Should More Female Patients Be Visiting Your Cath Lab?

Talking with Ginger Graham Advisor to the President, Guidant Corporation*, Santa Clara, California
Talking with Ginger Graham Advisor to the President, Guidant Corporation*, Santa Clara, California
Why focus on women’s heart disease? My interest started out somewhat personally. I have a history of heart disease in my family both my grandmother and my mother, along with other people in my family. Then, about five years ago, I was asked to speak at a women’s luncheon for the American Heart Association (AHA). To help prepare my talk, I began doing research, and the more research I did, the more I realized the lack of understanding about the risk of heart disease for women. Most people, including healthcare professionals, don’t know that more women are dying of heart disease every year than are men. It was a huge surprise to me, and I have been in the healthcare business and focused on cardiology for almost a decade. After I gave my first talk at the AHA, I then began to have conversations with customers and with other people who were also talking about women’s health. I found that there was a huge dearth of information about cardiovascular disease in women. At Guidant, half of our employees are women. We try to engage the women at Guidant to get the message out about heart disease through communities, through our customers, to the world at large as best we can. It is an opportunity for our company to really be making a difference and have a chance to influence a very large number of people. To help support those efforts, we created an organization we call GROW, which stands for Guidant Reaches Out to Women. GROW has three areas of focus: 1. Education. GROW works to educate healthcare professionals, our own employees, and women everywhere about their risk of heart disease. The American Heart Association forecasts that almost one out of two women will die of heart disease, and also notes that heart disease is underdiagnosed and undertreated in women. At Guidant, we can provide information about the risk of cardiac and vascular disease in women through employee education, patient and consumer outreach, and by partnering with our customers. 2. Partnership. We’re using our customer-based organizations around the world (in other words, all the people located in every market for Guidant working with healthcare professionals) to help support programs for women’s heart disease, and to create opportunities where physicians and healthcare professionals can come to learn more about women’s heart disease. They can share best practices and hopefully employ programs that will actually increase the number of women that get to specialists for heart disease. At Guidant, we’ve observed that the percentage of female patients that present to a cath lab or an electrophysiology lab is very small. With more women dying of heart disease than men, and yet maybe only 1 out of 5 people who get treated with the most sophisticated therapies for heart disease being women, there is certainly a disparity in treatment. We are working with all our customers and specifically reaching out to women physicians. There are very few women physicians specializing in cardiology, so we are trying to help them build a network and enhance their professional skills. In the long term, they will be able to have a large influence on the care for women with heart disease. 3. The third element of GROW is internal. The GROW network engages the employees of Guidant for their own personal and professional development. The program offers networking, mentoring, and skill-building opportunities. Our employees can get involved with the women in heart disease initiative and have other experiences that help them develop as women professionals in the company. It’s a huge initiative and investment for us. Guidant is also working with other organizations that are interested in women and heart disease. The National Heart, Lung, and Blood Institute has launched a campaign against women’s heart disease. The campaign is called The Red Dress. The Red Dress is actually a symbol. It’s a little pin that looks like a woman’s red dress. The NHLBI is supplying advertising materials that have images of many different red dresses, with a slogan that says, Heart disease doesn’t care what you wear. We’re hopeful that the First Lady is going to become more involved in this topic as well, and there’s some indication that this may happen. Guidant is also working with an organization called WomenHeart (www.womenheart.org).Womenheart.org is an organization of women who have experienced cardiovascular events. They formed an advocacy group to help raise the issue in Washington, D.C. to get it on the political agenda and to get it on the corporate agenda for the big pharmaceutical companies, biotech companies and medical technology companies. We found this organization a few years ago and began helping to support their efforts. We also partner with them on a lot of educational activities. The New Yorker recently ran an insert put together by WomenHeart which Guidant helped fund. We estimate that another 750,000 women in the U.S. annually would be treated with minimally invasive therapies if women were treated the same as men who present with cardiovascular disease. We see this as a huge opportunity to change health. It’s also an enormous obligation we have, as a company dedicated to cardiac and vascular disease, to try to help our customers understand the disparity of care and how to change outcomes for women. Some of the simplest things, such as the different signs and symptoms for women, can be very different from men. There has been some discussion about how women respond differently to stress, as another example. Well, the research is not nearly as robust as we would like. We do know that there are major differences. For many years, it was believed that women do not have heart disease, primarily because of hormones. It was also believed that only after menopause, and when women were very elderly, did they become high-risk candidates for heart disease. Actually, we know now that there are very high numbers of women at young ages women in their 20s, 30s and 40s who suffer from cardiovascular disease. Women’s mortality rates are actually increasing, while the mortality rate for men with heart disease is decreasing. Based on studies of the influence of hormones, we know a little about how women handle stress differently from men. We also know something about what I would call the mechanics. Women generally have smaller arteries than men. It appears that women may have more diffuse disease. Some researchers believe that women are more susceptible to electrical imbalances in the heart since the electrical activity in a woman’s heart changes during her menstrual cycle. There’s evidence that for women, body shape matters like it does for men. A woman with a body shape more like an apple may have higher risk for heart disease than a woman with a pear shape. Some women will have the same symptoms as men, some women will have the same appearances from an EKG standpoint as men, but in general, women have a higher rate of false negatives and false positives with their EKGs. The rate of cardiovascular disease progression is faster for women over 60 than it is for men. Clearly there’s a whole body of data from which we’re learning, which says women’s heart disease is different than men’s. There are also many places where the commonality is high, but the healthcare system doesn’t know to look for it. If you go to womenheart.org, you’ll see an enormous number of stories about women who were having a heart attack and went to the emergency room. Since their presentation didn’t look like men’s or because the healthcare professionals didn’t even think about heart disease when they saw a woman walk in, those women were sent home to have significant events, without any care, even though they presented at the emergency room. There is a huge need for education, and there is enough data to understand that women do have heart disease, women can be treated like men and have good outcomes, and that intervening in the process early for women has a positive aspect. In other words, if you talk to women early, educate them and modify their lives, in terms of activity levels, smoking, weight management and other things related to heart disease, you can have a huge impact. A large study called the Nurse’s Health Research Study (www.nurseshealthstudy.org) had researchers following tens of thousands of women who had different lifestyles. Those women who managed their lives more actively had much better outcomes. We know there’s an opportunity to make a difference if the message is understood and if people take it seriously. What are the differences in symptoms for women having a heart attack? It’s very interesting, because some women will present just like men do, i.e., substernal chest pain or pressure (an elephant standing on your chest, pain down your left arm and weakness). However, many women will present differently. It’s one of the complexities of women with heart disease, because they present with what’s called non-specific symptoms. Their symptoms look like a lot of other things: Pain in your upper back, your jaw or your neck. Being very short of breath or having symptoms that are like the flu, nausea, vomiting, cold sweats. You might even feel anxious, lose your appetite, or just not feel right. It’s very common for women to report these kinds of symptoms, and then be sent home on an anti-acid of some sort, or to be sent home with Valium or an anti-anxiety drug. They actually don’t get treated at all for what’s really moving forward a very serious cardiovascular event because it doesn’t look like one. If you take an EKG, it’s more likely that it might be wrong, showing either a false positive or a false negative. Ultimately, it may be that women need an imaging test of some kind, for women to be identified as clearly as men as having a cardiovascular event. If a woman and a man both have a heart attack, the likelihood of a woman dying within a year of that heart attack is very much higher than a man. Also, the death rate for women who have had no symptoms before the first is very high. We wonder if they actually did have symptoms and no one recognized them as cardiovascular symptoms. Again, the real challenge is education. I could ask you several questions and then we could determine your risk factors, and be a lot more sensitive. If you said to me that you were post-menopausal, you had been smoking for 20 years, and that your father died of a heart attack, then I would think differently about you than if you were 31 years old, exercised 4 days a week, had no family history of heart disease, never smoked, and managed your weight really closely. There are very obvious signs and symptoms. There’s research indicating that breast artery calcium in your mammogram correlates with an increased risk of heart disease. If you’re carrying 30 lbs. of extra weight, never have any physical activity, diabetes runs in your family and you have early-stage diabetes, you have a highly increased risk of heart disease. Women can do some very simple things, like have a baseline workup and also look at the factors in their workup differently. For example, in the past, when we thought of cholesterol, it would be in regard to lowering bad cholesterol factors. Yet, new data suggests that it may be more important for women to focus on their HDL (good cholesterol) and raise it as high as possible. For men, they recommend 35-40 mg/dL. For women, levels between 50-75 mg/dL may be helpful in reducing their risk of heart disease. If you went to your healthcare professional knowing that you are at risk of heart disease, you can should begin to monitor factors like high plasma Lipoprotein A (LpA), HDLs, and C-reactive protein, as well as getting a baseline EKG so they know what your normal looks like. Then you and your healthcare professional could both be paying attention to your risk. How many women have a cardiologist that they go to, say over the age of 45, on a regular basis? I was very pleased to see the Time cover article earlier this year (The No. 1 Killer of Women, April 28, 2003), because when something makes the cover of Time, it must be news. The depressing part is that in 2003, women having heart disease is news. It just shows how great our challenge is. The Time article talked a little about the difference in plaque buildup between men and women. Some of this is based on early research. There are a few theories. One that I mentioned earlier is that women have more diffuse disease, as opposed to just a major clog that can be easily fixed or opened. It seems that vulnerable plaque also behaves differently for women than for men. The response in our arterial walls is different. If in fact this proves to be true, it may also explain why women have so many sudden events or there are no prior symptoms. Vulnerable plaques are silent until you have a dramatic event. It could be that a woman’s different makeup actually causes our arterial walls to progress differently, which puts us at different kinds of risks. There’s also some data showing that women are more at risk for heart failure than men, especially women of color. If you look at African-American women, you’ll see they’re at higher risks for heart disease, diabetes, and heart failure. They have many more complicating factors predisposing them to heart disease risk. In that community, there’s not an acceptance that heart disease is a risk. It’s one of the highest-risk populations in the world: higher than white women, black men, and white men. Meanwhile, we have very little information about what this population should do to try to manage their risk of heart disease. Why is it that black women are at such high risk? We don’t really know. It may be a combination of carrying higher average body weight, a different diet, a lack of physical activity, and just the fact of being African-American that increases their risk. These are still huge topics for research. My view is that we already know enough to realize that it is a huge, huge challenge for the healthcare community in this country to learn that women have heart disease. We need to not only learn this fact, but also get current on the available research, and get women to be evaluated for heart disease. You had mentioned that women should receive an imaging exam. What are your thoughts about the increased cost of such an exam versus an EKG? Regarding cost, a woman is more likely to be uninsured than a man, especially if she’s divorced. It may be that the ex-husband provides healthcare insurance for the children, but not their mother. Women are more likely to have a lower-paying job and to be part-time workers. All of this means women have less access to healthcare coverage than men. It can be a factor for any increased cost at all. Generally, these early tests, like a stress echo or some kind of nuclear imaging, are covered if a woman has any kind of healthcare coverage, and it’s a minor increase in costs. We do have some data showing that if women are left untreated, that they can become very expensive. They have higher rates of peripheral vascular disease, they have higher rates of stroke, they have more dehabilitating heart attacks, and they spend many, many more years in long-term care or nursing home facilities. From an overall socioeconomic standpoint, we can both justify and encourage the more aggressive, early treatment and lifestyle management of women at risk for heart disease. In the short term, we have to deal with issues of access and coverage. You’ve been in the healthcare industry and focused on cardiology for many years. You must hold a unique perspective on the industry. The healthcare industry is a huge business. We generally don’t talk about healthcare as a business because health is so personal. It also has many social, ethical and moral overtones to it. We must address all those aspects and acknowledge that healthcare is a very large business in this country. If you look at the percentage of GDP, it’s one of our largest enterprises. Managing it has become a huge social challenge. There are many business challenges, even within the provider side, that need to be addressed. One trend has been the continued and increasing need for healthcare as the U.S. population ages. As another 18 million women in this decade become postmenopausal, as we bring forward therapies and opportunities to improve care, the demand and utilization of healthcare are going up. That puts more pressure on cost, and gives more intensity to conversations on affordability and who has access to care. The issues of the uninsured, of portability of care, of privacy and the cost of care, are more pronounced than they’ve ever been in the history of this country or really, than any other country in the world. I think because of that we see a much higher investment in technology. In most parts of our lives, we understand that technology can improve the quality of our lives and that technology over time will make us more efficient, more effective and provide us with lower cost options. If you look at the capability of your calculator today as compared to 20 years ago, it’s a tenth of the cost and magnitudes more functional. Technology and healthcare are really the same challenge for us. It’s expensive to develop, but think today of all the people who never have to go into the hospital for a bypass because of angioplasty and stenting. Think of all the people who are not institutionalized with mental health problems because of all the wonderful advances in drugs for mental health. Think about the high cost of people who used to be in the hospital for days and weeks with serious events like sepsis, or a critical care event. Today, with so many new drugs, very advanced machinery and capabilities, and with very sophisticated nurses and physicians, people get out of the hospital very quickly. Today, when you go in for a AAA procedure, you can be out in 2-3 days, and that used to be a procedure where you’d be hospitalized for weeks. Think about the implications behind the human genome, and the possibility of personalized medicine. All of those things are dramatic changes in the field and really provide us with the opportunity to be more involved as consumers in our own health. We’ll be challenged with the social and economic burdens and implications of those changes. The good news is that I think we are going to have choice as well as a lot of opportunity and we are really going to be able to change the lifespan and quality of life for human health. It will come with a lot of challenges. It’s going to take visionary leaders, open dialogue and participation by the person being treated. This participation means economic participation, choice, understanding the implications of your choice, and self-management. The most exciting field in business is health, and we need to attract even more talent. The best and brightest, in my opinion, of all the business and management schools ought to be going into health, because that is really where the action is how we deliver care, how a lot more people will live longer, and how well we live. To me there’s just not a more exciting industry than the healthcare industry. What about the healthcare industry outside the U.S.? There are very, very sophisticated hospitals and physicians in all corners of the world. If you were going to go to Hong Kong or Singapore, you will see some of the most sophisticated hospitals in the world, with very well-informed, highly technically accomplished physicians who are involved in some of the world’s leading research. If you go to India or Brazil, you’ll find some of the best cardiac hospitals in the world. Go to China, and look at the dramatic increase in the number of cardiovascular suites. You’ll be amazed. You can see major growth happening across all of Asia and Southeast Asia, and scientific leadership. Today, if you read the major cardiology publications, you would see a large number of physicians from that region of the world. They are doing cutting-edge research and they have leading capabilities. The issue has always been that the populations are so large that access by percentage of the population is very low, and the capital (facilities and equipment) has not always been readily available. That’s an issue in China and in India, too. We believe that the growth of facilities and equipment in these countries will continue. There are large numbers of the population that can afford health care and the government can afford to support basic healthcare. We still have challenges, just like we do in the U.S., of access for all the people in the country, and affordability. Really the conversation about access to innovative healthcare and affordability of care are global topics, and ones that have to be addressed. Every company in the healthcare business, every public policy individual, every legislator, every elected official, every government in the world has to think about these things. Hopefully industry will be able to make major contributions to that, by bringing forward the technology that helps care be shorter-term, less acute, more effective and last longer. Then we’re going to have to deal with the fact that a large part of the world’s population can afford to participate in their healthcare and need to do so, so those that can’t afford to participate will have an economic support system under them that allows them to have access to innovation. I think those are going to be the topics for the next 50 years of our lives. Do you believe the excitement over drug-eluting stents (DES) is justified? I believe DES will be a meaningful improvement in the outcomes for people with vascular disease who experience restenosis. The early data is promising. It’s always appropriate, when a new therapy is being introduced into mass use, to be very circumspect about its application and the data we have. We have a limited number of patients in a limited number of drugs, with a limited number of indications. The early data are very promising, and we’re learning a lot. The good news is that the data is so promising that there will be substantial investment and enormous amounts of research done to actually validate these early findings. Partnerships with the regulatory agencies around the world have actually been able to bring these products to the market with increased reimbursement. So they do have a chance of being available to people who really need them, which will cause the vascular intervention market or industry to be sizably larger. If it’s sizably larger, then the overall cost in the healthcare system for buying stents will go up, if in fact, the reduction in restenosis is sustained over time. We’ll see restenosis rates dropping 20, 30, 50% in very complicated patients. It will certainly be very cost-effective in other words, fewer hospitalizations, less repeat procedures, many more people who won’t have to undergo follow-on procedures, which I think is the important purpose of the technology and justifies the cost. If you look at one patient and ask, for this one patient, in this one procedure, is it more expensive, the answer may very well be yes. It is more likely to be yes if they use a drug-eluting stent versus a bare metal stent. I think that’s why doctors are being very prudent early on, to make sure that they pick the right patient and they have the opportunity to observe the patient’s response to the product over time. Many physicians will be very careful about the patients that they introduce to a DES. They’ll track those patients over time, they’ll learn where a DES is the most effective and they’ll use the technology for those patients. Physicians will continue to use the bare metal stent, which has the lowest published restenosis rates today, in the low teens, and they’ll continue to be highly effective for many, many patients. The market always finds a way to understand where the product is best used and we have lots of examples. Products that are not effective disappear. I believe DES have the data that justify their appearance on the marketplace, and then actual utilization in the hands of thousands of physicians with hundreds of thousands of patients will begin to tell us over time where they are the most effective. Of course, we have a 10-year history with bare metal stents to help us understand which patients they work best on, and where there are still opportunities for improvement. You frequently are asked to speak on leadership, as you did at the June 2003 Cath Lab Digest Annual Symposium on Cardiovascular Care (ASOCC). Can you talk about how people who are not in official positions of leadership can also exhibit leadership qualities? It’s very easy and we all do it every day. We see people who step up and make decisions, who take accountability for the choices they made, who reach out to other people that are struggling, who actually look at the opportunity for improvement and act on it, instead of saying, why don’t they fix that? Those are individual acts of leadership every day. In your life, look around and say, Who do I go to when I’m struggling with a problem? Who is there for me when I’m struggling with a difficult issue and provides the right guidance or the right words? What you’ll end up finding are a group of people that are probably not running companies or running hospitals or running institutions. They’re leaders in their personal lives, and they have an impact on you, because they’re people who can see objectively and clearly, who talk with you about what’s best for you, not with an agenda of their own, who offer wisdom, a perspective from their own experiences, who are good listeners, and who generally help you think about the right decision as opposed to the easy decision. I think people like this exist in any situation. Just think about what happens when someone begins to have a significant cardiac event in the cath lab. People step up and make very important decisions. They make them based on their training, their intuition and their experiences, and they make a difference in someone’s life by doing so. Those are individual acts of leadership that affect people’s lives. Part of my message is that it is not George Bush’s and the president of Intel’s or Microsoft’s job to lead us. We all need to step up in terms of making our own decisions. When it comes to the question of how we deal in general with the issues of healthcare cost, all of us need to participate in using care appropriately, by making sure that we pay our fair share, what we can afford to pay, and by giving back if we have the means to do so. Those are acts of leadership and personal accountability that I think can change an institution, a community, and a society. Leadership means we essentially act on our own accountability and responsibility and don’t wait for someone else to do that for us. You’ve contributed a great deal to the success of Guidant Corporation. What are your current plans? I do travel quite a bit and speak, primarily at business schools, about the healthcare industry. I teach at several business schools in the country; I do a lot of speaking for women’s health, and a lot of other travel and public speaking about leadership and some of my thoughts about business leaders and personal responsibility in today’s environment. Personally, I plan to take some time off this summer and then I’ll be looking toward other opportunities in the future. *Editor's note: Ginger Graham has since changed positions and is currently the President and CEO of Amylin Pharmaceuticals, Inc. (San Diego, California).