The future of cardiology and cardiovascular disease care

• Significant advances in cardiovascular medicine rely on a dual strategy: discovering new therapeutic targets while aggressively implementing underutilized tools like Lipoprotein(a) testing
• Rising obesity rates are driving a shift toward multi-system care that treats the heart, kidneys, and metabolism as an interconnected unit: a holistic approach
• Experts highlight that the future of heart disease treatment prioritizes precision biomarkers to identify high-risk individuals and prevent catastrophic events like heart attacks before they occur

Cardiovascular Disease (CVD) remains the leading cause of mortality globally^1-3, yet recent advancements in both therapeutic discovery and risk stratification markers offer a profoundly optimistic outlook for prevention and management.^4-11 This article explores the perspectives of four leading experts in cardiology and cardiometabolic medicine (Dr. Christie Ballantyne, Dr. Naveed Saatar, Dr. Pam Taub, and Dr. Gemma Figtree) on the continuously evolving landscape of CVD care. 

As our understanding of cardiovascular disease development deepens, these experts emphasize the need to tackle novel targets, implement existing tools more effectively, and address the rising tide of non-atherosclerotic disease driven by obesity. Together, they outline a vision for modern treatments for heart disease and holistic cardiology that is increasingly precise and preventative.

Dr. Ballantyne insightfully highlights a two-pronged strategy for the future of cardiology, in which both novel discovery (new therapies) and implementation science (optimizing the use of current, powerful diagnostic and therapeutic tools) have to go hand in hand. He posits that while groundbreaking research introduces new targets,^7,10,11 many effective, established biomarkers and drugs remain underutilized, signifying a need for better clinical adoption strategies.

There is a lot of excitement surrounding new therapies targeting persistent residual risk, including those aimed at lowering elevated lipoprotein(a), modulating triglyceride-rich lipoproteins, reducing inflammation, specifically targeting the inflammasome pathway, and generally treating foundational conditions like obesity, diabetes, and kidney disease.

However, Dr. Ballantyne stresses that an equally crucial opportunity lies in the better implementation of existing knowledge and tools, citing two significant examples of underutilized, powerful markers:

• Lipoprotein(a) measurement: Despite being a strong, hereditary risk marker for CVD, its measurement is not routine.
• N-terminal pro–B-type natriuretic peptide (NT-proBNP): A robust prognostic indicator for heart failure, which remains under-measured in clinical settings.

Prof. Naveed Sattar acknowledges the significant successes achieved in combating atherosclerotic cardiovascular disease (ASCVD) through measures like statins, blood pressure (BP) control, and reduced smoking, but warns that the etiology of cardiovascular disease development is shifting.  In high-income countries, the emerging challenge is the rise of non-atherosclerotic cardiovascular disease, primarily driven by the obesity epidemic and resulting multimorbidity.

There is an epidemiological shift in CVD etiology, where improved ASCVD survival and increased longevity, coupled with high rates of obesity, are increasing the prevalence of non-ischemic heart pathologies, such as heart failure with preserved ejection fraction (HFpEF).

While acknowledging the need to "tighten" on existing ASCVD elements, including targeting Lp(a), achieving even lower LDL levels,⁹ and recognizing that optimal hypertension targets are often lower than the historical 140/90 mmHg,⁸ Prof. Sattar highlights two new challenges:

• Rise of Non-Atherosclerotic CVD: Driven by parallel increases in obesity, there is a noted rise in heart failure (with increasing mortality) and arrhythmias (such as heart block), which are increasingly linked to obesity and increased longevity.
• Multimorbidity: Patients with CVD are increasingly living with complex multimorbidity, including diabetes, chronic kidney disease (CKD), and cancer, necessitating a more comprehensive and holistic approach to care.

Prof. Sattar's vision for the future of heart disease treatment is that the imperative is now on prevention and management of obesity to curb non-atherosclerotic CVD, alongside adopting a more holistic perspective on patient risk assessment.

Dr. Pam R. Taub emphasizes the need for a broad definition of prevention that encompasses the wide spectrum of cardiometabolic disease. The current era is a "revolution" demanding a holistic, multi-system approach to cardiometabolic disease, recognizing it as the underlying driver of various conditions from ASCVD to heart failure and arrhythmias (e.g., Atrial Fibrillation).

Dr. Taub addresses the notion that organs previously viewed in isolation (heart, kidney, liver) are interconnected through common metabolic pathways. This understanding justifies the use of therapies originally developed for one condition (e.g., diabetes) to treat others (e.g., heart failure, CKD).

Cardiometabolic disease is a critical "underlying driver and substrate" for a wide range of conditions. Even conditions like Atrial Fibrillation (AF), often not strictly defined as cardiometabolic, are strongly associated with metabolic risk factors such as obesity, diabetes, and hypertension, and optimizing these risk factors improves arrhythmia outcomes.

The holistic revolution entails thinking about the interaction between the kidney, heart, liver, and endocrine system. This approach validates the use of newer pharmacotherapies, such as Glucagon-like Peptide-1 (GLP-1) receptor agonists and Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors, which have demonstrated broad cardiovascular and renal benefits, exemplify how advances in cardiovascular medicine are now treating the whole patient rather than a single organ. Crucially, Dr. Taub maintains that significant lifestyle components remain integral to effective prevention. The ultimate goal is to improve patient outcomes and quality of life through integrated lifestyle and pharmacotherapeutic strategies.

Prof. Gemma Figtree sharpens the focus on the acute, catastrophic event: the heart attack. A major unmet need in prevention is the discovery of a reliable, predictive biomarker that can accurately identify individuals with "a ticking time bomb" of vulnerable coronary artery disease.

Professor Figtree is addressing the clinical conundrum where current risk scores (like Framingham or ASCVD Risk Estimator Plus) are good for population-level prevention but often fail to identify individuals at high risk of an imminent event who would benefit most from aggressive, plaque-stabilizing therapies.^4-6

Her passion lies in heart attack prevention, and she discusses the need for a biomarker that enables precise and equitable access to the most effective treatments, specifically those that can halt the progression of atherosclerotic plaque in situ. Prof. Figtree’s vision for the future of heart disease treatment is an ambitious yet achievable future  "I hope that in ten years’ time we will see heart attack as something that is really very rare, and a very avoidable catastrophic endpoint." This vision relies on successfully moving beyond population-level risk prediction to individual, real-time vulnerability assessment via a novel biomarker.