Viewpoint: What will — and won't — change about cardiology in 50 years

Almost nothing that we view as modern cardiology was available 50 years ago. Cardiac procedures and surgery, cardiac intensive care units, almost all cardiovascular medications and even cardiology as a specialty were either unknown or very early in development in the early 1970s. It is likely that cardiology will change as much in the next 50 years as it has in the last 50 years.  

I will highlight a few major changes I foresee in the future. One is the advent of personalized medicine: Currently patients are treated with similar medications whether they are male or female, old or young, large or small. In the future, these characteristics will play more of a role, but most importantly, genetic information will be incorporated into medication decision-making. There is an expanding evidence base that genetic information can help predict responses to medications and in particular, efficacy and side effects. This information will be used in the future to customize medication regimens.

A second change will be a de-emphasis of randomized controlled trials to determine safety and efficacy of various treatments. RCTs are now the gold standard, required by the FDA for approval in order to minimize bias. But there are many problems with RCTs, including that they are expensive, take years to complete and, in general, enroll a narrow population of patients. Going forward, the widespread availability of electronic health records will enable the performance of "pragmatic trials" in which data is extracted in real time and relevant to the population treated by that medical center. 

A third change will be a focus on environmental factors that impact cardiovascular health. These factors, such as toxins in water supplies, air pollution and chemicals in food products, will be found to be as important as patient specific risk factors such as lipid levels and blood pressure. A major difference, however, will be that these will be dealt with mostly at the population health level, although some patient-specific interventions may prove to be effective such as water filters for those using well water and avoiding processed foods.

A fourth change: Nutrition will become a major research focus. In the current environment, tens of millions of dollars are spent on a single clinical trial of a medication few people will ever use, but little money is spent on nutrition research, which would affect tens of millions of people. To bring about this change, the funding mechanism behind clinical research will need to evolve – either the federal government will create a National Institute of Food and Nutrition or private companies will launch trials of specific food products. 

A fifth change is that major progress will be made in treating cardiomyopathies. Currently there are limited options for a failing heart; while medications are largely effective early in heart failure, the only options for terminal heart failure are ventricular assist devices and cardiac transplantation. In the future, therapies will be developed that will recruit myocytes to the failing heart (e.g. stem cell infusions) to replace those irreversibly damaged. 

A sixth change will be in the delivery of healthcare. Patients will always want to have a local physician who they trust but they will now have far more access, via telehealth, to specialists at medical centers for specific questions. In the current paradigm, physicians in the community learn from experts via medical journals, meetings, podcasts, etc., and then apply this knowledge to their patients. In the future, because of the explosion in medical knowledge, physicians won't be able to stay informed in all areas and thus will defer to experts at a lower threshold. In the cardiovascular area, this means that patients will have the benefit of a consult with a hypertension expert, lipid expert, etc., far more frequently than they did in the past, while having their care coordinated by their primary cardiologist or primary care provider. 

A seventh change will be that we will see the use of more interventional procedures for the treatment of chronic diseases. On the forefront of this change will be renal denervation for hypertension, but other techniques will be developed to replace chronic medications in diabetes, heart failure, arrhythmias, etc. For these conditions, a patient will be given the option of using medications daily or undergoing a procedure to control their disease.

Lastly, there will be a better understanding of family transmission of cardiovascular disease. For diseases that tend to run in families like hypertension, coronary artery disease and heart failure, studies will be done that will distinguish genetic, epigenetic and environmental factors. This information will be used to help break the intergenerational suffering from heart disease that is all too common in some families. 

Two notable changes that are already in progress and will continue during the next 50 years are: 1) Cardiac procedures and cardiac surgery will have better outcomes due to improved technology and techniques but will be used less frequently as the focus turns to prevention rather than treatment; and 2) Weight reduction will become a primary focus for cardiovascular risk factor management. For obese patients, use of a glucagon-like peptide-1 (GLP-1) agonist and other weight loss medications will be an early addition to help reduce blood pressure, lipid levels and glucose levels. 

I will close by mentioning a few things that won't change. One is that exercise will still be prescribed but rarely followed. Second is that the widespread availability of cheap, non-nutritious calories will continue to be a scourge. Third, patients will continue to engage in behaviors that are detrimental to their health. While specific behaviors might change (e.g. less cigarette usage), other harmful behaviors will arise. And no matter how much progress we make, people will still die from heart disease.

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