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Guiding patients through heart disease

Yale Medicine Magazine, 2005 - Autumn


A cardiologist provides a handbook so patients can better understand their disease and how to treat it.

Half of all patients don’t take the medications that their doctors prescribe. And the majority of cardiac patients leaving the hospital don’t know the target numbers for optimal blood pressure or cholesterol. For cardiologist Harlan M. Krumholz, M.D., M.Sc., the Harold J. Hines Jr. Professor of Internal Medicine and of Epidemiology and Public Health, these findings reflect lost opportunities for patients to participate in their care. Hopes of fostering better patient involvement in their care motivated Krumholz to write The Expert Guide to Beating Heart Disease: What You Absolutely Must Know (HarperResource, $14.95).

Krumholz said that patients who understand their disease and the options for treating it can collaborate more effectively with their physicians in choosing and following the strategies that are most likely to help them reach their goals. “If patients understand the rationale behind the strategies, they’re more likely to follow them.” Krumholz also argued that informed patients are more likely to get good care.

“We have this illusion that medicine is being practiced uniformly and is of high quality throughout the country,” he said. “That perception is just not true. There is ample evidence that treatment strategies that are well-established by the literature and endorsed by national guidelines are not uniformly being recommended by doctors or pursued by patients.”

Unfortunately, patients are not often encouraged to become well-educated about their condition, said Krumholz. “We’re still in an era when most people come in, they’re told what to do and given a prescription, and if they don’t comply, they’re seen as letting down the physician.”

Patients seeking to educate themselves about heart disease may feel overwhelmed, however. “If you got sick, where would you start? There’s such an avalanche of information,” said Krumholz. He views his 152-page book as a “travel guide” that provides essential facts about how heart disease develops and what can be done to treat it. The book describes seven key strategies: controlling blood pressure, managing cholesterol, exercising, maintaining a healthy weight, managing blood sugar, quitting smoking and using medication effectively.

Krumholz chose these seven strategies based on national guidelines and his expertise in evaluating the quality of heart disease care. A prolific researcher himself, he has helped set national standards for cardiovascular care for organizations ranging from the American College of Cardiology to the Department of Defense. Based on the published evidence, his book describes approaches that work (such as taking beta-blockers after a heart attack or controlling cholesterol with statins), those that probably help (eating fish regularly), those of uncertain value (taking vitamins) and those that have proven harmful (hormone replacement therapy for women).

A grant from the John A. Hartford Foundation in New York allowed Krumholz to hire a researcher—Susan Cheng, M.D., then a medical student at McMaster University in Ontario, now a resident in internal medicine at Johns Hopkins. Krumholz and Cheng field-tested the book: they sent about 100 copies to relatives, friends, friends of friends with heart disease and patients, asking them to circle sections that were confusing and to pencil in questions.

“We said, ‘Write all over this. It won’t hurt our feelings.’ ” Their approach seems to have worked; a critic for Kirkus Reviews writes that “Dr. Krumholz has a gift for translating jargon into clear, accessible language that the concerned reader can easily absorb.”

Writing for a general audience was a departure for Krumholz. He has clinical responsibilities one day each week, and as director of the Robert Wood Johnson Clinical Scholars Program at Yale, he spends a lot of his time guiding postdoctoral fellows in the program as they do research on improving clinical care and population health. His own research appears in 40 to 50 articles annually. But he called those papers “just a means to an end.”

“At the end of the day, it’s not about the number of publications but about whether people can benefit from the work we’ve done. The book is a tool to help promote that.”

For more on the book, visit