The Dalio Institute of Cardiovascular Imaging and its clinical program, HeartHealth, aim to revolutionize cardiac disease prevention and treatment
By Beth Saulnier
Photographs by John Abbott
Alain Baume is 59, the same age his father was when he died of heart failure in their native Italy. Because of that family history, Baume has long been concerned about his cardiac health; when he'd get out of breath from hurrying up a flight of stairs, for example, he'd worry that it was a harbinger of incipient disease rather than simply a sign of being a bit out of shape.
His wife, 67-year-old Marialuisa Baume, on the other hand, has no family history of heart disease. Although she does smoke cigarettes on occasion, she exercises regularly — "more than him," she says with a laugh, in her lyrical Venetian accent — and has no worrisome symptoms. But during a routine visit to the family internist, Dr. Serena Mulhern, an assistant professor of medicine, the physician detected a moderate heart murmur and referred her to a colleague, cardiologist Dr. Erica Jones.
Dr. Jones, an associate professor of clinical medicine and of medicine in clinical radiology, doesn't run a typical cardiology practice. She has a special emphasis on prevention — and when the Baumes came to see her, she was gearing up an ambitious new program that aims to curb heart disease long before symptoms appear. "Right now we're in our infancy, but we have a lot of vision," Dr. Jones says of the program, dubbed HeartHealth. "We're going to be able to take patients who are at risk and show them significant change." Formally launched this winter, HeartHealth combines tried-and-true strategies — promoting a nutritious diet and regular exercise; prescribing medications like statins — with state-of-the-art imaging technologies that promise to revolutionize how medicine approaches heart disease. "What's the problem in cardiac care?" Dr. Jones muses. "More than half the time, it's that we find people in the end stage of disease. They have a positive stress test, they're having angina, they've had a heart attack. Most cardiologists are very interested in prevention — it's just that by the time we see our patients, it's often too late. They tend to be referred to us after they've had an event."
Where the heart is: Dr. James Min (center) and colleagues at the Dalio Institute of Cardiovascular Imaging in the Belfer Research Building
The Baumes, who live in Manhattan and run a high-end shoe company with offices on Fifth Avenue, routinely attend their medical appointments as a couple, and both signed on as Dr. Jones's patients. They each had a comprehensive exam, plus CT scanning that sought to identify calcium in the arteries that could lead to heart attack. The results were surprising. "He, with the bad risk, ended up having a completely beautiful, clean scan, but hers actually showed a lot of calcium," says Dr. Jones, who spoke about the Baumes' cases with their permission. "It showed he was at less risk than he thought he would be, and she was at more."
Based on those results, Alain is continuing on the cholesterol-lowering statin drug Lipitor at the same level as before; Marialuisa has had her dose doubled and is working to quit smoking. Dr. Jones is monitoring the murmur, and Marialuisa is heartened by the fact that even if a valve replacement becomes necessary down the road, it can be done non-invasively. "I didn't know what to expect, so when I went there I was a bit nervous, but the people there are so nice they make you feel relaxed," Marialuisa says of her experience at the practice, located on the eighth floor of the Weill Greenberg Center. "I feel like I'm in good hands. I would recommend it to everyone."
HeartHealth's special focus stems from its affiliation with the program that oversees it: it's the clinical arm of the Dalio Institute of Cardiovascular Imaging, a joint venture between NewYork-Presbyterian Hospital and Weill Cornell that was established in fall 2013 with the aim of better understanding heart disease through the use of such tools as MRI, CT, PET, and novel technologies such as 3D printing and computer modeling of blood flow dynamics. Funded by a $20 million gift from NewYork-Presbyterian life trustee Raymond Dalio through his Dalio Foundation, the institute has set an ambitious goal. "Our hope," says director Dr. James Min, a professor of radiology and of medicine who is board certified in cardiology, "is to imagine a world without heart disease."
Headquartered on the first floor of the Belfer Research Building, the Dalio Institute is involved in some two dozen multicenter trials, with ongoing investigations into a wide variety of topics — from the efficacy of absorbable stents to the role that endothelial wall shear stress (pressure that runs perpendicular to the artery) plays in heart disease. Dalio researchers are casting their net wide, partnering with experts in engineering, fluid dynamics, genetics, metabolomics, molecular imaging, and a host of other specialties.
They're studying data from healthy patients — one project, for instance, is examining the coronary calcium scores of members of an Amazonian tribe that never gets heart disease — as well as from people who have died of heart attack, and from those in between. In an effort to develop more accurate guidelines for diagnosis, for example, Dalio researcher Dr. Quynh Truong, an assistant professor of radiology and of medicine and co-director of cardiac CT, is leading a clinical imaging program for patients who come into the ED with chest pain. "In more than 50 percent of patients who have coronary heart disease, their first symptom is either a heart attack or death," Dr. Min notes. "That accounts for more than 500,000 sudden cardiac deaths per year. It's a true public health epidemic, and it occurs in people who are healthy and asymptomatic. So if we have early detection and good treatments, we can cut into that."
The essential takeaway, says Dr. Jones, is that not all plaques are created equal — and while medicine has become much better at assessing cardiac risk in recent decades, it still has a long way to go. "There are many people at risk who do great until their '90s and '100s — and many who are at ‘no risk' and have their first heart attack at 40," Dr. Jones says. "Who are these people? We're not good at understanding that yet."
For researchers and clinicians working in the field today, the canonical example of a patient that the current system failed is Tim Russert. In 2008, the journalist died suddenly of a heart attack due to an arterial blockage at age 58, just weeks after having passed a stress test. "They told him, ‘You're OK,' " Dr. Min says. "But we didn't use the proper tools to assess his risk, and I think we can do more for patients like that." The key — and the Dalio Institute's holy grail — is to identify what's known as "vulnerable plaque," the kind that actually causes heart disease and leads to ill health and death. "Dalio is challenging the existing paradigm with new ways to see the coronary arteries — and not just seeing them broadly, but looking at aspects that can't be easily seen on noninvasive or even invasive tests," says Dr. Joshua Schulman-Marcus, a fellow in clinical cardiology at NewYork-Presbyterian/Weill Cornell Medical Center. "Does the way they look affect how they're going to behave or respond to medication? That kind of research is only being done in a few places in the country. And while not all of it is ready for clinical prime time, it's a game-changing, paradigm-challenging research that will advance the field as a whole, and may advance prevention in a way that we just can't anticipate right now."
Dr. Schulman-Marcus — whom Dr. Jones lauds as "the future of prevention" — is working with Dr. Min on a project analyzing cardiac CT data with the aim of ascertaining which medications have the best results in patients with arterial blockages; he's also collaborating with Dr. Truong on the study of cardiac CT in the emergency department. In July, he began a one-year fellowship in cardiovascular disease prevention at HeartHealth, which ultimately aims to offer patients such risk-reduction resources as behavioral psychology, nutrition counseling, and exercise physiology. "Clinically, the most interesting aspect to me, and the part that I want to spend more of my career focusing on, is how to change behavior," Dr. Schulman-Marcus says. "It's easy and nice to talk about risk factors, but it's hard to change people's behavior from a lifestyle standpoint."
In addition to altering patient behavior, the clinicians note, change is needed in the healthcare funding system to promote early detection. Dr. Jones points out that while technologies like CT angiogram — which illustrates blood flow through the heart — can help cardiologists better assess risk, they're new enough that insurance companies often have to be convinced that they're necessary. Sometimes, she says, her patients opt to pay $100 to $150 out of pocket for a blood test to assess calcium score, which is increasingly seen as a predictor of a potential heart attack, or even foot the $650 to $800 bill for a CT angiogram. "I have to tell some of my patients, ‘The insurance company will pay for x, y or z, but it isn't the study that I want,'" Dr. Jones says. "For whatever reason, insurers have not jumped on board — which to me is quite shocking, because they're willing to pay for a nuclear stress test that costs more than $2,000 and gives the patient more than 10 times the radiation."
As an example, Dr. Jones cites a hypothetical patient who's 45, the same age his father was when he died of a heart attack — but who's so fit that he runs marathons. "I don't need a stress test on that gentleman," she says. "He's not symptomatic; his EKG is normal. I want to know if he's got asymptomatic disease." Ultimately, she says, the right testing doesn't just save lives — it can offer a solid return on investment. "What we need to do as clinicians and researchers is to keep at it, to prove that this is changing care," she says. "We need to work with these large insurance companies and HMOs to say, ‘Look, if I show you that this 45-year-old with a terrible family history has no calcium, then you don't have to pay for his statin for 10 years, because he's safe. If I end up telling you that he does have significant calcium, fine; you end up paying for generic statin, which is very inexpensive, but I've possibly just saved you from a hospitalization for a heart attack.'"
Dr. Michael Wolk, a clinical professor of medicine, is a past president of the American College of Cardiology and the chief contracting officer of the Weill Cornell Physician Organization. He places the new technologies that Dalio and HeartHealth are spearheading in a long line of advances he has seen in his four decades of practice — lifesaving breakthroughs that include bypass surgery, angioplasty, percutaneous valve replacement, and the development of statins. "I love the concept that Dr. Min has brought forward," Dr. Wolk says, "which is, ‘How early can we diagnose coronary artery disease before there are clinical symptoms, decreasing cardiovascular events and therefore minimizing the need to do expensive interventions?'" While heart disease remains the leading cause of mortality in the United States, he notes that thanks to such advances, the incidence of vascular-related death has been cut by half in the past 35 years — and that the World Health Organization has set an ambitious goal of continuing that trend by reducing mortality from noncommunicable disease by 25 percent by 2025. Says Dr. Wolk: "It's only through people like Dr. James Min — who are getting innovative and thinking of how to diagnose people before events occur — that we'll be able to achieve such progress."
With the aim of getting patients at elevated risk into the HeartHealth program, Dr. Jones has been spreading the word about the practice to her colleagues. She's been speaking to high-risk obstetricians, for example, because women who had preeclampsia or diabetes during pregnancy are at higher risk of cardiac events later in life. Similarly, she led grand rounds at Hospital for Special Surgery — speaking to rheumatologists about patients with inflammatory disorders, also at increased risk — and at Memorial Sloan Kettering Cancer Center, since cancer survivors can have arterial calcification due to the higher doses of radiation that were administered in years past. "The purpose of HeartHealth is not to see the patients who've already had a heart attack, but to serve the population who isn't sick enough to have a cardiologist but has risk factors like family history or inflammatory diseases that predispose them to heart disease," says Dr. Truong, who is also a cardiologist and will be seeing patients through the new clinical program. "HeartHealth is unique in that it integrates the latest technology to help patients understand their risk. It's really important for us to have this armamentarium of imaging modalities and incorporate it into how we treat patients. Even something like a calcium score, which is very inexpensive, will be able to guide us in terms of, ‘Do you need to take that statin for the rest of your life, and how low do we need to bring that LDL cholesterol level?' These are all beneficial tools to help us decide how aggressively to manage patients in their lifestyle and risk factor modifications."
For Alain and Marialuisa Baume, Dr. Jones's combination of individual attention and appropriate testing is the perfect fit. They also praise the practice's patient-friendly logistics. "When we call, we get immediate responses," says Alain, speaking in the midst of a busy week last February, when the couple was working on their shoe company's winter 2015–16 collection and Marialuisa was preparing for a trip to India. "You never feel like you're ‘just another patient.' It's so personal, and we feel so well taken care of."
This story first appeared in Weill Cornell Medicine,Vol. 14, No. 1.