Dr. Forwand is Chief of Cardiology at Harvard’s Mt. Auburn Hospital, one of the nation’s top 100 cardiology centers. He is also Assistant Professor of Clinical Medicine at Harvard Medical School. He studied medicine and received degrees from Columbia University College of Physicians and Surgeons and Union College in Schenectady, New York. Dr. Forwand is an author of numerous technical papers and abstracts and is currently overseeing several clinical studies in arrhythmia management and cardiac pacing.
What research are you currently working on?
We are counterpulsing patients and have pretty much just started, so we don’t have a very large group. But we will eventually break them down into subgroups to try and figure out whom this is good for, whom this works on and whom it doesn’t work on. And if we can, then figure out why it works on some people and why it doesn’t work on others. That’s the initial thrust of the counterpulsation research.
How did you become involved with counterpulsation?
I got involved in counterpulsation when I became a cardiology fellow in 1963. There was counterpulsation research at the New England Medical Center in the cardiology department. I first found out about it then, and we had some devices that I looked at. I think I was even in one at that time. The Fellow who was directing that research was Dr. Harry Soroff, who became instrumental later on in developing the commercial product. When I then came to Mt. Auburn Hospital, Dwight Harkin was the chief of heart surgery at the Brigham and also at Mt. Auburn. He was involved with Soroff in a number of projects, including trying to get a clinical version of this machine running.
We had a counterpulsation machine at Mt. Auburn in the 1970s. And we actually counterpulsed some patients then. In fact, one of our chief techs in our non-invasive cardio department remembers sitting with a patient -- who I can see very clearly in front of my eyes now -- and counterpulsing him for several days. That patient’s daughter is still a nurse in our IC unit at Mt. Auburn and I bet she remembers her father having that procedure done.
Anyway, that’s how we got started. We were involved in one of the first studies, which was a study of the use of counterpulsation with acute myocardial infarction back in the 1970s and I believe that paper was published in 1980.
Is it a mainstream treatment
It’s not quite mainstream. It’s getting there. There are now about 500 centers around the country that are doing counterpulsation. The technique has been approved by HCFA (COS) for payment by the federal government and they don’t do those things lightly. There was one real study that the government counted heavily on when they approved this in 1999, and that was a study of counterpulsation vs. sham (fake) counterpulsation and it clearly showed that the treatment does work and can help angina. It was on that basis that it was approved by Medicare.
There is also a large international data registry on counterpulsation patients being kept by the School of Public Health at the University of Pittsburgh. They have over 5,000 patients in that registry from all over the world and they are still writing papers on those patients.
They’re subdividing the large group of patients into subcategories to find out who counterpulsation helps, who it doesn’t help, and thereby trying to figure out why it works. There were three abstracts presented at the ACC meeting in March. One that showed it works as well on the elderly as on the non-elderly, one that showed it works as well in women as in men and there was a third as well. Compared to some other things it’s not mainstream in that sense, but there are paper being written, people are thinking about it and it is being used.
Who would be an ideal candidate for counterpulsation and how can they get it?
An ideal patient is one who has had stents, bypass surgery or a combination of the two, is still having angina and for one reason or another is not a candidate for any more surgery or stents. He’s either got other conditions which contraindicate those procedures or he’s got anatomy that suggests surgery isn’t going to help him. And there are people who have renal disease where you can't give them enough contrast to put stents in. So people who are basically end of the line cardiac patients -- those are the ideal patients.
But there’s a caveat here. They may be the ideal patients for 2002, when in fact, there may be a much larger group of patients for whom this is even better. But right now these are the patients for whom we’re doing this. And this is true of any new modality of treatment in medicine – the worst cases are usually the ones that are treated first and everybody else gets the standard treatment. But at some point you can well imagine that if this is good for people who have terrible coronary disease and have bad angina, there are plenty of people who have terrible coronary doses and don’t have bad angina. They die pretty often too, and maybe this is better for them.
Now, if you are a patient who falls into that category, what do you do? You see your primary care doctor, who we hope will refer you to a cardiologist who knows about counterpulsation and will consider sending you for this treatment. And there are some preliminary tests that you have to have to get through the door. You’ve can't have aortic valvular insufficiency, so you need an echocardiogram; you’ve can't have an abdominal aortic aneurysm, so you need to have an ultrasound of your abdominal aorta to make sure that’s OK; and, you’ve got to have studies of your leg arteries and veins to make sure they’re without clogs.
We ask the cardiologists to get these four tests for us and then generally what happens is that the patient contacts the counterpulsation center and we try to set up the logistics. Then we have them come over and watch a session for a few minutes and then maybe get into the machine for a few minutes to see what it feels like. And then we start, and we gradually build them up to their one-hour sessions depending on how well they’ve tolerated it.
What does the machine feel like?
I think the best analogy is that you are lying on your back riding a horse. That’s what they look like. Their pelvises are bumping up and down as the balloon blows up and down. And most of them say it isn’t uncomfortable. We’ve done people who are over the age of 80 and are pretty fragile, and they may take a couple more days to get up to the full hour and full pressure, but they have gotten there. We have not had anyone drop out because they couldn’t tolerate the machine. We did have one fellow who is very obese and has diabetes who had to take a week off because the cuffs braided the skin on his legs, but other than that there has really been no problems.
Could this treatment be used to treat non-cardiac conditions?
There’s one paper from Germany showing that this is good for erectile dysfunction. There is another showing this is good for diabetic retinopathy. Theoretically, this should be good for any disease that is due to a lack of blood supply, and there are an awful lot of diseases for that. But they have not yet been studied with counterpulsation.