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CVD management: Getting to the heart of the matter - Health Europa

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Professor Hugo Katus and Ms Christina Dimopoulou of the European Society of Cardiology discuss the key challenges in cardiovascular disease prevention and care.

Cardiovascular disease (CVD) is the leading cause of death globally. According to The WHO, out of the 17 million premature deaths from noncommunicable diseases in 2019, 38% were due to CVD. CVD is an umbrella term for a range of conditions affecting the heart or blood vessels, with some of the most common being stroke, heart failure and arrhythmia. While great strides in cardiovascular research and treatment have helped to reduce CVD mortality rates, the number of people now living with CVD has almost doubled in the past 30 years. This has put substantial strain on healthcare systems and thus increased the urgency to enact policy initiatives that support equitable access to early diagnosis and support, and raise awareness of these predominantly preventable diseases.

One organisation that is paving the way for policy change and the advancement of the CVD prevention strategies, diagnosis and management is the European Society of Cardiology. Part of the organisation’s remit includes the dissemination of evidence-based scientific knowledge to support cardiovascular professionals and facilitating a dialogue with key health stakeholders in Europe to advocate regulatory frameworks that support CVD care and prevention. Health Europa spoke to Professor Hugo Katus, Advocacy Chair, and Ms Christina Dimopoulou Advocacy team manager, about key challenges in CVD research and treatment as well as promising developments to reduce the burden of cardiovascular disease at European level.

The number of people living with CVD has almost doubled from 271 to 523 million between 1990 and 2019. What would you attribute this increase to? Are there particular demographics or groups who are more at risk of developing CVD?

Many different causes may contribute to the increased prevalence of people living with CVD.

First, during the last 30 years there has been substantial progress in CV medicine both in acute and chronic care, resulting in a further decline of CV-mortality and prolonged life-expectancy in many European populations. Thus, today many more patients survive acute and life-threatening cardiac events such as myocardial infarction, acute heart failure or decompensated valvular heart disease, and better treatment options have further reduced mortality in chronic cardiac disease conditions.

Second, there was also substantial progress in acute care and interventional procedures for congenital heart disease and many children with complex congenital heart disease today survive until adulthood. In fact, grown-ups with congenital heart disease are a rapidly growing population of patients with chronic CVD.

Third, we have seen much progress in other medical disciplines as well, and CVD is a very frequent co-morbidity in these patient groups. Patients suffering from cancer may serve as an example since, thanks to better cancer treatment, many more patients survive cancer but then die of CVD which may be due to toxic treatment effects of cancer therapies or to pre-existing CVD.

Finally, it is also important to indicate that major inequalities in CVD prevention and CV care still exist in Europe. Particularly in some eastern European countries and in certain European populations such as those with lower income, poorer education or other minorities, CV diseases are highly prevalent. This high incidence of CVD is likely due to poor risk factor control, unhealthy lifestyles, the obesity pandemic, and lack of provision of guideline recommended care. The European Society of Cardiology has made tremendous efforts during the past years to collect evidence on CVD healthcare inequalities through its Atlas of Cardiology project providing compelling arguments for increasing action to support cardiovascular health policy.

What is the significance of screening and early diagnosis in improving treatment rates for CVDs? Could risk prediction models play a significant role in determining a patient’s likelihood of developing cardiovascular issues? What data informs the development of these models?

There are many approaches reported that allow screening for early CVD and associated CVD risk. The modalities tested in many trials include highly sensitive biomarker of cardiovascular injury and remodelling such as hs-troponins; the analyses of disease associated biomarker changes such as natriuretic peptides; the high assessment of molecular and genomic variables such as DNA variants or epigenomic marks, and advanced high-resolution imaging techniques such as CCT or CMRI. The predictive power of single marker testing may be significantly enhanced by the use of comprehensive risk prediction scores including multiple variables and may even be further improved by the application of novel algorithms and artificial intelligence.

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Less data is available on the impact of earlier treatment based on risk prediction tools in asymptomatic subjects with early CVD. The use of genetic risk stratification for arteriosclerosis and heart attack as a decision tool for an earlier initiation of statin therapy showed promising results and in those with a higher genetic risk score preventive measures such as physical activity provided the highest benefit. Others have shown that early visualisation of coronary artery disease by cardiac CT triggered the initiation of more appropriate medical treatment and adherence, resulting in better outcome. However, the most important consequence of the early detection of CVD and its communication to the affected person may be a better motivation to opt for a healthier lifestyle and improved risk factor control. EU Member States but also EU decision makers should prioritise early screening for secondary CVD prevention through their funding programmes or national health plans. Improving citizens’ cardiovascular health will contribute to achieving equity, and strengthening healthcare systems’ resilience, the economy and society more broadly.

The COVID-19 pandemic revolutionised the uptake of digital technologies, how can digital and technological innovations contribute to the prevention, diagnosis, and treatment of the disease?

Practice of medicine and particularly also of CV medicine will change markedly as a consequence of the impressive progress in digital transformation, information technologies, artificial intelligence, and robotic automation.

Integration of molecular and clinical data, and their comprehensive and sophisticated analyses by AI, will hopefully enable a more personalised approach in CV medicine and enhance precision of treatment and follow up. We will also see novel diagnostic indexes derived from an already available rich data source stored in medical and imaging devices and identify as yet unknown treatment targets by sophisticated analyses of molecular and clinical data. Implanted and wearable devices will facilitate chronic treatment guidance and the empowered patient will interact as an educated partner. Telehealth will become routine practice including dedicated core centres for image analyses, remote control of interventional procedures, and teleconsulting will become an established component of physicians’ practice. Teaching in medicine and training in interventional procedures will use virtual or augmented reality. Since progress in digital technologies goes in parallel with advances in robotic automation, many interventional treatment strategies will be assisted by or even done predominantly by robots.

These advances in digital technologies, computation sciences and robotic automation will not just change practice of cardiology but generate fascinating opportunities to follow all steps in the patient’s disease trajectory, to personalise guidance of primary and secondary prevention, to enhance precision and speed in cardiovascular diagnostics and to assist in procedures when needed. Needless to say, this transformational technology driven process will need education of patients and physicians, training of medical staff and students, acceptance in societies and adequate reimbursement to enable translation into patient care.

What is the significance of the European Alliance for Cardiovascular Health in driving forward a collaborative approach to tackling CVD? Can you outline some of the Alliance’s key objectives?

Cardiovascular disease is still the leading cause of death in Europe and contributes markedly to health care spending. What in addition is often ignored, is the fact that many CVD deaths occur before the age of 65 (premature death) and more than 30 million people in Europe live with CVD.

Despite this concerning disease burden, public awareness of the mortality risks associated with CVD and the detrimental impact of CVD on quality of life is poor. This wrong perception of the severity and prevalence of CVD seems to be shared by policy and decision makers in healthcare and CV research. While cancer research and care are (rightly) heavily funded by national and European initiatives and many novel compounds are under development against cancer, comparable programs in CV research, for translation of innovation and for structure building for CV care are neither established nor in a concrete planning phase. Therefore, it is crucial that all stakeholders engaged in CV medicine must stand up for their patients and fight for more public and financial support to enable the much-needed progress against the high CVD morbidity and premature mortality due to CVD.

In the EACH-Alliance many stakeholders in CV medicine including patient organisations, medical device and pharmaceutical industry, health insurances, and many scientific/medical organisations join forces to more efficiently reduce the burden of CVD and improve CV medicine for millions of patients. Such a concerted action is highly appreciated and urgently needed.  The Alliance provides a platform to aggregate knowledge and expertise of key stakeholders active in the field of cardiovascular health, and to advise and guide policymakers. The Alliance calls for greater focus on improving cardiovascular health and reducing the burden cardiovascular disease at European level.

Are there any notable developments or current issues in research or treatment which you would like to highlight?

Progress in CV medicine has for years- nearly exclusively- contributed to the substantial increase in life expectancy. This was due to the progress in prevention and medical care. In the last decades we have seen further major advances such as the introduction of high sensitivity troponin testing providing unprecedented precision in the detection of myocardial injury, the advances in CV-imaging by CT and MRI providing unprecedented morphological and functional phenotyping, the progress in interventional procedures including percutaneous valve repair even in the elderly and frail patient, the novel treatment options in atrial and ventricular arrhythmias and new medical therapies in heart failure, to name a few.

However, this success should not distract from a high and still increasing mortality rate due to CVD in many countries, including the USA, and the growing number of patients living with CVD. Therefore, we definitely need more research spending and more investments to improve cardiac care. CV research must better target the molecular disease causes and develop novel compounds for a higher precision and individualisation of CV-medicine. Digital advancements and data management tools must be made available for individualisation of CV care during patients’ lifetime, and high-quality registries across the entire EU are urgently needed to understand the deficits and to enable an optimisation of CV care. With the current public and industry spending for CV research and innovation and considering the existing major obstacles in translation of innovation and of reimbursement of novel technologies CVD will- unfortunately- remain a leading cause of mortality and morbidity in the EU and substantially impair the quality of life of many citizens.

Professor Hugo Katus Advocacy Chair Ms Christina Dimopoulou Advocacy team manager European Society of Cardiology www.escardio.org

This article is from issue 20 of  Health Europa Quarterly .  Click  here  to get your free subscription today.

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