March 21, 2025
In the last 50 years, vast prevention and treatment strides for cardiovascular disease have brought new possibilities. But cardiovascular disease is still the leading cause of death worldwide, cautions Bernard J. Gersh, M.B., Ch.B., D.Phil., consultant in Cardiovascular Medicine at Mayo Clinic in Rochester, Minnesota, and an emeritus professor of medicine and cardiology at Mayo Clinic College of Medicine and Science.
The future looks different.
The cardiovascular expert sees positive change ahead with novel advances for patient care. Here, Dr. Gersh delves into the developments set to transform cardiovascular medicine and bring better outcomes for more patients.
New prevention and risk stratification approaches
We've had huge advances in predicting who is at elevated risk of cardiovascular disease. The next 10 to 20 years will be dominated by primary, secondary and primordial prevention. This is because we now have innovative approaches to risk stratification using genetics, sophisticated imaging, scans and other modalities that use artificial intelligence (AI). For example, with some imaging techniques we can look at inflammation in the arterial wall, which we couldn't do 5 to 10 years ago. What this means for prevention is we'll increasingly be able to identify people at high risk earlier and more precisely.
With these risk-stratifying tools of imaging, AI and genetics, there's potential for people to know their risk of heart disease before symptoms appear. We're going to see polygenic risk scores for cardiovascular disease. Polygenic risk scores are tools developed by scientists that analyze multiple genetic variants across a person's genome. They help access the likelihood of developing a condition. In the future, experts could potentially use the risk scores to customize prevention and treatment strategies and improve diagnosis.
RNA-targeted therapies
There will be a shift from traditional pharmacological approaches to using RNA-targeted technology. The RNA-targeted therapeutics are unequivocally going to play a prominent if not a revolutionary role in the near future. Rather than just lower cholesterol, the therapeutics will treat biological systems underpinning disease entities. With these more-precise RNA-targeted therapeutics, we can get into the biological system that causes higher cholesterol, hypertension and other conditions. We're on the cusp of some of these advances already in the clinical arena.
- Dramatic lipid lowering. Why is cardiovascular disease still the leading cause of death worldwide? Human beings have high lipid levels and become hyperlipidemic. But we're getting close to therapies that can lower serum cholesterol levels to unprecedented levels. The clinical trials are ongoing right now, and for some of these new drugs we already know how much they can lower cholesterol. We're waiting another year or two to see whether the results show a striking reduction in cardiac events, and that will be the last piece of the puzzle.
- Treating hypertension. We can also use RNA technology to develop targeted therapeutic agents for hypertension, and several new antihypertensive agents are currently undergoing clinical trials. Hypertension is extremely common in the United States and around the world. Many Americans with hypertension don't take their medications. The new drug may only need to be given twice a year.
Complex interventions
We'll see a profound impact on percutaneous structural interventions on the prognosis of valvular heart disease, especially the tricuspid valve. Technology advances such as transcatheter aortic valve replacement (TAVR) and angioplasty will continue. TAVR is the first step in what will evolve over the next decades. We've moved from the aortic valve to the more complicated mitral valve. We now have percutaneous treatments for mitral valve regurgitation.
The next fruit on the tree is the tricuspid valve. This is much more complex. But tricuspid valve replacements are already being tested in clinical trials, and some have been approved by the Food and Drug Administration. We will see earlier intervention for the unnatural history of the disease with improved outcomes. It won't prevent tricuspid and aortic mitral valve disease, but it will change the course of the disease for the better.
Gene modification
Researchers can understand the genetics of disease by studying the effects of DNA variants between people. The CRISPR-Cas9 (clustered regularly interspaced short palindromic repeats and CRISPR-associated protein) system is a widely used gene-editing tool. It allows researchers to precisely change the sequence of a genome and study the effects on cellular function.
The role of CRISPR-Cas9 editing is significant to stop disease before it starts, or in some patients, modify disease already present. This technology suggests that in diseases that have a genetic etiology, there is potential to modify that gene in utero or early in life. For example, if a person is born with the gene for hypertrophic cardiomyopathy, it may take 10 years for the disease to clinically manifest. But specialists can prevent the disease by altering the gene. Clinical trials are in progress. We have a long way to go, but this is part of the future.
Challenges and obstacles
Early detection and focused interventions can transform healthcare, but there will be obstacles to overcome:
- Social and economic disparities. In the U.S. and around the world, there are social and economic disparities that have an impact on the outcomes of cardiovascular disease. Despite new technology, these disparities and income inequality could have a major negative impact.
- Lack of compliance. There are large numbers of people not taking their medications or the prescribed amount, and this is particularly the case with antihypertensive agents.
- Diabetes and obesity. The epidemic is rampant around the world.
- Misinformation. Resisting science and spreading misinformation are huge impediments to global health.
- Impact of climate change on cardiovascular diseases. The loss of life expectancy from air pollution is about the same as tobacco smoking. In many parts of the world, pollution levels are already at unacceptable levels. Climate change influences the cardiovascular system. It can trigger inflammation, clotting, hypertension and mental stress — all risk factors for the development and adverse prognosis of cardiovascular disease.
- Cost. Who is going to pay for what is needed in the future?
Strategic change
With the techniques for predicting who is high risk more precisely, we'll overcome the barrier of treating people earlier. For those with a family history of coronary disease, there's been a resistance to treating people in their teens and 20s. But that will change.
Many diseases, such as atherosclerosis, begin early in life. If we're going to prevent them, our strategies need to change. The time to reduce cholesterol is not when people are 65 years old; it's when they're 20. We'll have better drugs, and we'll need to learn to give them earlier. The future of cardiology is exciting, and perhaps we're close to a therapeutic revolution.
For more information
Refer a patient to Mayo Clinic.