“Caring for vascular patients is going to take a team,” concluded Marc Bonaca (Boston, USA) at the 2019 Vascular Interventional Advances (VIVA) conference in Las Vegas, USA (4–7 October). Bonaca opened the conference with a presentation on the major demographic trends in vascular disease “from head to toe,” as part of a session on the most controversial clinical challenges of 2019. He argued that physicians “as a community” need to tackle continuing issues with health disparities and increasing costs and urged delegates: “Do not be an island”.
Bonaca began by highlighting an “important trend” in cardiovascular mortality, which he noted rose steadily until the 1970s and 1980s, when the level plateaued. “We have made progress in cardiovascular mortality,” he said, “until recently”. He remarked that there has been a recent uptick in mortality attributable to diseases of the heart. “[Cardiovascular mortality] is slightly increasing and it is poised to increase more as our population ages,” he told delegates. “It is still the leading killer”.
Bonaca also mentioned diabetes and obesity as “key drivers” of vascular disease. He detailed that the majority of men and women are either obese or overweight and that there is a trend towards this becoming more common. He also commented that, while there is a geographic heterogeneity with regards to diabetes and obesity, “there is really nowhere safe”.
On a more positive note, Bonaca acknowledged that there are now better preventive therapies available for patients with vascular disease. For example, the recognition that LDL cholesterol is a toxin and that it can be modified has led to progressively lower rates of cholesterol in the population with drugs such as statins. In addition, public health efforts recognising the harms of smoking have led to lower rates of cigarette use. He did, however, remark that there has been a recent increase in e-cigarettes “of unknown significance”. Bonaca detailed geographic trends here too, with the use of tobacco products, for example, being more widely used in the South and South East of the USA.
After establishing that people are in general smoking less and have better cholesterol control, but at the same time there is more diabetes and more obesity, Bonaca posed a number of questions: “How do these trends drive vascular events and what we are going to see in our vascular patients?”. Considering the issue from a “head to toe” perspective, he began by remarking that there have been reductions in stroke and stroke mortality. “We have seen a 13% reduction in the incidence of stroke in high income countries,” he noted, however, the same cannot be said for low and middle income countries. Again, however, while there have been reductions in stroke mortality due to better prevention techniques and better treatment, “there is significant geographic heterogeneity,” he remarked.
Bonaca mentioned that, as a result of the lower rates of stroke and stroke mortality, we have also seen lower rates of carotid procedures and endovascular approaches. Similarly, the incidence of acute coronary syndrome is decreasing, as is the mortality for this disease. “More importantly,” he commented, “I think that we see the type of acute coronary syndrome shifting.” For example, “in the setting of diabetes we see fewer young patients coming in with their first STEMI [ST-elevation myocardial infarction] but we are now seeing older patients with multi-vessel disease, and multiple comorbidities”.
Furthermore, Bonaca noted that venous thromboembolism (VTE) is increasing and that “this is intuitive if you think of the relationship between VTE and obesity, age, and the inflammatory milieu associated with diabetes”. He posited that this trend may shift as we see better long-term preventive options, but, for now “VTE is on the rise”.
He mentioned that atrial fibrillation (AF) is also increasing, adding that “not only is the prevalence [of AF] expected to increase, but there may be a logarithmic increase, because AF is now increasingly detected and there is an increased incidence of the risk factors.” He detailed that as AF is closely associated with body mass index (BMI) and diabetes, which are both increasing in prevalence.
“We are also seeing more peripheral arterial disease [PAD],” he informed delegates. Bonaca referenced data from Fowkes and others, published in the Lancet in 2017, which shows that, between 2000 and 2010, there was a 23.5% increase in the prevalence of PAD. “There are over 200 million cases of PAD globally and this number is expected to rise, particularly in the setting of diabetes,” he commented. However, he noted that we must recognise that what PAD looks like may shift from younger smokers to obese patients with diabetes and more comorbidities.
Bonaca then made some observations about demographic trends in critical limb ischaemia (CLI). “We do not see reductions in the number of CLI cases and perhaps that is because of the increasing prevalence of diabetes,” he posited. “Stable CLI admission rates show that we are not doing enough to prevent CLI, but we see decreasing rates of amputations and decreasing mortality,” he added. However, he noted that the demographics of the patients presenting with CLI suggest that this cohort are “sicker than they used to be”. He detailed that, in CLI patients today, there has been an increase in hypertension, a threefold increase in obesity, there is more diabetes, over a third hve chronic kidney disease, and almost one in five has had a prior amputation.
In addition, chronic kidney disease—what Bonaca described as “a form of microvascular disease closely associated with diabetes and hypertension”—is steadily increasing. He remarked that, “with vascular disease, whether it is VTE, PAD, stroke, or any cardiovascular disease, we are going to see a lot of chronic kidney disease, which adds complexity and adds risk”.
Moving beyond demographic factors, Bonaca also briefly discussed economics, suggesting that cardiovascular disease will “drive up costs” as the population ages. “That is going to be a challenge in our space,” he speculated. Furthermore, he considered the development of novel therapies. “We are lucky to live in an age where we not only have statins but we have PCS-K9 inhibitors, we have rivaroxaban for CAD [coronary artery disease] and PAD, and we have new diabetes drugs,” he said. Despite all these developments, however, Bonaca believes there are many as yet unanswered questions in the field: “How do you manage all these drugs? How do we manage polypharmacy? And how do we best take care of our vascular patients?”, he enquired.
To summarise demographic trends in vascular disease “from head to toe,” Bonaca detailed that, on a positive note, we are seeing fewer young patients presenting with STEMI or stroke in the setting of reduced smoking and better risk factor control. “But overall, we are seeing a greater burden of disease in the setting of an ageing population, more obesity, poor diet and activity, and diabetes,” he said.
“Our patients are going to be more and more complicated. They are going to have more comorbidities, more polyvascular disease, more chronic kidney disease. Concomitant AF and heart failure is going peripheral artery disease but it is going to be PAD in the setting of diabetes, probably more tibial disease, more microvascular disease, more CLI,” he detailed. Furthermore, he said “polypharmacy is going to be a challenge. There are going to be overlapping indications your patient is going to have PAD, a history of pulmonary embolism [PE], and AF.” Finally, “you are going to have to contend with different doses, pressures to prioritise—do we add the antithrombotic first or the lipid lowering therapy?”
After delineating the current demographic landscape facing vascular specialists, Bonaca ended the presentation by putting forward the idea that a “key trend” going forward will be the increasing need for multidisciplinary care teams in integrated systems of care, indicating that teamwork will be the best way to tackle the challenges ahead.