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- Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
- ↵⁎Address correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
We live in a world of constant change and evolution, and this is certainly true of health care. With the passage of time, major changes are occurring in the science, delivery, and funding of medicine. Nowhere in medicine are such transformations greater than in cardiovascular disease. The scientific advances in cardiology in my lifetime have been extraordinary, and there is very little that I do these days that I did as a resident or fellow. These advances also brought with them alternations in the prevalence of disorders, the nature of practice, and the systems and finances of delivering clinical care. In many respects, the changes occurring in cardiovascular medicine are even greater outside of the United States, especially in the developing world.
To keep abreast of the changes that are taking place, the American College of Cardiology has commissioned a document called the Environmental Scan that provides information and statistics regarding the prevalence, diagnosis, therapy, and policy issues of cardiovascular disease worldwide. We published this document as a Supplement in December, 2012 (1). It provides fascinating data in regard to the alterations that are underway in the United States, but even more interesting facts about the state of cardiovascular disease in the rest of the world. It seemed to me that much of this information was worthy of reflection.
The enormity of cardiovascular disease and the financial burden it imposes upon society continues to amaze me. Heart attack, stroke, and hypertension have long been the major causes of death in the industrialized (high income) world, but now are increasingly prevalent even in the developing (low and middle income) world. Noncommunicable diseases have now overtaken communicable diseases as the major cause of death in the world, and cardiovascular disease accounts for nearly half of such deaths and half of the economic losses due to them. Mortality due to cardiovascular disease is rapidly increasing in low and middle income countries, where it occurs at a younger age and has a greater economic effect. Increasing cardiovascular mortality in low/middle income countries is likely to continue since the prevalence of hypertension and smoking is greatest there. In addition, increasing urbanization in the developing world will likely bring with it less exercise, exposure to environmental pollution, and a more atherogenic diet. The United States has the dubious distinction of leading the world in the greatest increase in body mass index. The World Health Organization estimates that failure to implement prevention and therapy for cardiovascular disease could result in a cost of $47 trillion in the next 25 years, a cost that will be borne more heavily by low and middle income countries since they account for 80% of cardiovascular deaths. The increasing incidence of cardiovascular disease and the relatively low level of preventive and therapeutic services in low/middle income countries points to the importance of concerted health care efforts in this part of the world, both for global health and the global economy.
An aging population represents another challenge to the health care system. Statistics demonstrate that average life expectancy is increasing throughout the world, even in countries with an average annual income of $10,000. The implications of aging upon health care costs are obvious. Of interest, the percent population over 65 years is highest in Western Europe and Asia (Japan and Korea), countries in which it is anticipated to increase the most over the next 30 years. It is also worthy of note that the United States ranks 27th in life expectancy in the world.
An important factor influencing health in the United States and worldwide is the physician workforce. In the United States, one-third of surveyed physicians plan to retire in the next 10 years and the American Association of Medical Colleges estimates that the country will be short from 90,000 to 130,000 physicians by 2025. In the absence of corrective measures, it is estimated that there could be a national shortage of 15,000 general cardiologists by 2025. The need for additional manpower exists for all subspecialties, including interventional cardiology, electrophysiology, pediatric cardiology, and cardiac surgery. The cardiovascular manpower may be influenced by the relatively small number of women in the field, although that number is increasing rapidly. The problem is also accentuated by the geographic variability in the distribution of physicians, which is greatest in the northeast and less in the southeast and west.
It appears that the shortage of physicians in high income countries has had a detrimental effect upon manpower in the low/middle income countries. It was estimated that 1.5 million health care professionals from developing countries were working in industrialized nations. In the United States graduates of foreign medical schools make up 30% of the cardiology manpower, and account for approximately the same percentage of those in cardiovascular training programs. The exodus of highly trained medical personnel is, of course, an enormous economic loss to developing countries. Given the increasing incidence of cardiovascular disease in low/middle income countries, the lack of medical professionals to provide care is particularly distressing. It seems paradoxical that high income countries with great resources are siphoning off desperately needed physicians and nurses from countries with much fewer resources and an already existent shortage of such individuals.
The availability of new pharmaceutical agents also plays a significant role in global cardiovascular health. In this regard, the growth of pharmaceutical sales has fallen in recent years. Many of the leading drugs used to treat cardiac disease such as atorvastatin and clopidogrel have come off patent, leading to an estimated loss of $78 billion worldwide. Interestingly, the loss of revenues to generic drugs, which has been beneficial to patients needing these agents, has been offset by greater sales in the developing world. Despite the continued high prevalence of cardiovascular disease, there are only approximately 150 new agents under development for these disorders, compared to nearly 700 under development for cancer. Data indicate that growth is more robust for cardiac devices, where the introduction of new stents and percutaneous treatments for valvular heart disease such as transcatheter aortic valve replacement continues to be brisk. Nevertheless, slowing in the introduction of new cardiovascular drugs is a definite cause for concern in the cardiology community.
There is much more interesting data and many more fascinating statistics in the Worldwide Environmental Scan (1). It provides useful information regarding many of the changes underway in the funding of health care in the United States, and of the prevalence of cardiometabolic risk factors. However, what was most striking to me was the increasing incidence and importance of cardiovascular disease in the developing world. Given the greater prevalence of heart attacks and strokes, and the absence of extensive medical capabilities, cardiovascular disease in low/middle income countries seems to be “low hanging fruit” for effective intervention. The relocation of physician manpower from, and growth of the pharmaceutical markets, in low/middle income countries attests to the global health care interdependence of countries worldwide. As John Donne said in his famous poem, “no man is an island, entire of itself, each is a piece of the continent, a part of the main” (2). It will do us all well to increasingly think of cardiovascular disease in a worldwide perspective, and to pursue scientific, clinical care, and policy changes accordingly.
- American College of Cardiology Foundation
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- ↵John Donne. Devotions upon emergent occasions and several steps in my sickness-Meditation XVII, 1624.