Coronary Artery Disease – Cardiology LEGEND Dr. Deepak Bhatt Explains
Deepak L. Bhatt
MD, MPH, FACC, FAHA, FSCAI, FESC
Dr. Deepak Bhatt serves as faculty for K2P’s LEGENDS series, where he has provided a retrospective on coronary artery disease. He also contributes regularly to other K2P activities, providing education and an expert perspective to many of our programs.
He serves as Executive Director of Interventional Cardiovascular Programs at Brigham and Women’s Hospital and Professor of Medicine at Harvard Medical School (Boston, MA). He has authored or co-authored over 1800 publications and was the inaugural Chair of the AHA-GWTG (Get with the Guidelines) Quality Oversight Committee. He is also a Co-editor of Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, Editor of Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease. and Editor of Opie’s Cardiovascular Drugs: A Companion to Braunwald’s Heart Disease.
Dr. Bhatt is regularly recognized as one of America’s top doctors and educators. He received the Eugene Braunwald Teaching Award for Excellence in the Teaching of Clinical Cardiology from Brigham and Women’s Hospital in 2017, ACC’s Distinguished Mentor Award in 2018, and AHA’s Distinguished Scientist Award in 2019.
Interview with Dr. Deepak Bhatt, LEGEND in CurrentMD Cardiology
What would you like learners to take out from your K2P Legends Series talk on coronary artery disease?
I think it’s important for learners to understand that a lot has gone on in coronary artery disease over the past decade or two. Whatever they might have learned, say in medical school, a lot of it might actually be out of date. And this is true in all fields of medicine—it’s important to try to keep up.
Coronary disease, in particular, is such a prevalent condition and even if someone’s main focus in practice isn’t caring for patients with coronary artery disease, certainly they will encounter these patients, so I think it’s worthwhile to know that there have been a lot of advances in terms of approaches to lifestyle modification, things we know about risk factor control using pharmacotherapy, about different strategies of testing with non-invasive imaging like CT angiography, which has become very popular based on the data. Things like coronary intervention, which has a tremendous amount of data now supporting it, especially in acute coronary syndromes, and advances in bypass surgery, as well.
So, the care of ACS has been revolutionized, and I think it’s important for physicians and other healthcare providers to be aware of those advances in the management of unstable, but also stable coronary artery disease.
Where do you think we will be in the management of coronary artery disease in 10 years?
I think we’re going to see lots of changes in the world of coronary artery disease over the next 10 years. One area that I think will be particularly fruitful is driving LDL-cholesterol levels even lower than they are now. There are already effective therapies, such as statins, ezetimibe, and PCSK9 inhibitors, but there are even more promising LDL-lowering therapies on the horizon, more durable approaches, more intense approaches, like inclisiran. So, I think having these therapies and deploying them in larger numbers of patients is going to be a major advance over the next decade.
Do you have any best practices that you can share in the assessment of a patient with CAD?
In assessing a patient with coronary artery disease, it’s important to first ascertain, are we talking about a stable or an unstable patient? It really is important to see if they are having symptoms and how bad are those symptoms?
If they have symptoms, first-line therapy is medical therapy to control those symptoms, medications like beta-blockers, nitrates, calcium channel blockers. But it’s equally important, having identified that patient with possible coronary artery disease to make sure that lifestyle modification and effective secondary prevention therapies to reduce cardiovascular risk—medications like statins—are employed right away.
I think a mistake that’s sometimes made in the stable coronary artery disease setting is just focusing on the symptoms and relieving them either with medical therapy or percutaneous therapy or potentially even bypass surgery, but not giving equal importance to risk reduction, such as cholesterol-lowering therapies, antithrombotic therapies, blood pressure control, diabetes control, smoking cessation, control of weight, or weight loss, if indicated. All of those different approaches are really important, both in the short term, but especially in the long term.
In the patient who has unstable coronary artery disease and potential acute coronary syndrome, of course that’s an entirely different algorithm, where things have to move at an extremely quick pace that involves in-patient care. And there we’ve made tremendous advances both in terms of pharmacotherapy, but also in terms of strategies and procedural therapy, in particular, the catheterization lab and percutaneous coronary intervention in ACS patients, with bypass surgery also for patients with complex multi-vessel disease.
Are you working on any exciting new projects now?
I’m working on lots of different, exciting projects. Certainly, working on the most recent 12th edition of Braunwald’s Heart Disease was quite an honor. I’ve contributed to earlier editions, but this was the first edition for which I served as an editor. I hope that that educational resource will be utilized worldwide as it has been for several years.
I’ve also been involved with a large amount of research having to do with cardiovascular risk reduction, focusing on areas such as greater LDL reduction and targeting triglycerides as a risk factor, for example, with icosapent ethyl, though the predominant mode of benefit there doesn’t actually appear to be triglyceride reduction per se. I’m also working on more potent antithrombotic strategies, ones that, we hope, will decrease the risk of thrombotic events but won’t increase bleeding risk in the way current ones do.
I’ve also been very interested in the SGLT 1 and 2 inhibitors. These seem like agents that are almost statin-like in their potential applicability. I think the evidence base for the use of SGLT 2 inhibitors is now quite robust and the majority of patients with diabetes, barring contraindications, should be on an SGLT 2 inhibitor. I’ll go one step beyond that and say the majority of patients with heart failure and chronic kidney disease should also be on SGLT 2 inhibitors. I’m involved with a fair amount of research in that area as well.
How has your career in cardiology been different than you expected?
One of the reasons I entered cardiology was because even when I was entering it, there was rapid change occurring in the field, and one thing that’s surprised me is that, even though I went into it for that reason, the pace of change has been much faster than I would have ever anticipated.
I am really shocked sometimes when I think about how much information that I learned in fellowship is already obsolete, maybe not entirely, but at least has morphed based on really good trial data, and in some cases observational data. So, what was surprising has just been the incredible pace of change, even though that’s true in some respects for all of medicine, it seems to be particularly true for cardiovascular medicine.
What career would you have chosen if you hadn’t chosen to become a physician?
I think there are a lot of potential things that I might have done. I was one of those people that liked everything I would ever study or read about; well, maybe not everything, but lots of things. So, one thing that I wanted to be when I was young was an astronaut. I also did like basic science research. At one point, I thought I might be a cancer researcher and initially I sort of headed in that path, but then I pivoted from basic research to clinical research and to clinical care, of course. So those are two potential pathways I might have taken.
What’s an interesting fact about you?
One thing that I’ve done that most people may not be aware of was that I mapped the orbit of an asteroid when I was much younger. I guess that goes along with that early interest in being an astronaut.