Plenary Lecture: The Evolution of Cardiovascular Disease Worldwide: New Frontiers

Dr Fuster is a distinguished figure in the cardiology field. Following his graduation from the University of Edinburgh he commenced work at the Mayo Clinic and Mount Sinai, where he is now physician-in-chief. In 1996 he received the Principe de Asturias Award of Science and Technology, the highest award given to a Spanish-speaking scientist. In 2010 Dr Fuster received an Honoris Causa from the University of Edinburgh, one of the 40 that he has achieved to date. As of December 2016 Dr Fuster has served as Program Director for the American College of Cardiology’s Annual New York Cardiovascular Symposium for 22 consecutive years. He has also authored books and starred in a movie, The Resilient Heart, which focused on his work in prevention of cardiovascular disease (CVD). Dr Fuster is a member of the Institute of Medicine of the National Academy of Sciences.

The evolution of CVD therapy worldwide is moving towards identifying risk at early stages of life.¹ While recent advances in surgery, intervention, pharmacology, imaging and genetics have been impressive for the treatment and understanding of later stage CVD; mechanisms of disease differ at different life stages. The 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guideline for the Management of Heart Failure (HF) guidelines was based on advanced disease.² While recent work has highlighted the rapid advances that have been made in understanding dilated cardiomyopathy, a precursor to HF,³ and assist devices have proven effective in end-stage disease,⁴ Dr Fuster emphasised the need to focus on people at high risk for HF, but without structural heart disease.

He highlighted recent additions to the guidelines that have included biomarkers that may help identify an at-risk population.⁵ These include screening assays based on levels of pro-brain natriuretic peptide⁶ and troponin,⁷ leading to high-sensitivity cardiac troponin (hs-cTn) assays.⁸ Sixyear increases in the levels of hs-cTn, suggestive of progressive myocardial damage, are independently associated with HF.⁹ A risk model based on these biomarkers has been used to develop a robust tool for the prediction of cardiovascular death in patients with stable coronary heart disease.¹⁰ Other aspects of changing approaches to CVD include a greater focus on the atherosclerotic disease burden rather than on features of individual plaques,¹¹ and the evolving paradigm of CVD as a systemic disease that is dependent on macrophage activity.¹² Imaging studies of patients after acute coronary syndrome (ACS) have demonstrated increased splenic metabolic activity after ACS and its association with proinflammatory remodelling of circulating leukocytes.¹³ Evolving non-invasive technologies are also evaluating ischaemia at the microcirculation level.¹⁴ In the future, Dr Fuster predicts that ischaemia of each artery will be assessed by noninvasive techniques.

Dr Fuster turned his focus to the evolving landscape of CVD and what he believed the future hold for its various treatments. Due to the increasing prevalence of diabetes, Dr Fuster predicts an increasing use of coronary artery bypass grafts and decreasing use of optimal medical therapy and percutaneous intervention. However, pharmacology may play a role in earlier disease stages. Of particular interest are the proprotein convertase subtilisin/kexin 9 inhibitors,¹⁵ and the results emerging from cardiovascular outcome trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 analogues.¹⁶ In addition, new treatment modalities for HF that are employed at the early stages of the disease are emerging,¹⁷ and cardiovascular regenerative medicine using genetic editing is advancing rapidly and offers considerable future potential.¹⁸

Dr Fuster turned his attention to the challenges of treating HF in older patients. Chief among his concerns was patient adherence to therapy, which has led to the development of the polypill for cardiovascular prevention.^19–21 Also important is the issue of cognitive degeneration due to microvascular disease. The cumulative burden of cardiovascular risk factors from childhood/adolescence has been associated with worse midlife cognitive performance independent of adulthood exposure.²² Dr Fuster is currently undertaking a study known as the Trans-Atlantic Network to Study Stepwise Noninvasive imaging as a Tool for Cardiovascular Prognosis and Prevention (TANSNIP) heart to heart (H2H), to investigate the relationship between levels of dementia and cardiovascular risk factors.

Finally, Dr Fuster emphasised that of all the risk factors for CVD, behaviour is the most difficult to modify. However, a number of successful community interventions have illustrated the value of education.²⁵ Several studies and health programmes have independently indicated that behaviour modification, in terms of preventing CVD, is best achieved if the intervention is applied at early ages. Dr Fuster is personally involved in many educational initiatives that promote cardiovascular health during childhood.²⁶ Dr Fuster concluded by reinforcing the importance of identifying CVD at an early stage.

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