Beyond Big Hospitals: Where Cardiology Is Headed Next

As interventional cardiologists, we are well acquainted with the ever-increasing rates of cardiovascular disease and the pressures on the medical community to slow its advance. The American Heart Association’s most recent report on heart disease and stroke states that over half of adults in the United States have diabetes or prediabetes and that CVD claims more lives than all forms of cancer and accidental deaths, the number 2 and number 3 causes of death, combined. 

To combat rising rates of disease, we increasingly feel compelled to do more: diagnose earlier, intervene faster, and manage ongoing care. But doing more is hardest in rural communities where access to specialty services like cardiology are already limited. 

Mississippi, where I’ve practiced for the last decade, has one of the lowest physician densities, with just over 240 primary physicians and specialists per 100,000 patients. By comparison, in Washington, DC, there are more than 870 doctors for the same number of people.

It’s also well known that life expectancies in rural, Southern communities like mine are significantly lower than in other parts of the country. In Mississippi, the average life expectancy is 72.6 years, almost 5 years less than the national average. The rate of heart disease deaths per 100,000 people is also the second highest in the country. 

Complicating things further is the fact that many patients with severe, untreated CVD are asymptomatic. That leaves many people in rural communities, where doctors are less accessible and disease rates are highest, unaware of their disease. 

In the 100 years that CVD has been the leading cause of death, there has never been a universal screening tool for asymptomatic patients the way there is with other commonly fatal diseases, including colon and breast cancer. In order to reach more people before their disease leads to a heart attack or stroke, cardiologists need tools that increase our diagnostic capacity. Specifically, we need tools that empower regional health centers like the one where I work to identify at-risk patients before they end up in the emergency room. 

The Current Diagnostic Landscape

When a patient comes to us with chest pain, shortness of breath, or another symptom suggestive of heart disease, the stress test remains our default first step. It’s effective and appropriately central to how we diagnose heart problems, but it’s also demanding for patients, who typically must hold certain medications beforehand, arrive fasted, and set aside the better part of a day for the appointment, or even longer if imaging is involved. For a patient who lives 90 minutes from the nearest cardiology practice, that often means missing a full day of work and arranging transportation, since some protocols advise against driving immediately afterward.

That burden would be more justified if the stress test caught disease early, before symptoms appeared. Unfortunately, it doesn’t work that way, and it wasn’t designed to. We order a stress test because a patient already has symptoms or risk factors raising clinical suspicion. It tells us whether disease is present and how severe it is, but it says nothing about the patient who feels fine and has no reason to book an appointment, which describes a meaningful share of rural patients.

There are tools that come closer to true preventive screening exist, but they are not usually deployed that way. Coronary artery calcium (CAC) scoring, where the CT scan detects calcified plaque before a patient becomes symptomatic, is the closest thing cardiology has to a genuine screening test for CVD. However, it’s generally reserved for patients already flagged as intermediate risk, not offered as a baseline screening tool for the broader population, and it requires CT infrastructure many rural health systems lack on-site. What most rural patients receive instead, if they receive anything, is a lipid panel or blood pressure check through primary care: useful for flagging risk factors, but no substitute for a test that can see the disease itself.

Improving CVD Health Outcomes for Rural Patients

Slowing the advance of CVD in rural populations requires rethinking how we deploy the tools and diagnostic technologies already at our disposal. Some technologies, like office-based coronary computed tomography angiography (CCTA), which has a lower cost and smaller footprint than cardiac catheterization labs or advanced echocardiography services, are easier to establish in rural hospitals and private clinics. These technologies bring fast, advanced imaging directly to local clinics in rural communities, reducing travel times for patients and helping doctors diagnose coronary artery disease sooner without sending people to distant hospitals. 

However, we’re still missing the protocol and reimbursement structure to deploy these technologies earlier and more broadly for patients who present with risk factors but not yet symptoms, rather than reserving them for those already flagged as intermediate risk through other means.

Expanding access in rural communities also means finding ways to work around the lack of cardiologists. For example, imaging can be acquired by a radiologic technologist and read by a radiologist or a cardiologist anywhere in the US, with results routed back to a primary care physician or nurse practitioner who typically is the point of contact for rural patients. The cardiologist’s role shifts to managing the patients that screening identifies, which is a more sustainable model than expecting specialists to be physically present for population-level screening in every community that needs it. 

Telehealth consultation offers another path toward the same goal. When a primary care physician in a rural clinic identifies a patient with concerning risk factors or ambiguous test results, a same-day video consultation with a cardiologist can determine whether the patient needs urgent referral, additional testing, or ongoing monitoring at the primary care level. This model supports in-person cardiac care when intervention is needed, making specialist input more accessible to patients who would otherwise wait weeks for an in-person appointment or forgo it altogether given the distance involved. Paired with expanded imaging access, telehealth consultation lets rural primary care physicians act on findings in near real time rather than defaulting to a referral process that many patients never complete.

A recently updated risk calculator illustrates what a low-barrier tool for rural primary care can look like. Earlier this year, the American College of Cardiology and the American Heart Association updated their joint guideline for managing cholesterol and lipid levels, emphasizing a new tool called PREVENT to estimate a patient’s 10- and 30-year risks of heart attack or stroke. Unlike CAC scoring or a stress test, PREVENT requires no imaging or specialized equipment. It draws entirely on information already gathered during a routine physical, including cholesterol, blood pressure, age, and health history, to generate a risk score that can guide whether a patient needs lipid-lowering therapy or further workup. It does not detect disease the way imaging does, but it gives primary care clinicians in resource-limited settings a way to flag elevated risk using data they already collect.

How We Move Forward

A century after cardiovascular disease became the leading cause of death in this country, we still lack a true screening test for the average patient, the kind of tool that exists for other leading causes of death. That gap falls hardest on rural communities, where specialist access is already limited and disease often goes undetected until it becomes an emergency. Directing the tools we already have, from imaging to telehealth, toward patients before they become symptomatic rather than after would close much of that gap without waiting on a medical breakthrough.

Off Script is a first-person blog written by leading voices in the field of cardiology. It does not reflect the editorial position of TCTMD.