A Balance Between Discovery and Delivery
William A. Zoghbi, MD; David R. Holmes, MD
The past 30 years have seen major shifts in cardiovascular science and medicine. In the United States, mortality due to cardiovascular disease (CVD) has declined by more than 60% as a result of new therapeutic approaches, including the introduction of statins, better anticoagulants, angiotensin-converting enzyme inhibitors, devices such as implantable cardioverter-defibrillators, and—perhaps foremost—the application of evidence-based scientific guidelines.1 There is every reason to believe further progress will occur during the next few decades, although some signs suggest that the current emphasis may change.
EXCITING INNOVATIONS AHEAD
With genomic medicine arriving shortly and getting less expensive, there is much enthusiasm about the prospect of personalized medicine, with better risk stratification and enhanced pharmacogenomics to tailor drug choice, dosing, or tolerance. As incandescent as this vision of the future might be, it will not be simple to achieve: the most prevalent CVDs, coronary disease and hypertension, are not only polygenic disorders but are influenced by environmental interactions and even socioeconomic factors that remain largely undefined. Newer and more powerful computational approaches combined with data from large epidemiological studies will be needed to delineate these complex interactions and tailor them for targeted therapeutic interventions.
Cardiovascular physicians have been innovators in the area of percutaneous devices and minimally invasive procedures to treat coronary artery disease, and now peripheral and cerebrovascular disease as well. Major improvements in imaging technology from echocardiography to cardiac computed tomography and magnetic resonance imaging have enabled earlier detection of disease and have facilitated guidance of therapeutic strategies. The widespread use of coronary arterial stents have led to the development of in-depth knowledge of vascular biology (eg, wound healing) and the development of drug-eluting stents and now biodegradable stents to achieve the desired effect of relief of obstruction and ischemia. These new approaches will obviate or minimize the need for dual antiplatelet therapy. New strategies for treatment of hypertension are also the focus of intense study. Early data on the use of radiofrequency renal artery sympathetic denervation, based on this type of treatment in electrophysiology, are promising. Management of hypertension in patients with advanced disease may therefore substantially change in the next few years.
Structural heart disease has also become a focus, with new percutaneous devices to occlude or obliterate the left atrial appendage (a source of emboli in atrial fibrillation), and transcutaneous replacement of the cardiac valves. Aortic and pulmonary transcatheter valves are used with increased frequency; mitral and tricuspid valves are currently undergoing regulatory assessment for approval. This is changing the approach to cardiovascular therapeutics, creating a greater need for interventional cardiologists and surgeons to collaborate. A new emphasis on a “heart team” approach is filtering through to the training of the next generation of cardiovascular interventionalists and surgeons: hybrid training for a hybrid procedure.
Collaboration between cardiologists and surgeons has also flourished in the field of heart failure. Left ventricular assist devices have been miniaturized and will soon be powered wirelessly; the quest for a total artificial heart is closer to reality. At the same time, promising research continues so that cardiac regeneration with stem cell therapy eventually may become a reality. Advances in stem cell biology have provided enhanced understanding of cardiac biology and physiology through efforts to understand this complex synchronized syncytium of muscle cells.
CHALLENGES OF DELIVERY
Although earlier detection of disease and ensuring access to more effective therapies to patients will continue, challenges will remain. The United States currently is facing an epidemic of obesity: close to 30% of US adults are obese and 60% are overweight. Recent data have also shown that the prevalence of untreated or poorly treated hypertension in the United States is close to 50%, the same for hypercholesterolemia, and appropriate aspirin use; smoking prevalence is close to 20%.2 These statistics are cause for concern and were the impetus for the Million Hearts initiative from the US Department of Health and Human Services to prevent a million myocardial infarctions and strokes over 5 years. Better control of these risk factors would lead to significant health benefits and further reduction in cardiovascular mortality and morbidity, without the need—or the cost—of any new drug or device.
While cardiovascular mortality in the United States has decreased, the incidence of CVD and related mortality are increasing around the globe. Reasons include the increasing prevalence of treatable or avoidable basic risk factors for coronary artery disease, with hypertension and smoking being the most common. Among noncommunicable diseases, CVD is by far the most prevalent and now accounts for one-third of all deaths around the world.3 This alarming increase in CVD has led to an emphasis on better control of noncommunicable diseases globally, with the first United Nations High Level Meeting on noncommunicable diseases held in September 2011, the second such meeting on health in the history of the UN.4
Professional societies such as the American College of Cardiology, World Heart Federation, American Heart Association, European Society of Cardiology, and others can play central roles in the process of improving global cardiovascular health. Together, physicians and other members of these organizations can expand efforts at unlocking the scientific processes involved in the development of disease; help implement changes in local, regional and national policies such as smoke-free environments; educate populations and patients in terms of primary and secondary prevention; partner with industry to develop treatment strategies in both drugs and devices; and develop approaches to empower patients to more fully participate in their own health care decisions, emphasizing a patient-centered approach. The American College of Cardiology (ACC) has recently launched the new CardioSmart website,5 a site dedicated to patients, to improve patient education and adherence, to enhance interaction of individuals with health care professionals, and to facilitate shared decision making. This site is scheduled for launch at the ACC Scientific Session in March 2013, which has the theme “From Discovery to Delivery,” highlighting the opportunities and challenges at hand for both health care professionals and society at large in improving cardiovascular health.
Following the UN summit, the World Health Organization approved the ultimate goal of reducing premature mortality from noncommunicable diseases by 25% by the year 2025.6 This is an admirable and yet challenging goal. The task force on CVD, which includes numerous cardiovascular professional organizations, published a position paper emphasizing the urgent timing of action and adoption of targets for cardiovascular health.7 The concept of “one size does not fit all” is germane, because achievement of these targets will be variable: national needs must be prioritized according to local conditions. At the same time that cardiovascular medicine and science have become more and more adept at intervention by treatments based on understanding disease mechanisms, the US and global populations have fallen behind in controlling the origins and risk factors for CVD. Trends in certain cultures have had greater influence in promoting smoking, poor diets, and sedentary and high-stress lifestyles than physicians have had in advocating more healthful ways. For cardiovascular medicine, the vision of health must broaden; understanding of professional responsibilities must evolve to address these cultural factors publicly and directly.
Scientific discovery continues to unfold the secrets of disease and its manifestation. Support of this journey by governmental agencies, patient advocates, and professional societies is a crucial aspect necessary to reach the goal of health for members, for patients, and for society as a whole.
