION FROM A PATIENT

Shmuel Ravid, MD Does Prilosec, which I take for heartburn, increase my risk of a heart attack? I read that it diminishes the effects of Plavix, which I take in order to prevent blood clots in my stent.
Drug-eluting medicated stents (DES) are frequently used to open blocked heart arteries. However, the medicine in the stent, which helps to prevent tissue growth and future blockages might interfere with prevention of blood clot formations and result in stent occlusion (thrombosis). To minimize the risk of DES thrombosis, patients are treated with long-term Plavix (clopidogrel) and aspirin to thin their blood. The downside of this intensive treatment with two blood thinners is a higher risk of bleeding, in particular gastrointestinal (GI) bleeding. Proton pump inhibitors (PPIs) such as Prilosec, Protonix, and Nexium are frequently prescribed to patients with DES to address their higher risk for GI bleeding. However, because they compete for the same metabolic pathway, PPIs may inhibit Plavix transformation to a more potent form resulting in a potential decrease of active Plavix availability by almost 50%. Although this interaction is of concern and theoretically might increase the risk of stent thrombosis and subsequent incidence of heart attacks, so far there are no credible high-quality clinical studies that conrm worse outcomes in DES patients using PPIs. Based on current evidence, medical associations have formulated the following recommendations: 1. Following placement of DES, aspirin and Plavix or a similar drug are recommended for at least one year. Patients who are at high risk for bleeding or who are expected to have surgery within a year after stenting might benet from a bare-metalnon-medicated stent, which does not have the long term anti-clotting properties of a drug-eluting stent, and therefore requires only short term treatment with Plavix. 2. PPIs may be prescribed quite safely to patients taking Plavix if they are at very high risk for signicant GI bleeding, or have experienced such bleeding previously. 3. Patients with heartburn or other mild symptoms of acid reux should use H-2 blockers such as Zantac (ranitidine) or Pepcid (famotidine); but not Tagamet (cimetidine) instead of PPIs in order to minimize a potentially harmful drug interaction with Plavix.

Email appointment reminders

The Lown Center continues to collect and update patient email addresses in anticipation of installing an email alert system to remind patients of upcoming appointments. These emails will be sent a week before the appointment. Please update your demographics during your next visit, or call the oce at 617-732-1318 x3315.

New government regulation

Do not be surprised if you are asked to provide your drivers license or social security card when checking in at your next appointment. Federal legislation aimed at protecting medical information and records from fraudulent use requires health care providers to conrm patient identity. We are striving to copy a governmentissued ID of all patients seen at the Lown Center. Your cooperation is appreciated.

Meet ProCors summer interns

The Lown Foundation welcomed three interns during the summer of 2010. They worked on a number of ProCorrelated projects including writing and posting prevention ProCor Interns: Romey, Zoe, and Fiat updates and other daily content, creating and evaluating a survey of the ProCor community, investigating the eectiveness of social media in developing countries, and producing a global CVD fact sheet. Meet the interns! FiatVongpunsawad,MPH, is a 2010 graduate of Boston University School of Public Health. He received his Bachelor of Science degree from Brigham Young University. His focus of study includes epidemiological surveys, oral public health, and Southeast-Asian orphanage health policy. ZoeBlatt is a junior at Union College in Schenectady, NY. In addition to pursuing a Bachelor of Science degree in Environmental Sciences with a minor in Sociology, she is on the Pre-Med track. She spent part of her summer in Alaska examining the interface between science and societys role in mitigating hazards. RomeySklar is a long-time Brookline resident and a senior at Brookline high school. He is interested in pursuing an education and career in foreign relations and global communications in college. His other interests and skills include website and graphic design.

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A new renaissance in medicine

Bernard Lown, MD
This spring Louise and I visited Rome and Florence. Italy for us evokes images of expressive people, radiant sunshine, good wine, delectable food, and above all else, the Renaissance. This cultural rebirth, begun seven centuries ago, transformed the way human beings perceived themselves and the natural world around them. During the preceding era of medievalism, life was short, uncertain, and miserable. The dominant worldview was insular, steeped in superstition, charged with dread and bigotry. The singular aim of life was to serve an inscrutable, unpredictable God. Human history had reached a dead end. The Renaissance, in the course of two centuries, washed away much of this medievalism. Launched in Florence, it swept through Italy and Europe. The new vision was captured in painting, sculpture, architecture, literature, and science. Thinking dramatically shifted away from the centrality of God to the godliness of man. An invitation from the distinguished Italian cardiologist Attilio Maseri would have elicited an automatic acceptance but for the oddity of the stated purpose of the visit. Apparently I was to have an audience with Pope Benedict XVIin the Vatican. An extensive email exchange over the ensuing months revealed a dierent intent.

Dr. and Mrs. Lown in Florence, where the Italian translation of The Lost Art of Healing was launched in May 2010.

and I surprised the ponti by giving him a copy of the edition published in German, his native language, with a painting on the cover by Goya, himself as patient being ministered by his doctor. We shook hands, we were blessed, and we received rosaries. The book launch in Florence took place in the Palazzo Vecchio, the most important civic monument in Florence and the former home of the Medici family. A symposium titled A New Renaissance in the Relationship between Doctor and Patient assembled distinguished political, academic, scientic, and medical leaders. Among the speakers were the president of Tuscany, the mayor of Florence, the rector of the university, the dean of the medical school, the director of the Italian equivalent of our NIH, and leaders from various medical specialties.

The key issue addressed was the loss of the human relationship between doctor and patient. Speakers acknowledged that medicine is increasingly focused on the diseased organ rather than the troubled This mini-drama began when human being. They also recognized Leonardo Bolognese, the editorthat many medical decisions are in-chief of the Italian Journal of shaped by economic forces to the Cardiology, serialized over four detriment of patients. Time consecutive months (Septemberpressures and ever more December 2009) an unabridged sophisticated technologies are translation of my book, The Lost rapidly industrializing the practice of Art of Healing. This unprecedented medicine. Interesting ideas were action evoked a urry of raised on how to integrate scientic approving letters from readers. It Pope Benedict XVI, Dr. Attilio Maseri, and Dr. Bernard advances without losing sight of the led to the publication of the book Lown during the papal blessing of the Italian centrality of the human narrative. by a Florentine-based medical translation of The Lost Art of Healing. foundation, Fondazione per il tuo The gauntlet thrown down from a modest Cuore. A rst printing of 10,000 copies was distributed cardiovascular clinic in Brookline some four decades ago without charge to every Italian cardiologist. is now being taken up by the world. The Lost Art of Healing has been published in Brazil, China, Germany, By the time we arrived in Rome, it seemed that the India, Italy, Japan, Korea, Russia, and Taiwan and is being meeting with Pope Benedict XVI was a formality merely to translated in other countries. It was appropriate, bless the Italian edition. The book was to be launched in though, that Italy reminded us of the urgency of a Florence. But in Italy few events are enacted without second Renaissance, a rebirth of human values in the operatic air. In St. Peters Square, with an assemblage of doctor-patient relationship. To continue medicine as a more than 10,000 Catholic pilgrims from around the calling, physicians need to reclaim their long hallowed globe, Dr. Maseri handed the pope the Italian translation, tradition of healing.

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The Lost Art of Healing: A tale of many translations

The Lost Art of Healing was rst published in 1996. Dr. Lown had authored several medical texts, but this was his rst book for a non-clinical audience. A summation of medical experience over four decades, The Lost Art took three years and a lifetime to write, he recalls. I wrote it for patients, not for medical professionals. It expresses a style of clinical care that combines advancing scientic insights with a core of human values. The way to inuence medicine is to educate patients so they will have a higher level of expectation. Though The Lost Art received positive reviews in the media and medical literature and remained on the Boston Globes bestseller list for months, It wasnt a stunning success, he notes. Unexpectedly, however, it was translated and published in Japan in two beautiful volumes. After several years, a German translation was published and was immensely popular, appearing in four hardcover editions and in paperback. Translations followed in Taiwan, South Korea, China, and Brazil. In 2009, the book was picked up by a publisher in India, where it was heralded by the popular press. Then I received a call from a professor of English I had met in Moscow, who asked me if she could translate it into Russian, Dr. Lown recalls. She said, I got such joy out of it, I want it to exist in the Russian language. She took her translation from publisher to publisher, and it appeared in Russia in May 2010 under the title Children of Hippocrates of the 21st Century. Though each of the translated versions was a surprise to Dr. Lown, he was most astonished by the recent translation of The Lost Art into Italian where it was serialized in a leading cardiovascular journal, then published in hardcover and distributed at no cost to 10,000 Italian cardiologists. I have not had a role in any of the books that have come out in other countries, he observes. I think it reects a humanitarian crisis that aicts medicine because the profession is losing its human touch.
Order The Lost Art of Healing and other books authored by Dr. Bernard Lown at www.bernardlown.org.

LOWN CARDIOVASCULAR CENTER

NewsBeat
Dr.FredMamuya was the keynote speaker at the Healthy Living Expo on May 4, 2010 in Hyannis, MA. The topic of his presentation was Your heart, your health. Dr.CharlesBlatt addressed the NewBridge on the Charles community on May 19, 2010 in Dedham, MA. The topic of his presentation was "Bypassing the bypass: The overuse of coronary bypass surgery in America." Dr.TomGraboys and his wife Vicki discussed his memoir, Life in the Balance, at the Ogden SurgicalMedical Societys 65th Annual Medical Conference in May in Ogden, Utah. Dr. Graboys and his daughter, Dr. Sarah Graboys Valeo were guest speakers on June 24, 2010 at Chestnut Parks Summer Author Series in Brighton, MA, where he discussed his book and his experience as a patient. Dr.BrianBilchik, ProCor director, and BennGrover, ProCor editor, attended the 8th Annual National Forum for Heart Disease and Stroke Prevention in April 2010. The two-day conference, Creating the Will for A Heart Healthy and Stroke Free Society took place in Washington, DC. Dr. Bilchik facilitated the session, Organizing Global Initiatives to Improve Education and Training in CVD Prevention. TheBernardLownAwardfor ExcellenceinTeachingat BrighamandWomensHospital was awarded to Dr.Tracey Milligan at the Harvard Medical School Teaching Awards Celebration on May 10, 2010. Since joining the neurology Dr. Tracey Milligan and faculty at BWH, Dr. Milligan has Dr. Bernard Lown taken on diverse teaching and leadership roles in education. Dr. Milligan is a well known and highly regarded teacher and lecturer, which nominees attributed to both her brilliance and her interactive, approachable style. Dr.VikasSaini has given a series of talks over the last three months in several local communities, including Acton, Milton, and Belmont. See page 12 for a related story.

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Patient guide to the role of family in heart health

Brian Bilchik, MD

Genetics: Legacy of risk, knowledge

Recently, a man who accompanied his wife to her appointment at the Lown Center stopped in my doorway and said: My mother just had a heart attack and bypass surgery. I wonder if I should get myself checked out? Inherited risk factors for heart disease come in two forms. Some, like cardiomyopathy (thickened or weakened heart muscle), valve problems, or aortic aneurysms, are silent until an acute problem manifests. Or someone may be having symptoms of an underlying condition and not realize it. People who have experienced the sudden, early death of a close relativeparticularly a parent or siblingshould be proactive in being screened. A thorough family history coupled with a careful clinical examination and noninvasive tests like EKGs or echocardiograms can help identify abnormalities and set people on the path to avoiding future problems.

If risk factors, premature heart disease, or sudden death are part of your family history, its never too early to check out your cardiovascular healthwhether you make an appointment at the Lown Center or elsewhere. Addressing modiable risk factors at an early age is imperative. We cant exchange our genetic inheritance, but we can change our lifestyle and environment.

Behavior and environment

Heart disease, diabetes, hypertension, and obesity are aecting more people at earlier agesa result of tobacco use, unhealthy foods, and sedentary lifestyles. Younger people, especially teens and young adults, comprise an increasing segment of Lown Center patients. Concerned parents who have learned the importance of healthy

Addressing modiable risk factors at an early age is imperative. We cant exchange our genetic inheritance, but we can change our lifestyle and environment.
behaviors often bring their children who are overweight or who smoke. Others, grappling with their own heart disease, want their children not only to be screened but also to understand the importance of early intervention. Sometimes children who bring their parents to appointments recognize that they might have a problem too. Inherited risk for cardiovascular disease and lifestyle behaviors coexist in a complex relationship within the context of peoples lives. Environmental factors such as work, stress, and air pollution play a signicant role in contributing to cardiovascular disease. It is important for physicians and patients to understand and respond to environmental factors, and control them to the extent that it is possible.

For example, sons of mothers with coronary artery disease tend to develop heart problems ten years earlier than daughters. If a condition is identied early on, we can determine whether it is benignit poses no risk or how we can reduce risk. For many people, quitting smoking, reducing salt intake, regular physical activity, or losing weight can be enormously helpful in protecting their health despite the presence of such conditions. Hypertension and high cholesterol can also be inherited. A nonsmoker with a healthy diet and active lifestyle may unknowingly develop high cholesterol or high blood pressure at an early age. With early detection and appropriate management, problems later in life can be averted. An older patient of mine who is diabetic and has coronary artery disease recently learned that two of her three grandchildren have type 2 diabetes. She wept as she told me how guilty she feels for passing this on. I made it clear to her that science has advanced remarkably, and that her grandchildren were identied at an early age. I reassured her that by being positive and supportive she can encourage them to adopt the behaviors that will protect them as they grow older.

Education and empowerment

People generally wont implement change unless they understand why its important. This requires individualized education and support from someone who is trusted and respected. If a person has a family history of coronary artery disease, I strive to empower them by giving them information they can understand and use about the potential consequences of their choices. I may explain, Tobacco

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will increase your risk of heart disease ve-fold. Modifying what you eat and your level of activity can double your protective factors, but you cant do one without the other. If you smoke, you negate all the other benecial things you might be doing. I never use scare tactics. When people understand how their bodies work, they are more likely to make informed decisions and healthier choices. We achieve this by not talking down to people, but by taking the time to help them understand the biology and letting them know were interested in their well-being. Individualized messages are much more eective than one-size-ts-all. If theres an inherited disorder, knowledge is powerful. Education about heart health, especially for young people, needs to be sustaining and consistent; it requires reminders and feedback, empowerment and motivation. The most important asset we all share is a desire to live longer and healthier. Family history can be a powerful motivator in choosing a heart healthy lifestyle.

A family history how-to

At the Lown Cardiovascular Center, home to generations of patients and a committed core of physicians, medical histories are maintained and transmitted. New patients who come to the Lown Cardiovascular Center complete a detailed family history questionnaire which is reviewed in advance of the rst appointment, when patient and cardiologist thoroughly discuss all relevant information. We encourage patients to bring a family member or close friend to their appointments. Their support, perspective, and integration into future planning are of enormous benet to both patient and physician. For new and established patients alike, its important to keep your history up-to-date. Let us know if and when close relatives experience signicant health issues. Talk to your physician about any new stresses or events in your life. At the Lown Center, we all rmly believe in the importance of taking time to talk, and we are committed to working in partnership with you to achieve optimal health outcomes.

Modeling healthy behaviors: Eat healthy and stay active!

Modeling healthy behaviors for children is key to helping them grow up healthy. Unhealthy behaviors and addictions to tobacco, salt, or sugar and even screen addiction are often learned within families and passed on from generation to generation if you spend your time in front of the television or computer, your child will most likely do the same. Fortunately, healthy behaviors can be modeled and subsequently adopted by those around us. Many people nd it easier to change their own behaviors when they realize that it will benet their children, and spouses are often willing to change the habits of a lifetime when they realize it will enhance the life of the person they love. An obese patient of mine was nally able to address her own health issues when she recognized that her nineyear-old daughter was also signicantly overweight. She changed the way her family ate, and they bought a dog so they could walk together every day. Her strong motivation improved not only her own health, but that of her whole family. Modeling healthy behaviors benets us all: it increases our chance of seeing future generations grow up, it increases the likelihood that they will grow up healthy, and it helps families and extended families to enjoy each other more and longer.

How to provide a good history

Be open and accurate: Sometimes people are hesitant
to report their family history, and may hide their own symptoms or behavior out of concern about its eect on insurance premiums, or because they do not want to be judged. Or they may unconsciously deny the signicance of family medical history due to fear of what it might mean for them. Remember that your family history is not your fateits a valuable tool that can help you protect your health and avert trouble before it nds you.

Provide a context: Determining the circumstances

around a close relatives death are important. Was it anticipated? Did it happen during a time of stress, or were there other contributing circumstances?

Be a detective: If a parent or other close relative died

prematurely, obtain the autopsy report if one exists. Though it may be painful, or you might not want to know why mom or dad died, this information will help us determine the best approach to managing your health.

When there is little or no family history

For people who lack information about the health of their relatives or who are adopted, information about the environment in which grew up and background on behaviors are still important. Working with your physician, you can be attentive and proactive in protecting and managing your health. You may not have a choice in your genetic inheritance, but you can control how you approach your own health.

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Heart health on a global stage

Benn Grover, Editor, ProCor
I recently had the opportunity to attend the World Heart Federations World Congress of Cardiology (WCC) in Beijing, China. The WCC is the worlds largest cardiology conference, with over 500 presenters and 10,000 attendees. The three-day aair provided the opportunity for ProCor to learn about the most recent cardiovascular research, participate in global discussions on cardiovascular health advocacy, and meet several of ProCors members. Because ProCor targets cardiovascular health workers in developing countries, a majority of our audience is unable to attend conferences like the WCC. By attending the WCC, one of our goals was to provide daily updates on research presentations and discussions that are relevant to the ProCor community. Perhaps the biggest research news to come from the WCC was the results from the INTERSTROKE study. The three-year study involving 22 countries found that ten risk factors are responsible for 90% of all strokes. Five of those ten (high blood pressure, smoking, abdominal obesity, poor diet, and lack of physical activity) are responsible for 80% of all strokes. These ndings are particularly important to ProCor because, for the rst time, the burden of stroke is heavier on developing countries than developed countries, and the majority of strokes can be prevented by lifestyle modications like exercising and healthy eating. Although I spent a tremendous amount of time running to dierent presentations, I also had the opportunity to meet with several ProCor colleagues from across the globe. Dr. Collins Kokuro, Assistant Director of the Ashanti-ProCor Project to Increase CVD Knowledge and Practice Among Health Workers, several ProCor members, and I discussed the future of cardiovascular health education in Ghana and what strategies we could employ to meet the informational needs of cardiovascular health workers in rural areas. Ideas for meeting those needs ranged from creating low-literate health education pamphlets to developing a massive mobile phone textmessage network to provide cardiovascular health updates. Once we nish with the Ashanti-ProCor project, we will look at these options in greater detail as we determine what action steps we can take to increase their knowledge of cardiovascular health. Dr. Toakase Fakakovikaetau, the director of the rheumatic heart disease (RHD) prevention program in Tonga and our 2008 Louise Lown Heart Hero Award winner, discussed with me the progress made on eradicating RHD in Tonga. Unlike most heart diseases, RHD is caused by an infection,

Rajesh Vedanthan, MD MPH, Mount Sanai Medical Center; Benn Grover, ProCor editor; Srinivas Ramaka, MD, Srinivasa Heart Centre; Collins Kokuro, MD, Komfo Anokye Teaching Hospital, Kumasi, Ghana and Assistant Director, Ashanti-ProCor Project.

and 95% of cases occur in developing countries. It also happens to be one of the easiest heart diseases to preventthanks to penicillin. It only costs around US$46 to prevent one case of RHD and it is very successful (60 children need to be treated before one case of RHD is prevented; whereas for hypertension, 800 cases need to be treated before one case is prevented). Dr. Toas program is making tremendous strides in catching RHD in children before its too late, however RHD remains a neglected disease relegated to developing countries. The World Heart Federation has recognized the need for more advocacy and has made eradicating the disease one of its six main goals for the years to come. The UN has recognized the burden of non-communicable diseases (NCDs) on the developing world, and will convene a general summit in 2011 to discuss the issue. The goals of the summit are recommended and determined by the member states, and organizations such as the World Heart Federation and Australias Heart Foundation work to inform member states what those goals should be. Several brainstorming sessions to determine this unied, global strategy for advocacy were held during the WCC. By participating in these ground-level discussions, ProCor is working to ensure the needs of cardiovascular health workers in developing countries will be at the forefront of the UNs agenda. The last UN general summit on a health topic (infectious diseases) resulted in the Global Fund to ght HIV/AIDS, Tuberculosis, and Malaria as well as mandated disease reporting from member states. The greatest advocacy goals going into the new summit are to raise NCDs to a similar level of global awareness and to push for similar funding and reporting requirements for NCDs.
A tremendous amount of the information presented is available on the ProCor website. To read about the presentations at the WCC or learn more about the global impact of CVD, please visit www.procor.org.

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Training future leaders, inuencing the future of health care

Dr. Saini taught me to listen, said HMS student Marc Walker who trained with Dr. Vikas Saini at the Lown Center.

will probably be much more successful at treating the patient, managing cost, and producing an acceptable level of reimbursement given the care that is being provided.

Training the next generation: A Lown Center tradition

Thirteen Harvard Medical School students trained at the Lown Center during the 2009-2010 academic year. Also completing their year-long Primary Care Clerkship at the Lown Center were Walter Lin, who trained with Dr. Fred Mamuya, and Ibrahim Khansa, who worked with Dr. Brian Bilchik. The Lown Center also provides intensive training to one HMS student each month through its Clinical Cardiology in the Outpatient Setting course, which has been directed for more than a decade by Dr. Charles Blatt. In addition to spending each day seeing patients with Lown physicians, these students attend weekly Lown Center clinical conferences; develop and present a seminar; and accompany Lown Center physicians to Grand Rounds and medical conferences at Brigham and Women's Hospital. Russell Goodman worked alongside Dr. Blatt every day during the month of June. Ive never before had the opportunity to work alongside someone all day, every dayand to receive so much one-on- Dr. Charles Blatt and Russell Goodman, one of ten HMS students who completed one teaching, he said. Dr. Blatts Clinical Cardiology in the The Lown Centers Outpatient Setting course in the past year. outpatient setting gave me the opportunity to see the strength of the relationships people have formed with Dr. Blatt, sometimes over decades, and observe how he interacts with them. One of the biggest lessons I learned is that often the best medicine is gentle and conservative, that you can be a great physician by watching the patient closely and making small, gradual changes. At other facilities, patients often receive interventional procedures that are unwarranted. The Lown Center taught me that you dont always need to send the patient to the operating room.

Marc Walker is one of a small but growing number of medical students simultaneously working toward a Master of Business Administration (MBA) degree. In the past decade, the number of US medical schools oering MBAs doubled from 33 to 65, and a recent survey showed that the vast majority of MD-MBA graduates remain involved with patient care, take on a leadership role in their rst jobs, and rate making a dierence in medicine as a high priority. My experience at the Lown Center oered a dimension of comprehensive care that I would never have seen in an inpatient service, where you have specialists and technology at your ngertips. I wanted to see patients more than once and take care of them over a longer period of time. And though I assumed that patients in a community practice like the Lown Center dont present with acute issues, in fact they do and I was able to see how they are treated in an outpatient setting, which is where most medicine takes place. During his Lown Center training, Marc reports that he learned more than clinical skills and cardiovascular expertise. Dr. Saini taught me to take the time to listen and build a comprehensive picture of the patient, and then use that for diagnosis and management rather than just jumping to radiology or invasive procedures. Issues in the patients life may be contributing to their health problems. For example, chest pain can be associated with stress or an unhealthy diet. Taking the time to listen to peoples personal struggles, then counseling them on exercise and good nutrition, makes it easier for patients to comprehend and comply. Surveying health care systems from a business perspective, Marc feels that the Lown Center is at the forefront of the new wave of medical practice. If you compared outcomes at acute care facilities with those at outpatient centers that focus on listening and comprehensive care, I think youd nd that the time invested on the front end by the physicians at the Lown Center will more than pay o in the long run. This model

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Four generations, one familys history

continued from page 1

Based on her mothers condence in the young Dr. Lown, Carol convinced her husband, Tony Sr., to seek Dr. Lowns advice. When Carol herself developed heart disease, she became a patient of Dr. Graboys. Concerned about their family history, so eventually did their ve children, including Tony Jr., and their childrens children, who are in their twenties and healthy. Many years ago my mother had a serious cardiac issue and they called in Dr. Lown, Carol recalls. A little later my husband began having angina pains. His doctor told him, Put a ask in your back pocket. When my mother heard that she said, Look, you try to make an appointment with Dr. Lown because you need care and hell give you the right care. Weve been with the Lown Center ever since.

him healthy for ten years. A lot of other doctors, they just tell you that you need bypass. In 1982, after Tony Sr.s bypass surgery became necessary, We red him, Tony Jr. reports. We said, Weve got the business under controlgo spend your time with Mom and enjoy life. It was hard for him but easy for us. Hed still pop in at the store, passing out his Jarvis Appliance grippers and selling stu. Because both Carol and Tony Sr. had angina, they decided their childrens heart health should be checked. Tony Jr., came to the Lown Center for a simple checkup in 2006. I felt ne, he says. But all hell broke loose on the treadmill. Dr. Bilchik showed me the multiple blockages they found and went over the report with me. He recommended that I have bypass, and I did.

Carol and Tony Jarvis, Sr. met when he was a service person for Sears and she Afterwards, I lost a lot of worked in the oce. They weight because of Dr. got married 3 months later Bilchik. Before, I was and were married for 57 enjoying life, having fun, years until Tony passed and I didnt know how bad I away in 2009, one week was inside until he told us. I before his 88th birthday. started walking, eating Shortly after their marriage, healthy, and taking Tony opened his own Tony Jarvis, Jr. and Carol Jarvis, both patients of Dr. Brian Bilchik, medication. I take the stairs business, operating out of a represent two of the four generations of Jarvises who have been part instead of the elevator. 1957 black-and-white of the Lown Center community over several decades. When I golf, I park my cart Plymouth station wagon with far from the hole and walk or jog to it. Hes brainwashed a Jarvis Inc. sign in the window. In 1966 he bought a me into doing the right thing, he jokes. store in Wellesley that previously housed a boat business. For two years he sold appliances and boats, Carol After her early years with Dr. Lown, Carol saw Dr. Graboys recalls. and now Dr. Bilchik as her cardiologist. If her own Tony Jr. and siblings grew up at the store. I remember going there as a little kid. Mom did the bookkeeping and answered the phones, so she brought us babies in and put us in playpens by her desk. When we kids all got married, our spouses started working there too. My sister Nancy and my wife brought our kids in as infants; we turned Dads old oce into a daycare. Tony Sr.s angina was managed by Dr. Graboys with medication and lifestyle for more than 10 years. At the Lown Center, they are not invasive as far as surgery goes; they try to ward it o, notes Tony Jr. My father knew hed need surgery sooner or later, but Dr. Graboys kept cardiologist is not available, she sees any of the other Lown doctors. Dr. Lown instilled his principles in all of them, she notes. Theyre all really caring, they really listen to you, they know whats important for you. My husband and I passed along heart disease to our children, they all have some issue. Now they are being taken care of, and my grandchildren are coming in for EKGs and stress tests tootheyre in their twenties, theyre healthy, theyre doing all the right preventive things. Its like a big family here at the Lown Center, Tony Jr. concludes. Everyone works together. Its a lot like our business. Customers are our family.

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FAMILY PORTRAITS

Mom knows best: JeanAnn and Alicia

For more than 5 years, Alicia accompanied her mother, JeanAnn, to appointments at the Lown Cardiovascular Center. Alicia, a mother of four young children, felt and looked healthy. Im 38 years oldit never once crossed my mind that at my age I might need a cardiologist. But Alicia, Jean Ann, and sister Jennifer because of my family history, coupled with some minor symptoms I was experiencing, my mother kept urging me to make an appointment for myself. As the mother of four children all under the age of 11, I knew it was important for me to take care of myself, so I nally did, Alicia recalls. Seeing Dr. Bilchik gives me peace of mind, Alicia explains. Each visit is very thorough; he always manages to put my fears to rest. I asked him early on if he sees a lot of people my age, and he reassured me that he does. In fact, he prefers to see people when theyre young, before they have a problem. A lot of people hear cardiologist and assume they are doctors for the elderly. But thats not true. Seeing Dr. Bilchik has been a really positive thing in my life. Im being proactive and taking care of myself.

When you come across a group of individuals who care about you as a person you are blessedOur experiences at the Lown Cardiovascular Center have been top notch. When we came to the Lown Center, we experienced the kind of care that truly makes a dierence. Receiving patientcentered care is simply wonderful. Each time we contact the oce, we are treated with respect and provided the support needed from simple rells of medication to questions about changes in my condition. Patient letter, January 2010 The Lown Cardiovascular Research Foundation promotes cardiac care that advocates prevention over costly, invasive treatments and restores the relationship between doctor and patient.
BoardofDirectors Nassib Chamoun Chairman of the Board Vikas Saini, MD President Bernard Lown, MD Chairman Emeritus Thomas B. Graboys, MD President Emeritus Patricia Aslanis Charles M. Blatt, MD Joseph Brain, SD Janet Johnson Bullard J. Breckenridge Eagle Carole Anne McLeod C. Bruce Metzler Barbara H. Roberts, MD Ronald Shaich Robert F. Weis AdvisoryBoard Martha Crowninshield Herbert Engelhardt Edward Finkelstein William E. Ford Renee Gelman, MD George Graboys Barbara Greenberg Milton Lown John R. Monsky Jeffrey I. Sussman David L. Weltman CONTACTUS

Sisters: Elizabeth and Helen

At age 90, Elizabeth still works part-time at the company where she has worked for 62 years. Her relationship with the Lown Center began more than 25 years ago, when a coworker suggested she see Dr. Tom Graboys. Soon after her visit, she recommended Dr. Graboys to Sisters: Helen and Elizabeth her sister, Helen. The sisters have been coming to the Lown Center ever since and now both see Dr. Bilchik. Our father had heart trouble and passed away in his 50s as a result, Elizabeth recalls. My sister and I each rst came to the Lown Center because of dierent heart trouble. They attribute their longevity to a small glass of pomegranate juice every day. Hard work has kept their minds active, but they always made time to relax. People dont rest enough today, Elizabeth observes. Its important to slow down.

LownCardiovascular ResearchFoundation
21 Longwood Avenue Brookline MA 02446 (617) 732-1318 info@lownfoundation.org www.lownfoundation.org www.procor.org LownCardiovascularCenter Brian Z. Bilchik, MD Charles M. Blatt, MD Wilfred Mamuya, MD, PhD Shmuel Ravid, MD, MPH Vikas Saini, MD LownForum Editor Catherine Coleman Editorialsupport Claudia Kenney Jessica Gottsegen
c2010 Lown Foundation Printed on recycled paper with soy-based ink.

Lown Cardiovascular Research Foundation 21 Longwood Avenue Brookline, Massachusetts 02446-5239

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Contributing to health in the heart of the community

In March 2010, the Lown Cardiovascular Center launched a heart health education campaign within the greaterBoston community. For many years, the work of the Lown Center has been recognized throughout the country and the world, but little has been done to reach out to our local community, says Dr. Vikas Saini, President of the Lown Cardiovascular Research Foundation. Big changes are coming to the health care system, and we expect the perspective of the Lown Group to be valuable as we grapple with achieving quality without unnecessary interventions. Through a series of lecture events at malls, assisted living facilities, and senior centers, the Lown physicians have been connecting with the local community to provide education about the importance of heart disease prevention. A wide range of topics, including nutrition, exercise, stress reduction, alternatives to surgery, and second opinions, have been presented. The lectures introduce the physicians to the community, so people can get to know them and have their questions answered, says Nancy Stuart, Outreach
Coordinator at the Milton Council on Aging, where a recent lecture took place. During the past ve months they have given lectures in Watertown, Acton, Milton, Brookline, Newton, Woburn, Dedham, Belmont, and Cambridge. People who attend the lectures often comment on the valuable information presented and the time the physicians take to listen and answer questions. According to one audience member, The information was easy to understand and the group setting allowed us to share dierent perspectives on what was being discussed. The Lown Center has taken the campaign a step further by reaching out to local businesses to establish worksite wellness events. Connecting with employees provides a valuable opportunity to educate adults in their 30s, 40s, and 50s on the prevention of cardiovascular disease. Today, the media is saturated with news about medical developments, making it dicult for individuals to separate the wheat from the cha, says Dr. Saini. Many people dont realize that much of what passes for medical news is actually sponsored messaging by vested interests. At our lectures, we oer an alternative and unbiased view of technology and practices in the health care system. We see that there is a huge interest in this kind of information and discussion. Our events give people an opportunity to ask questions that they dont often have time to ask their own doctor during a regular oce visit. A participant noted, This was truly an eye-opener for me! I learned so much in just one hour and I havent stopped sharing what I learned with my family and friends.
Dr. Vikas Saini presented on the topic of exercise at the Minutes in Motion event at the Brookline Senior Center in May 2010. If you are interested in hosting a lecture on heart health at your worksite or community organization, please contact Jessica Gottsegen (jgottsegen@partners.org or 617-732-1318 x3805).