Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine launched the Center for Cardiovascular Innovation to improve the quality of care provided to millions of people with heart disease. We are inviting individuals who want to make a difference in the lives of heart disease patients to learn more about the initiatives of our Center, which is led with great distinction by internationally recognized cardiologist, scientist, and scholar Robert Bonow, MD.
Despite advances in diagnosis and treatment, cardiovascular disease is the number one cause of death in the United States. More than 860,000 Americans die from cardiovascular conditions each year. Cardiovascular disease also leads in the consumption of U.S. healthcare resources, with an annual expense that exceeds $574 billion. Unfortunately, there is growing evidence of gaps in care, which reflect notable divisions between what we know and what we do. Unnecessary testing, procedures, and hospitalizations occur, often with less than optimal patient outcomes.
To address these gaps in care, new research models are needed to:
- Measure clinical performance of physicians, hospitals, and healthcare systems
- Develop new systems of healthcare delivery
- Study the comparative effectiveness of tests and treatments
- Investigate models of communications among providers and the patients they serve
Our goal is to seek new knowledge that will directly inform healthcare policy decisions that will enhance the quality of care for patients with heart disease.
To succeed, we must conduct innovative research studies and broadly disseminate our findings to health professionals, policy makers, and the public. Dr. Robert Bonow is championing our new Center and is joined by Drs. Mihai Gheorghiade, Steven Farmer, Kathleen Grady, and Peter Pang, who bring unique backgrounds, talents, and expertise to our collaborative efforts.
The Center for Cardiovascular Innovation plans to perform research in healthcare quality and outcomes designed to:
- Improve systems of healthcare delivery, including seamless transitions from inpatient to outpatient care settings
- Enhance quality of life and clinical outcomes from the patient’s perspective
- Reduce mortality and rehospitalization rates
- Reduce underuse, overuse, and misuse of tests, procedures, and medications
- Expand Northwestern’s impact in addressing the worldwide burden of cardiovascular disease
The mission of the Center for Cardiovascular Innovation is to overcome gaps in knowledge and gaps in care by developing innovative treatment strategies to improve the outcomes of patients with cardiovascular disease.
We will achieve these goals by leveraging the individual skills of our members in cardiovascular care, research, and mentoring and by implementing the triad of commitment, cooperation, and communication. We intend that the Center for Cardiovascular Innovation will be an international force for improving cardiovascular care.
Gaps in cardiovascular care need to be overcome at many levels:
- The need for new therapies for patients in whom existing treatment options have been exhausted
- The need to identify patients at greatest risk of preventable death or hospitalization
- The need for systems of care in which proven, existing therapies are provided uniformly to those who will benefit from them
- The need to develop cost effective solutions to address rising cardiovascular healthcare costs
Learn more about our programs below.
Despite major advances in diagnosis and treatment, cardiovascular disease remains the leading cause of death in the United States and worldwide. Over 900,000 individuals in the United States and 17 million throughout the world die from cardiovascular diseases each year. The aftermath of heart attacks, strokes, and heart failure rob millions of men and women of fruitful, productive years. These conditions also create a huge economic burden and represent the greatest drain on healthcare resources.
Although basic research must continue in order to develop new therapies to prevent and treat cardiovascular diseases, we already have a number of the tools necessary to reduce their impact. Many treatments have been proven effective in multiple large scale clinical trials, and clinical guidelines specify how, when, and in whom these treatments should be provided. Despite guidelines, however, these treatments can be underused, overused, or misused. The risk factors for cardiovascular disease are known but are often ignored, underappreciated, or untreated. There is compelling evidence of variations in the quality of care that is provided to patients with heart disease in the United States, even within the same city, as is the case in Chicago. There is a gap between knowledge and implementation, between what we know and what we do.
The system of cardiovascular care delivery needs to be scrutinized, studied, and redesigned.
The Center is actively engaged in the national discourse on healthcare quality. Drs. Bonow, Goldberger and Grady have leadership roles in a number of the organizations addressing cardiovascular healthcare quality at the national level, including the American College of Cardiology, the American Heart Association, the American Medical Association, the National Heart, Lung, and Blood Institute, the Agency for Healthcare Research and Quality, the National Quality Forum, the National Committee for Quality Assurance, and the Joint Commission.
At Northwestern, our initial focus is improving the quality of care for patients with heart failure, because of the significant impact of this condition on human lives and healthcare resources. As we become more adept at treating the acute phases of heart disease, such as heart attacks, the dividend we pay is the growing number of older patients surviving with chronically weakened hearts. Heart failure represents the leading cause of hospitalization in patients over the age of 65. Following hospitalization, over 30% of patients will die or be re-hospitalized within the next 60 days. Much of these poor early outcomes hinge on inability to identify the patients at greatest risk and the precarious transition of care from the inpatient to the outpatient setting, which is ripe with potential errors in medications, communication, and scheduling of outpatient care.
Dr. Gheorghiade provides expertise from decades of work in clinical trials of heart failure treatment, and he is leading efforts to identify predictors of mortality and hospitalization from large scale databases. Dr. Pang is assessing processes of care from the perspective of the emergency department, which is the entry point of hospitalization and re-hospitalization. Dr. Farmer is studying health policy implications of heart failure management. We are assessing the role of electronic medical records and dedicated nurse practitioners in improving heart failure outcomes. Partnering with the American Medical Association, we have used the Northwestern Electronic Data Warehouse (EDW), a unique resource linking inpatient and outpatient electronic medical records, to determine factors that identify patients during a heart failure hospitalization who are at highest risk of death or hospital readmission following discharge. We are also assessing factors that predispose to hospitalization from the patient’s and family’s point of view. This detailed analysis, which cannot be ascertained with large administrative databases, allows us to develop targeted interventions for patients at highest risk.
Heart failure – the inability to supply adequate blood flow to meet the body’s need for oxygen and nutrients – has reached truly epidemic proportions. There are more than 1 million hospitalizations for heart failure in the United States every year, and similar numbers in Europe. Those numbers will continue to grow due to the fact that heart failure is age related and advances in heart care are successful in keeping patients alive after heart attacks that result in weakened heart muscle. The post-discharge mortality and rehospitalization rate can be as high as 15% and 30% respectively within 60-90 days, in spite of the implementation of evidence based therapies. It is important to emphasize that in spite of the successful implementation of federal performance measures in the United States, this event rate has not changed over the past decade. There is no other medical condition for which a patient becomes hospitalized, responds to therapy, and then has such a high event rate within such a short period of time. Importantly, none of the available therapies for chronic heart failure have been well tested in patients hospitalized with acute heart failure, and every single trial conducted to date with novel drug targets have been negative in terms of efficacy and/or safety.
- ART-HF. Given our wealth of experience in every aspect of drug development in heart failure and the availability of many new molecules for new drug development, Dr. Gheorghiade has spearheaded the creation of the international Acute Research Team – Heart Failure (ART-HF), comprised of leaders from centers of excellence across North America, Europe and Asia who have an enormous experience in drug development and the treatment of heart failure. We have already developed a collaborative strategy between preclinical pharmacology, clinical pharmacology, clinical development and ART-HF in which the main goal is to improve post-discharge outcomes by targeting the use of the new drugs to specific patient characteristics. A significant partnership has already been developed with the pharmaceutical industry, and we are now in the implementation phase.
- Improve HF Bridge. Dr. Gheorghiade and colleagues are also in the process of implementing new strategies with proven, existing therapies in order to enhance post-discharge outcomes. One of the studies will be conducted in the near future at major medical centers in the United States and will evaluate measures to close the gap between what doctors know and what doctors actually do. This will develop systems of care to implement guidelines recommendations in the real world management of patients hospitalized for heart failure. This will include close coordination of physicians and nurses in the transition from inpatient to outpatient care, including a comprehensive assessment at a post-discharge outpatient visit within one week of hospital discharge.
- Convening the International Stakeholders in Drug Development. Dr. Gheorghiade has brought together the world’s leading experts in developing and evaluating new drugs for heart failure, in order to identify new opportunities to design how promising new therapies should be tested and implemented. He chaired several meetings in which academic leaders and representatives of the Food and Drug Administration, the National Heart, Lung and Blood Institute, and the pharmaceutical industry identified common barriers to evaluating novel drugs in well-designed clinical trials and came to consensus that a new model for clinical trials is necessary. Dr. Gheorghiade has now been charged with creation of a new international Clinical Trial Initiative that will be an important cornerstone of the Center for Cardiovascular Innovation.
On July 13, 2008, journalist Tim Russert was recording voiceovers for a newscast, when, suddenly, he collapsed and died. Years before, Russert had been diagnosed with heart disease, and, though he had a weight problem that worsened his condition, he appeared to be doing well overall. A dynamic man and respected commentator, Russert—at only 58 years old—seemed to be in the prime of his life. Russert seemed to take his health seriously. He exercised each morning, took medication to manage his blood pressure, and had recently performed well on a “stress test” that measured blood flow in the arteries in his heart. All told, his heart disease seemed under control. That he could go to work one morning feeling fine — and then die suddenly without any significant warning — is an idea that seems incomprehensible. Tim Russert experienced sudden cardiac death—a condition in which the heart stops beating abruptly and without warning.
There are different estimates of the number of sudden cardiac deaths in the United States that range from approximately 200,000 to 400,000 persons per year. This is the single largest cause of death related to the heart. While there are several causes of sudden cardiac death, one of the most common causes is a rapid, disordered heart rhythm or arrhythmia. These rapid heart rhythms can be restored to normal by shocking the heart either with an Automatic External Defibrillator (AEDs are found in public places such as the airport) or an implantable defibrillator. While AEDs are highly effective when deployed immediately, unfortunately the vast majority of people who experience sudden cardiac death do not survive. Even more unfortunate, our ability to identify patients who will experience sudden cardiac death prior to the event is poor. This is a critical endeavor to enable treatment to be in place before a person experiences a fatal arrhythmia
Members of the Center have provided national leadership in addressing the pressing issue of sudden cardiac death. Dr. Goldberger, an established researcher and a thought leader in this area, chaired the American Heart Association’s Scientific Statement Committee on risk stratification for sudden cardiac death. Dr. Bonow served as co-chair of the National Heart, Lung, and Blood Institute’s report on research priorities in sudden cardiac death, and serves on the Joint Commission’s technical panel on sudden cardiac death prevention. Dr. Goldberger has formed a national think tank that brings together a broad array of stakeholders – clinicians, epidemiologists, health economists, government agencies, and industry – on an ongoing basis for the purpose of developing a more focused approach to this problem. He and his team are developing novel approaches to identify those individuals who are at risk for sudden cardiac death, so that these individuals can receive prompt and appropriate treatments to reduce the risk of this devastating condition.
- Kong T, Goldberger J, Parker M, Wang T, Kadish A: Circadian variation in human ventricular refractoriness. Circulation 92:1507-1516, 1995.
- Levine J, Waller T, Hoch D, Greenberg S, Goldberger J, Kadish A: Implantable cardioverter defibrillator: use in patients with no symptoms and at high risk. Am Heart J 131:59-65, 1996.
- Kanaan N, Robinson N, Roth S, Ye D, Goldberger J, Kadish A: Ventricular tachycardia in healing canine myocardial infarction: evidence for multiple reentrant mechanisms. Pacing Clin Electrophysiol 20:245-260, 1997.
- Goldberger J, Horvath G, Inbar S, Kadish A: Utility of predischarge and one month transvenous implantable defibrillator tests. Am J Cardiol 79:822-826, 1997.
- Taneja T, Goldberger J, Parker N, Johnson D, Robinson N, Horvath G, Kadish A: Reproducibility of ventricular fibrillation characteristics in patients undergoing implantable cardioverter defibrillator implantation. J Cardiovasc Electrophysiol 8:1209-1217, 1997.
- Goldberger J, Horvath G, Donovan D, Johnson D, Challapalli R, Kadish A: Detection of ventricular fibrillation by transvenous defibrillating leads: integrated versus dedicated bipolar sensing. J Cardiovasc Electrophysiol 9:677-688, 1998.
- Cheema A, Sheu K, Parker M, Kadish A, Goldberger J: Nonsustained ventricular tachycardia in the setting of acute myocardial infarction: tachycardia characteristics and their prognostic implications. Circulation 98:2030-2036, 1998.
- Horvath G, Racker DK, Goldberger JJ, Johnson D, Jain S, Kadish A: Electrophysiologic and anatomic heterogeneity in evolving canine myocardial infarction. Pacing Clin Electrophysiol 23(7):1068-1079, 2000.
- Taneja T, Goldberger J, Johnson D, Kadish A: Is all ventricular fibrillation the same? Influence of mode of induction on characteristics of ventricular fibrillation. J Cardiovasc Electrophysiol 11:1355-1363, 2000.
- Taneja T, Horvath G, Racker DK, Goldberger J, Kadish A: Excitable gap in canine fibrillating ventricular myocardium: Effect of subacute and chronic myocardial infarction. J Cardiovasc Electrophysiol 12:708-715, 2001.
- Rankovic V, Karha J, Passman R, Kadish A, Goldberger J: Predictors of appropriate implantable cardioverter-defibrillator therapy in patients with idiopathic dilated cardiomyopathy. Am J Cardiol 89:1072-1076, 2002.
- Kadish A, Dyer A, Daubert JP, Quigg R, Estes M, Anderson KP, Calkins H, Hoch D, Goldberger J, Shalaby A, Sanders WE, Schaechter A, and Levine JH, for the Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators: Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 350:2151-2158, 2004.
- Bello D, Fieno DS, Kim RJ, Pereles FS, Passman R, Song G, Kadish AH, Goldberger JJ: Infarct morphology identifies patients with substrate for sustained ventricular tachycardia. J Am Coll Cardiol 45(7):1104-1108, 2005.
- Kadish A, Schaechter A, Subacius H, Thattassery E, Sanders W, Anderson KP, Dyer A, Goldberger J, Levine J: Patients with recently diagnosed nonischemic cardiomyopathy benefit from implantable cardioverter-defibrillators. J Am Coll Cardiol 47:2477-2482, 2006.
- Goldberger J, Subacius H, Schaechter A, Howard A, Berger R, Shalaby A, Levine J, Kadish A, for the Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators: Effects of statin therapy on arrhythmic events and survival in patients with nonischemic dilated cardiomyopathy. J Am Coll Cardiol 48:1228-1233, 2006.
- Robin J, Weinberg K, Tiongson J, Carnethon M, Reddy M, Ciaccio C, Quadrini M, Hsu J, Fan J, Choi P, Kadish A, Goldberger J, Passman R: Renal dialysis as a risk factor for appropriate therapies and mortality in implantable cardioverter-defibrillator recipients. Heart Rhythm 3(10):1196-1201, 2006.
- Dasgupta A, Montalvo J, Medendorp S, Lloyd-Jones DM, Ghossein C, Goldberger J, Passman R: Increased complication rates of cardiac rhythm management devices in ESRD patients. Am J Kidney Dis 49:656-63, 2007.
- Sanders GD, Al-Khatib SM, Berliner E, Bigger JT, Buxton AE, Califf RM, Carlson M, Curtis AB, Curtis JP, Domanski M, Fain E, Gersh BJ, Gold MR, Goldberger J, Haghighi-Mood A, Hammill SC, Harder J, Healey J, Hlatky MA, Hohnloser SH, Lee K, Mark DB, Mitchell B, Phurrough S, Prystowsky E, Smith JM, Stockbridge N, Temple R: Preventing tomorrow’s sudden cardiac death today: part II: translating sudden cardiac death risk assessment strategies into practice and policy. Am Heart J 153:951-959, 2007.
- Goldberger JJ, Cain ME, Hohnloser SH, Kadish AH, Knight BP, Lauer MS, Maron BJ, Page RL, Passman RS, Siscovick D, Stevenson WG, Zipes DP: American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific statement on noninvasive risk stratification techniques for identifying patients at risk for sudden cardiac death. A scientific statement from the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology and Prevention. Circulation 118(14):1497-1518; 2008.
- Goldberger JJ: Evidence-based analysis of risk factors for sudden cardiac death. Heart Rhythm 6:S2-7, 2009.
- Goldberger JJ, Passman R: Implantable cardioverter defibrillator therapy after acute myocardial infarction: The results are not shocking. J Am Coll Cardiol 54(22):2001-5, 2009.
- Kadish AH, Bello D, Finn JP, Bonow RO, Schaechter A, Subacius H, Albert C, Daubert JP, Fonseca CG, Goldberger JJ: Rationale and design for the Defibrillators to Reduce Risk by Magnetic Resonance Imaging Evaluation (DETERMINE) Trial. J Cardiovasc Electrophysiol 20(9):982-987, 2009.
- Gordon D, Kadish AH, Koolish D, Taneja T, Ulphani J, Goldberger JJ, Ng J: High resolution electrical mapping of depolarization and repolarization alternans in an ischemic dog model. Am J Physiol 298(2):H352-359, 2010.
- Goldberger JJ: The Coin Toss: Implications for risk stratification for sudden cardiac death. Am Heart J 160(1):3-7, 2010.
- Patel RB, Ng J, Reddy V, Chokshi M, Parikh K, Subacius H, Alsheikh-Ali AA, Nguyen T, Link MS, Goldberger JJ, Ilkhanoff L, Kadish AH: Early repolarization associated with ventricular arrhythmias in patients with chronic coronary artery disease. Circulation Arrhythmia and Electrophysiology 3: 489-495, 2010.
- Fishman GI, Chugh S, DiMarco J, Albert C, Anderson M, Bonow RO, Buxton A, Chen PS, Estes M, Jouven X, Kwong R, Lathrop D, Mascette A, Nerbonne J, O’Rourke B, Page R, Roden D, Rosenbaum DS, Sotoodehnia N, Trayanova N, Zheng ZJ. Sudden cardiac death prediction and prevention: report from a National Heart, Lung, and Blood Institute and Heart Rhythm Society workshop. Circulation 2010;122:2335-2348
- Bello D, Einhorn A, Kaushal R, Kenchaiah S, Raney A, Fieno D, Narula J, Goldberger J, Shivkumar K, Subacius H, Kadish A: Cardiac magnetic resonance imaging: infarct size is an independent predictor of mortality in patients with coronary artery disease. Magn Reson Imaging.29:50-56, 2011.
- Goldberger JJ, Buxton AE, Cain M, Costantini O, Exner DV, Lloyd-Jones D, Kadish AH, Knight BP, Lee B, Moss A, Myerburg R, Olgin J, Passman R, Rosenbaum D, Stevenson W, Zareba W, Zipes DP: Risk stratification for sudden cardiac death: Identifying the roadblocks. Circulation 123(21):2423-2430, 2011.
Diabetes is associated with many complications, particularly those that result in heart and kidney disease. Diabetes also affects the body’s nerves. The nerves that control the heart, including its rate and rhythm, are not under voluntary control and are called cardiac autonomic nerves. When these nerves are affected by diabetes, this is called cardiac autonomic neuropathy. Although this condition usually does not cause symptoms, unless severe, it is associated with worse survival. Diabetes affects an estimated 23.6 million Americans and 171 million people worldwide, with this number projected to double to 366 million people by the year 2030. One in nine Chicagoans have diabetes. Approximately one in five patients with diabetes has cardiac autonomic neuropathy, and this increases the risk of dying 3.5-fold, making cardiac autonomic neuropathy a significant risk factor for dying from diabetes.
There are many treatments for diabetes. In a large National Institutes of Health study, called the ACCORD trial, it was shown that intensive control of glucose (blood sugar), blood pressure, and cholesterol do not improve survival in patients with diabetes. There are no known treatments for cardiac autonomic neuropathy despite its associated risk. As diabetes is characterized by high blood sugars and is often associated with high blood pressure and high cholesterol, it was thought that intensive control of these factors would improve survival in diabetics. The ACCORD trial shattered this notion and demonstrates that there are likely some other factors that underlay the increased risk of death in diabetes. The race is on to identify these other factors. Cardiac autonomic neuropathy, which can cause serious abnormalities of the heart rhythm, is high on the list of possibilities.
Dr. Goldberger is a specialist and established researcher in heart rhythm disorders and the effects of the autonomic nervous system on the heart. He has developed a novel exercise based approach to diagnose cardiac autonomic neuropathy. His team has shown that this approach is more sensitive than currently used methods. They are extending these studies to different groups of patients with diabetes and are proposing to study the effects of an exercise training regimen on cardiac autonomic neuropathy. This groundbreaking work could substantially improve survival in diabetes.
- Goldberger J, Ahmed M, Parker M, Kadish A: Assessment of effects of autonomic stimulation and blockade on the signal averaged electrocardiogram. Circulation 89:1656-1664, 1994.
- Goldberger J, Ahmed M, Parker M, Kadish A: Dissociation of heart rate variability from parasympathetic tone. Am J Physiol 266:H2152-H2157, 1994.
- Ahmed M, Kadish A, Parker M, Goldberger J: Effect of physiologic and pharmacologic adrenergic stimulation on heart rate variability. J Am Coll Cardiol 24:1082-1090, 1994.
- Cheema A, Ahmed M, Kadish A, Goldberger J: Effects of autonomic stimulation and blockade on the signal averaged P wave duration. J Am Coll Cardiol 26:497-502, 1995.
- Ahmed M, Kadish A, Goldberger J: Autonomic effects on the QT interval. Annals Noninvasive Electrocardiol 1:44-53, 1996.
- Goldberger J, Kim Y, Ahmed M, Kadish A: Effect of graded increases in parasympathetic tone on heart rate variability. J Cardiovasc Electrophysiol 7:594-602, 1996.
- Burke J, Goldberger J, Ehlert F, Kruse J, Parker M, Kadish A: Gender differences in heart rate before and after autonomic blockade: evidence against an intrinsic gender effect. Am J Med 100:537-543, 1996.
- Ahmed M, Kadish A, Goldberger J: Autonomic effects on noise recorded during signal averaged electrocardiography. Pacing Clin Electrophysiol 20:1796-1799, 1997.
- Kim Y, Ahmed M, Kadish A, Goldberger J: Characterization of the factors that determine the effect of sympathetic stimulation on heart rate variability. Pacing Clin Electrophysiol 20:1936-1946, 1997.
- Burke J, Ehlert F, Kruse J, Parker M, Goldberger J, Kadish A: Gender-specific differences in the QT interval and the effect of autonomic tone and menstrual cycle in healthy adults. Am J Cardiol 79:178-181, 1997.
- Goldberger J: Sympathovagal balance: how should we measure it? Am J Physiol 276(4 Pt 2):H1273-H1280, 1999.
- Challapalli S, Kadish A, Horvath G, Goldberger J: Differential effects of parasympathetic blockade and parasympathetic withdrawal on heart rate variability. J Cardiovasc Electrophysiol 10(9):1192-1199, 1999.
- Goldberger JJ, Challapalli S, Tung R, Parker MA, Kadish AH: Relationship of heart rate variability to parasympathetic effect. Circulation 103:1977-1983, 2001.
- Taneja T, Larsen J, Goldberger J, Kadish A: Age, gender and autonomic tone effects on surface electrocardiographic indices of ventricular repolarization. Ann Noninvasive Electrocardiol 6:290-297, 2001.
- Kannankeril P, Goldberger J: Parasympathetic effects on cardiac electrophysiology during exercise and recovery. Am J Physiol 282:H2091-H2098, 2002.
- Kannankeril P, Le F, Kadish A, Goldberger J: Parasympathetic effects on heart rate recovery after exercise. J Invest Med 52(6):394-401, 2004.
- Goldberger JJ, Le FK, Lahiri M, Kannankeril PJ, Ng J, Kadish AH: Assessment of parasympathetic reactivation after exercise. Am J Physiol 290:H2446-H2452, 2006.
- Endres S, Mayuga KA, de Cristofaro A, Taneja T, Goldberger JJ, Kadish AH: Age and gender difference in ST height at rest and after double autonomic blockade in normal adults. Ann Noninvasive Electrocardiol 11:253-258, 2006.
- Sundaram S, Carnethon M, Polito K, Kadish AH, Goldberger JJ: Autonomic effects on QT-RR interval dynamics after exercise. Am J Physiol 294:490-497, 2008.
- Banthia S, Ng J, Chicos A, Molitch M, Kadish A, Goldberger JJ: Early detection of cardiovascular autonomic neuropathy using exercise testing in patients with type 2 diabetes mellitus. Circulation 118(18):S648, 2008.
- Chicos AB, Kannankeril PJ, Kadish AH, Goldberger JJ: Parasympathetic effects on cardiac electrophysiology during exercise and recovery in patients with left ventricular dysfunction. Am J Physiol 297:H743-749, 2009.
- Ng J, Sundaram S, Kadish AH, Goldberger JJ: Autonomic effects on the spectral analysis of heart rate variability after exercise. Am J Physiol 297(4):H1421-1428, 2009.
- Ulphani JS, Cain JH, Inderyas F, Gordon D, Gikas PV, Shade G, Mayor D, Arora R, Kadish AH, Goldberger JJ: Quantitative analysis of parasympathetic innervation of the porcine heart. Heart Rhythm 7(8):1113-1119, 2010.
- Laing ST, Gluckman TJ, Weinberg KM, Lahiri MK, Ng J, Goldberger JJ: Autonomic effects of exercise-based cardiac rehabilitation. J Cardiopulm Rehabil Prev. 2010.
- Bergner DW, Goldberger JJ: Diabetes mellitus and sudden cardiac death:what are the data? Cardiol J 17(2):117-129, 2010.
- Bergner DW, Goldberger JJ: Autonomic determinants of early heart rate recovery after exercise differs in type 2 diabetes mellitus. Circulation 120(18): S634, 2010.
- Wang NC, Chicos A, Banthia B, Bergner DW, Lahiri MK, Ng J, Subacius H, Kadish AH, Goldberger JJ: Persistent sympathoexcitation long after submaximal exercise in subjects with and without coronary artery disease. Am J Physiol 301(3):H912-920, 2011.
Atrial fibrillation is the most common heart rhythm disorder. It is a chaotic activation of the top chambers of the heart, typically at rates of 400-500 beats/min (much faster than the normal rates of 50-80 beats/min), that interferes with the heart’s normal pacemaker function. Atrial fibrillation affects over 2.2 million people in the U.S.; some estimates project that it will affect 12 million people in the U.S. by 2050. Atrial fibrillation increases the risk for heart failure, stroke, and death. Of the estimated 600,000 ischemic strokes that occur yearly in the US, 15-20 percent are thought to be secondary to atrial fibrillation.
There are many different treatment approaches to atrial fibrillation, which include medications or interventional procedures to restore normal rhythm, as well as blood thinners to prevent stroke, one of the most devastating complications of atrial fibrillation. Which treatments are optimal for individual patients is currently unknown. Many of our treatments are either not very effective or have significant side effects, toxicities, or other risks. Moreover, it is not known which treatment will be effective for an individual patient, requiring a trial-and-error approach in the selection of treatments. One example of this challenge is in the use of blood thinners for patients with atrial fibrillation. While these agents are very effective at reducing the risk of stroke, they come at the price of a significant yearly risk of major bleeding, including hemorrhagic stroke. Currently, we treat many more patients with these blood thinners than actually need them, thereby exposing them unnecessarily to the bleeding risks. Yet, there is no better way to pick patients for treatment than the current approach.
Dr. Jeffrey Goldberger, a specialist in heart rhythm disorders and an established researcher in this area, has assembled a multidisciplinary team to foster new ideas and new collaborations to address these many problems related to this public health issue. Specialists in arrhythmias, clinical research, basic science, imaging, engineering, and epidemiology are developing new approaches that will leverage existing technologies and new paradigms that can change the face of therapy for atrial fibrillation. The figure below shows a novel MRI technique that is being developed by Dr. Goldberger and colleagues from the Departments of Cardiology and Radiology to identify areas of low blood flow in the atrium during atrial fibrillation that are responsible for the development of blood clots that can lead to strokes.
- Ehlert F, Goldberger J, Rosenthal J, Kadish A: Relation between QT and RR intervals during exercise testing in atrial fibrillation. Am J Cardiol 70:332-338, 1992.
- Schilling R, Kadish A, Peters N, Goldberger J, Davies DW: Endocardial mapping of atrial fibrillation to the human right atrium using a non-contact catheter. Eur Heart J 21:550-564, 2000.
- Horvath G, Goldberger JJ, Kadish AH: Simultaneous occurrence of atrial fibrillation and atrial flutter. J Cardiovasc Electrophysiol 11(8):849-858, 2000.
- Schilling RJ, Peters NS, Goldberger J, Kadish AH, Davies DW: Characterization of the anatomy and conduction velocities of the human right atrial flutter circuit determined by noncontact mapping. J Am Coll Cardiol 38:385-393, 2001.
- Larsen J, McPherson D, Kadish A, Goldberger J: Course of intraatrial thrombi resolution using transesophageal echocardiography. Echocardiography 20:121-128, 2003.
- Passman RS, Kadish AH, Dibs SR, Engelstein ED, Goldberger JJ: Radiofrequency ablation of atrial flutter: A randomized controlled trial of two anatomic approaches. Pacing Clin Electrophysiol 27:83-88, 2004.
- Passman RS, Weinberg KM, Freher M, Denes P, Schaechter A, Goldberger JJ, Kadish AH: Accuracy of mode switch algorithms for detection of atrial tachyarrhythmias. J Cardiovasc Electrophysiol 15(7):773-777, 2004.
- Ng J, Kadish AH, Goldberger JJ: Effect of electrogram characteristics on the relationship of dominant frequency to atrial activation rate in atrial fibrillation. Heart Rhythm 3(11):1295-1305, 2006.
- Arora R, Ng J, Ulphani J, Mylonas I, Subacius H, Shade G, Gordon D, Morris A, He X, Lu Y, Belin R, Goldberger JJ, Kadish AH: Unique autonomic profile of the pulmonary veins and posterior left atrium. J Am Coll Cardiol 49(12):1340-1348, 2007.
- Weinberg KM, Denes P, Kadish AH, Goldberger JJ: Criteria for the electrocardiographic diagnosis of atrial flutter improve diagnostic accuracy. Am J Med 120:814-8, 2007.
- Ng J, Kadish AH, Goldberger JJ: Technical considerations for dominant frequency analysis. J Cardiovasc Electrophysiol 18:757-64, 2007.
- Ulphani JS, Ng J, Aggarwal R, Cain JH, Gordon D, Yang E, Morris AR, Arora R, Goldberger JJ, Kadish AH: Frequency gradients during two different forms of fibrillation in the canine atria. Heart Rhythm 4:1315-1323, 2007.
- Ulphani JS, Arora R, Cain JH, Villuendas R, Shen S, Gordon D, Inderyas F, Harvey LA, Morris A, Goldberger JJ, Kadish AH: The ligament of Marshall as a parasympathetic conduit. Am J Physiol 293(3):H1629-1635, 2007.
- Ng J, Goldberger JJ: Understanding and interpreting dominant frequency analysis of AF electrograms. J Cardiovasc Electrophysiol 18:680-685, 2007.
- Arora R, Ulphani JS, Villuendas R, Ng J, Harvey LA, Thordson S, Inderyas F, Lu Y, Gordon D, Denes P, Greene R, Crawford S, Decker RS, Morris A, Goldberger JJ, Kadish AH: Neural substrate for atrial fibrillation: implications for targeted parasympathetic blockade in the posterior left atrium. Am J Physiol 294:134-144, 2008.
- Weinberg KM, Denes P, Kadish AH, Goldberger JJ: Development and validation of diagnostic criteria for atrial flutter on the surface electrocardiogram. Ann Noninvasive Electrocardiol 13(2):145-154, 2008.
- Dibs SR, Ng J, Arora R, Passman RS, Kadish AH, Goldberger JJ: Spatiotemporal characterization of atrial activation in persistent human atrial fibrillation: multisite electrogram analysis and surface electrocardiographic correlations--a pilot study. Heart Rhythm 5(5):686-693, 2008.
- Aistrup GL, Villuendas R, Ng J, Gilchrist A, Lynch TW, Gordon D, Cokic I, Mottl S, Zhou R, Dean DA, Wasserstrom JA, Goldberger JJ, Kadish AH, Arora R: Targeted G-protein inhibition as a novel approach to decrease vagal atrial fibrillation by selective parasympathetic attenuation. Cardiovasc Res 83:481-492, 2009.
- McCarthy PM, Kruse J, Shalli S, Ilkhanoff L, Goldberger JJ, Kadish AH, Arora R, Lee R: Where does atrial fibrillation surgery fail? Implications for increasing effectiveness of ablation. J Thorac Cardiovasc Surg 139(4):860-867, 2010.
- Berry JD, Prineas RJ, van Horn L, Passman R, Larson J, Goldberger J, Snetselaar L, Tinker L, Liu K, Lloyd-Jones DM: Dietary fish intake and incident atrial fibrillation (from the Women's Health Initiative). Am J Cardiol 105(6):844-848, 2010.
- Ng J, Borodyanskiy AI, Chang ET, Villuendas R, Dibs S, Kadish AH, Goldberger JJ. Measuring the complexity of atrial fibrillation electrograms. J Cardiovasc Electrophysiol 21(6):649-655, 2010.
- Schwartz GG, Chaitman B, Goldberger JJ, Messig M: Effect of high-dose atorvastatin on risk of atrial fibrillation in patients with prior stroke or transient ischemic attack: An analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Am Heart J 161:993-999, 2011.
- Ng J, Villuendas R, Cokic I, Schliamser JE, Gordon D, Koduri H, Benefield B, Simon J, Murthy SNP, Lomasney JW, Wasserstrom JA, Goldberger JJ, Aistrup GL, Arora R: Autonomic remodeling in the left atrium and pulmonary veins in heart failure – creation of a dynamic substrate for atrial fibrillation. Circulation Arrhythmia and Electrophysiology 4(3):388-396, 2011.
While the US healthcare system is the most technologically advanced in the world, the system is highly fragmented, inefficient, and grows ever more costly each year. Despite spending twice as much on healthcare as other industrialized countries, the US ranks poorly on important health outcomes and on preventable mortality. Moreover, nearly 50 million Americans are uninsured with another 25 million underinsured. Decades of work on regional variations in healthcare has demonstrated that the care a patient receives is not a function of medical need but is a function of where a patient lives. Further measures are desperately needed to improve value and curtail unsustainable growth in healthcare spending.
Because cardiovascular diseases are highly prevalent and result in a high burden of morbidity and mortality, cardiovascular disease results in enormous direct and indirect healthcare expenditures. Over the past decade, cardiology imaging has grown disproportionately compared to other areas of medicine, and there is widespread belief amongst policy makers that these tests are overused. Lifesaving technological advances such as implantable defibrillators, left ventricular assist devices, and cardiac transplantation come with a staggering price tag. Comparative effectiveness research is required to assure that the highest possible return is gained from the large investment in cardiovascular medicine. Further, research is urgently needed to assess the impact of recent policy interventions under the Affordable Care Act on access, cost, and quality of care.
How is the Center for Cardiovascular Innovation addressing this problem?
The Program in Cardiovascular Healthcare Policy undertakes interdisciplinary research to promote evidence based policies at the state and national level which enhance access, cost, and quality of cardiovascular care.
- Variations in use of cardiovascular imaging following heart failure diagnosis. In this NIH-funded pilot study, Dr. Farmer and colleagues make use of rich clinical and financial data from the Dartmouth Atlas of Healthcare and the Cardiovascular Research Network (CVRN) to explore variations in rates of cardiovascular imaging use at the hospital level. The CVRN includes data on more than 11 million patients from 14 geographically diverse health plans nationwide. Subsequent work will assess the medical and non-medical factors driving this variation, and the relationship with several outcomes of care.
- Developing a conceptual model of heart failure readmissions. This Department of Medicine funded pilot study lays the foundation for Dr. Farmer’s planned multicenter NIH proposal. Despite the tremendous resources allocated to healthcare in the United States, concerns are mounting that existing practice models fail to deliver consistent, high quality, evidence-based, cost effective care, especially for patients with chronic conditions. These gaps in healthcare delivery can contribute to inefficient and ineffective resource utilization, as well as poor patient outcomes. This study will combine qualitative input from clinical experts, patients and caregivers with existing data from the published literature to develop a robust conceptual model of readmissions after heart failure hospitalization.
- Impact of medical malpractice risk and financial incentives on cardiovascular testing. Currently under review at the NHLBI, this proposal makes use of malpractice claims data, CVRN data, and the Medicare 5% random sample. This work will examine how malpractice risk and financial incentives interact to jointly influence physician behavior in the rate of utilization of cardiac imaging tests. These interactions are likely to be important. For example, if testing is profitable, both the desire to reduce malpractice risk and the desire to enhance profitability could combine to induce higher testing rates. In contrast, even if testing becomes unprofitable, providers’ desire to reduce malpractice risk could provide a “floor” on testing rates and ensure that clinically valuable tests are order
The members of the Center for Cardiovascular Innovation are members of the full time faculty at the Northwestern University Feinberg School of Medicine within the Division of Cardiology at Northwestern Memorial Hospital. Their diverse backgrounds and expertise provide unique opportunities for interdisciplinary work with other departments at Northwestern University and with external organizations engaged in improving cardiovascular quality and outcomes.