An interesting debate has emerged in cardiology this week. The science is interesting, but equally intriguing–for a general audience–is the stage on which this debate plays out.
That social media features prominently could only be called cool.
First the debate:
What role, if any, should genetic testing play in guiding modern heart care?
The specifics here are whether patients who undergo stent placementâ€”and thus require the anti-platelet blood-thinner clopidogrel (Plavix)â€”should also have a simple test that identifies genetic susceptibility to a muted response to the drug. Itâ€™s felt to be important because individuals that have this uncommon but not rare trait harbor an increase in abrupt clotting of their stent. Whatâ€™s more, knowing this susceptibility is actionable, as these patients can get a different blood thinner, or higher doses of clopidogrel or a different kind of stent.
The larger picture is whether, or how, personalized medicine will get incorporated into heart care. This is futuristic, but the obvious precedent here is in the care of cancer, where we already know that genetic markers guide effective treatments.
Those on stage are both prominent opinion leaders who in the past were close colleagues at the Cleveland Clinic, co-authoring many studies together.
Dr Eric Topol is currently the chief academic officer at the Scripps Medical Clinic. He is also a strong proponent of gene-testing. His vision holds that heart disease treatment will become highly directed by one’s genes. He cites numerous studies supporting the argument that a simple blood test provides important and personalized information that improves outcomes after a stent. Plus, his argument makes common sense.
His antagonist, Dr Steve Nissen, now chair of Cardiology at Cleveland Clinic, has authored an editorial in JAMA suggesting that gene testing for altered clopidogrel handling does not improve outcomes. His editorial emphasizes the conclusions of a JAMA meta-analysis (a pooling of many different studies) that showed a lack of benefit of this specific gene-test. Dr Nissen was bold in his editorial, saying that gene testing should be used either rarely or not at all. Ouch.
Dr Topol, and others, counter that the meta-analysis was flawed because researchers excluded important stent studies and included studies of clopidogrel use in other non-related diseases like AF, thus muddying the waters concerning stents.
Itâ€™s an interesting debate on its own. Both make compelling arguments. As a humble heart rhythm doctor, itâ€™s hard for me to favor one side or the other. The debate, however, provides great learning opportunities concerning issues of genetics, which many believe shed light on the future of medicine. So I like it.
The other likable thing is the difference in the medium used to voice each side of the argument.
Social Media’s role:
Dr Topol tweets, blogs and even creates home-spun video in which he appears relaxed and in a collared shirt, sans tie. He speaks informally and looks energetic. He even interacts with commenters on his blog and twitter feed! And the coolest part: you can read and listen to his opinion for free.
Dr Nissen, on the other hand, writes academically in the Journal of the American Medical Association, which requires a subscription. You can read only 150 words of his rebuff of gene-testing. Dr Nissen does not tweet or blog. This, of course, does not diminish his opinion. I think a lot of his opinion. (And he trained, at least partially, in Kentucky!)
Both of these leaders add tremendous usable information. And the current debate will surely help both patients and doctors understand the complex issues at hand. Good news.
The problem is that unless you are a connected academic, or a paid subscriber to JAMA, you can only read Dr Nissenâ€™s opinion second-hand, as reported by others. Dr Topol, speaking through social media, surely reaches many more. Social media amplifies his voice.
I hope Dr Topolâ€™s embrace of social media leads more of his esteemed colleagues in this direction. Itâ€™s about time these important debates are had on a stage capable of interactivity and in real-time.
I stand ready to follow more of these @importantdoctor.blogspots. Many patients would follow along too.
And one final note: It is hard not to like the Southern California, loose-collared approach to disseminating knowledge. Can’t science and knowledge be serious and fun at the same time?
See these links at Cardiobrief and TheHeart.org for better coverage than mine.
2 replies on “Social media figures prominently in the current debate on gene testing in Cardiology”
Thank you for this very interesting post. In my view, Dr. Topol is right on (and Dr. Nissen needs to get with the program.)
Nowadays, for as little as $99 anyone can have his DNA tested (by 23AndMe, for example) and learn about his reponse to Clopidogrel. I have. What I learned, was that the effects on Clopidogrel efficacy are â€œunknownâ€ in my genotype combination (CYP2C19 *2/*17), and that more research on the *17 version of CYP2C19 is needed. Other possible results were: typical, reduced, and greatly reduced Clopidogrel efficacy.
Weâ€™re all in this together, and learning together is a big part of it. Thatâ€™s what participatory medicine is all about. More patients should engage in their care and learn all they can about their genes. And Dr. Nissen should step outside of the stuffy pages of JAMA and share his knowledge with the rest of the world as Dr. Topolâ€”and yourselfâ€”so generously have.
So if it were I, it would be tempting to know.a good friend of mine recently rethrombosed. Was he a gene positive?
The actionable differences that come with knowing sway me in the same that it does you.
Thanks for saying.