It may come as no surprise that the practice of medicine often goes beyond prescriptions and test results, often integrating diet and lifestyle patterns as effective mechanisms to promote heart health. The overwhelming prevailing opinion among Cardiologists (including from our own Heartbeat Cardiology team w/hundreds of combined years of experience treating cardiovascular disease) is that people can benefit from adopting a Mediterranean diet, so let’s dive in and understand what that really means.
When we talk about any nutrient or food in the context of dietary changes, we must think about the practical application of the diet, which translates to swapping out foods to create room for new ones. On a given day, you are going to get 100% of your calories from all the things you eat, and if you eat more of X as a part of that 100%, you are going to eat less of Y. When we move from one diet to another, we must think about reducing and replacing foods with better choices.
The Mediterranean diet has proved itself as a sustainable and palatable way of living, evidenced by its practice in real-world populations over a span of generations. Not only is it recommended to many patients by our Heartbeat Cardiologists, it is also well-loved by modern food policy and nutritionist brains, from Mark Bittman to Lisa Young. It has many flavors depending on geography, from North Africa, the Middle East, and Southern Europe, notably including some Blue Zone communities. Nutritionist Antonia Trichopoulou identified the key ingredients in the modern Mediterranean diet and what those dietary patterns have in common: beans, legumes, whole grains, vegetables, fruits, and high levels of olive oil, in particular, extra virgin olive oil in both cold and cooked foods. The diet is rather high in fat, which surprises and contradicts most modern thinking, that fat is always bad when in fact there is an important distinction: unsaturated fat from olive oil, nuts, and avocados can actually improve blood cholesterol levels and ease inflammation while saturated fat from butter, sausages and bacon contributes to high cholesterol and high blood pressure which can lead to heart disease.
Modern research starting in the 60s helped to graduate the Mediterranean diet into the medical community. Ancel Keyes in 1963 published pivotal research that for the first time associated the diet with improved health outcomes, more specifically, showed a correlation between the traditional Mediterranean diet and a lower risk of coronary heart disease. Keyes noticed marked differences in populations and was among the first to utilize a scientific lens to determine if differences in lifestyle and dietary patterns could be adopted by other populations to reduce unfavorable health outcomes. In February 2013, the clinical trial known as the PREDIMED Study published in the New England Journal of Medicine produced findings that adhering to a Mediterranean diet reduces the risk of cardiovascular disease by approximately 30% and also reduces the risk of stroke in high-risk patients. This study helped to solidify the place of the Mediterranean diet in the medical community. Shortly thereafter in 2016 and 2019, the American Cardiology Association and American Diabetes Association, respectively, recommended the Mediterranean diet as a healthy dietary pattern to help prevent cardiovascular diseases and type two diabetes.
So, let’s recap; we have identified primary foods: beans, legumes, and fish as principal protein sources, dairy and meat as limited protein sources, fruits, vegetables and whole grains as carbohydrates, and a significant portion of fat from olive oil, avocado, nuts, and seeds. We also know the more of one thing we eat, the less room there is in the same diet for another thing. For example, the more beef you eat the more protein you get from that meat, and the less room there is to get any given percentage of that protein from beans or lentils, which provide not just protein but also unsaturated fat and fiber— which can lower blood pressure and reduce cardiovascular risk.
It takes planning and commitment to adopt a diet from a different culture. Creating structure and meal prepping can be helpful to integrating those foods into lifestyle and habit. We have much to gain by adjusting our food choices, choices that can help to make meaningful improvements towards reducing cardiovascular disease, high cholesterol, and high blood pressure.
The first recorded mention of the term “Accountable Care Organization” was by Dr. Elliott Fisher during a 2006 public meeting with the Medicare Payment Advisory Committee (MedPAC).
Then, six years later in 2012, The Patient Protection and Affordable Care Act (ACA) authorized the use of Accountable Care Organizations (ACOs) to improve the safety and quality of care and reduce health care costs in Medicare. ACOs are defined as groups of doctors and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. They matter because their member bases are growing fast, and they’re driving both better outcomes and lower costs.
As of January 2022, there are 483 Medicare ACOs serving over 11 million beneficiaries across the country (per the National Associations of ACOs). There are many flavors of ACOs — including hospital-based ACOs, independent ACOs that offer what tends to be called “facility-based primary care” (that is, they build and run their own centers), and “over the top” players such as Aledade, Evolent, and Privia that collaborate with existing independent primary care practices. This network dynamic from Aledade et al enables independent practices to participate in the ACO model when otherwise they probably would or could not.
These days, it’s significant that The Center for Medicare and Medicaid Innovation has clearly expressed that they want every Medicare beneficiary in an accountable care plan by 2030. And their newest program, called ACO Reach, has attracted hundreds of applicants, as CMS seeks to ensure historically underserved patients are fully included.
Primary and Speciality Collaboration
Over especially the last two decades, primary care in America has been limited in what it can or will do in regards to specialty care, such as for categories such as kidney, cardiovascular or GI. But now, given the economic incentives that are baked into the ACO model, along with the rise of advanced diagnostic devices, the specialty line in American primary care is being redrawn much higher – that is, the lower ~40% of acuity in any specialty such as cardiovascular disease will be addressed in the ACO, and only the top ~60% of acuity will be referred out to specialists.
This has led to a “hub & spoke” effect – the idea is that ACOs employ advanced diagnostics and curated clinical data to identify gaps in care. In cardiology, that diagnostic is commonly a cardiovascular echo. What happens next is a partner such as Heartbeat Health conducts a same day read, and if the patient has low-to-moderate cardiovascular disease (CVD), the ACO typically keeps the patient and treats their heart issues face-to-face. If the patient has high-to-acute CVD, the spoke is invoked – the patient is referred to, as an example, virtual cardiology team for ongoing heart care, given the convenience that virtual visits represent for the patient. This “hub & spoke” effect is transforming how primary care tied seamlessly to speciality care work together across disciplines.
The ACO REACH Model
To make matters more nuanced, the new ACO REACH model is now here. REACH stands for Realizing Equity, Access, and Community Health. It replaces the Global and Professional Direct Contracting (GPDC) Model. The GPDC was launched during the Trump administration, with the aim of allowing traditional and non-traditional risk-bearing entities to take on risk for lives across an entire market beyond the normal attribution method for other ACO models.
A major focus of the Biden administration’s ACO REACH program is health equity. A new benchmark adjustment prominent in the REACH rubric is to positively incentivize ACOs covering underserved communities and beneficiaries — or at least avoid inadvertently penalizing them for doing so.
The ACO REACH Model accepted applications in April 2022, and will officially launch next year, likely with known players from the ACO and GPDC realm, and new organizations as well.
All ACOs in the REACH model will have to develop a plan for how they will identify health disparities in their respective communities and then take specific actions to address those disparities. This is a requirement that does not exist currently in Medicare.
Virtual models will also be key in regards to health equity. Medicare patients have proved far more facile with video visits and HIPAA-compliant texting than prognosticators imagined, especially when no smartphone app is required. Since there’s increasingly appreciated “value in the visit,” web and mobile web video encounters appear to be especially effective with seniors, and lead to a level of appointment adherence far greater than what is seen in the face-to-face model.
Patients in ACO REACH – and other ACO models – actually receive more benefits than those in traditional Medicare. Broad use of telehealth is very much allowed, as is the waiving of a requirement for a three-day inpatient hospital stay before an admission to a skilled nursing facility. Patients can receive cost-sharing support to help with copays, as well as rewards for managing their chronic diseases. REACH also allows much more generous use of home visits after patients leave the hospital.
This home visit component is important, because the “Last Mile” is being paved at a rapid rate in America, whereby a nurse with advanced diagnostics can get to the patient’s home in a growing set of major markets in less than 4 hours. Then, the visiting nurse can stream diagnostic data in real time to relevant providers, typically specialists. Prominent “Last Mile” firms include Dispatch Health, Medically Home, MyNexus (owned by Anthem), OneHome (owned by Humana), Livio (owned by Blue Cross of Minnesota) and Emcara (owned by Florida Blue). And there are many dozens more.
The hub for any ACO, traditional or the new ACO REACH model, appears to be face-to-face primary care. The spokes, however, are likely to be increasingly virtual as a function of patient convenience and achieving lower costs of care. And the recasting of the specialty line will mean “V1Cs” (Virtual-First Care companies, as named by the Virtual First Medical Practice Collaboration) are operating in every specialty, representing a rich menu of choices for ACO and ACO REACH players alike.
Are there ways to simplify specialty care, like heart care, for PACE plans?
Scheduling an in-person visit with a cardiologist is downright difficult. Nationally, it takes upwards of 45 days to see one and the prospect of getting yourself there can be a challenge for many. For PACE plans (Program of All Inclusive Care for the Elderly) who manage care for thousands of individuals in their network – this reality is an incredible challenge and extends beyond one speciality area like heart care. The responsibility that falls under a program providing all inclusive healthcare for the elderly includes so much more than standard primary care. The all inclusive aspect of care in the PACE model is also one of the greatest assets to its participants, but what happens when specialty care becomes too complex for the participant to reap the benefits?
As background, PACE programs provide the entire continuum of care and services to seniors with chronic care needs while maintaining their independence in their home for as long as possible. Services are all inclusive, a participant relies on the PACE organization to provide all care, inclusive of transportation and social services related to care. Programs receive a set amount monthly from Medicare and Medicaid to provide nearly everything for people over 55 whose needs qualify them for a nursing home but who don’t want to enter one. This includes doctors’ visits, tests, procedures, physical, occupational and speech therapy, social workers, home care, transportation, medication, dentistry and hearing aids. Participants typically visit a PACE center several times a week for meals and social activities as well as therapy and health monitoring.
So the question arises – are there ways to simplify specialty care, like heart care, for PACE plans?
At Heartbeat Health, we provide an opportunity for a primary care provider in a PACE facility to easily refer a patient directly to a Heartbeat virtual cardiologist. The participant can set up a virtual visit instantly or on another day that they will be back in the PACE facility, or even at home if they choose. This simplified workflow eliminates scheduling headaches, transportation coordination burdens and the visit itself is lower cost than an in person visit. Not to mention, this simplifies the experience and lowers stress barriers reduction for the participant as well.
Additionally, given the barriers that participants face, such as the need for translation services or access to a laptop or WiFi, there are concerns among some that Virtual-First care will exacerbate the digital divide. Fortunately in the PACE model, an interdisciplinary team of health professionals provides PACE participants with coordinated care and assistance. For most participants, this opens a door for simple virtual visits, with their care team in the facility to help if needed. Furthermore, Heartbeat’s virtual visit experience (televisits) takes those issues into account and as a result, systematically improves access to treatment.
Lastly, given the at-risk nature of the payment model for PACE, cost reduction also becomes a very important piece of the puzzle. With facility fee costs eliminated, the average savings can be ~$200 per visit across most markets. This coupled, with a reduction in costs in eliminating transportation costs, presents a great opportunity financially for a PACE program.
Additionally, Heartbeat can conduct cardiovascular risk assessment across the entire PACE population. This can be done either through chart review or in-person diagnostics or remote diagnostics, to identify participants with rising risk or existing CVD. This may allow the PACE plan to adjust risk scores and potentially increase reimbursement per participant.
PACE plans are responsible for some of the widest variety of services for any healthcare organization taking on risk. The complexity that each plan faces to ensure their participants receive high quality specialty care is just too much. The time is now to untangle the logistics, scheduling burden and cost for specialty care for PACE plans – and deliver better clinical outcomes for PACE participants at scale.
An in-depth look at our business case for SOC 2® compliance.
The risks of mishandling user data are increasing constantly. Cyberthreats are growing in sophistication and prevalence every year, and international regulatory bodies are demanding more stringent controls to ensure sensitive information is transmitted, stored, and leveraged in a manner that prevents it from being lost, leaked, adulterated, or misused. As part of our commitment to data security, in 2022, Heartbeat Health obtained SOC 2® certification, a standard developed by the American Institute of CPAs and one of the most respected and comprehensive security frameworks today. It verifies that our digital security practices are consistent, auditable, repeatable, and in line with the most rigorous standards for protecting data. Heartbeat is growing quickly and we are helping some of the largest healthcare companies reduce their spend on cardiac care while improving outcomes — but we are equally aware that the trust of our partners and patients is dependent upon systematically protecting their data.
The decision that everyone puts off
We take our users’ clinical data seriously. At Heartbeat, we already adhere to the Health Insurance Portability and Accountability Act (HIPAA) developed by the U.S. Department of Health and Human Services (HHS) to protect the security and privacy of health information in addition to many other regulatory requirements associated with virtual first clinical care. Most certifications and security frameworks share or have overlapping controls, so we began SOC 2® certification with the assumption that we would not need to start the process from scratch. A common misconception is that teams should wait or that they need to be a certain size before they take on the certification process due to the time commitment. The truth is that it is easier to start formalizing your compliance approach as soon as your product roadmap has stabilized and before going into a growth phase. Furthermore, the process changes necessary to support a new level of compliance are easier to roll out when a team is smaller.
We’ll trust you after you fill out this survey
With so many embarrassing and damaging data breaches making headlines these days, users and organizations of all types are justifiably concerned about the safety of their data. They need good evidence that they are entrusting it to parties that will safeguard it appropriately. The standard process for new payer and digital health clients involves completing a survey describing the compliance program and security safeguards that are in place, which provides assurances that customer data will be well managed. These questionnaires are time consuming and can require a bit of back and forth until both security teams are aligned on risk. In order to short circuit this process, we have found that most of the questions and concerns in a risk survey are covered by our SOC 2® Type 2 report. We still get questionnaires from prospective clients, but it helps move the conversation forward to focus on scope and terms instead of getting held up in a security review. This can save weeks to months on a sales process, which should help prove the case that it’s wise to make this investment in security as early as possible!
Compliance is a team sport
Many of the members of our leadership team, as well as many of our engineers and contractors, come from a health care tech background and have deep experience achieving certifications and working in a heavily regulated environment. In addition to leveraging the crosswalk of best practices from HIPAA, we were able to rely on the fact that a lot of the expected controls were already designed into our platform and we had existing processes in place that would meet control guidelines. We also enlisted the help of a contracted Chief Information Security Officer, a compliance platform, and an audit partner. Vanta is a software service that helps automate and manage compliance for a number of different certifications. It connects to our cloud providers, project management, human resource systems, and other workflow tools. If you already meet a control or have a gap, a platform like Vanta rapidly identifies issues in need of remediation. Helping internal teams understand the importance of compliance brings security to the forefront and asks everyone to do their part.
Risk mitigation and security at Heartbeat
Recently, cybercriminals announced they had successfully breached both Microsoft and Okta, a widely used identity management platform that helps organizations prevent unauthorized access from digital intruders. Heartbeat was well prepared to respond to these hacks thanks to our ability to track and document issues as they were announced. With the processes in place to support our SOC 2® controls, we were protected from these public attacks by having best practices in place. As a growing company that relies on third party vendors to support technical and operational work, having plans around disaster recovery and steps to proactively mitigate risk using multi-factor authentication and limiting access are absolutely essential. Also, ensuring that every vendor is well vetted is an important practice that SOC 2® helps enforce. No company is safe from a breach or hack as threats can come from anywhere and are constantly evolving. However, having steps documented and tested in preparation for these types of events helps manage risks proactively and limit the impact of exposure to a security incident.
Development process and velocity
We are proud of the work that we do at Heartbeat and the platform that we have built to care for our patients. Enterprise companies put a lot of trust in us, and hitting this milestone is a testament to the diligence and care that we put into building our software and operational processes. Achieving SOC 2® certification is just a starting point. Renewing our certification is a recurring exercise and an opportunity to build on a strong foundation for risk management and data security. We were also mindful about not impacting our product or development velocity by introducing new policies and requirements for our teams too quickly and we counter that prospect by focusing on automation wherever possible. We brought in third party security firms to test our security, prove that our system is resilient, and remove avoidable bias from the process of penetration and vulnerability testing. The added assurances that we have implemented during our last audit period are now baked into the development process. Our teams are more productive and save time during architectural planning because the risks are managed.
We are already well into our next audit period, expanding our compliance programs, and continuing to raise the bar. The valuable and sensitive digital assets we are entrusted with are always at great peril because the risks of a cyberattack or other data disaster are sadly more elevated than ever before — which is why we pledge to continually invest in transparently building and deploying security programs that meet and exceed industry standards and keep our data where it belongs: in the hands of patients and providers to enable a new generation of digital healthcare.
“Doc, your patient is here,” said one of the clinical staff members.
We were closing up for the day when my patient arrived over an hour late. He moved slowly and leaned into his cane as if it would split at any moment, looking exhausted.
He sat down apologetically to explain the taxing journey that he had taken to get to the clinic that day—a half mile walk to the bus stop to catch the 106, only to hop off and onto the 44 and then the 52.
I looked down at the reason for the visit: “blood pressure check.”
That was seven years ago. When I think back to that moment, I realize I knew even then how unjust and illogical it was to put our patients in situations like that. It was the comfortable model we were accustomed to, one that a fee for service structure caters to, but there was clearly a better way. Now, several years into Heartbeat Health’s experience, it is evident that a Virtual-First approach is the exact solution that we needed all along.
So what exactly is Virtual-First cardiology and how is it helping healthcare providers avoid issues like my clinic patient faced? It is specialty cardiac care that leverages data, device connectivity and clinicians to deliver on-demand cardiovascular services. It’s data-driven care connected not to a location but to the patient, able to serve them just as effectively remotely as in person. These elements serve as the foundation for care delivery — rather than the face to face experience that anchors traditional healthcare settings.
At Heartbeat, our collective experience over the last several years proves that this model is an optimal fit for a very wide range of cardiovascular conditions. In the ‘healthiest’ of cardiac populations, those who have not yet developed cardiovascular disease but who are at moderate to high risk of it, Virtual-First care allows them to meet a cardiologist from the comfort of their home on their phone or at their computer. Patients get engaged, educated, and involved with preventative measures such as statin therapy and lifestyle changes that may add years to their lives.
For the sickest of cardiac patients, those who are leaving the hospital with advanced heart failure or who just had a heart attack, Virtual-First cardiology enables frequent virtual visits driven by AI-driven algorithms which identify the most pressing risks. That prioritization model is then complemented by daily remote monitoring and ongoing care milestones. Among our historical patient panel, we have already observed 70% and 33% reductions in cardiac and all-cause readmission, respectively, with this approach.
Given the barriers that some face, such as the need for translation services or access to a laptop or WiFi, there are concerns that Virtual-First care will exacerbate the digital divide. However, thanks to the rapid pace of technological growth, many of those obstacles to accessing virtual treatment are rapidly disappearing. Furthermore, modern telemedicine, when done correctly and intentionally, takes those issues into account and systematically improves access to treatment.
For example, Heartbeat offers platform-agnostic mobile access with translator services to extend the reach of Virtual-First care. For patients without easy access, we work closely with family members, nurses, and medical assistants who can facilitate virtual visits. And for patients that still struggle to connect with us, we embed in brick and mortar PCP offices and offer services via mobile devices and digital tablets. This allows patients to reap the benefit of a high impact health visit with coordinated care between their central physician and a specialist.
Our approach represents a massive upgrade in the patient experience away from outdated, time consuming, expensive, one-size-fits-all care to a model that is significantly more efficient, convenient, and personalized.
It would be inaccurate to say that Virtual-First care will replace all face to face care. As physicians, we know the value of placing a hand on someone’s calf, detecting a subtle drop in body temperature, and knowing that they have decompensated into a low output cardiogenic shock. Yet, not every patient or situation requires in person care — and those visits can be avoidably wasteful in time, effort, and cost. That’s why Virtual-First care is the perfect complement to face to face visits; it emphasizes low-cost, easy and early access options which cater to most cardiac patients.
Virtual-First care also prioritizes medical management first, now thematic in most ACC/AHA guidelines, rather than a procedure-first approach. It allows for early recognition of organ system failure as the result of a disease’s progression so that we can more proactively prioritize those who need escalation in care.
As a practicing Virtual-cardiologist at Heartbeat, almost every day I think back to that patient who struggled to take three buses to our clinic in Philadelphia just for a routine blood pressure check. I often wonder how things would have been different had that patient been in our Virtual-First care model today. The answer is clear, and it keeps me and our growing team motivated every day to evolve our company and our model so that it extends to the greatest number of people that can benefit from it.
Cardiovascular diseases (CVD) affect nearly half of all American adults, and in addition to their impact on health outcomes, they have significant economic implications. 17% of all annual healthcare costs in the U.S. are associated with these conditions, the largest across all disease categories. In 2018, cardiovascular outcomes researcher Dr. Leslee Shaw and her collaborators published “10-Year Resource Utilization and Costs for Cardiovascular Care.” Four years on, it is still among the most extensive studies measuring the progression of cardiovascular diseases among initially healthy individuals and associating the costs of treating CVD with different risk factors.
Connecting Risk Factors to Costs
The Shaw study reviewed 6,814 asymptomatic participants from the Multi-Ethnic Study of Atherosclerosis (MESA) sponsored by a NIH National Heart, Lung, and Blood Institute. Her study examined expenditures connected to:
The study’s cost figures were derived from Medicare nationwide and zip-code-specific data that was inflation-corrected, discounted at 3% per year, and presented in 2014 dollars.
Each participant completed a baseline visit at the beginning of the study where they self-reported their “history of diabetes, hyperlipidemia, hypertension, family history of CVD and smoking history.” They also had their lipids, glucose, blood pressure, high-sensitivity C-reactive protein (hsCRP), and coronary artery calcium scoring (CACS) measured.
Participants were assigned a Framingham Risk Score (FRS), an algorithm that estimates 10-year cardiovascular risk based on age, sex, cholesterol, blood pressure, diabetes, dyslipidemia, hypertension treatment, and smoking.
Throughout the 10-year observation window, participants returned for follow-up visits twice per year where they reported their office visits, CVD medication usage, CVD diagnostic usage, and whether they were subject to any invasive procedures.
While age is the most obvious cardiovascular disease risk factor, Shaw’s study found that correlations between future CVD costs and age decreased after the age of 65. Age and future CVD costs correlated closely for male participants ages 45 to 64. But male participants in the study older than 65 actually demonstrated future CVD costs that declined with age. Age and future CVD costs also stopped correlating for women participants older than 65.
Like age, diabetes, dyslipidemia, and hypertension are also widely accepted as cardiovascular disease factors. Shaw measured the incidence of these factors throughout her study’s 10-year period, and the incidence of all three increased:
Diabetes increased 93% (from 10% of the participants to 19.3%)
Dyslipidemia increased 41.6% (from 37.3% of the participants to 52.8%)
Hypertension increased 27% (from 44.9% of the participants to 57%)
Though all three factors saw substantial increases in incidence, they varied in their impact on CVD costs when compared to the study’s average 10-year CVD cost of $23,142:
Diabetic participants incurred an average of $29,290
Dyslipidemic participants incurred an average of $25,406
Hypertensive patients incurred an average of $25,843
For both men and women, initial Framingham Risk Scores correlated strongly with 10-Year CVD costs observed over the life of the study. FRS improves on age as a signal by including sex, cholesterol, blood pressure, diabetes, dyslipidemia, hypertension treatment, and whether the participant has a history of smoking.
Shaw goes one step further from the strong signal FRS provided by creating low-risk, high-risk, and very high-risk buckets of study participants:
Low-risk: FRS < 10%, CACS = 0, and normal glucose values (1,182 participants)
High-risk: FRS ≥ 20% and CACS > 400 or diabetes (2,250 participants)
Very high-risk: FRS ≥ 20%, CACS > 400, and diabetes (126 participants)
Lower Risk Means Lower Costs
Low-risk participants of Dr. Shaw’s study accounted for 10-year average CVD costs of just $7,008, compared to $23,142 on average across the study. Despite making up 19.1% of the study participants overall, the low-risk group only contributed 5.2% of all costs.
The high-risk group, which accounted for 40.8% of the study’s participants, contributed 48% of total CVD costs. On average, they accounted for 10-year CVD costs of $37,732 in the case of high-risk women and $35,814 in the case of high-risk men. Very high-risk participants incurred 10-year CVD costs of approximately $50,000 in the case of women and $60,000 in the case of men.
The implications of Shaw’s study are extremely clear: there are substantial cost savings for both payers and providers when patients are able to avoid or delay the onset of major CVD risk factors like diabetes, unhealthy levels of fat in the blood, and high blood pressure.
Back in 2017, nearly a decade into my clinical training, I had just finished a difficult overnight cardiology shift managing critically ill patients with advanced cardiovascular disease. As I rode the New York City subway back to my upper west side apartment recounting the patients I had managed, and the decisions I had made that night, a lingering thought began growing. “There had to be a better way to reach patients, before they get so sick.”
As a practicing cardiologist, the majority of care I have been privileged to provide in the past 10 years has been focused around advanced illness–patients with existing heart disease. These patients typically need care in order to reduce risk for worst case scenarios – including intense suffering or staving off death. This is incredibly valuable work that has been built on decades of data-driven research and alleviated the burden of cardiovascular disease for tens of millions of people.
However, for years working in academic health systems, this practice of caring for advanced illness has become somewhat paradoxical to me. While it’s critical to spend time and resources on patients in high need, in doing so we give up the ability to spend on those upstream in order to stay ahead of the impending disease. The current practice has failed to significantly shift the focus of its care to earlier, proactive care that manages people before they get so sick. Our health system has historically not been incentivized, nor really capable, of changing this reality.
So, in 2017, Heartbeat Health was born, with a core mission to change the way cardiovascular care is delivered.
We started with a simple idea, and a small office in a run down office building in Columbus Circle in New York – that a modern, tech-enabled experience would make cardiovascular care more accessible, and better, for patients. As the practice grew, and patients came through, our growth was tempered by the fact that we weren’t connecting with the right people – patients with significant cardiovascular risk or disease who needed us more than the ‘worried well’ modern healthcare fan. So we shifted our business model as we realized proving clinical outcomes over time was where we could make a bigger and more impactful difference.
We have now developed a Virtual-First approach that uses technology and virtual care to improve the access, quality, and outcomes of cardiovascular disease. By delivering Virtual-First cardiology, we are able to provide connected care through remote diagnostic testing, televisits, referrals and data analytics that cares for patients in every state in the US, across every cardiac condition, and at every level of severity.
Over the years, after some difficult, but necessary pivots, we’ve finally landed, with a model that works, that is repeatable, and has a large potential for growth.
If we break down Heartbeat’s long-term vision into 3 primary stages, Heartbeat is currently in Stage 1: growing our virtual cardiology services footprint as widespread as possible, as a service provider to value based care partners, and usually in a fee-for-service pricing model. In doing so, we’re growing a dataset and generating evidence that demonstrates our outcomes produce cost savings and deliver high quality care .
Stage 2 is all about taking risk on our outcomes, delivering higher quality results at lower costs and sharing in those savings. And finally, Stage 3 is to add back the ‘terrestrial’ footprint that provides true hybrid cardiovascular care and that is needed to inflect larger cost savings in a value based ecosystem.
While our new model requires execution across many complex moving parts, and with many existing stakeholders with different incentive structures, I’m confident that it will work, and optimistic that we will get there.
Beyond Heartbeat, we’re living through a critical moment for the growing health-tech ecosystem at large. The pivotal question – do new tech-enabled interventions demonstrate clear and proven clinical outcomes for specific at-risk populations? This needs to be assessed and answered in order for our space to succeed and join the daily practice of medicine for clinicians and patients. This is the road we’re paving at Heartbeat and the future is bright.
Preventing heart disease is all about the long game. It takes endurance, dedication, will-power, and a good support network. For some that may sound like pain, suffering, and torture. It doesn’t have to be like that though. Staying healthy can be challenging, but it’s rewarding, feels good, will boost your self-esteem, and can help you from becoming just another statistic.
To help you understand your risk of heart disease and what to do about it, here are 5 facts that all men need to know:
1. Just because you don’t have symptoms doesn’t mean you don’t need to see a doctor
The key thing to know about heart disease is that it’s not like a sprained ankle or a paper-cut. Heart disease takes years, often decades, to develop. When people finally have symptoms like chest pain, shortness of breath, or leg swelling, it may be too late. The best time to combat heart disease is before it starts. Although it may not be as simple as this, many people would probably prefer to exercise and eat well than have to be subjected to daily medications, procedures, and even surgeries years down the line. Modern medicine has great treatments for heart disease, but they’ll never get your heart back to what it was in the first place. There’s no better time to start than right now to get yourself on the right track.
2. Lifestyle changes are an important first step in being healthy, but some people need medications too
Let’s face it… no one wants to take medications if they don’t have to. On the flip side though, you shouldn’t feel like a failure if your doctor recommends a medication to help control your risk of having heart disease. For example, exercise and dietary changes can have great effects on your blood pressure and cholesterol. Some people still have numbers that are too high with those changes alone though. You may ask yourself, “If I feel fine and I’m living a healthy lifestyle, why do I need medicine?” If you’ve thought that before, the answer is simple. Lifestyle changes are definitely beneficial in reducing your risk of heart disease, but if they don’t bring your risk factors into a low risk category, adding a medication can actually help you prevent a heart attack, stroke, or other form of cardiovascular disease. It’s not that you’re not doing well enough, or trying hard enough. Some people have genetic contributions to their risk profile or just need a little extra to help them out. One shouldn’t be substituted for another, nor should it be an either or decision.
3. The average age of having a first heart attack in men is 65
There’s no getting around this one. In your 30s and think you’re off the hook? Think again. It takes decades for heart disease to develop? The reason why heart disease is so preventable – 80% preventable according to the World Health Organization – is because if you start early enough with lifestyle changes to prevent it, most of it won’t happen. The key point here is that you only know your risk if you check it. Since heart disease is the #1 cause of death in the US, everyone should have a heart check to make sure they understand their risk factors and how to modify them as best as possible to prevent anything bad happening years down the road.
4.Erectile dysfunction can be a sign of heart disease
Have people always told you to think with your brain and not your penis? That may be good advice, but in this case, you should definitely pay attention to what your penis is trying to tell you. Erectile dysfunction can have several different causes, but one important cause is called peripheral arterial disease. Essentially, the same way that arteries of the heart can become blocked by cholesterol, fat, and inflammation – called plaque – arteries in other parts of the body can become blocked the same way. The risk factors for both are the same, as are the treatments and preventive strategies. Don’t be embarrassed of this issue since it’s a very important one to discuss with your doctor if you have it. Research shows that erectile dysfunction can be an early sign of heart disease and present years before someone might have a heart attack.
5. Man’s best friend actually can help you live longer
Dogs have always been man’s best friend, right? Well, aside from all the other ways they’ve got your back all that drool and dog food may actually help you live longer. Dog owners actually tend to live longer than those going it alone. It probably relates to the exercise you get being active with your dog since those with hunting breeds get the most benefit. Regardless, pets are great for stress relief, companionship, and forcing you to be a little less of a couch potato. If dogs aren’t your thing, marriage can also actually help you live longer… for better or worse, in sickness and in health.
As you’ve probably heard, the guidelines that doctors should be considering to decide whether your blood pressure is “normal” or high have changed in the past couple years. Whereas anything less than 140/90 used to be reasonably okay for the majority of adults out there, the new guidelines have been criticized for being overly strict. So what are they? In general, the categories are now as follows:
Stage 1 Hypertension
Stage 2 Hypertension
With these new categories, about 50% of adults over 40 will be classified as having at least elevated blood pressure, according to the American Heart Association (AHA)! Many have argued that for this reason it’s just a ploy to be able to prescribe more medications. They argue it’s quite the contrary though. Instead, by being able to classify more people with high blood pressure starting at lower numbers, this will provide the opportunity for many more to have recommendations to implement lifestyle changes earlier on. In fact, these lifestyle changes such as the right diet and exercise can lower blood pressure by as much as about 10 points. With that in mind, the number of people for whom a prescription medication is recommended to treat blood pressure actually isn’t much higher than it was before.
Before we get into what you can do about your blood pressure, let’s get into the nitty gritty of what blood pressure actually is. Then we can talk about why it matters and what you should do about it.
What is it?
Blood pressure is the result of the amount of fluid going through your blood vessels as a factor of how tight the blood vessels are – the resistance. Without getting into too much of the Physics, the easy way to think about why this matters is by using the analogy of lifting weights. No, this isn’t the age old trick question of whether it’s easier to lift a bag with a pound of rocks or a pound of feathers (it has to be the feathers, right?). Think of it in terms of whether it’s easier to carry a bag filled with rocks or an empty bag. Now put that in the perspective of your heart and blood vessels, which have to carry that load 24 hours per day, 7 days per week for your entire life. Of course, offloading the pressure too much – or causing very low blood pressure – might mean that there isn’t enough pressure to keep blood flowing to all of your organs given that us humans are upright and gravity is relentless. (Think of living on the top floor of a high rise versus the first floor if the water source is in the basement… your shower water pressure will be a lot better on the first floor.) However, blood pressure that’s too high forces your cardiovascular system (your heart and blood vessels) into overdrive in order to deal with it. Over the course of years, this can cause irreversible changes if left unchecked.
How should you check it?
Checking blood pressure isn’t as straight-forward as it may seem. Often times, doctors’ offices don’t even check it correctly. There’s more evidence that the best way to check blood pressure is throughout the day, multiple times with something called an ambulatory blood pressure monitor. It checks your blood pressure intermittently throughout the day and night while you do different activities to get a full range of what your blood pressure is actually like. This probably better represents your true numbers as opposed to the classic guideline-directed way of checking it in a quiet room in a seated position after you’ve had time to relax. A good, easy compromise between wearing a continuous monitor and checking in your doctor’s office all the time is to get yourself a good home blood pressure monitor. You can check your blood pressure daily and keep a log of the day, time, heart rate, blood pressure, and if you have any symptoms (such as pain, anxiety, headache, etc).
What should you do about it?
If you’re in the Normal category, great for you! It doesn’t mean you’re off the hook though. You’ll want to maintain a healthy diet and a regular exercise regimen to ensure that you stay as healthy as possible for many years to come. Since heart disease takes years to decades to develop, the sooner you start with healthy lifestyle changes, the better.
For those in the Elevated category, here’s your wake-up call. Blood pressure’s relationship to cardiovascular disease is directly related meaning that the higher it gets, the higher the risk. Although being in the category is certainly not a high risk situation, it’s an opportunity to really take advantage of the benefits that healthy lifestyle changes can have. By implementing a heart-healthy diet and an exercise program targeted at lowering your blood pressure, you could very well find yourself in the Normal category within a few weeks to months.
If your blood pressure falls into one of the Hypertension categories, fear not! Depending on your risk factors and how high your blood pressure is, you may be able to start with lifestyle changes to see if that brings you down to a normal range. However, most people in Stage 1 require at least one medication and most people in Stage 2 require two or more medications in order to control their blood pressure. The worst thing you can do is blame yourself for this and think of taking medications as a failure on your part. If that thought crossed your mind, let it keep crossing until it’s far gone. Many things factor into what your blood pressure is: diet, exercise, weight, stress level, hormones, age, sex, genetics, etc. While you can modify some of these factors, there are a good number of them we refer to as non-modifiable risk factors for heart disease, several of which are associated with higher blood pressure. While these things certainly aren’t your fault, it’s crucial to know about them because there are medications out there nowadays that you can couple with those important lifestyle changes to help you bring your blood pressure down to the normal range, essentially “curing” your high blood pressure. If you do take medication for hypertension and it’s working, don’t stop! Medications only work if you take them. It’s not like an infection where once you treat it for a little while, you’re good to go.
Furthermore, just because you take a medication doesn’t mean it replaces a good old fashion healthy lifestyle ((the best medicine of all).
Speaking with your doctor regularly to make sure you’re meeting your treatment goals is important since most people will require adjustments in their medications over time.
Key dietary changes you can make to help lower blood pressure are to decrease the amount of salt and red meat you eat. Salt has a tendency to hide in a lot of foods so it’s important to look at the nutrition labels of what you’re eating to truly get a sense of how much you’re taking in. Common offenders are processed foods such as deli meats or sausages, pasta sauce, and soup. You’ll want to aim for less than 2 grams of salt (sodium) per day if you’re looking to have an effect on your blood pressure.
If you’re worried that food won’t taste good without much salt, you’re in luck! Some great alternatives to salt that can really pack some flavor into food are garlic powder (not garlic salt) and salt-free seasoning mixes such as Mrs. Dash. Replace your salt shaker with those on your dinner table and you won’t even remember what salt is. If you really must have some of that salty flavor in your food, try potassium-based salt products instead of the usual sodium-based table salt.
When it comes to exercise for blood pressure control, it’s important to add in resistance training to your workout plan. The new guidelines put forth by the AHA recommend 2.5-5 hours of moderate intensity physical activity that includes aerobic activity most days of the week and strength/resistance training on two or more days of the week. Basically, you’ll want to try to do some form of physical activity such as brisk walking, jogging, swimming, or biking that’s hard enough where you can’t say more than a few words without needing to take another breath. Then at least a couple days per week, you’ll want to do something like weights, squats, or yoga where you’re actually working on different muscle groups.
Aerobic exercise is important for your blood pressure because it gives your heart a workout that makes its usual job of pumping easier. Strength training is just as important though because as you work out individual muscles in your body – called skeletal muscles – the muscles grow and more blood can flow to them. As more blood flows to more places in your body, your overall blood pressure will go down. A good analogy for this is the water pressure flowing through your tap when you just have the sink running versus when you have every sink and shower running at the same time. When the water has to go to a lot of different places, the water pressure goes down… a concept that’s not good for your morning shower, but great for your blood pressure.
The job of Cardiologists is to individualize the guidelines. More than that, one single blood pressure reading that is elevated does not necessarily mean someone has a diagnosis of high blood pressure (hypertension). Even further, just because the guidelines classify blood pressure into these categories doesn’t mean that everyone has the same blood pressure goals. It very much depends on each individual person’s other medical issues as well as some other considerations.
All that said, as long as your doctor said it’s safe to do so, the first steps in lowering blood pressure are recommendations that everyone should follow. This includes lifestyle changes such as diet, exercise, and weight loss (if appropriate).
When it comes to heart health, things can get complicated. There are many more risk factors for heart disease than people may initially be aware of, but that doesn’t mean they don’t matter. More importantly, we don’t have control over all of our risk factors. The ones that we can change are called modifiable risk factors, such as blood pressure and diet. The ones we can’t, such as our age and family history, are called non-modifiable risk factors. Knowing some important information about your risk profile for heart disease can help you frame your outlook on how aggressive you should be about preventing it. One thing is certain… prevention works!
Here are five numbers you should know about yourself to help define your risk. Furthermore, they are the numbers you should try to work toward to optimize your risk and not become just a statistic.
There has been more recent evidence from research studies looking at what the best blood pressure is. To summarize the current train of thought for how low you should go, you must ask yourself, “How low can you go? Can you go down low?” We’re not talking about the dance floor here, but a blood pressure of less than 120/80 is ideal.
Checking blood pressure is easy and since it fluctuates throughout the day, the more data points you have, the better idea you’ll have of what your “real numbers” are. Just checking at your doctor’s office might not be enough to give an accurate representation of what your blood pressure is when it comes to how it affects your risk of heart disease. Automatic blood pressure cuffs are reasonably priced and could help keep you on top of your health game.
There are a few different types of cholesterol hat doctors will check for to fully understand your risk, but in general you want a total cholesterol less than 200, an LDL less than 130 (or lower if you have other risk factors), and an HDL over 40 for men or 50 for women. If you have other health issues such as diabetes or a history of heart disease, your target numbers might be lower.
The best way to check for diabetes is to check a blood test called hemoglobin A1c (HbA1c). This test gives a sense of how high your blood sugar has been over the past 3 months. Type I diabetes, or the kind that people get diagnosed with as children is fundamentally different than type II diabetes, which is the more common type that more often affects people in middle-age or later. This is how type II diabetes happens.
It’s normal for blood sugar levels to fluctuate depending on whether you eat or are fasting, but the range of blood sugar should not be that wide. Insulin is something that our bodies make that comes from the pancreas and is responsible for allowing the cells in our body to use blood sugar for energy or store it for a later time. Just like the boy who cried wolf, if blood sugar remains high for long periods of time, our cells become less sensitive to the insulin our body is making, which results in the sugar staying in our blood stream. Insulin levels rise as blood sugar remains high to attempt to get cells to take up the excess circulating sugar. However, the cells in our body are trying to ignore the insulin because they don’t need any more sugar than they already have. When this imbalance of circulating sugar levels that get too high gets to a certain point, we call it diabetes. The more sugar there is sticking around in the bloodstream, the more it will cause changes to the cells in the blood. That’s exactly what we measure with the HbA1c. It’s essentially measuring the amount of “sugar-coating” on red blood cells, which are always circulating. A HbA1c less than 5.7% is ideal. Between 5.7% and 6.4% is called pre-diabetes, which is an at-risk category. More than that is when we diagnose diabetes.
BMI, or body mass index, is a calculation that gives a measure of how you weigh relative to your height. The formula is:
BMI = Weight (in kilograms) / [height x height] (in meters)
A BMI of 18.5-24.9 is normal. 25-30 is considered overweight and above 30 is obese. If you’re a bodybuilder and have a lot of muscle mass, the BMI equation doesn’t account for that. For most people though, it’s a reasonably good estimate at deciding whether you weigh too much, too little (yes, that’s not a good thing either), or just right.
Uh oh… yes, I said it. Exercise is an important part of having good heart health. Research shows that about 8% of deaths and $117 billion of spending could be prevented by meeting the exercise guidelines recommended by the American Heart Association. The new guidelines allow you to choose your own adventure, so-to-speak. If you’re a go big or go home kind of person, you can do as little as 75-150 minutes of strenuous aerobic exercise that incorporates some type of strength training (such as circuit training) each week. If you prefer to enjoy the journey, you can do 150-300 minutes of moderate intensity aerobic exercise spread throughout each week incorporating strength training on at least 2 days each week. The choice is yours, but the recommendation is important.
It may seem daunting to have to think about all these numbers and what they mean for you. The good news is that it’s not the snapshot of these numbers at any one point in time that’s the be-all-end-all for someone. The important part is what these numbers, along with other risk factors for heart disease, do over time. Heart disease usually takes decades to get to the point of a heart attack or stroke. That means you have plenty of time to work on your health and invest in making the future you the best version yet!