Author + information
- John Gordon Harold, MD, MACC, ACC President* ( and )
- John S. Rumsfeld, MD, PhD, FACC, National Director of Cardiology, U.S. Veterans Health Administration; ACC Board of Trustees
- ↵*Address correspondence to:
John Gordon Harold, MD, MACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
In March 1865, the Civil War was coming to an end and President Abraham Lincoln was entering his second term as president. As part of his second inaugural address, Lincoln focused on transitioning from the divisiveness of war to the healing of the nation. He closed his address with a now famous quote affirming the government's obligation to care for war veterans and their families.
“With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation's wounds, to care for him who shall have borne the battle and for his widow, and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations,” he said (1).
Today, a portion of this quote greets those entering the U.S. Department of Veteran Affairs (VA) headquarters in Washington, DC — and there are many who walk through the doors. The VA is the largest integrated health care system in the U.S., with over 1,400 sites including hospitals, nursing homes, and clinics. More than 8 million veterans are cared for in this system (2), many of whom suffer from, or are at risk of, cardiovascular disease. As such, hundreds of cardiovascular professionals are part of the VA system. Not to mention, >90% of clinicians trained in this country spend at least some of their training at a VA facility.
The VA hasn't always been known for high quality care. Indeed, it has undergone a remarkable transformation in the last 25 years, evolving from the woeful depictions of care such as in the movie “Born on the Fourth of July,” to being identified by many as the highest quality health system in the U.S. In the cardiovascular arena, VA cardiology has developed widely acclaimed, innovative national programs, such as an active cardiac device surveillance system in collaboration with the Food and Drug Administration (3). In his book, Best Care Anywhere, author Phil Longman also cites the VA's national electronic health record system and commitment to evidence-based medicine as key drivers of its' successful transformation (4). In this era of health care reform, the VA is basically a model accountable care organization.
The American College of Cardiology (ACC) has long recognized the important role the VA plays in cardiovascular care and in recent years has moved to further strengthen the role of its VA, military, and public health sector members in college-wide activities. Today, VA clinicians serve on the ACC's Board of Governors and Board of Trustees and other national ACC committees, and, conversely, multiple FACC's have national leadership roles in the VA system. This past ACC.13 in San Francisco included special sessions designed specifically to bring together ACC members working within the VA, Army, Air Force, Marines, and public health sector to address challenges and opportunities unique to these groups.
However, the care of veterans does not end with the VA health care system. In thinking about U.S. veterans today the answers to the following ‘True or False’ questions may be surprising:
1. The majority of U.S. veterans are cared for primarily within the VA health care system. Answer: False
2. In the current U.S. veteran population, there are more “Gulf War era” veterans than the Korean War and World War II era veterans combined. Answer: True
3. There are currently over 2 million women U.S. veterans. Answer: True
Today, there are over 22 million U.S. veterans comprising roughly 7% of the total U.S. population (2). This means that two-thirds of U.S. veterans receive their care outside of the VA system. It is, in fact, almost certain that all ACC members involved in adult (and in some cases pediatric) clinical care take care of veterans and/or their family members. Therefore, the U.S. health care system as a whole —including all cardiovascular clinicians and the ACC as an organization — shares the responsibility, and honor, of providing high quality care for our veterans.
While most cardiovascular professionals are familiar with World War II, Korean War, and Vietnam War era veterans, many may not yet be familiar with the following acronyms: OEF, OIF, and OND. These stand for Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn, together representing the “Gulf War era” veterans. There are over 1.6 million OEF/OIF/OND veterans (2). And while OEF/OIF/OND veterans are less likely to have extant cardiovascular disease than older veterans, they have elevated cardiovascular risk factors that deserve our attention. As one example, the rate of active smoking in the general U.S. population and the overall VA population is ∼19%, while over 35% of OEF/OIF/OND veterans are active smokers. These veterans also have a high prevalence (over 30% by some estimates) of post-traumatic stress disorder (PTSD), which is predictive of the development of cardiovascular disease. The ACC and its' members have a major opportunity to serve OEF/OIF/OND veterans through prevention of cardiovascular disease by effective risk factor recognition and treatment.
Similarly, it may be surprising to learn that about 10% of U.S. veterans, or more than 2 million, are women (2). With women currently representing over 15% of active duty military, this number will continue to grow. As the numbers of women veterans increase, it is becoming clear that many have cardiovascular risk factors, including active smoking, diabetes, obesity, hypertension, and dyslipidemia. At least one major cardiovascular risk factor is present in approximately 30% of women veterans under age 45, 65% of women veterans between ages 45 to 65, and 80% of women veterans over 65 years of age (5). Moreover, about 1 in 3 women veterans under 65 years of age have depression, which is independently predictive of developing heart disease.
Semper Fidelis, the motto of the U.S. Marine Corps, means ‘always faithful’ in Latin. Only a few days ago, the U.S. celebrated Memorial Day — a dedicated day to remember and honor those who were “always faithful” and gave their lives in military service. Our challenge — our own opportunity to be Semper Fidelis — lies in the months and years ahead as we care for those veterans and their family members who find their way into our offices and our lives.
- American College of Cardiology Foundation
- ↵Lincoln, A. Second Inaugural Address. March 4, 1865. Available at:http://www.abrahamlincolnonline.org/lincoln/speeches/inaug2.htm. Accessed May 4, 2013.
- ↵Department of Veterans Affairs Statistics At A Glance, and Veteran Population Projections FY2010 to FY 2040. Available at: http://www.va.gov/vetdata/. Accessed April 30, 2013.
- Longman P.
- ↵Whitehead AM, Davis MB, Duvernoy C, et al. The State of Cardiovascular Health in Women Veterans, Volume 1. Women's Health Services, Veterans Health Administration, Department of Veterans Affairs, January 2013.