‘Green Cardiovascular Care’ Needed to Protect Environment, Bolster Health

With the world facing unprecedented threats to the environment, it’s time to start thinking creatively—and taking real action—toward “green cardiovascular care” that produces less waste and responsibly uses resources, asserts a new editorial in the European Heart Journal.

There’s growing awareness that the environment, whether through temperature extremes, pollution, or other risks, affects human health. “But very few people think about the impact of healthcare on the environment—the flip side,” said Sadeer Al-Kindi, MD (Houston Methodist Hospital, TX), the paper’s senior author.

Cardiovascular disease, as the number one killer, affects many people and inherently involves a lot of resources. Moreover, as cardiologists, “we use a lot of equipment—we use stents and devices, we have a cath lab and operating room that’s very active, so there are a lot of things that go into the landfill and [things] that are single use,” Al-Kindi told TCTMD. Advanced imaging, too, is resource intensive.

Al-Kindi co-authored the editorial with Robert D. Brook, MD (Wayne Health and Wayne State University, Detroit, MI), and Sanjay Rajagopalan, MD (University Hospitals, Cleveland, OH).

They point out that the medical field contributes a substantial amount toward greenhouse gas emissions—in the United States, it’s responsible for 8.5% of the total. These US-based healthcare emissions make up a quarter of all greenhouse gas emissions produced by healthcare worldwide.

It’s not that clinicians, who see waste firsthand, aren’t aware of the problem. But in writing their paper, the authors wanted to provide a clear picture. They pulled together what’s known about cardiology’s carbon footprint, with a “call to action” about what steps healthcare systems and healthcare professionals can take.

“We provide a potential framework, so that people can think about solutions,” said Al-Kindi. “There is no easy answer here. This is a complex issue.” As such, “systems thinking,” a framework that looks at the whole rather than single parts, is helpful, he explained. “Everything is connected. Everything has an impact on different things.”

This awareness can not only lead to improvements but also avoid unintended consequences. “We don’t want to spare costs at the individual [patient] level and compromise health,” stressed Al-Kindi.

Where to Start

The paper tracks resource use and offers potential strategies for reducing it across the continuum of cardiovascular medicine: the outpatient clinic, diagnostic testing, interventions, surgery, and inpatient care. Something as seemingly simple as the food patients eat in the hospital requires not only the meals and the staff to serve them, but also cleaning up afterward and knowing what to do with uneaten food and disposable utensils. Drugs and devices are made from raw materials that must be obtained, and then there is the energy involved in producing the products, packaging, and distribution.

Ultimately, linking the carbon footprint of healthcare services back to patient care and community health may make the message stronger. Sadeer Al-Kindi

Al-Kindi and colleagues say that sustainability will require policies that incentivize green healthcare delivery, technological innovations that help reduce waste, and other big-picture fixes. Cardiovascular prevention can play a key role in promoting sustainability by reducing disease burden, as well. “A lot of the healthcare emissions and waste that happens in cardiovascular practices are related to advanced diseases,” Al-Kindi pointed out, adding that a better environment will, in a self-reinforcing cycle, lead to better heart health.

For individual clinicians, the complexity of the problem can feel daunting.

Al-Kindi, however, suggested that some solutions can be simple. Unused parts of cath lab kits, for instance, can be repackaged for another case, or staff can make sure to turn out the lights and turn down the air conditioning when they leave an operating room.

How receptive cardiologists are to the sustainability message varies, said Al-Kindi. “But I would say that people, whenever we talk about this topic, are interested and they want to help and they want to understand.”

Clinicians are, by nature, caring. “Ultimately, linking the carbon footprint of healthcare services back to patient care and community health may make the message stronger,” he said, noting that if this link is ignored, harm will result.

Shifting Priorities

David Kandzari, MD (Piedmont Heart Institute, Atlanta, GA), commenting for TCTMD, said he admires the authors for raising this topic. More and more, he’s heard the concept of environmental sustainability come up at scientific meetings and advisory councils.

“It’s been very interesting to me to hear about this,” Kandzari said. “For example, I was recently in a meeting talking about the evolution of renal denervation therapy,” where a physician stood up to call for companies to go beyond discussing the treatment’s benefits and address the “carbon footprint that’s left behind from the construct of catheters and things. On the one hand, I think all of us were sitting in the room silently [thinking] to ourselves: ‘This is really coming out of left field.’ But at the same, of course, it’s meaningful, too.”

The difficulty, said Kandzari, is that individual actions can only go so far. Healthcare systems hold the power to have the greatest impact, he added, and will gain support if professional societies take up the cause.

“We would all agree that this is very important,” he said, “but the fundamental issue is: where does this fall on the ranking of priorities for healthcare systems right now? [They] are really facing headwinds, ranging from changes in reimbursement to the higher costs of travel nurses and travel staff, for example, and even [the need for] IT security.”

Amid all these concerns, environmental sustainability may feel less urgent, Kandzari said. Making changes, though they may save money in the end, will require an initial investment. Thus, unless incentives are put in place, systems may not be eager to take steps toward reducing their carbon footprint.

Still, there are signs of early progress. For instance, a recent study showed that recycling could enable cath labs to cut back on the garbage they produce, and some are already participating in these programs. Industry partners are increasingly being encouraged to be active in promoting such moves toward sustainability. One example of this is Stryker, which reprocesses catheters so that they can be reused, Kandzari said. Some efforts may be invisible from the outside: at Piedmont Heart Institute, where he works, the newly constructed tower was built with a system for recycling gray water that reduces waste.