Heart failure

Renowned cardiologist predicts a bleak future

Thrombo-cardiologists will be replaced by diabeto-cardiologists, diabetes drugs will become heart drugs and cardiovascular disease will bankrupt society.

They are bleak predictions but these are some of the challenges Dr Joseph Hill, Professor of Medicine and Molecular Biology at UT Southwestern Medical Center in the US and editor-in-chief for the American Heart Association’s journal, Circulation believes will be the future of cardiovascular disease.

Speaking at the conference in a session called Understanding the failing heart, the renowned heart failure expert, whose own research focus is molecular biology and heart-tissue regeneration, said while there has been a ‘spectacular’ decline in MI age adjusted mortality people are instead being sent home with heart failure.

“Despite successes accruing since the 70’s such that larger infarcts were being salvaged, MI is still far and away the number one killer of both men and women around the world – it’s just morphed into a new set of problems called heart failure,” he told the audience.

According to Dr Hill, more people than ever are living with varying degrees of heart failure. In particular the prevalence of HFpEF is expanding rapidly – just this last year the diagnosis exceeded HFrEF for the first time and it will likely continue to grow, Dr Hill told delegates.

“The drugs that have been shown to provide benefit in HFrEF – ARBs, ace inhibitors, beta blockers, digoxin and so forth – all of these are evidence based therapies that we know either prolong survival or improve quality of life or both.

“However, every single one of these agents has been neutral in HFpEF.  The number of drugs that we have to treat this prevalent syndrome equals zero despite the fact that HFpEF is just as mortal as HFrEF.  It’s is a problem that many of us in the room, including me, are working on.”

One of the reasons that’s so challenging in HFpEF is that the condition affects the entire circulatory system, he explained.

“HFPeF is not simply a myocyte issue; it’s a global systemic circulatory issue affecting the heart, the kidneys, the lungs and muscle and that is the puzzle that many of us are trying to wrestle with – what are the common molecular features of a disorder that aren’t myocyte specific? It’s a real challenge but progress is being made”.

Dr Hill also said cardiologists will need to become very familiar with the newer classes of diabetes drugs.

“There is a blurring of the margins between heart disease and metabolic disease like diabetes. New diabetes drugs like the GLP-1 receptor agonists and the SGLT2 inhibitors have effects that make your heart better that decrease the incidence of heart failure without changing your diabetes – your A1c doesn’t change – I would argue that these drugs will become heart drugs and that patients with diabetes will migrate more and more into the realm of cardiovascular medicine.”

Relaying some disturbing statistics about the prevalence of diabetes Dr Hill said rates are ‘exploding’ around the world – in the US and China prevalence rates sit at 11%.

“In a country like China with a population of 1.4 billion that’s 11% of a very large number,” Dr Hill said adding that the prevalence of pre diabetes metabolic syndrome in China now sat at a staggering 40%.

While the prevalence of hypertension has become relatively stable in developed countries, Dr Hill said that over the last two decades the risk factor has been exported to the developing world.

His predictions for how the future of cardiovascular disease will affect the economy are, in short, not good.

The doomsday scenario is a surge of people with heart failure who also have comorbid cognitive impairment – they are institutionalised for decades and that will bankrupt society, he argued.

“If you add up expenditure from heart disease plus hypertension plus other circulatory conditions and stroke add those together and 43% of [public health funding in the US] goes to cardiovascular disease. It’s far and away the number one point of expenditure in healthcare.”

But urging cardiologists in the room to ‘aim for where the puck is going to be’ instead of where it is, he emphasised that the opportunities in cardiovascular medicine have never been greater.

“I’ve highlighted many of the challenges of what I think the future looks like over the next 20 years but the resources and tools at our disposal our absolutely spectacular. Big data, precision medicine, new technologies are all at our disposal, that we can harness, to approach these different challenges.”

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