Tackling Coronary Heart Disease the Biggest Success in 50 Years

Professor Guy De Backer, Emeritus Professor at Ghent ‏University, Belgium, will be a keynote speaker at the ‏ESC Conference in Rome on August 27-31, delivering ‏the ESC Geoffrey Rose Lecture on Population Sciences on ‏“Epidemiology and Prevention of Cardiovascular Diseases: ‏Quo Vadis?” Prior to the conference, he gave an interview to ‏HealthManagement.org about the past, present and future of ‏cardiology, where he reflected on perceptions and personal ‏experiences working as a cardiologist in a western society. ‏His research domain has been cardiovascular epidemiology ‏and prevention, while, as a clinician, Prof. De Backer has ‏been working in noninvasive cardiology and in particular in ‏cardiac rehabilitation.

How different is cardiology today from 50 years ago? ‏What would you say are the biggest achievements in ‏this discipline —the human learning or the technology ‏side?

The cardiological discipline has changed tremendously over ‏the past 50 years. I started my cardiology training in 1968. ‏At that time, we used our clinical experience, electrocardiography, ‏phonocardiography, x-rays and a few biochemical ‏measurements. Patients suffering from an acute myocardial ‏infarction (AMI) were treated with bed rest, pain relief, oxygen ‏and monitoring; most of them were kept in hospital for 4-6 ‏weeks. The rate of return to work was less than 50 percent. ‏Nowadays, an acute myocardial infarction (AMI) can still be ‏very serious, but most uncomplicated cases are discharged ‏after a few days, and return to work is over 85 percent. This ‏is just one example of changes that took place on the basis ‏of better knowledge, better treatments and societal changes. ‏

Personally, I think that the greatest achievement in cardiology ‏has been the reversal of the epidemic of coronary heart ‏disease (CHD ) that started after World War II. In most western ‏European countries, we have been able to reduce CHD ‏mortality by more than 50 percent over the last 30-40 years. ‏A large proportion of the gain in life expectancy that we have ‏observed in the past 30 years is due to fewer cardiovascular ‏deaths.

More than half of that gain—and in some countries such as ‏Finland up to 70 percent of the reduction of CHD mortality— ‏is related to prevention and the rest to better treatments. ‏

Prevention means in the first place smoking cessation and, ‏a balanced healthy diet and physical exercise. Unfortunately, ‏in more recent years, we have seen a growing epidemic of ‏obesity and type 2 diabetes, important risk factors for CHD ; ‏the gain in CHD mortality that we observed mainly in the 1980s ‏and 1990s seems to have slowed down in recent years.

‏CVD prevention is possible and has worked and this is not ‏on the basis of new technologies, but due to better insights ‏into pathogenesis, epidemiology and CVD risk factors. One ‏of the main challenges nowadays is the implementation of ‏that scientific knowledge into practice, a challenge for society ‏including cardiologists and their societies.

But cardiology has also gained a lot from discoveries in the ‏field of pharmacology and medical devices. The latter has ‏led us to a discipline with a different kind of ‘super-specialist’, ‏dealing exclusively with electrophysiology, percutaneous ‏coronary intervention (PCI), percutaneous aortic valve ‏replacement (PAVR), support devices etc.

These developments are fascinating and very welcome, ‏but in terms of “what is best?” they should not be balanced ‏against prevention or noninvasive approaches. The trend ‏towards a more personalised medicine is welcome in this ‏respect; each patient should be considered on his own ‏and the best approach for their personal problem should ‏be offered on the basis of expert opinion from a team of ‏cardiologists in dialogue with the patient. All these different ‏approaches should also receive sufficient support for further ‏research and development.

For noninvasive cardiologists, one of the challenges is that ‏within an actual generation we have prevented premature ‏CVD mortality and disability-adjusted life years (DA LYs), but ‏the result is more a postponement than a complete prevention; ‏this has resulted in an epidemic of more advanced clinical ‏entities of atherothrombotic cardiovascular disease (CVD) in the elderly and in the very old, such as heart failure and ‏vascular dementia. This requires more care than cure and ‏will increase healthcare costs.

Where would you like to see new achievements in the ‏next few years?

For the immediate future, I think that we need more research ‏on preventive strategies, a shift from aetiological research into ‏preventive research. We need to know how to overcome the ‏barriers for the implementation of prevention guidelines into ‏daily clinical practice. At the level of the individual patient we ‏hope that epidemiological research will help us in understanding ‏the complex interactions between the genome and the ‏environment. This could help us in identifying novel targets ‏for a more personalised preventive strategy.

How important is multidisciplinary teamwork in ‏cardiac rehabilitation?

Cardiology has always required teamwork and in the field of ‏CVD rehabilitation this is even crucial.

‏In my experience in the cardiac rehab unit in Ghent University ‏Hospital, the social nurse was the key player in identifying ‏in a given patient the problems that affected his or her ‏quality of life. Based on that information, the whole team was ‏responsible for relieving these problems in order to achieve ‏the most optimal results for that patient. The same is true ‏for the management of patients with chronic heart failure, ‏where the ‘heart failure nurse’ is in a key position to coordinate ‏the efforts made by the cardiologist, the family doctor, ‏the dietician and the physiotherapist. It is probably true that ‏what the cardiologist has said to the patient may be differently ‏perceived by the patient than what comes from the other ‏team members; therefore it is crucial that all team members ‏know what message to give and what goals to reach.

How important has the European Society of Cardiology ‏contribution been to improving quality of healthcare, ‏technological development and also education ‏of young cardiologists?

The European Society of Cardiology (ESC) has played a major ‏role in bringing cardiologists together in Europe. In the 1960s ‏and 1970s, European cardiologists went mostly to the scientific ‏meetings of the American Heart Association and the ‏American College of Cardiology; these meetings are still of ‏great interest, but the meetings of the ESC and affiliates ‏(associations, councils, working groups, etc.) have improved ‏tremendously and attract more and more attention in Europe ‏and globally. Initially, we met mainly to discuss study results ‏and to exchange experiences; this has expanded to other ‏aspects related to education, continuing medical education, ‏research, guidelines, surveillance, networking and international ‏collaboration.

What do you see as the biggest healthcare problem ‏in Europe today?

It is hard to identify ‘the biggest health problem in Europe ‏today’. It depends on how you define health in the first place. ‏Personally, I feel that we have failed in decreasing social ‏inequalities in health, and this is also true within the field ‏of cardiology. We have been successful in decreasing CVD ‏mortality in all classes of society, but the social differences ‏that existed already years ago have not diminished.

How important is it to have both public and private ‏healthcare? Which one is more efficient?

Healthcare is responsible for a large proportion of the gross ‏national product in most societies in Europe and public ‏money should be spent as efficiently as possible. Different ‏healthcare systems have been tested in Europe; they all ‏have advantages and limitations. We should learn from each ‏other. Good management of large departments in university ‏hospitals that are responsible for teaching, medical care ‏and research is very important and this requires the input ‏of a team of experts from different disciplines.

If you had not become a cardiologist, what would you ‏be today?

In my experience the choice of a professional career is not ‏influenced by inspiration but mainly by circumstances. I never ‏thought of doing something else. I have had the great privilege ‏of working in almost ideal circumstances, in a community ‏free of war and catastrophes, doing a job that I loved with ‏a family that gave me a maximum of opportunities. I do not ‏believe in reincarnation. So that will be it.

Key Points

• The greatest achievement in cardiology has been ‏the reversal of the of coronary heart disease (CHD) ‏epidemic that started after World War II.

• Prevention of CHD means in the first place no ‏smoking of tobacco, a balanced healthy diet and ‏physical exercise. Unfortunately in recent years the ‏prevalences of obesity and of type II diabetes have ‏increased and counteract what has been gained in ‏the 80s and 90s.

• CVD prevention has worked, not on the basis of new ‏technologies, but on better insights into pathogenesis, ‏epidemiology and good management of CVD ‏risk factors.