The Evolution of Vascular Medicine
When the ACC was founded after World War II, the chief breakthrough in medicine was the advent of antibiotics. These new, transformative drugs resulted in the overthrow of infectious disease as the nation’s leading cause of death and cardiovascular disease emerged as the new top killer. This swift rise to prominence along with innovations in research, technology and widespread availability of health insurance, worked to shape cardiology into a major academic and clinical discipline.
Now over 65 years later, cardiovascular medicine has evolved to include a myriad of sub-specialties ranging from interventional cardiology to geriatrics. In the last 30 years, vascular and endovascular medicine have taken off as majorly important components of cardiology.
When the College originally formed its Peripheral Vascular Disease Committee in 1988, the majority of vascular disorders were being treated by physicians without formal vascular medicine training. But as training has evolved from cardiology to cardiovascular medicine, there has been a marked change in the increased emphasis of the “vascular” component. In line with this shift, dedicated fellowships in vascular and endovascular medicine are now available.
“Vascular medicine has become a much bigger part of cardiovascular medicine since I completed my interventional training in 2003,” notes Herbert Aronow, MD, MPH, FACC, chair of ACC’s Peripheral Vascular Disease Member Section. “There were already a number of funded vascular medicine training programs in the U.S., however there were few emerging interventional cardiology fellows with expertise in both vascular medicine and endovascular intervention. Today, interventional fellows who complete an additional year of vascular training, typically finish with expertise in reading non-invasive vascular studies, and diagnosing and treating a panoply of arterial, venous and lymphatic diseases.”
Likewise, many cardiovascular medicine fellows desiring to specialize in vascular medicine, but not endovascular intervention, will pursue an additional year of vascular medicine training, during which they acquire all of these non-interventional competencies.
This shift among interventional cardiologists to become experts in both vascular medicine and endovascular intervention and the expansion of vascular medicine training opportunities for non-interventional cardiovascular medicine physicians was brought on by a desire to become full-service vascular providers. Cardiovascular specialists now manage the diagnosis, medical treatment and revascularization of many patients with these conditions – mitigating less-organized treatments.
In addition to changes in the way cardiologists are now trained, vascular medicine has also seen a number of medical breakthroughs.
Newer and more potent antiplatelet agents and the advent of PCSK9 inhibitors may help prevent atherothrombotic events in the high-risk peripheral artery disease population. Safer and more effective oral antithrombotic therapies have revolutionized the care of those with, or at risk for, venous thromboembolic disease. Broader use of exercise training in addition to revascularization has further improved quality of life and functional status among patients with claudication. A number of innovative devices have been shown to increase long-term patency following peripheral vascular intervention, including drug-coated balloons and drug-eluting stents.
There has been a paradigm shift in how critical limb ischemia is approached, with renewed emphasis on revascularization to facilitate limb salvage and newer techniques, such as ‘tibiopedal’/’retrograde’ access, to facilitate percutaneous revascularization of complex below the knee disease. Randomized trials have demonstrated the efficacy of percutaneous thrombectomy for reducing death and disability associated with acute stroke. Further, catheter-based approaches to deep venous thrombosis and pulmonary embolism may reduce the morbidity and mortality associated with venous thromboembolic disease.
These innovations have been huge in moving the field forward and as medicine continues to advance, it begs the questions: What’s next? What is on the horizon?
“Technologies appearing in the short term are apt to be procedural in nature, and include the use of bioresorbable vascular scaffolds for stenotic atherosclerotic vascular disease, lower profile devices that allow for treatment of complex aneurysmal disease without the need for an open surgical approach and an array of device therapies for treating uncontrolled hypertension,” says Aronow. “In the long term, I truly hope that vascular medicine will be about population health and disease prevention. That includes earlier introduction of exercise and heart-healthy diets, smoking cessation efforts beginning in the teenage years, and broader use of life-saving medical therapies for those with clinically manifest atherosclerosis.
“These efforts would go a long way toward addressing the massive burden of peripheral vascular disease and its associated adverse outcomes,” he adds.
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