Cardiovascular Science in the Service of National Strength

Abstract

ON OCTOBER 31, 1940, PRESIDENT FRANKLIN Delano Roosevelt dedicated the new Bethesda, Maryland, campus of the National Institutes of Health. As cardiovascular disease was emerging as the biggest threat to the nation’s health, and as threats of war loomed from Europe, Roosevelt declared, “Total defense . . . which the nation seeks, involves a great deal more than building airplanes, ships, guns, and bombs. We cannot be a strong nation unless we are a healthy nation. And so we must recruit not only men and materials but also knowledge and science in the service of national strength.” Nearly 61 years after Roosevelt’s dedication, the US government announced the Million Hearts initiative with a goal of preventing 1 million myocardial infarctions and strokes over 5 years “by implementing proven, effective, inexpensive interventions.” Centers for Disease Control and Prevention director Thomas Frieden and Centers for Medicare & Medicaid Services administrator Donald Berwick seek to implement the ABCS, namely, aspirin prophylaxis, reduction of blood pressure levels, reduction of cholesterol levels, and cessation of smoking. For each of these interventions, the research enterprise can take credit for discovering the problem and rigorously demonstrating, often through large-scale randomized trials, the value of clinical and public health interventions. The profound influence of cardiovascular research has been remarkable. Between 1960 and 2000, life expectancy in the United States increased by 7 years, with 70% of the increase attributable to fewer cardiovascular deaths. Improved cardiovascular health can be attributed to “high-technology” medicine, including cardiac surgery, acute revascularization, and defibrillators; “low-technology” medicine, including clinical and community management of blood pressure and cholesterol levels; and behavioral changes, in particular marked reductions in cigarette smoking. For each intervention, researchers played critical roles. Echoing Roosevelt, knowledge and science served admirably to improve national health. Yet all is not well. Cardiovascular disease remains the leading cause of death in the United States and in most of the world. In the United States, the nature of cardiovascular disease is changing, as thepopulationbecomesolder,moreobese, and more urban with substantial changes in nutrition, work, physical activity, and transportation.The incidenceandprevalence of acute ST-segment elevation myocardial infarction and rheumatic heart disease are decreasing while they are increasing for heart failure, degenerative aortic stenosis, peripheral arterial disease, and atrial fibrillation, conditions for which there is much to learn. Clinical cardiology has been criticized, as a recent magazine headline declared that “Cardiac care is a money-making machine that too often favors profit over science.” Nearly 90% of professional society recommendations are based on suboptimal evidence. Even though some cardiovascular research has been successful, much more needs to be accomplished. What is next for cardiovascular research? Several areas are likely to be of major importance.