The New Cardiovascular Medicine

The following is the editor’s introduction:

Despite aggressive guidelines and applications of advanced technology in cardiovascular (CV) medicine, the morbidity and mortality from coronary heart disease (CHD) is not declining worldwide. The traditional evaluation, prevention and treatment strategies for the top five CHD risk factors still result in a CHD gap. This means that about 50% of patients still have CHD or a myocardial infarction despite “normal” levels of these CHD risk factors as presently defined in the medical literature.  There are important details within each of these top five risk factors that are not being optimally addressed or applied clinically for the prevention and treatment of CHD. This suggests that in all likelihood, that we have reached a limit in our capacity to reduce CHD with our traditional approaches in cardiovascular medicine.

An evolved strategy is now required. It is time to redefine cardiovascular medicine and institute a “new” cardiovascular medicine paradigm. This “new” CV medicine can be interpreted or defined by a variety of terms such as “functional”, “metabolic”, integrative”, “personalized”, “individualized” or “precision”. Regardless of the language that we choose, the salient point is that we need to modernize our approach if we expect to have a positive impact on CV disease. 

Several key points need to be emphasized:

1. The traditional risk factor-induced development of CHD emphasizes only on the top five CHD risk factors of hypertension, dyslipidemia, diabetes mellitus, obesity and smoking and their relationship to CV target organ damage. This strategy has severe limitations, specifically, the “cholesterol centric” approach.
2. Recent results from clinical trials such as NAVIGATOR, ACCORD and ROADMAP suggest that we have reached a limit in terms of reducing CV events by solely controlling these top five CHD risk factors.
3. New approaches, new testing, genetics and other ancillary treatments will be necessary if we hope to reduce CHD in the future. 
4. It is required that we understand, measure, prevent and treat the downstream mediators of the CHD risk factors.  The CHD risk factors lead to specific mediators of vascular disease that create a “snowball-like” effect that may be difficult to interrupt or reverse once initiated. Therefore, early evaluation of the risk factors and mediators coupled with aggressive prevention and treatment programs is mandatory.
5. The blood vessel has only three finite responses to an infinite number of insults. These responses are inflammation, oxidative stress, and immune vascular dysfunction and imbalance. This model of cardiovascular medicine is shown in the figure below.
6. The blood vessel responds acutely to internal and external insults that are “correct and normal” but these chronic insults result in “a chronic exaggerated and dysregulated vascular dysfunction” with preclinical then clinical CVD due to maladaptation.
7. The subsequent environmental- gene expression patterns produce downstream mediators that damage the arteries.
8. Proper assessment, comprehension and treatment of the top five and numerous other CHD risk factors and the downstream mediators is required.
9. The vascular system is the innocent bystander.
10. CVD needs to be approached within a systems biology analysis and with the knowledge of the various organ system interconnections.
11. Environmental-genetic interactions, CV genetics, nutrigenomics, proteomics and metabolomics provide important connections to advanced CV testing that will provide optimal individual responses.

Healthcare providers must provide quality, patient satisfaction and value that is patient-centered and provides the best cardiovascular outcomes at the lowest cost.  We must move away from a cardiovascular disease orientation to a process and prevention orientation. The education and training of physicians to provide unique cardiovascular centers of excellence is paramount in this endeavor. This transformation of cardiovascular medicine will require much time and effort, but it must be done.

This cardiovascular textbook was written to address all of these concepts in the New Cardiovascular Medicine.  Leading experts in their respective fields have written the most comprehensive chapters on cardiovascular medicine that are available, which will appeal to internists, family physicians, osteopathic physicians, naturopathic physicians, cardiologists and cardiovascular specialists and many others.