Michael R. S. Hill
Cardiology is the study of the heart, blood vessels, and circulatory system and their functions in health, disorders, and disease. In health care, cardiology stands at the intersection of engineering principles/technology and cardiovascular physiology/basic sciences. Since 1921, for more than 100 consecutive years, cardiovascular disease has been the leading cause of death in the United States [1]. Globally, since 2010, cardiovascular disease has surpassed communicable diseases as the leading cause of death [2], [3]. Since 1950, engineers, scientists, academicians, and clinicians have made significant strides in combating cardiovascular disease resulting in a 60% reduction in cardiovascular death today in the United States and much of the western world [1]. This editorial explores the multifaceted advancements and collaborative efforts that have revolutionized cardiovascular care and the challenges that remain.
Four key factors have contributed to the significant improvements in all aspects of cardiovascular care resulting in the 60% reduction in cardiovascular deaths.
Collaborative efforts
The collaboration between engineers, scientists, academicians, clinicians, care providers, hospital administrators, patient advocacy groups, government regulators and reimbursors has been pivotal in creating innovative solutions. These partnerships have led to the development of new products, procedures, care pathways, and increased patient access that improve patient outcomes. The focus has been on delivering patient-centered outcomes in a cost-effective manner, ensuring broader access to advanced cardiovascular care.
Advances in understanding cardiovascular mechanisms
One of the most profound areas of progress has been in our increased understanding of the underlying mechanisms of various cardiovascular conditions. These include cardiac and vascular cell properties, genes impacting cardiovascular systems, ischemia, arrhythmias, and myopathies, as well as the intricate relationships and interactions between systems that control blood pressure, the autonomic nervous system, respiration, and blood, vascular, and cardiac components. This deeper understanding has paved the way for more targeted and effective diagnoses and treatments.
Technology innovations
Technological advancements have played a crucial role in transforming cardiology by the development of tools that enable new measurement capabilities, further research and better understanding of the normal and pathophysiological processes that lead to various untoward cardiovascular conditions. These advances have facilitated the creation of new tools used by cardiologists and care providers to improve the diagnosis, treatment and management of cardiovascular diseases. Technology has also played a role in increasing public awareness, advancing advocacy efforts, and shaping public policy regarding cardiovascular disease.
Advocacy and public awareness
Organizations like the American Heart Association, American Stroke Foundation, and American Institute of Medical and Biological Engineers have been instrumental in raising public awareness about cardiovascular health. Their advocacy efforts have promoted cardiopulmonary resuscitation (CPR), sudden death prevention, smoking cessation, healthier nutrition and lifestyles, and the importance of blood pressure and cholesterol control. These groups have emphasized and educated the public and clinicians regarding differences in presenting symptoms of a heart attack between men and women. They provide public information regarding disparities in care pathways and outcomes of minority and under-represented groups. These initiatives, backed by strong scientific data, have significantly impacted public policy and population behaviors improving patient outcomes.
Transformations in medical technology
Innovations in battery technologies, microelectronics, low-power wireless communications, biocompatible insulating materials and tissue-electrode interfaces have led to the development of smaller, longer lasting, safe and highly effective treatments such as the pectoral, active-can electrode, transvenous single lead, implantable cardioverter defibrillator system, the single chamber extravascular implantable cardioverter defibrillator system, and the very small transvascular leadless pacemaker and delivery system. Advancements in sensor technology, computational intelligence, and systems have enabled closed-loop, automatic diabetes control and long-term arrhythmia diagnostic monitoring. Advances in energy sources, materials, catheter designs, and manufacturing technologies coupled with real-time imaging capabilities have enhanced precision and efficacy of transvascular interventions such as radiofrequency, cryo, and pulsed field ablation procedures and cardiac vascular stent and revascularization interventions. Examples of new materials that have been game-changers include a collaboration between NASA and Medtronic, plc in the development and application of Langley Research Center’s Soluble Imide (LaRC-Si), a biocompatible, durable, insulating material that allowed smaller, more flexible cardiac leads; and nitinol (Nickel, Titanium, and the Naval Ordnance Laboratory), a metal alloy developed in 1959 with shape memory characteristics, enabling the transvascular placement of coronary stents and vascular grafts. Advances in imaging technologies such as echocardiography, computed tomography, magnetic resonance, and positron emission tomography provide different views of tissues for diagnostic and research purposes. Modeling and simulation coupled with the exponential growth in computational power have driven significant improvements in predictive engineering capabilities, more complete cardiovascular models, and in silico research trials for increased confidence in quality and reliability and accelerated regulatory approvals.
Technology miniaturization and minimally invasive procedures
Two major factors have enabled and driven the adoption of these advancements: the miniaturization of electrical components, power sources, materials, and other technologies and capabilities; and the shift from long, invasive surgical procedures to shorter, less invasive, more effective, catheter-based or outpatient procedures. This transition has resulted in better patient outcomes, quicker recovery times, fewer adverse events, and greater accessibility for a broader group of patients including frail and sicker patients. I recall a poignant example from my career: An 18-year-old high school football player was undergoing an open-chest, open-heart, cardiopulmonary bypass procedure to map, locate, and then surgically sever an accessory conduction pathway between the atria and ventricles (Wolff–Parkinson–White Syndrome). The surgery lasted four to five hours, followed by two days in the intensive care unit and a week in the hospital. Within two years, this procedure evolved into a transvascular procedure under fluoroscopic guidance, using catheters to map and then radiofrequency energy to ablate the accessory conduction pathway in just two to three hours, with the patient going home the same day. This transformation sparked my curiosity and desire to create novel technologies that would enable better solutions to unmet medical needs of patients resulting in improved patient outcomes. During my career at Medtronic, I feel fortunate to have had the opportunity to make significant contributions to several groundbreaking innovations. These include cardiac resynchronization therapy, transvascular valves, transvascular (leadless) pacing, implantable diagnostic devices, predictive integrated diagnostic algorithms, and cardiac and renal ablation therapies. Collaborating with other engineers, scientists, academicians, clinicians, regulators, reimbursors, and advocacy groups provided a framework for creating sustainable, patient-inspired innovations that have significantly changed the face of cardiovascular disease by meeting a medical need as inspired by the founders of Medtronic’s Mission to alleviate pain, restore health, and extend life.
Looking to the future
The future is incredibly promising with many additional opportunities on the horizon to further impact cardiovascular disease globally. For example, augmented intelligence (AI) and enhanced imaging technologies integrated with surgical robots are poised to revolutionize the field by performing repeatable, effective, autonomous procedures with remarkable precision and speed. Diagnostics and AI, through sensors embedded in wearables, clothing, furniture, mirrors, and even rooms at home and in public places, will continuously monitor, advise, and perhaps automatically adjust implanted device parameters as well as external environmental and behavioral factors to maintain and improve health and well-being. New energy technologies, such as laser, microwave, acoustic, and high-intensity focused ultrasound, combined with advanced diagnostic imaging, localization, and navigation technologies, will facilitate precise, focal, noninvasive ablation and revascularization procedures. Regenerative medicine, additive manufacturing, and novel material advances will enable vascular graft and cardiac tissue repair and replacement.
Interdisciplinary collaborative efforts combined with advances in understanding cardiovascular mechanisms, technology innovations, and advocacy have made significant strides in combating cardiovascular disease over the last 70 years. As we continue to innovate and work together, by addressing global health care challenges and pioneering new frontiers in medical technology, we can make additional substantial impacts in cardiovascular care by improving patient outcomes and extending lives.
References
- American Heart Association, “More than half of U.S. adults don’t know heart disease is leading cause of death, despite 100-year reign,” Jan. 24, 2024. [Online]. Available: https://newsroom.heart.org/news/more-than-half-of-u-s-adults-dont-know-heart-disease-is-leading-cause-of-death-despite-100-year-reign#:~:text=Since%201950%2C%20death%20rates%20from,high%20blood%20pressure%20and%20obesity
- World Health Organization, “The top 10 causes of death,” Aug. 7, 2024. [Online]. Available: https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death#:~:text=Leading%20causes%20of%20death%20in,9.1%20million%20deaths%20in%202021
- World Health Organization, “Global health estimates 2021: Deaths by cause, age, sex, by country and by region, 2000–2021,” 2024. [Online]. Available: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death