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Prof. Denis Clement ,
In a recent paper published in “Circulation” a surprising message is published about an unfavourable evolution in the management and funding of cardiovascular diseases (McClellan M. et al. 2019)
The authors start by reminding the reader about the “good” years when many positive trends were launched successfully in the prevention, diagnosis and treatment of Cardiovascular disease (CVD). As a result, there was a large and continued decrease in mortality. However, these “good “ years clearly are over as can be concluded from the list of items and parameters that have shifted into the wrong direction.
A few examples. The nice curve showing decrease of mortality due to CVD over the years has become largely flat what is in sharp contrast to what is seen in other diseases, more especially in oncology. Worse, in certain parts of the world, there even is a trend for cardiovascular mortality to increase what is particularly striking in rural, middle-aged non-hispanic white Americans. Such a negative trend is also seen in the mortality due to heart failure and stroke, areas where we believe that recent progress is made. At the same time, one can witness increase in the costs, both direct and indirect such as those due to loss of productivity at work.
A large part of this negative evolution is due to missed opportunities at every step in prevention and treatment of CVD. Not in the least, the failure to make significant further improvement of risk factor control plays an important role.
A few of the well-known risk factors have gone the wrong way in contrast to what could be expected. To cite some of them: the increase in body weight in the Western world and probably linked to it, the increase in diabetes seen both in Europe and in USA; control of Hypertension is not any better: both detection and treatment of high blood pressure are clearly not reaching the goals although everything is available to succeed. It was hoped that smoking would decrease but unfortunately this is not the case and vaping is becoming more popular.
There also is a failure to improve the follow up both of risk factors and diseases. Clinical experience has taught us that patients initially indeed agree to adapt their lifestyle and effectively do it the first weeks or months. However, they fail to continue in the good way for many reasons: too busy life, negative experience by other people in the immediate neighbourhood, not enough “appealing” campaigns on the benefits of healthy habits to block the process leading to cardiovascular disease. Such is true both in prevention as in follow up of treatment. As already mentioned, Hypertension is one of the best examples in this respect. A number of hypertensive patients indeed get detected either by chance, by systematic controls or whatever other means; treatment is set on and patients accept it along with the changes in lifestyle; but later on, they fail to go ahead with it not realising that treatment has to be continued lifelong: we still do not yet cure hypertension but fortunately we can control it very successfully.
The authors go further in pointing toward problems in the supportive care of diseases. For example, many patients with terminal heart failure still die in regular hospitals while comfort in their last days could be improved so much in centres for palliative care.
Along all of this, we can see that the development pipeline is becoming flat. There is a lack of new cardiovascular drugs; this again is in sharp contrast to drug therapy in oncology that constantly is progressing and provides clear improvement to control the disease. One of the reasons of this comes from the fact that the costs to develop cardiovascular drugs and to establish the proof of their efficacy has become incredibly high: huge numbers of patients are needed, with very elaborated complex protocols and long follow-up to prove that the new drug is better than the existing drugs. This again has discouraged researchers, clinicians and on top of them, the pharmaceutical industry.
At the end of this long list of negative aspects leading to less control of CVD, the authors of this paper in Circulation added a short section to actively propose means to reshape the curves, create new interest and pave the way to a better fate of cardiovascular disease; after all, CVD remains in many places of the world number one in mortality! The authors propose to set up “Roadmaps” for affordable drug and device development and to adapt realistic means for better detection, control and follow up of patients in the field of cardiology.
Hopefully this call to attention will reach all people concerned with this frightening evolution such as the population at large, scientists, patients and responsible leaders all over the world.
Mark McClellan, Nancy Brown, Robert M. Califf, John J. Warner : Call to action: Urgent Challenges in Cardiovascular Disease: Circulation: 2019:139:DOI:10.1161
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