he “Gray Tsunami”—the aging population in Alaska—is driving increased demand for cardiological services, Alaska Heart & Vascular Institute CEO Robert Craig III says.

“Cardiology typically serves patients in an older age category. If we were to do a per capita need for cardiology services in the state, I could probably hire another twenty cardiologists and just meet the need of what this state alone has,” Craig says. “It’s continually evolving—for our state in particular, it’s a growing need for cardiology.”

Alaska Heart & Vascular Institute, managed by Craig and a board of five physicians, comprises thirty-two cardiologists offering services from diagnostic testing and heart rhythm management to heart failure and interventional cardiology.

One of the biggest challenges Craig says he faces with operating the Alaska Heart & Vascular Institute is recruiting highly qualified staff.

“When I do physician recruitment, I have to cast a wide net—a really wide net—throughout the entire Lower 48 to entice a physician up here,” Craig says. “There are some great people that are up here in Alaska, and we leverage that as much as we possibly can. But there are times when we’ve got to bring somebody up from the Lower 48.”

In addition to a substantial salary, Craig says his team focuses on 401k and healthcare benefits—as well as other fringe benefits—when creating a compensation package to attract top talent to the state.

“We try to be as creative as possible… We’re constantly doing employee engagement surveys and taking the pulse of our staff to find out what are the issues for them and making them feel like they’re part of the organization,” Craig says. “I meet with every new employee as they come in. I always tell them they’re here because we only hire the best people and it’s my job to keep those people.”

Alaska Heart & Vascular Institute also attracts physicians through its ownership structure. The company is set up as an independent physician practice, owned by twenty-one of the thirty-two practicing physicians with the company. The physicians who are not owners are either part-time or considered “employed physicians.”

“Having physicians control their destiny is a big selling point for a lot of them,” Craig says.

Though some staff—often members of a military family—are hired locally, for the most part physicians are brought up from the Lower 48, Craig says.

However, once cardiologists make it to Alaska, the retention rate is above national levels, Craig says. In his four years with the company, only two physicians on his team have moved out of state.

“I think right now my turnover ratios are in the 20 percent range [for all staff],” Craig says, noting that some of his turnover is related to hiring members of military families. “Even that’s below the industry standard: for an independent physician practice it’s usually in the high 30s or 40s.”

Though an aging population is a significant force increasing demand for cardiological services, there are other lifestyle factors that play a role.

For example, many Alaskans in rural communities live in food deserts. “These are communities that don’t have access to a lot of fresh and healthy foods,” Alaska Native Tribal Health Consortium (ANTHC) Cardiology Medical Director David Trowbridge says.

Instead, these communities rely heavily on processed foods, which have been linked to obesity, diabetes, heart disease, and early death, Trowbridge says, noting the particularly damaging impacts of sweetened beverages.

Though ANTHC focuses primarily on Alaska Native health issues, food deserts are not a unique problem for Alaska Native communities or even Alaska, as they also exist in remote parts of the Lower 48 and inner cities.

But while the problem isn’t unique to Alaska, one possible solution is. Alaska Natives can revert to a heavy reliance on a traditional lifestyle to help maintain heart health, Trowbridge says, though he notes that there isn’t a lot of data on the issue.

“Anecdotally, we find that folks that are living a traditional lifestyle and avoiding typical things that are unhealthy such as tobacco, alcohol, and drugs seem to be pretty healthy and robust folks,” Trowbridge says. “Living the way that they’ve been living for a long time means that they’re not developing an early vascular disease or other conditions.”

Heart disease and stroke cause about one-third of all deaths in the Last Frontier. According to data from 2016, 4.3 percent of adults in Alaska report being diagnosed with heart disease. That’s about 24,000 people.

However, because heart disease is often asymptomatic and undiagnosed, the prevalence of heart-related conditions based on self-reporting is likely an underestimate, according to the Alaska Department of Health and Social Services (DHSS).

The most recent data available from DHSS reveals that in 2016 Alaska Medicaid recipients with heart disease alone or in combination with other chronic diseases needed more than $300 million in healthcare paid by Medicaid, explains Valerie Gosselin, a heart disease and stroke prevention specialist with DHSS.

Despite the “gray tsunami,” Gosselin says that the prevalence of heart disease in Alaska has significantly declined during the past ten years—following a national trend. But it is still the number two cause of death in the Last Frontier and the number one killer in the United States.

“The most common type of heart disease is coronary artery disease, which is the narrowing and the blockage of those coronary arteries around the heart,” Gosselin says.

The condition is caused by atherosclerosis, which is the hardening or clogging of the inner walls of the arteries due to a buildup of cholesterol and fatty deposits. Other common issues cardiologists in the state address are valvular heart disease, arrhythmias, cardiomyopathy, hyperlipidemia, hypertension, heart failure, and peripheral vascular disease.

Alaska’s remoteness also impacts heart-attack survival rates, says Gosselin.

“The fact that we do have a lot of villages that are not accessible by the road system makes heart health unique here,” Gosselin says. “If we think about the Lower 48, when people are having a heart attack they can—most of the time—be driven to the hospital to receive care with only a really short delay.”

However, for those living on the North Slope or in a Southeast village, patient evacuations are always dependent on weather and available airline services. Either way, it’s unlikely that responders will be able to medivac a patient as quickly as emergency services on the road system are able to transport patients in the Lower 48, Gosselin says.

And every minute counts when it comes to having a heart attack: from the time patients start having symptoms to the moment they reach the hospital.

So it’s important for adults to be able to identify when they may be experiencing a heart attack. Those symptoms vary significantly between men and women, Gosselin says.

“The classic picture we have of a heart attack is that chest pain like a knife getting in there… it’s going to have that pain in the neck and jaw. And they’re going to have difficulty breathing, a shortness of breath,” Gosselin says. “These are all really good symptoms to be aware of, but they are more for male heart attacks.”

Women’s symptoms are often different. Sometimes there will be more of a discomfort, rather than a sharp pain, in the shoulder and arm—and it can occur in the right arm as well as the left, Gosselin says.

Other symptoms of a heart attack for women are nausea, lower back pain, abdominal pain, and something similar to acid reflux.

“Often it will be a woman at home who will say, ‘I don’t know why I am so tired these last few days. I should rest more,’” Gosselin says. “They are actually facing an ongoing heart attack at the time.

“It’s really important to educate the population and providers about all of this because sometimes a women’s heart attack could feel very different from what is thought of as a traditional heart attack.”

Gosselin’s work focuses on preventing heart conditions associated with lifestyle choices from developing.

She points to obesity, lack of exercise, high blood pressure, high cholesterol levels, smoking cigarettes, and diabetes as underlying issues leading to heart conditions.

“We found out that more than half of our actual Alaskans—so about 60 percent of them—have at least two or more of those risk factors,” Gosselin says. “This is a high level of our population that are currently, as we talk today, at risk of developing heart disease. We need to get together to be able to fight those risk factors and lower the percentage of Alaskans with risk factors.”

The Alaska DHSS, through its Division of Public Health and Chronic Disease Prevention and Health Promotion programs, is trying to lower the incidents of heart conditions by addressing the prevalence of risk factors, Gosselin says.

“We have the physical activity and nutrition unit that is actually working to increase the physical activity with youth and trying to lower the intake of sugary beverages for kids, which has actually been proven to decrease child obesity.”

And in rural areas, telemedicine is creating opportunities for preventative programs and better healthcare.

The Alaska Heart & Vascular Institute is exploring telemedicine to better serve remote locations in the state without having to send a provider out into the field, making it more cost-effective and convenient for patients.

A lot can be done through telemedicine, Craig says.

“I am oversimplifying this, but we can put you in front of a camera, say in the Yukon, and I can have a cardiologist get your vital signs, talk to you, essentially do a visual and a verbal examination to make a determination as to the level of acuity for your particular heart condition,” Craig says. “That way it doesn’t always mean that you have to come to Anchorage for a procedure. Maybe it’s ongoing treatment or medication or something that’s a little easier to resolve for a patient rather than having to travel such a long distance.”

Gosselin says that Alaska is already pushing to increase access to telemedicine, but infrastructure issues and ensuring the protection of patient information are hurdles to progress.

“It’s the typical issue of the latency when you get into some of those really remote locations,” Craig says. “We’ve been working with different providers, talking to GCI and whatnot, about how we can help alleviate some of that. It’s getting better a lot quicker than what a lot of people realize.”

Tribal organizations, which are involved with many remote and isolated communities, are also pushing advances in telemedicine, says Trowbridge.

Though telemedicine provides better access to resources for those dealing with heart issues in rural communities, Alaskans need to focus on lifestyle changes to see significant improvements within the population.

Because most heart conditions are created through incremental damage and stress over decades, most preventive care efforts in the state will likely remain focused on youth, while healthcare providers work toward better educating the public in general about signs and symptoms.

“The thing for everybody to keep in mind is that cardiology is an ever-evolving field. It’s not just strictly the latest and greatest technology, which is continually evolving, but there’s always new advancements in heart health,” Craig says.

“I think the biggest thing for everybody to always keep in mind is just to be aware of being your own best advocate as a patient. We’re prepared from the perspective of highly trained physicians and providers and staff and equipment… We’re going to be prepared for it. The biggest challenge is for people to be in touch with their own cells, their own biology.”