In the last couple of weeks I have had two vigorous healthcare conversations that I am having trouble figuring out how to reconcile with each other. Both were related to how we best predict cardiovascular disease and both were incredibly compelling and engaging and involved super smart people – experts at the top of their field. And both had some really interesting Aha! moments in them. But in some ways, they are polar opposites of each other and I am confused about how to think about them as an integrated set, though I know they are related.
I’m going to lay this out for you and will be interested in your thoughts. Just to preempt the obvious, yes I know these things can be interrelated, but that is not the way they exist in the real world.
The first conversation took place between me, David Shaywitz (my podcasting partner in crime at Tech Tonics) and Dr. Sek Kathiresan, one of the nation’s foremost experts on the genetic predictors of cardiovascular risk. You are lucky in that you can actually listen to the entire conversation since it occurred on David’s and my Tech Tonics podcast found HERE and on iTunes.
Sek is truly lovely and engaging and is so human it’s hard to imagine he’s a hard core Harvard scientist. No offense to the myriad of wonderful people I know that meet that definition (love you David and Zak and Christine), but his description of his first interaction with McDonald’s French fries was pure gold and I so loved listening to him talk about his work figuring out the polygenic “smoothie” of cardiovascular disease risk. FYI, “polygenic” means derived from multiple genes.
Basically Sek’s life’s work is finding the mix of tiny genetic nudges that, together, create a numerical cardiovascular risk score that tells you whether you are more or less likely to have to worry about having a heart attack at a young age, much like many of his own family members did. Sek has done years of research to refine an analysis of 500 people who survived heart attacks at an early age (people in their 30’s, 40’s and 50’s) and is in the process of creating/disseminating a diagnostic algorithm that can use genetic testing, such as that available to consumers through Ancestry.com or 23andMe, and tell you where you are on the ”write a will” vs. “go ahead, have the 2nd order of french fries” spectrum. Let’s call this the Biologic Determinants of Health for a moment (my term not his). Now put that on hold for second.
My second conversation took place at my Aspen Health Innovators Fellowship reunion, held last week in Detroit. Quick detour: if you haven’t been to Detroit lately, you haven’t been to Detroit. I was amazed by how nice it was, how safe it felt and how hipster it has become. Seriously – ironic beards and funky lofts everywhere. They are well on their way to Kombucha on tap. Thanks Patrick Hines! But I digress…
But because you can only drink for 12 hours, not 24, we alumni include in our reunions a period of time where we read interesting, evocative works of writing (sometimes old, sometimes new) and talk about them seminar-style, like you would in college. We appoint someone the moderator and we take turns debating the meaning of the articles, the implications, the pros and cons, the whole megillah, as my grandma would say. This time we read a story that first ran in the New Yorker called The Poverty Clinic. Wow. If you are in healthcare and haven’t read this article by journalist Paul Tough, you need to do so right now.
The article is specifically about Dr. Nadine Burke, a Bay Area physician who, through her work in a clinic in a deeply disadvantaged and under-served community in the Bayview-Hunters Point area of San Francisco, realized how directly childhood trauma leads to adult physical illness. Yes, there is a ton of work out there talking about Social Determinants of Health, but this is highly specific, highly researched, and deeply disturbing data about how people who score high on the ACE test, which is a “a tally of different types of abuse, neglect, and other hallmarks of a rough childhood,” are far more likely to experience serious physical illnesses, like cardiovascular disease, later in life. Specifically, Burke’s work showed that the prior work of Vincent Felliti and Robert Anda, both from Kaiser and author of the ACE Study that was the seminal evidence for this theory, was the real deal in her everyday doctoring experience. And here’s what the work on the ACE test has found: if you have an ACE score of 4 or higher, you are twice as likely to have cardiovascular disease later in life than someone who scores under 4. If you score 7 on the ACE test, even if you are a person who does not drink, smoke, or overeat (in other words, who doesn’t have behaviors that would cause heart disease), you have a predictive risk of ischemic heart disease that is 360% higher than those with an ACE score of 0. Well that sucks.
The ACE test is, by the way, a list of 10 questions that anyone could take in less than 3 minutes and it asks you nothing about your medical history and specifically nothing about your genetic make-up. You can take the ACE test HERE. It asks about your childhood home, whether anyone beat you, ridiculed you, ignored you, drank to excess, was abusive to you or your parent, etc. It asks you not one single question about your actual “health” unless you consider these signs of mental health (which of course they are). And yet, the ACE test my well be as good a scientific predictor of cardiovascular risk as the polygenic risk test derived by Sek Kathiresan during his profoundly important work at Harvard.
What to think about that?!? So many things. The first is this: what is the right treatment to avoid cardiovascular disease? Clearly the answer includes a mix of pharmaceuticals (statins, beta blockers, etc) and behavioral changes (don’t eat those damn French fries). But what I came away with after the ACE conversation was this: holy shit by the time we are adults, assuming we had a tough childhood, it may be too late – we have already made a mess. Broken hearts lead to, well, broken hearts, and the real treatment people need is psychiatric/psychological, not biological. For those who wonder about whether the social determinants of health matter, the research around ACEs should give you clear evidence how important these things are. For those of you who spend all your time in the medical model, you may be missing something fundamental.
The other thing I was thinking: do you know how much money pours into basic research, clinical research, and drug discovery around cardiovascular disease? Squillions. Bazillions. So much and it’s still not enough to really get us where we want to be. I think I now know why far more clearly than I really had let crystallize in the past. Yes, all this biology stuff is essential too, but if you come to the game with a loaded psychological deck, you have a much higher burden to overcome and that is likely to suppress the value of the “traditional” treatments. Science is essential, but so is social science and psychology. Can medical treatment even work if psychological treatment isn’t attended to? That is my conundrum.
Maybe we should be matching the medical dollars spent on research and clinical development with the dollars spent on interventions in the social determinants of heart disease. We might actually get a lot farther. We are nowhere close on that measure. There are great organizations trying to get at this, including the American Heart Association, Robert Wood Johnson, Health Leads, Kaiser, etc. But are there any massive for-profit organizations pouring money into finding “cures” for childhood trauma? Please tell me because I’d really like to know. Talk about a blockbuster opportunity if you could figure out how to productize it. If you had organizations thinking about interventions for childhood trauma the way Pfizer and Amgen think about discovery and commercialization and earnings per share, I bet we would get much further.
So why doesn’t this happen? Many reasons, but one was articulated so well by my Aspen fellowship colleague, Dr. Eric Leuthardt, “The problem lies in the fiction we have created that separates the brain from the mind.” In other words, most of the people in the medical/biological world think that we can treat organs, like the brain, with drugs and other medical interventions and that the mind is a different thing altogether with uncertain boundaries, separate from the true medical treatment process and not susceptible to science in the same way. That’s some pretty deep stuff, but then again Eric is a neurosurgeon/neuroscientist who has spent large parts of his life thinking about the intersection of biology and psychology, so no surprise. You can listen to some of Eric’s thoughts on this Tech Tonics podcast. But Eric went on to say, as does the New Yorker article, that there are actual biological changes in the brain and the human body (even the DNA) that directly result from unresolved childhood trauma and which can directly affect the development of the cardiovascular system, the metabolic system, the regulatory system, inflammation, even fetal development. The list goes on and on. The mind-body connection is very real from a biological standpoint and yet we try so hard not to remember that in our healthcare system. Once again, the psychological and the medical are intrinsically intertwined and one must not be ignored in favor of the other.
In other words, American cardiologists should all be expecting to see a wave of patients in a few years who got to have the childhood experience of detention at the Mexico border, assuming they get to stay.
What is particularly worth nothing is that ACEs are found in every segment of the US population, across every type of community and ethnicity, rich and poor, etc. ACEs are not the purview solely of the Black community or the Latino community or the “bad neighborhood.” They are the story of all people from all walks of life who are dealt a hand that will make them struggle medically and, potentially, financially, given how the costs of using the healthcare shifting are rising for people across the country. No one whose childhood truly sucked is safe. There is lots of good information in this article, which shows that 1 in 10 children across the United States have experienced 3 or more ACEs.
So what to do, what to do? Do we seek out teens with high ACE scores and start them early on medical interventions known to have a prophylactic effect? Do we figure out how to fix our pathetic mental health system to ensure that people who need it actually get treatment that is preventative in nature, not just when they are already in crisis (or never, would never work for you?)? Do we figure out how to train the next generation of physicians to actually think of a whole person risk score that includes not just genetics, biological symptoms and current behavior, but also childhood experiences? I think the answer to all of those may be yes. But how and who pays? Dear Lord I wish I knew the answer to that one. There are all sorts of companies and organizations trying to tackle little pieces of this puzzle like the blind guys feeling an elephant, but there are few coordinated efforts on this front that really take into account a whole person from childhood to adulthood, brain and mind, body and spirit.
I am deeply puzzled by the clear resistance that still exists when one brings up the importance of treating people’s mental health to get to their physical health. Yeah, yeah, everyone pays lip service to the idea, but few in the business are acting on it. Burke’s clinic in Hunter’s Point is a great example of one that is really trying to do this on purpose. I love the work that Sachin Jain is doing here at Caremore around loneliness. But in general there are few that try, much less get this right, and our insurance system is designed not to think about it this way at all.
And worse, there are people who still question the science around social determinants, even the original ACE study and what has followed. I found it fascinating to learn that the original ACE study done by Felitti and Anda included 17,000 patients enrolled at Kaiser. 17,000 patients. Not a whole lot of clinical trials include 17,000 patients. And because their work took a look at the patients from a retrospective angle (e.g., you have heart disease so let’s ask questions about your past childhood trauma), skeptics pooh pooh the results, saying that patients will mis-remember/misreport their experiences. The fact is, most of the time people UNDER-report their traumatic experiences (witness the current eruption of women talking about 30-year old sexual trauma). And seriously folks, if it weren’t for retrospective data sitting in EMRs we wouldn’t have any healthcare-focused artificial intelligence products at all right now. Every one of those AI monsters is loading up retrospective data that is well-known to be riddled with error, ranging from self-report errors to recording errors to physician errors to lord knows what. But we like those retrospective studies because they are “technology” and investors and large companies are throwing money at AI innovators. What I say to that is this: 17,000 patients. And many, many confirmatory studies have followed the original ACE study, including those by Burke, and even a 30-year-long prospective study undertaken in New Zealand (the Dunedin study). Each time, the same results. So skeptics – wise up.
My thinking is that we really need to increase the value we place on pediatricians and early childhood development experts. We need all kids to take ACE tests in some safe setting and figure out ways to help educate parents about the impact of their behaviors – I know, yeah right, but there has been work done like this in some communities and even a few kids saved is a few kids saved from an early heart attach or disabling congestive heart failure diagnosis. Maybe we should pair ACE tests with physical fitness tests and think about prevention in a much more expansive way. It’s not just our genes that can determine our outcome and it’s not just our crappy food and bad behavior. We are the sum of all our characteristics and experiences. We are, as Sek so beautifully put it, a big smoothie of inputs. Let’s recognize that and act accordingly.
How do we create a healthcare system that can respond? I wish I knew but I’m going to keep working on it. I do want to call out many of my Aspen Institute and other colleagues who have made it their life’s work to integrate both the medical and psychological needs of people. There are too many to name but I am so honored to be among them. I am also grateful to people like Sek, my many dedicated colleagues affiliated with the American Heart Association, Dr. Lonny Reisman at Health Reveal and other cardiovascular physician scientists who so clearly are trying to improve the lives of patients by helping them prevent the misery of cardiovascular illnesses. Cardiovascular disease is the leading killer of Americans and yet money has flowed rapidly away from innovation, discovery and intervention here as it has shifted to oncology. Oncology clearly also needs attention — it all does. FYI, ACEs also dramatically increase your risk of cancer.
For all of you involved in the healthcare field, my call to action is this: your work cannot be an island – please make a concerted effort to build that bridge between the biological determinants of health and the social determinants of health as you go about your everyday lives. If we really want to improve the healthcare system, both sides need each other or the efforts are futile. Focusing only on either biology or psych/sociology is building a bridge to nowhere. And you know who hates bridges to nowhere? Venture capitalists! So you guys with the money, if you actually want to make the world a better place, please join in and think more expansively about what constitutes a good healthcare investment.
wow- thank you for the insightful read. I think its really hard to find the right bridge as you say as there is much known, but still so little known. Still, as you show, the evidence makes it necessary if we want to tackle such a large and multifaceted problem. Thanks again, I hope all is well.
Siobhan, thanks for the note – we have to keep looking for that bridge, for sure. Lisa
All I can say is YES!!! This is the right conversation to be having for so many reasons. The implications of ACE are not just health outcomes, but education and long term social stability. In school systems, we are seeing the adoption of mindfulness and empathy into curriculum because educators realize this is one of the ultimate human endeavors — raising young people. Healthcare is another ultimate human endeavor. If someone hasn’t already done it, we should study whether strategies to bring us closer to each other are not only prevent disease but heal us from the damage already done. Great freakin’ post, my friend.
Gracias TG!
Excellent post, thank you. Also see: https://www.sciencedirect.com/science/article/pii/S0306987718306145?via%3Dihub
Thanks Kiki!
Thank you for raising these issues and connections – this is incredibly important and insightful stuff. I am so glad that you are highlighting the reality that innovators and leaders in medtech must seek to understand social determinants of health as we look to make an impact on the unmet clinical needs that persist around the world.
We have made so many advances in understanding human physiology and pathophysiology and in using technology to address health problems where there are symptoms, phenotypes, and biomarkers that we can easily measure and visualize. It is key that we formulate new paradigms and develop new tools for investigating and understanding the root causes of health and disease to truly enable all people to live healthy lives. We must accept that these new tools may fall outside of what we are comfortable with, and beyond the concepts and assumptions we have built our institutions around.
Ayo, could not agree more. Lisa
This is big stuff, Lisa. I took the ACE test and then had to go have a wee lie-down when I saw my score (4). As you rightly ask, too: who is working on finding ‘cures’ for past childhood trauma?
I’ve been writing for years about the tendency of specialists to treat just a specific organ, not the whole person. As Mayo Clinic cardiologist Dr. Sharonne Hayes (founder of the Mayo Women’s Clinic) once said: “Cardiologists may not be comfortable with ‘touchy-feely’ stuff. They want to treat lipids and chest pain. And most are not trained to cope with mental health issues.”
So that makes me suspect we need to start this ACE awareness with med school students.
Right now, I honestly don’t see much hope that the profession as a whole will include ACE tests into their practice arsenal any time soon. A good example to explain my low expectation is supervised cardiac rehabilitation classes following a cardiac event ( a pretty great program of mind/body connection that helps freshly-diagnosed heart patients when they need it most). But it’s hard enough as it is to convince cardiologists to refer their eligible heart patients to supervised cardiac rehabilitation (considered a Class 1 treatment protocol by every professional cardiology society worldwide – meaning it should be highly recommended to help prevent a secondary cardiac event).
In fact, recent research suggests fewer than 20% of all eligible heart patients are actually referred to cardiac rehab by their cardiologists. That’s an appalling statistic! One possible remedy, the researchers postulated, was that all cardiologists should be “educated” about the proven longterm benefits of CR, which made me choke on my coffee. I have yet to meet even one cardiologist anywhere who is not very well “educated” about prescribing statins to every heart patient with a detectable pulse – yet the same doctors somehow don’t know anything about cardiac rehab?
Thanks so much for this introduction to this provocative and interesting topic.
regards,
C.
Education about how we are a unitary organism, a system of systems, needs to start well before med school.
Intensive Short-Term Dynamic Psychotherapy practitioners are trained to address the unconscious core emotions around attachment ruptures from trauma and years of research by Dr. Allan Abbass in Halifax, NS has shown how effective it is for somatization. I have certainly found it, and neurofeedback, very helpful in my practice.
Trauma demands diversion of energies and focus from important developmental tasks for basic survival. Afterward, our habits surrounding core emotions, anxiety, and defenses steal our energies and create high tonic levels of stress hormones, robbing from production of other vital steroid hormones, hardening vasculature, causing oxidative damage and mitochondrial dysfunction all over the body.
We need to address all aspects of a person. I agree with many who commented here: more needs to be done on the mental and emotional side of care, in a fully-functional blend with useful allopathic and naturopathic interventions.
The mental and emotional techniques, like ISTDP and other emotion-focused psychotherapies, directly address better connections between limbic and cortical centers and all connected systems. They aim at the core issues, the engines, of post-traumatic dysfunction: now dysfunctional (originally survival-oriented) automatic implicit procedural rules for managing one’s interpersonal world.
Mine was also 4! Haven’t stopped hyperventilating and rewriting my health history since!
Thank you for a great – and provocative post Lisa…..have only been following you for a few months now, but you are already one of the highlights of my week!
The dilemma you have outlined is under study now in several research communities – including mental health and global health. But as you have pointed out, none of these are areas of high investment by healthcare or industry – and none have the power on their own to change our strategies in research or delivery of care. We have learned much about the importance of social determinants – yet we keep practicing the way we always have – looking for the answer under the lamppost. Cannot help but be struck by how often we blame interventional failures (drugs mainly) on biology – when in point of fact, the social determinants of health are not considered in trial design.
A re-set in our thinking about methods and aims is needed. We can learn much from big data – and real world studies are essential to realizing a truly holistic approach to health. Interesting things happening in this area in the UK via the Research Councils and Wellcome and other charities…..time for other big funders to get on board.
Brilliant
Based on what we are seeing, what we strongly suspect is the secret sauce in cardiac rehab is that it actually focuses on the social determinants of health – what are the barriers to medication adherence, what family issues prevent adoption of a healthier diet, how do patients in peer support groups help each other, what barriers at home prevent individuals from getting help, how can we increase health literacy etc. There is a lot more potential of course. I think where we are getting stuck is that the current medical payment system only pays for “tangible transactions” like prescribing meds, performing EKG monitored exercise, ordering lab tests. I also feel that the cardiologist community is trained to think that such approaches are “real medicine.” However, slowly things are changing, we hear more and more about how in ACOs, people are using home visits or follow up coaching more and seeing results. Kaiser Northern California has done this amazingly well, to the point of delivering frozen meals to their members free of charge to address issues like high sodium diets. I feel that having flat payment structures and giving healthcare providers the freedom to operate within those structures may help. Also, training the next generation of doctors on the importance of social determinants is going to be key.
Finally, I struggle with the studies you mentioned because based on what I understood, they isolate risk factors for the purposes of academic sanitation (which is what they should do and makes them great studies). That isolation rarely happens in the real world and less is known on how risk factors themselves interact (or counteract) with each other. On the other hand, it’s probably not worth beating a dead horse – if you know something is bad for you then moderate its influence. And then we move medicine forward a little bit more.
As always, beautifully written, Lisa.
The truth is that we in this country have only episodic interest in the social contract, mostly when in times of deep economic crisis it affects “us,” the middle class. Otherwise, unless the working class and poor attract our attention by some anti-social act (rioting, dying conspicuously from opioids.), we would rather not invest in actions which “lift all boats” in society. It’s just who we are as Americans.
Just like we’d rather buy jet fighters than send unstable nations food aid (or buy $1 billion tanks rather than infantry training), and we’d rather invest billions in driverless cars rather than fix our deteriorating bridges and streets, we as a nation would rather invest in the technology of medicine instead of the people-to-people interactions to prevent expensive medical problems that the technology treats.
I just wrote a short profile of CareMore Health for the Tincture blog. They do a wonderful job, but, like the Kaiser example you cite, a putatively Judeo-Christian nation that believes in “feed the hungry, clothe the naked..if it helps you turn a profit on your capitated health care premiums” is pursuing a policy that is both ethically and economically dubious.
Lisa, very insightful as always. Once the incentives for providers are properly aligned, you will begin to see sustainable change. When it comes to treating kids, those of us who do this know that we are reimbursed a fraction of what adult providers receive. No wonder many studies and innovations focus on adults and as if there is no context to how “adult” health issues are created. Also, since most physicians have no solution for the social determinants of health, we focus on what we can “fix,” or what is likely to get reimbursed. Thank you for your call to action and I will follow-up offline with some ideas I have to incorporate social determinants of health into my sickle cell research and pediatric ICU practice (alongside the biology of course 😉).
From both sides of the spectrum:
Read Prevent and Reverse Heart Disease by Caldwell Esselstyn.
Read The Body Keeps the Score by Bessel Van Der Kolk.
Read this: The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma
Book by Bessel van der Kolk for an excellent primer on this growing field of research into mind/brain.
And, then follow what many educators and public health providers are doing with ideas such as those in this book: Trauma-Sensitive Schools: Learning Communities Transforming Children’s Lives, K–5
Book by Susan E. Craig
There is a whole world of us working on these issues one child, one family at a time with little fanfare and limited resources.
The book the Body Keeps Score was one of the best reads for really understanding how trauma impacts our perception of the world and therefore our health. As an Executive Coach, reading this book helped me work with clients regarding the stories we tell ourselves and helping us rewrite our stories.
The other thing I loved about the book is how the author realized different approaches work for different people. He suggests various practices to help recover from trauma. It would be amazing to see a study on how this impacts our health. We need a healthcare system that treats the whole person and understands individual differences based on evidence-based practices.
Thank you Janel!
Nadine Burke Harris has a book: “The Deepest Well” which sets out the above in more detail as well as her latest ventures and thoughts on how to best deal with the multiple problems caused by ACE’s. I cannot recommend it highly enough.
Thanks Matt! I’m going to order that now!
I was directed here by the NY Times What we are reading section. I was the depressed mom referred to on the ACE test. My daughter suffers from depression as did my mother although we didn’t know it.
The separation of mind and brain in our society is something that I struggle with and I am lucky enough to have Kaiser as my health provider.
If someone like you is on the job looking for a solution and funding for that solution, I can rest a little easier. If only we could somehow erase any mention of poverty from the statement of the problem, then the powers that be would pay attention.
Mary Beth, thank you for sharing your story. Many in my family have also struggled with depression. Poverty can amplify the ACE challenge but it certainly isn’t the baseline factor. All people can experience these challenges, as you and I know well. Keep at the good fight! Lisa
I score a solid 7 on the ACE test. I am 49 years old. My father had a triple bypass 3 weeks ago and is awaiting surgery for 2 2.5 inch aorta aneurysms. His heart surgeon says he is the worst case he has seen in 26 years, and I can certainly understand why. I grew up with physical/ emotional abuse, neglect and addictions/ alcoholism in the household. At age 43, after my divorce I decided enough was enough. I dropped all hobbies, extracarricular activities, TV, etc. So that I could focus solely on myself and my healing. I began walking regularly, eating healthy and most importantly, dealing with massive amounts of stuffed feelings. I work with a therapist weekly and attend a great Al-anon group in my area. I have had to commit 100% to myself and my healing. I mentor/sponsor 3 other men as well, one of which is a licensed and practicing psychotherapist. I cannot rely on someone to come along to heal me, I must commit to that. Living a life with spiritual principles has turned me around. I still have work to do and am pressing forward, but I am so much stronger and healthier than I was. Most importantly I have these moments of feeling genuine love and gratitude in my heart rather than the shame, hate and anger I used to feel. I am a layperson but I sincerely thank all professionals who are bringing awareness to this subject and who are wracking their brains trying to find a solution to this. Much Love.
Mike, that’s quite a story but so glad to see the happy latter part. Thank you for sharing it here and here’s to continued joy. Lisa
This is a great read Lisa.
I just graduated from Penn Nursing and I am a new nurse at the Johns Hopkins Hospital in the NCCU.
One of my favorite classes in school was Ezekiel Emmanuel’s class on Modern American Healthcare. It has made me reflect so far on my practice as a new nurse and recognize, that while our system has many flaws, there are articles, like yours, that I want all of my friends to read to understand that we are at the frontline of healthcare. We have to think about the past, present, and the future of our patients, and the best way to do it is to treat each patient case individually. There is a lot of innovation that has occurred to help patients get help such as companies like Aspire or Quartet.
While in school I was able to travel abroad and work as a nurse intern in a township outside of Cape Town. It was the first time I truly recognized how crucial it was for me to apply the “social determinants of health” to my patients needs and background. As I have moved to the inpatient setting, I have realized it is vital to involve families and work on an interdisciplinary team, and then ensure that patients are able to receive follow up care and continue to be “well” following hospitalization or outpatient visits.
Thank you for writing this article.
Thanks so much for your note! Lisa
Now that you know where and why you are now what can you do now ? Help is on the way our woman owned company is developing very novel cardiovascular devices. They have a wireless handheld point of care diagnostic/prognostic device that can read 13 biomarkers and diagnose a heart attack (before tissue damage) in 15 minutes ! On the prognostic side it will indicate if you are at high risk for a heart attack in the next 6-8 months . We were the winners of the Mar 1 Boston Scientific/Google “connected patient challenge” competition. Cardiologists at Baylor Med Ctr, Brigham Women’s Hospital and Mayo Clinic like our patented technology. In fact Mayo wishes to do a 1500 patient study with us. We are looking for champions/advocates and some funding , it’s too bad we can’t find any women that want to help. For people with known CVD problems we will have an “at home” device to send info directly to their doctor.
Best of luck with your project! You might check in with the AHA as they are interested in things like this. Lisa