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People's cardiovascular health hasn't been going well for a few decades and that's nothing new. This debate gained strength in the early 2000s, as experts confirmed the main risk factors for heart disease. Even so, the efforts so far have not been enough: not only have the numbers not improved in recent years, they have worsened and the future seems to follow the same line.
According to the report ”Global Burden of Diseases” (GBD), from 1990 to 2022, deaths due to heart diseases increased 39.4% around the world. In other words, we are talking about a scenario that affected 12.4 million people and now impacts more than 19 million.
Meanwhile, in Brazil, the cardiometer from the Brazilian Society of Cardiology (SBC) estimates that by the end of the year, at least 400,000 Brazilians would have died as a result of this scenario. For better visualization, imagine: that's at least 1100 deaths a day, 46 people per hour, 1 every 90 seconds.
Another indicator of the worsening of the scenario is the fact that cardiovascular diseases currently cause more deaths than all types of cancer combined. Thinking about a comparison, it can be said that mortality from cardiovascular diseases:
- It exceeds the mortality of cancers;
- it is 2.3x greater than external causes (such as accidents and cases of violence);
- 3x higher than respiratory diseases;
- and 6.5x higher than all infections (including AIDS).
In addition, the article from 2023 of the Brazilian Society of Cardiology (SBC), indicates that the direct and indirect costs of cardiovascular diseases are generating costs of 10 billion dollars for the supplementary health system. To arrive at this estimate, global data were considered, in addition to the fact that public institutions serve more than 70% of the brazilian population and that in the private system the combination of direct and indirect costs can be up to 5 times higher than the direct cost in the SUS.
“Evaluating Brazil and the rest of the world, cardiovascular diseases kill the most. In this, we have two main actors within this group of cardiovascular diseases, the infarction and the stroke”, start Diandro Mota, cardiologist who is a member of SOCESP (Society of Cardiology of the State of São Paulo) and medical director of the startup Neomed. “We no longer consider this scenario an epidemic, it's an endemic issue. It's data that doesn't come from today, it doesn't come from yesterday, it's already long-standing. What we need is to join forces to change this reality,” says the cardiologist from SOCESP.
But after all, how did we arrive at such high numbers?
Risk Factors
As a matter of fact, some conditions can be genetically inherited. However, when it comes to the heart, there are a significant variety of risk factors that can influence even more than gene inheritance.
To understand cardiovascular diseases, we first need to divide them into two groups: the first are conditions affecting the hearted itself, while the other mainly affects the blood vessels — that is, circulation.
Next, we must consider that they are uncontrollable factors: age, ethnicity, gender, and family history. In parallel, there are at least 8 controllable factors, which are also the key influencing elements when it comes to cardiovascular health.
According to Diandro Mota, the answers, in general, are already there. “The scientific literature has already detected that 90% of all cases of first heart attack are associated with controllable health factors,” says the expert. Therefore, it is possible to manage:
- cholesterol levels;
- smoking;
- hypertension;
- overweight in the central abdomen and obesity;
- feed quality;
- alcohol consumption;
- diabetes;
- psychosocial factors (stress, anxiety, and depression).
That is, we are mainly talking about a population perpetuating an unhealthy lifestyle.
Challenges within the office
Inside the office, there are two main challenges for the doctor: to help the patient to establish habit changes and to adhere correctly to drug treatment.
Encouraging the change of habits
Although most factors are controllable, “habit change is not an easy thing to do,” says the cardiologist. He continues, explaining that cardiology care would benefit from the application of behavioral science strategies, so that the patient can truly transform their treatment into habits.
“We are used to saying that every unhealthy behavior has a history. That's because there is a context in which it began and they have a purpose in a person's life,” explains Mota. Thus, the use of new tools and strategies to understand with the patient how the clinical condition reached that point can optimize interventions in the office.
This difficulty is mainly due to the fact that the lifestyle of each individual is composed of several pillars, which makes this entire process end up resembling “the assembly of a puzzle”, as the member of SOCESP says.
“Every cardiologist who works with prevention must: take data from the patient, from their personal history, data from the patient's family history, information from the detailed physical examination and combine with other information from complementary exams, which are essential to assemble this puzzle”, explains Diandro.
With a process so complex and rich in detail, it has been increasingly common to use monitoring by wearable devices and use of predictive algorithms. The combination of these technologies helps to stipulate the risks that patients face in the coming years, answering questions such as: when will a heart attack occur? What is the risk of having a stroke? What is the risk of a heart attack?
Drug adherence
Even within the office, proper medication adherence is also a challenge. “When we talk about adherence, we refer to the percentage of patients who follow medical prescriptions correctly, using medications for 80% of the recommended time,” explains Diandro Mota.
For example, a patient who has a heart attack and is discharged from the hospital usually leaves the hospital with the guidance of treating himself with five medications. “However, when we reevaluated this patient a year later, we found that more than 50% of them are not using even two of the recommended medications. This reveals very low adherence, which is a serious problem, because without secondary prevention, the risk of a second heart attack or stroke is very high,” says the member of SOCESP.
Considering these challenges, the latest in cardiology is welcome. Let's see below.
The latest in cardiology
Innovative medicines
With regard to drug treatments, innovations for metabolic diseases also help the cardiology sector. In 2024, we see the arrival of new substances, which recall the functioning of Ozempic, but with a focus on lowering cholesterol instead of diabetes.
“One of the main advances is the class of injectable drugs known as inhibitors of PCSK9. These medications are administered by subcutaneous injection and have been shown to be highly effective in aggressively reducing LDL cholesterol, the 'bad' cholesterol,” explains Roberto Cury. In practice, injectable treatment should represent a major step forward in the adherence and control of drug treatments.
On the other hand, the cost is still high. Which means that a significant portion of the population may not access these medications. “It is crucial that there be greater competition in the market so that these drugs become more affordable and can benefit a larger number of people,” adds the cardiologist.
Other technologies for cardiology
“If we look at the last 20 years, we have made great progress in the early detection of cardiovascular diseases,” says Roberto Cury, cardiologist, CEO of Virtual Core and medical and patient experience director at DASA.
In Cury's view, the highlights go mainly to chest tomography for evaluation of Score Of calcium. “This is a non-contrast tomography that measures the amount of calcium present in the coronary arteries, allowing the creation of a cardiovascular risk score based on the age, race and sex of each patient. The higher the calcium level, the greater the individual's chance of having a cardiovascular event, such as a heart attack or heart failure,” explains the CEO of Virtual Core.
The cardiologist also reiterates that this type of examination complements the traditional cholesterol assessment. For example, “if the Score If calcium is above 400, this indicates that cardiologists need to be more aggressive in their treatment and use medications such as statins (rosuvastatin or simvastatin) to lower LDL cholesterol levels to less than 50 or 70, depending on the patient's risk. This personalization in treatment is an example of precision medicine“, explains Roberto Cury.
In addition, it highlights the evolution in the evaluation of patients with symptoms of chest pain. “In the past, we used scintigraphy, ergometric testing and, in more serious cases, catheterization. Today, with coronary angiotomography, we are able to evaluate the composition of plaques in arteries, such as fatty plaques, and identify whether they are stable or unstable. This allows us to intervene early, avoiding complications. If the obstruction is greater than 70%, for example, we recommend catheterization and, in some cases, angioplasty or even heart surgery,” she adds.
New guidelines
At the end of August this year, the annual congress of the European Society of Cardiology (European Society of Cardiology, ESC) presented a series of new medical guidelines, bringing important updates on atrial fibrillation, chronic coronary syndromes (ETC.), peripheral artery disease (DAP) and aortic diseases and hypertension.
Below, we highlight the main points of the new guidelines. For more detailed information, we recommend the e-book developed by specialists from the continuing education platform MedHealth, in partnership with CardioRReview.
- Hypertension
One of the most notable changes was the revision of the concept of “ideal blood pressure”, which was traditionally considered the famous “12 by 8” (120x80 mmHg). This measure has now been reclassified and is no longer seen as an ideal pressure indicator. In the new Systemic Arterial Hypertension (SAH) guidelines, a new category called “high blood pressure” has emerged, which covers people with values between 120-139x70-89 mmHg. This means that the “12 by 8” pressure, previously considered normal, is now in a subcategory that, although it does not constitute hypertension, is also no longer seen as ideal.
Another significant change is related to the diagnostic criteria in the office. To avoid errors caused by the so-called “white coat hypertension” - when the patient's blood pressure rises solely due to the anxiety of the doctor's appointment - it is now recommended to use measurements using MAPA (Ambulatory Blood Pressure Monitoring). In addition, measurements greater than 139x89 mmHg are already indicative of hypertension, and treatment can be initiated as early as the first consultation.
- Atrial Fibrillation
The main innovation regarding atrial fibrillation was the introduction of the AF-CARE protocol, which provides an approach more focused on comprehensive patient care. This protocol includes:
- C (Comorbidities): Assessment of associated comorbidities;
- A (Anticoagulation): History of stroke or embolism;
- R (Reduce Symptoms): Reduction of symptoms;
- E (Evaluate): Continuous patient assessment and reassessment.
The focus is on more patient-centered care, considering their risk factors and general condition, and not just the control of arrhythmia.
- Chronic Coronary Syndromes
In the field of chronic coronary syndromes, the changes were significant. The disease is no longer considered an exclusively physiological condition, but rather a cardiovascular alteration at a micro and macroscopic level. In addition, regular aerobic exercise, lasting between 120 and 140 minutes per week, was now recommended as a fundamental part of the treatment. Another novelty was the inclusion of new drugs in the protocol, such as the inhibitors of dapagliflozin (ISGLT-2) and semaglutide (AGLP-1), which have shown benefits in the management of patients with cardiovascular diseases.
- Peripheral Artery Disease and Aortic Diseases
In the new guidelines for peripheral artery disease and aortic diseases, there has been a change in the treatment approach. Now, the need to manage these conditions comprehensively, considering the patient's entire arterial circulation, is emphasized. That is, if there is a problem in an artery, treatment needs to take into account the entire circulatory system, rather than focusing only on the specific site of the obstruction.
These updates reflect an advance in diagnostic and treatment approaches, with an emphasis on personalized medicine and comprehensive patient care.
Health technologies in Brazil
“In Europe and the United States, technological adoption for early diagnosis and advanced procedures is widespread. In Brazil, the main health centers are closely aligned with the best hospitals in the world when it comes to supplementary health. However, when we talk about public policy in the SUS, we have seen significant advances, but still at a lower level than what we observed in supplementary health, and this is largely due to investment issues,” explains Roberto.
Along with this, there is also the issue of uneven distribution of these technologies throughout the states and regions of the country. The farther away from urban centers, the more difficult it becomes to access cutting-edge technologies.
Therefore, “Brazil has good technologies comparable to the best in the world, but the great challenge is to ensure a more equitable distribution of these innovations throughout the country”, concludes Roberto.
The market and the future of cardiology
In the view of the CEO of Virtual Core, the cardiology market will always be aimed at improving medical devices and procedures. However, currently, the focus is on optimizing technologies that allow diagnostic and early treatment, “which means that the number of people having a heart attack or experiencing serious cardiological complications tends to decrease,” says the specialist.
This implies that, in the long term, the need to perform invasive procedures such as catheterization, angioplasty or heart surgery must cease to be something so frequent. “If we look at the volume of heart surgery 30 years ago, it was much higher than today. This is due to the advancement of less invasive procedures, such as catheterization and angioplasty with stents, which have taken the place of many heart surgeries,” Cury points out.
For the cardiologist, “this is the future of cardiology”, he reinforces. “As the population ages, especially looking at 2030 or 2050, we will see an inversion of the age pyramid in some countries. This should increase the prevalence of arrhythmias and cardiovascular diseases, especially atrial fibrillation.”
Consequently, cardiologists are betting on increasing procedures related to these conditions. “While we see this evolution toward less invasive methods, there will still be a balance. Early diagnosis will be crucial to reduce comorbidities, and doctors who dedicate themselves to this will play a fundamental role in the preventive care of their patients,” he concluded.
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