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Cardiology: where to go from here?
PRESENT
AND FUTURE
mIM Cardiology: where to go from here?
cardiography, nuclear magardiovascular diseases netic resonance imaging, will continue to be a positron emission tomovery important cause graphy) and the development of mortality, morbidity, and of new imaging techniques Hein J J Wellens rising health-care costs far (electron-beam tomography, into the next century. In Raman spectroscopy) will lead to better and more industrialised countries we will continue to have a high patient-friendly non-invasive ways to diagnose disease. incidence of cardiovascular disease for two reasons: Therapeutically, we will see a change to fewer surgical more patients are kept alive during the acute phase of interventions and more catheter-based interventions. ischaemic heart disease, changing them into patients This will require better understanding and control of with a chronic disease who often develop thrombotic and vascular processes in the vessel wall. heart failure; and the ageing of the population will result Angiogenesis and the in increasing numbers introduction of new of patients with cardiomyocytes will be degenerative diseases applied in patients with such as atrial fibrillischaemic and muscular ation, conduction disheart failure. Cardiac turbances, and valvular xenotransplantation will disease of old age. This become an option when shift to more patients rejection is controlled with chronic illnesses and infection prevented. will create a very costly The important problem health problem. In of sudden death out of developing countries, hospital and our inability "westernisation" (eg, smoking, changes in to recognise most of these patients before the dietary habits, moveevent, will lead to ment from rural to urban areas) will lead to the wide application of more ischaemic heart devices able to recognise disease. Persistence of and treat life-threatening rheumatic fever and Expected changes in therapeutic approaches to cardiovascular arrhythmias. disease in the future cardiac damage from The unravelling of The increasing ability to offer curative therapy will lead to diminuation and other infectious diseases basic mechanisms, the disappearance of palliative therapy. Ultimately (but after how long?), prevention will further contribute to clinical application of of cardiovascular disease will be possible. the growing pool of new information, and cardiac patients. the essential contribution of medical technology can be Although we have seen formidable improvements in thought of as three overlapping circles. T h e common our diagnostic and therapeutic abilities, most of our part of the three circles is the zone of so-called activities are palliative only. We are frequently able to "translational" medicine. In the future, a major improve the quality and length of life, but we can very challenge will be to create a new breed of cardiologists rarely cure our patients. With hope, what we will see in working in that zone with sufficient understanding the next century and beyond is a gradual replacement of of both the basic and the clinical aspects of palliative treatment by curative therapy, with ultimately cardiology to translate basic information into clinical a marked reduction and disappearance of cardiovascular application. diseases by preventive measures (figure). Although the In the coming years, map of the human genome will soon be completed, it we will see a dramatic will take quite a while before genetic therapy has a rise in costs of cardiomajor effect on our therapeutic possibilities, and it will vascular disease. Health take a long time before we will have an animal in the policy makers, university backyard with our own genetic blueprint, able to replace leaders, hospital adminour organs when needed. istrators, and insurance Progress may go faster than foreseen, but it seems companies should realise unlikely that in the coming two decades we will be able that the period of rising to identify all genetic and environmental factors that costs can only be shortened by investing in play a part in the development and progression of cardiovascular disease, to enable us to cure or prevent research, in order to these factors. Realistically, therefore, at this time we still move as soon as possible have to concentrate on improving our diagnostic from palliation to cure methods and therapeutic options to better palliate our and prevention. Money patients, while--simultaneously--new information is well spent now will obtained at the cellular, subcellular, and the genetic lead to major health and level to be translated ultimately to curative financial benefits in the therapy. Improvements in existing techniques (echofuture.
C
The Lancet • 2000 • 354 • December
° 1999
sir8
AND FUTURE
mIM Cardiology: where to go from here?
cardiography, nuclear magardiovascular diseases netic resonance imaging, will continue to be a positron emission tomovery important cause graphy) and the development of mortality, morbidity, and of new imaging techniques Hein J J Wellens rising health-care costs far (electron-beam tomography, into the next century. In Raman spectroscopy) will lead to better and more industrialised countries we will continue to have a high patient-friendly non-invasive ways to diagnose disease. incidence of cardiovascular disease for two reasons: Therapeutically, we will see a change to fewer surgical more patients are kept alive during the acute phase of interventions and more catheter-based interventions. ischaemic heart disease, changing them into patients This will require better understanding and control of with a chronic disease who often develop thrombotic and vascular processes in the vessel wall. heart failure; and the ageing of the population will result Angiogenesis and the in increasing numbers introduction of new of patients with cardiomyocytes will be degenerative diseases applied in patients with such as atrial fibrillischaemic and muscular ation, conduction disheart failure. Cardiac turbances, and valvular xenotransplantation will disease of old age. This become an option when shift to more patients rejection is controlled with chronic illnesses and infection prevented. will create a very costly The important problem health problem. In of sudden death out of developing countries, hospital and our inability "westernisation" (eg, smoking, changes in to recognise most of these patients before the dietary habits, moveevent, will lead to ment from rural to urban areas) will lead to the wide application of more ischaemic heart devices able to recognise disease. Persistence of and treat life-threatening rheumatic fever and Expected changes in therapeutic approaches to cardiovascular arrhythmias. disease in the future cardiac damage from The unravelling of The increasing ability to offer curative therapy will lead to diminuation and other infectious diseases basic mechanisms, the disappearance of palliative therapy. Ultimately (but after how long?), prevention will further contribute to clinical application of of cardiovascular disease will be possible. the growing pool of new information, and cardiac patients. the essential contribution of medical technology can be Although we have seen formidable improvements in thought of as three overlapping circles. T h e common our diagnostic and therapeutic abilities, most of our part of the three circles is the zone of so-called activities are palliative only. We are frequently able to "translational" medicine. In the future, a major improve the quality and length of life, but we can very challenge will be to create a new breed of cardiologists rarely cure our patients. With hope, what we will see in working in that zone with sufficient understanding the next century and beyond is a gradual replacement of of both the basic and the clinical aspects of palliative treatment by curative therapy, with ultimately cardiology to translate basic information into clinical a marked reduction and disappearance of cardiovascular application. diseases by preventive measures (figure). Although the In the coming years, map of the human genome will soon be completed, it we will see a dramatic will take quite a while before genetic therapy has a rise in costs of cardiomajor effect on our therapeutic possibilities, and it will vascular disease. Health take a long time before we will have an animal in the policy makers, university backyard with our own genetic blueprint, able to replace leaders, hospital adminour organs when needed. istrators, and insurance Progress may go faster than foreseen, but it seems companies should realise unlikely that in the coming two decades we will be able that the period of rising to identify all genetic and environmental factors that costs can only be shortened by investing in play a part in the development and progression of cardiovascular disease, to enable us to cure or prevent research, in order to these factors. Realistically, therefore, at this time we still move as soon as possible have to concentrate on improving our diagnostic from palliation to cure methods and therapeutic options to better palliate our and prevention. Money patients, while--simultaneously--new information is well spent now will obtained at the cellular, subcellular, and the genetic lead to major health and level to be translated ultimately to curative financial benefits in the therapy. Improvements in existing techniques (echofuture.
C
The Lancet • 2000 • 354 • December
° 1999
sir8