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Cardiology’s journey into the future: the European perspective

Europe’s contribution to the development of cardiology as an effective medical specialty for the diagnosis and treatment of cardiovascular conditions has been
exceptional. But many challenges remain

Thomas F Lüscher
MD, FRCP, Cardiology
University Hospital Zurich
CH-8091 Zurich
[email protected]

Cardiology is medicine and science of the heart, and so goes to the heart of the matter. Indeed, cardiovascular diseases
still remain the major cause of morbidity and mortality in Western countries. In addition, the load of cardiovascular diseases is steadily increasing in developing countries such as India and China and has also reached an impressive prevalence in the Middle East.

The spectrum
Cardiovascular diseases encompass a variety of clinical  conditions, but the most common remain coronary artery disease and its complications, such as myocardial infarction, heart failure and sudden death. In addition, diseases of the
cerebrovascular circulation such as ischaemic haemorrhage and haemorrhagic stroke remain important. The vast majority of these conditions are caused by atherosclerotic changes of the major arteries supplying the heart, brain, kidney and legs.
Although, the causes of atherosclerosis are not fully understood, it is now clear that obesity, high blood pressure, high blood levels of cholesterol, smoking and diabetes are the major risk factors. Thanks to the enormous progress made in the management of patients with cardiovascular disease, their
morbidity and mortality have decreased over the last decades in Europe and the US.

Europe’s record

Europe’s contribution to the development of cardiology as an effective medical specialty for the diagnosis and treatment of cardiovascular conditions is remarkable. Indeed, English clinicians of the 19th century were the first to describe coronary artery disease and the first remedies to alleviate its symptoms. John Withering described the effects of foxglove, currently used
as digitalis, in patients with dropsy in the 18th century, while Thomas Lauder Brompton was the first to recognise the beneficial effects of amyl nitrite in angina pectoris. William Eindhoven in Leyden then developed the electrocardiogram
and Werner Forssman was the first to perform a cardiac catheterisation on himself in 1923 in Berlin. The introduction of cardiac catheterisation was the prerequisite to performing surgery in patients with congenital malformations and later
coronary artery disease. In the late 1950s, Ake Senning was the first to implant a pacemaker in patients with third-degree AV-block, and in 1977 Andreas Grüntzig performed the first coronary angioplasty in a patient with a narrowing of the left-anterior descending coronary artery in Zurich. Besides interventions, novel diagnostic tools have contributed significantly to advances in the field. Two Swedish engineers developed echocardiography in the 1960s, a technique initially
used for the navigation of ships, for the diagnosis of heart disease. Today, echo is the major diagnostic tool for practising and hospital cardiologists.

Drugs for the heart
Following digitalis and nitroglycerine, aspirin was the next important drug for cardiology, and at first was used exclusively to treat patients with fever. In the 1960s, however, it was discovered that aspirin inhibits platelet aggregation and in 1984 the Oxford group demonstrated that it significantly lowered mortality in patients with acute myocardial infarction. Beta-blockers were discovered by Henry Black in the UK in the 1970s and were the next important remedy to treat patients with arrhythmias and acute myocardial infarction. Finally, Europe was essential in further developing balloon angioplasty to stenting, which today is common practice in the  interventional treatment of patients with coronary artery
disease and infarction.

European cardiology
The European Society of Cardiology (ESC) was founded more than 50 years ago. At that time, it was a relatively small society until its rapid growth at the end of the 1970s and particularly in
the last three decades. Indeed, today, the ESC’s annual congress attracts over 30,000 participants from 69 countries and the society has more than 40,000 members. The ESC pursues its mission to reduce the global burden of cardiovascular disease through educational activities – that is, the main congress, as well as subspecialty congresses on heart failure, echo, nuclear cardiology, arrhythmias (Europace) and heart failure.
In addition, the ESC produces a large number of scientific journals, among them the European Heart Journal with a current impact factor of around nine and available online or in print every fortnight. Under the new editorship of the European Heart Journal, the ESC’s journal family has grown together through regular manuscript transfer. Indeed, the European Heart Journal can only accept 15% of its submitted manuscripts
and so transfers an additional 10% of well-rated papers, which are too technical for the main journal, to its subspecialty journals, such as the European Journal of Heart Failure, the European Journal of Cardiovascular Prevention and  Rehabilitation, Europace, Eurointervention, the European Journal of Echocardiography and the European Journal of Cardiovascular Nursing.
Finally, the ESC has assigned three editors (John A Camm, Thomas F Lüscher and Patrick W Serruys) to produce the European Textbook of Cardiovascular Medicine, which just appeared in its second edition at the time of the ESC Congress in Barcelona in 2009.
The future of European cardiology is bright, though a few challenges and threats have to be considered. The ESC has become the most successful society in cardiovascular medicine,
organising the largest congress worldwide and providing its own textbook and an impressive journal family. Furthermore, an increasing number of cardiological societies from non-European
countries became affiliated, most recently the cardiological society from mainland China.

Dreams for the future
Scientifically, European scientists have the lead in stem cell research, trying to develop this novel technology into an effective treatment for everyday practice. At this point, stem cell therapy is still experimental and its effects are still below our expectations. Indeed, it became clear that stem cells of patients with acute myocardial infarction or heart failure are dysfunctional, particularly in those with diabetes. Thus, novel
approaches have to be developed to improve stem cell function in these patients and in turn enhance perfusion and contractibility of the diseased heart muscle.
Another dream for the future in cardiology is personalised medicine. In this regard, hopes do rest on gene technology and its ability to get more insights into the biology of an individual patient, allowing for tailor-made treatment strategies. Initially, researchers have been overwhelmed by the large number of genes and an even greater number of single nucleotide polymorphisms and other genetic alterations in cardiovascular
patients. Novel technologies, however, will most likely make it possible to get insights into an everincreasing number of genetic alterations and their clinical importance. It is hoped that through this research and the development of personalised
medicine, the management of patients with cardiovascular disease will be further improved.

Imaging the hidden organ
Although the imaging of the hidden organ with echo, X-rays, computer tomography and MRI has improved cardiovascular diagnosis considerably, several clinical needs are yet to be met. Importantly, imaging of the vulnerable plaque, which is responsible for acute coronary syndromes, is still in its infancy, although progress has been made experimentally. The development of biological imaging that provides a characterisation of plaque composition at the cellular and molecular level would allow for an early diagnosis of plaques that are prone to rupture. This would enable early diagnosis of acute coronary syndromes and, hence, therapeutic measures before infarction ensues.

The journey ahead
Cardiology has developed enormously since its infancy in the middle of the 20th century, thanks in no small part to European contributions. Since Eisenhower’s heart attack in 1955, mortality in such patients has dropped from 50% to less than 5% – an enormous achievement. This has been made possible through improved diagnosis at the biochemical and technical level, new interventions and devices, as well as potent drugs to inhibit platelets, lower blood pressure and cholesterol and, in part, diabetes. However, further research is required to address unmet needs in patients with heart failure, genetic diseases and
rare conditions. The growth of cardiology has been exciting and the journey into the future will remain so over the next decades.