June 25th, 2013
What Will We Count in 30 Years?
Robert L Rosenthal, MD and James De Lemos, MD
From the perspective of today, cardiology 30 years ago was full of wrong ideas and practices. What will cardiology today look like in 30 years? In a paper published in the American Journal of Cardiology entitled “What We Counted,” Robert Rosenthal remembers practices that were once considered dogma but were later proven to be either incorrect or even harmful. He then speculates about which current practices will be judged in the future to have been misguided. James de Lemos interviewed Dr. Rosenthal for Cardioexchange.
de Lemos: Dr. Rosenthal, I thoroughly enjoyed reading your paper in the Am J Cardiol. I think it provides a great temporal context for “modern” cardiology. What prompted you to write this piece?
Rosenthal: I have always been interested in hearing how life was “back in the day”, stories told at first by my elderly relatives and recently by my patients, especially those who served in World War II. As a medical student, I was able to sit down with some great medical legends like H. Houston Merritt and Franz Ingelfinger, who enjoyed being asked what it was like for them to practice medicine when they were young. So I wanted to pick out some stories that I would tell if I was asked.
de Lemos: You seem to focus on history. What practical information can a young cardiologist learn from studying past practices in that field?
Rosenthal: No matter what field, cardiology or otherwise, I think you are at a disadvantage if you can’t place yourself in the context of time and appreciate what was understood and undertaken 20, 30, 40 years before you. As a specific example, all we had in our day were M-mode echos. Now, we don’t even perform or teach M-mode echo at our hospital. It is regarded as obsolete. But M-mode provides a more precise measuring and timing tool than current techniques. It will become a lost art like phonocardiography, which is a shame because both provide distinctive insights. Most current cardiology fellows would not even know what a phonocardiogram was.
de Lemos: When you look at contemporary cardiology, what are the current practices that you think we will look back on as useless or even dangerous?
Rosenthal: Of course, we don’t know now what will be looked on years hence as harmful or we wouldn’t be doing them, but I think we can be pretty certain that some of the things we do fall into that category. I did give examples in my article of practices that I think may become obsolete. I think we are seeing some of that evolve pretty rapidly in the field of lipids and so maybe 20 years from now people will be astonished to hear that doctors around the year 2000 actually focused on measuring and trying to raise the HDL. There are certainly a lot of fashions that come and go: coronary spasm and silent myocardial ischemia were very fashionable topics for a while, but now you don’t hear them spoken of much. Today’s fashions may be fractional flow reserve or diastolic dysfunction.
To our readers: Which of today’s practices or paradigms do you think will be looked upon in the future as folly?
7 Responses to “What Will We Count in 30 Years?”
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Finally we will know that the normal or physiological value of the cholesterol is much less that the values we considered today. We will manage a total cholesterol in no more than 100 mg/dl and a LDL-c in no more than 50 mg/dl or 70 mg/dl. With this values the incidence of cardiovascular disease will be much less than today.
http://www.fac.org.ar/1/revista/12v41n3/art_revis/revis01/corral_ingles.php
Hi, Pablo,
In your future hypocholesterolemic world people will die young, .. though in accordance to your “physiological” table.
The supercentenarians have cholesterol in abundance. Please read the Encyclopedia Britannica: “The metabolic state of centenarians is paradoxical. Several groups have found that healthy, functional centenarians have metabolic characteristics that are commonly associated with disease, such as unfavorable cholesterol profiles, with high concentrations of harmful substances such as triglycerides and low-density lipoprotein cholesterol (LDL-C) and low concentrations of the beneficial high-density lipoprotein cholesterol (HDL-C). They also have high levels of proinflammatory cytokines such as interleukin-6, and high levels of prothrombotic substances. Several theories try to explain these paradoxical findings.” (http://www.encyclopedia.com/doc/1G2-3402200067.html)
Hi, Antonio:
“My future world” is not hypocholesterolemic, is the “normal or physiological” world and people will live for more years than now a days.
The vast scientific evidence, shows that the human needs only 25 mg/dl of LDL to live, for the synthesis of the hormones and vitamins, and for the cellular membranes.
If you have time, please read my article, and you will find more real evidence about the cholesterol value.
http://www.fac.org.ar/1/revista/12v41n3/art_revis/revis01/corral_ingles.php
Remember, without abnormal cholesterol values, you can’t have atherosclerosis.
Best regards.
Pablo.
Thank you Pablo for suggesting me to read your paper, which I did which much interest. You wrote “The vast scientific evidence shows that the human needs only 25 mg/dl of LDL to live, for the synthesis of the hormones and vitamins, and for the cellular membranes.”… Surely, LDL is not the same as cholesterol. LDl is not cholesterol, rather it is a very complex system that contains a single apolipoprotein B-100 molecule, and carriers of cholesterol together many other substances that are vital to cells. As every cell in the body is able to manufacture cholesterol, carriers of cholesterol, as LDL is, cannot be considered a truthful proxy of cholesterol physiological cholesterol utilization by cells. Then, as you noted, if your “transport system” is down-regulated, cells are able to compensate for, at some extent. The question arises:”why cells are prone to manufacture at a such high levels such a harmful substance?”
In your paper you state: “Cholesterol values obtained from the umbilical cord of newborn babies show that human beings need and have values much lower than those reached in adulthood” Actually, LDL particles have a fundamental role as part of the immune system. Infants are vulnerable to infections, specially at TC concentrations bellow 200 mg/dl. Babies typically drink 750 mL/day, so a breastfed baby’s daily cholesterol intake is 100 to 200 mg). (http://www.nap.edu/openbook.php?record_id=10490&page=547). Healthy babies achieve serum cholesterol levels around the adult norm of 200 mg/dl by age six months. Formula-fed babies have lower TC than breastfed babies ( http://www.niaid.nih.gov/about/organization/dait/infantimmunityworkshop/Pages/default.aspx). People from the“hunting-harvesting” tribes” you refer have low average TC but also they die at young ages, namely from infectious diseases: See for instance (Beaglehole R et al. Cholesterol and mortality in New Zealand Maoris. Br Med J. 1980 Feb 2;280(6210):285-7. http://pmid.us/7357343. Free full text:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1600122/?tool=pubmed.)
In fact your physiological LDL-c taget, i.e. “the value of physiological LDL-c or in which the pathological subendothelial deposit of this lipoprotein will not occur from different points of view; next we show evidence that prove that the value of LDL-c should be between 30 and 70 mg/dl” cannot be achieved by over 95% of the world population, unless all these people are put on statins for the rest of their lives.
In your paper you state “After plenty of decades of discussion about the origin of atherosclerotic disease and with the indisputable lipid theory of atherosclerosis, nowadays we can state that the increase in cholesterol in blood, mainly LDL-c is the cause for the genesis and development of atherosclerosis [1-5]”.Actually there is also a “vast scientific evidence” in that cholesterol is not the direct culprit of heart disease. This is not true. Actually you ignore the “vast scientific literature” with evidences that the so-called LDL cholesterol is not the primary culprit of heart disease, which cause is much more complex as all of we know. I understand that it is comfortable to some of us to blame LDL cholesterol as the main culprit, though I believe that this diverts the attention of researchers and physicians from the real cause of heart disease.
In summary, I believe that all the “vast literature” (pro, against and in between the mainstream views) must be considered if we really want to reach progress in heart disease prevention and treatment. Stay open-minded!
Dear Antonio, thanks for your answer.
Actually I think we disagree on several points.
1 – The deregulation of cholesterol levels (LDL-c specially) is clearly the major cause of atherosclerosis and cerebrovascular disease. Smoking, diabetes, arterial hypertension can function as adjuvants, but without lipid alteration, there is no atherosclerosis.
2-There is no firm evidence to show that individuals with LDL-c levels between 30 mg / dl and 50 mg / dl have greater predisposition to die from infections.
3-It is true that children quickly reach adult level of cholesterol, but also it is known that fat striations, primary lesion of atherosclerosis, begins at a young age.
4-The interesting article by BMJ date of more than 30 years, and there is already ample evidence that the lower the cholesterol level is better. No J curve for cholesterol levels, unlike with blood sugar and blood pressure, so back to say that the lower the cholesterol level is better and the sooner the better.
5-Stay open minded, but also read and look what current evidence shows. Studies such as TNT, JUPITER, PROVE IT TIMI 22, REVERSAL and ASTEROID have shown no adverse effects reaching very low levels of LDL-c.
Please read this wonderful editorial summarizes much of the above.
http://ac.els-cdn.com/S0002914910019545/1-s2.0-S0002914910019545-main.pdf?_tid=3be368e0-e1e5-11e2-aa8b-00000aab0f6c&acdnat=1372638724_cc1f96f582e12021f6d15e6dcfd99903
http://www.ncbi.nlm.nih.gov/pubmed/21029840
Best regards.
Pablo.
In 30 years we will no longer exclusively be using a “one size fits all” approach using data from randomized studies of “controlled groups of of people”. On the contrary we will be using a genetically personalized approach specifically geared to the actual genetics behind whatever problem we are dealing with in the person we are treating. Eventually, the “N=1” study will be as important as the broad statistical randomized trial.
I can already see this beginning to happen in oncology and it will eventually spread to the other chronic non communicable disease treatments as well as perhaps infectious diseases.
In 30 years the medicine will be corporative, all physician will be employes. We will have a drought of talent. If you want to pursue a investigation or clinical career you will need to sell your soul to a big companie. The insurance companies, Heath corporations and government will dictates the Heath policies and revenues. We will be old, very old and remember our teachers, I will be nostalgic but everybody will say we are archaic and they are better without us. They will have recipes or as they call them protocols and if you follow them you will be free of any criticism and generate big revenues to the corporations. We will never knew if a medicine or procedure is adequate, the lobbyist will do. If you challenge anything they will say you don’t have the the background or knowledge to give an opinion, only them. We will just survive but the insurgence company will charge stratospheric bills and blame the physicians. The medicine will be a big business for insurance and health corporations and a nightmare for the humanity. Or maybe not… Hope for the best and prepare for the worst.