ARTICLE
President’s page: predicting the future
George A. Beller, MD, FACC
Reprint requests and correspondence: George Beller, MD, FACC, Cardiovascular Division, Department of Internal Medicine, Health System, University of Virginia, P.O. Box 800158, Health Sciences Center, Charlottesville, Virginia 22908-0158
The field of cardiovascular medicine has experienced tremendous growth and progress in the 50 years since the American College of Cardiology (ACC) was founded. Since 1949, we have witnessed remarkable progress in our understanding of the pathogenesis and pathophysiology of cardiovascular disease (CVD) and the emergence of the new diagnostic modalities, effective therapies and prevention strategies that have reduced the age-adjusted mortality rate from CVD by nearly 60%. Despite this impressive reduction in the death rate for CVD, the growth in the prevalence of chronic heart and vascular disease is predicted to be twice that of the growth of the general population in the first 20 years of the new millennium (1).
In December, as part of the ACC’s fiftieth anniversary celebration, the College invited three leading futurists to consider the impact that changing demographics, technology and costs will have on the future of cardiovascular care. These experts collaborated with working groups of ACC members and then presented their predictions at the ACC Forum on the Future in New York City, December 3, 1999.
In addition to the groups that focused on forthcoming changes in demographics, technology and cost, a fourth group composed exclusively of ACC members developed an article examining what the College’s response to the predicted changes in these three areas should be. After the articles were presented during the morning of the forum, and a lively discussion had taken place, the four groups spent the afternoon revising their articles. The results of their efforts were published in the March 15, 2000, issue of the Journal (2–5).
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More people with CVD
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When experts gaze into the future, they see many more people with CVD. According to David K. Foot, PhD, of the University of Toronto, and the Demographics Working Group chaired by Richard P. Lewis, MD, the aging of the Baby Boom generation will cause the number of cases of chronic heart disease to skyrocket. His calculations suggest a projection that deaths from heart disease will increase by 128.5% between 2000 and 2050, associated with a whopping 93% increase in the prevalence of heart disease in the same time period.
To meet this challenge, the Demographics Working Group stressed the need to begin recruiting new cardiologists now. There will be a need for more cardiovascular specialists to enter the workforce as patient loads, patient complexity and the number of cardiovascular operations and procedures increase. During the next 15 years, we must develop a strategy to attract the best and brightest children of the Boomers into the profession to provide optimal cardiovascular care to their aging parents.
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Technological advances and accompanying ethical dilemmas
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New technologies will also help us to meet the challenges posed by an aging society. Although technological innovations are notoriously difficult to predict, Joe Flower, of the What If ... , and the Technology Working Group chaired by Leonard S. Dreifus, MD, provided an exciting glimpse of what the future might look like. Over the next decade, after the Human Genome Project is completed, preclinical genetic diagnosis will become available so that individuals can undergo genetic screening early in life and receive their individual risk profiles for various CVDs and lipid disorders. Advances in molecular genetics will also permit the use of recombinant genes as therapies to treat CVD. This will lead to the introduction of an entirely new class of pharmaceuticals during the next decade, together with angiogenesis and myogenesis drugs. There are predictions that swine hearts will replace human hearts for transplantation and that mechanical replacement hearts will become more common. Later, in the first quarter of the new century, replacement organs grown in the laboratory using stem cell technology could become a reality. Nanotechnology will permit delivery of pharmaceuticals to precisely targeted locations, and minute sensing devices will be produced that can be injected into the bloodstream to register biologic information to be recorded by outside monitors. These are only a few of the predicted advances, but we all know that many yet undiscovered technologies will emerge that will be effective in detecting and treating both preclinical and established CVD.
Not surprisingly, Mr. Flower’s predictions prompted lively debate. But no matter what the future actually brings, we can all agree that cardiovascular medicine will continue to be at the nexus of both biological and information technologies. Great ethical debates can be expected with respect to such issues as privacy regarding genetic screening and the transplanting of animal hearts into humans.
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Rising costs
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Cost, of course, is a crucial issue as we consider the future. According to Donald M. Steinwachs, PhD, of the Johns Hopkins School of Hygiene and Public Health, and the Cost Structures Working Group chaired by Ruth L. Collins-Nakai, MD, heart disease–related expenditures will increase by 54% during the next 25 years. Costs for heart diseases are projected to increase to $157 billion annually by 2025. Although the introduction of new pharmaceuticals could reduce use of expensive invasive procedures, and the use of porcine hearts could lower transplantation costs, the successful treatment brought about by these and other innovations will lengthen people’s lives and thus increase overall health care expenses. Our aging population will be the main force driving up costs for heart disease care. In his presentation, Dr. Steinwachs commented that the average cost of heart disease is more than four times higher for people over age 75 than for those under age 65.
Dr. Steinwachs and his group noted that the current financing of health care is already inadequate, and they described several scenarios for paying our health care bills of the future. The economy could grow enough to accommodate increased costs, they suggested, or the nation could invest in finding ways to make health care dollars go further. Alternatively, the future could find us falling deeper into a system in which the level of care depends on the ability to pay. We may well be headed toward the latter scenario and the disenfranchisement of more and more segments of the population. The only solution is to find a way to provide health care coverage for all Americans.
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The College’s role
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How will the ACC respond to these changes? The ACC Response Working Group, chaired by Francis J. Klocke, MD, is stressing the importance of flexibility. As needs change, so will the resources and emphasis allocated to each of the College’s major goals: education, advocacy and clinical standard setting. The mission of the ACC has always been and will continue to be fostering optimal cardiovascular care and disease prevention. Because of the talent and spirit of volunteerism of its members, and the high quality of its staff, the College will strive to accomplish its mission in the face of the predicted changes in demographics, the emergence of new technology and the rising demand for and costs of health care. The College, whose history evidences its continuing ability to evolve and adapt to changing times and its members’ changing needs, will find new ways to help members adjust to challenges such as the changing roles of both clinicians and patients, the impact of the information age, and the need to be a practice manager as well as a practitioner. Promotion of research, translation of research findings into practice guidelines, and standard setting will remain high priorities for the ACC. One thing is sure: The College will continue to be the best and most relevant source of cardiovascular medical education, practice guidelines and advocacy for all of us, and for all of our patients, who are concerned with fighting CVD.
Many thanks to all of the people whose hard work helped to make the Forum on the Future such a success. Here’s to another 50 years of excellence.
I welcome your own thoughts about the future of cardiovascular medicine. Please feel free to write to me at Heart House, 9111 Old Georgetown Road, Bethesda, MD 20814-1699; fax me at (301) 897-9745; or email me at pres@acc.org.
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References
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- Foot DK, Lewis RP, Pearson TA, Beller GA. Demographics and Cardiology, 1950–2050. J Am Coll Cardiol 2000;35:1067–81.
- Lewis RP. The ACC at 50: A Giant Grew In Bethesda. J Am Coll Cardiol 2000;35:1061–6.
- Flower J, Dreifus LS, Bové AA, Weintraub WS. Technological advances and the next 50 years of cardiology. J Am Coll Cardiol 2000;35:1082–91.
- Steinwachs DM, Collins-Nakai R, Cohn L, Garson A Jr., Wolk MJ. The future of cardiology: utilization and costs of care. J Am Coll Cardiol 2000;35:1092–9.
- Klocke FJ, Douglas PS, Nissen SE, Popp R. The role of the American College of Cardiology in promoting and maintaining the delivery of quality cardiovascular care in the future. J Am Coll Cardiol 2000;35:1100–2.
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More people with CVD
Technological advances and...