The first publication of one of the authors (GST) was an article on heart disease prevention written as a medical student 30 years ago.1 Upon finishing his cardiology fellowship in the mid-1980s, he was asked, “What will you do if this prevention stuff works?” He reassured himself, answering, “That would be a good thing; I’ll deal with it when the time comes.”
Well, the time has come. An ‘outbreak of wellness’ is affecting patients with and at risk for cardiovascular (CV) disease across the US. Life expectancy rose from an estimated 47.3 years in 1900 to 69.7 years in 1960 and to 77.7 years in 2006 (see Figure 1).2 Investigators attributed, respectively, 65 and 70% of these increases to decreases in CV disease mortality.3,4 Largely because the decrease in CV disease mortality was greater in men than in women, the gap in life expectancy between the two genders decreased from 7.6 to 5.1 years between 1970 and 2004 (see Figure 1).
Remarkably, the age-adjusted annual death rate for CV disease has decreased by a mean of 2–3% since 1960 (see Figure 2).2 Despite increasing rates of obesity and diabetes, these decreases accelerated in the most recent years for which data are available. Age-adjusted annual decreases in CV mortality between 2000 and 2005 were 3.8, 2.8, 3.3, 6.6, and 2.8%.
This is terrific news. As a population, and for each of us individually, we can expect to live substantially longer. In addition, the decreasing prevalence of disability generally results in these being quality years.5 Cardiologists have enjoyed heady times over this period, with increasing income and greater stature among specialties. New technology to diagnose and ‘fix’ patients has exploded. Testing and interventional volume increased in both the hospital and the office.
This outbreak of wellness, however, has now affected our volume of work. Remarkably, despite the increasing average age of Medicare patients, the frequency of admission of Medicare patients for acute myocardial infarction (AMI) decreased by an average of 5.5% annually between 2002 and 2007 (see Figure 3).6 Among those admitted, in-hospital mortality also decreased.7 Over the same time period, admissions for the diagnoses of unstable angina and coronary artery disease (CAD) decreased by an average of 19.9% annually (see Figure 4), while unstable angina decreased by 6.1% annually.5 Chronic heart failure (CHF) and dysrhythmia admissions were more stable, with mean annual decreases of 2.7 and 0.9%, respectively.5
As CV mortality has continued to decrease, one would expect these trends to have continued following study completion in 2007.
Diagnostic catheterization and percutaneous coronary intervention (PCI) in the Medicare population both peaked in 2004 (see Figure 5).7 Estimated total echocardiography procedures peaked in 2005.8 Total myocardial perfusion studies peaked in 2006,9 temporally coinciding with the release of the American College of Cardiology (ACC)/ American Society of Nuclear Cardiology (ASNC) appropriateness guidelines the following year.10 Annual decreases in myocardial perfusion imaging (MPI) from 2007 to 2009 were 2.1, 2.0, and 7%.9 This trend and the worldwide shortage of Tc 99m could presage a near doubledigit decrease in MPI in 2010.
Increasingly effective medical therapy in those with known CV disease and a more discriminating approach to the use of technology has also likely affected volume. A post-MI patient with a statin-related low-density lipoprotein of 60mg/dl on several other life-extending medications may well have a predicted annual event rate that a yearly MPI study is unlikely to influence. The increasingly used appropriateness criteria guidelines have incorporated such thinking. A greater focus on when and how to use diagnostic testing has led us to be more discriminating in the selection of patients for interventional procedures and cardiac surgery, and has also led to more selective use of diagnostic procedures. More effective and longer-lasting interventions such as the use of drug-eluting stents and arterial grafts have also contributed to a declining need for subsequent diagnostic and therapeutic procedures.
While we are unaware of data on the number of consultations, admissions, and follow-up hospital visits performed by cardiologists, fewer admissions in the Medicare population for MI, unstable angina, and CAD make a decrease likely.
Cardiac patients have been huge beneficiaries of secondary prevention and treatment efforts. Based on social security records, life expectancy following an MI was just under five years in 1984 and increased to six years in 1998.4 The advent of PCI-based therapy and other post-MI treatment options has likely resulted in an increase to much more than six years in 2010. Anecdotally, one of us saw a patient in the office in the week prior to completion of this article who had had their first MI when Lyndon Johnson was President and a second patient whose first and last MI occurred early in Ronald Reagan’s tenure. The implications of an increased lifespan are affecting the finances of the US government as it attempts to fund ever increasing Social Security and Medicare costs. However, the decreasing book of business is of great import to cardiologists. Common wisdom is that advances in CV therapy and the baby boom will increase the need for cardiologists.11 However, just as the polio vaccine and effective tuberculosis treatment changed the focus for pulmonologists a few generations ago, effective prevention and treatment of CV disease will affect the current and likely the next generation of cardiologists for years to come.