This year, Cleveland Clinic marks its 20th anniversary as the nation’s top-ranked center for cardiology and heart surgery in U.S. News & World Report’s “Best Hospitals” rankings. The cardiovascular specialties have seen remarkable changes over that time. Many treatments that held high promise in 1995 have lost favor. New and unexpected hypotheses have emerged. Some long-standing controversies still simmer. Others have been laid to rest by rigorous studies.
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The continuing overall decline in deaths from cardiovascular disease is proof that cardiovascular specialists have not labored in vain over the past 20 years. Yet cardiovascular disease is still the developed world’s top killer. And without significant breakthroughs, the demographic realities of age, obesity and harmful lifestyles will soon overwhelm us with cases of diabetes, coronary disease and heart failure. Much more remains to be done.
But now is a good time to take heart from the major advances in our field over the past 20 years — and to take stock of a few surprising bumps along the road to progress. We’ve assembled below a sampling of 50 key developments in cardiovascular care from the past two decades. The list includes advances and discoveries as well as a few course corrections. And we’ve thrown in a few past covers from Cleveland Clinic’s long-standing Cardiac Consult newsletter as signposts along the way.
The list is far from definitive, so take a look and tell us which developments we’ve missed in the Comments section at the end or at #CleClinicHeart50.
Two decades, 50 developments
- The plaque-rupture hypothesis is widely accepted as the cause of heart attacks.
- Ventricular assist devices (VADs) get smaller, more efficient and more implantable.
- A new generation of totally implantable artificial hearts is under development at Cleveland Clinic and other centers, including several nonpulsatile devices.
- As pacemakers and other implantable devices proliferate, Cleveland Clinic and other centers refine the complex procedures for extracting device leads that become defective or infected. Success rates for lead extraction now approach 99 percent.
- Stenting becomes a commonplace adjunct to angioplasty in the treatment of coronary disease. Stents themselves progress — from bare-metal designs to coated and drug-eluting models and then to bioabsorbable designs — in the quest to slow restenosis.
- Perception of HDL’s role in atherosclerosis is drastically revised as studies fail to prove that raising HDL levels can control cardiovascular disease. Closer investigation reveals a “bad” form of HDL that contributes to the formation of unstable plaques. Cleveland Clinic-led studies provide essential data.
- Open heart surgery, the very definition of a major operation, is challenged by minimally invasive approaches, including robotic, thoracoscopic and beating-heart procedures. Today many operations have minimally invasive alternatives.
- Research at Cleveland Clinic and other centers comes to focus more on understanding inflammation and oxidant stress in the development of atherosclerosis.
- Hybrid operating rooms enable new combinations of exo and endocardiac procedures. Thoracic aortic repair, transvascular aortic valve replacement, coronary artery bypass plus angioplasty, and other procedures can now be performed simultaneously or in sequence.
- Cardiac troponin T levels are found by Cleveland Clinic researchers to be a powerful independent risk marker for patients with acute myocardial infarction.
- As new cancer therapies improve survival, more patients live long enough to suffer the negative effects of damage to the heart from radiation and chemotherapy — and cardio-oncology emerges as a new subspecialty.
- Studies at Cleveland Clinic uncover an association between the use of COX-2 inhibitors and death from heart disease. The drugs’ use is restricted, preventing millions of premature deaths.
- Portable defibrillators become common in stadiums, airports and other public places.
- Endovascular stent grafting increasingly replaces open surgical repair of abdominal aortic aneurysms. Key innovations take place at Cleveland Clinic.
- The cardioprotective benefits of aspirin are generally accepted, but broad consensus remains elusive on who should take regular aspirin and at what doses.
- Intravascular ultrasound becomes a powerful research tool, enabling precise measurements of plaque regression in high-profile clinical trials designed and led at Cleveland Clinic.
- The time it takes the heart rate to return to normal after exercise is found to be a valuable diagnostic and prognostic tool by Cleveland Clinic-led research.
- The left atrial appendage becomes a target for surgical and endovascular closure techniques designed to prevent the escape of stroke-causing blood clots. A left atrial appendage clip designed at Cleveland Clinic is approved by the FDA.
- Niacin gains favor for its ability to raise HDL levels, then loses favor as later studies suggest health risks.
- Awareness of women’s heart disease increases, along with recognition of its particular manifestations and the need for more woman-specific heart disease studies.
- Studies show that statins can reduce the risk of a major cardiac event in patients with diagnosed disease. Key research is designed and led at Cleveland Clinic.
- High-dose statin therapy is proven by Cleveland Clinic studies to halt and even reverse the progression of atherosclerosis and improve survival by reducing LDL levels and possibly lowering inflammation.
- Cardiac imaging modalities expand to include echo, nuclear imaging, cardiac magnetic resonance and CT. Cross-training among these options is encouraged, as specialists work to find the most efficient and effective mix of options for each patient.
- Dyspnea is linked to coronary artery disease in Cleveland Clinic-led research and is shown to be a significant independent predictor of death from this and other causes.
- The special risk posed by trans fats in the diet is recognized.
- C-reactive protein emerges as a potent marker of inflammation and heart disease.
- Adult stem cells can, for the first time, be guided into becoming cardiac cells capable of repairing damaged tissue.
- Transfused red cells stored more than two weeks are found by a Cleveland Clinic study to be associated with greater postoperative complications and mortality.
- Reduction left ventriculoplasty (the Batista procedure) to surgically reduce ventricular mass in patients with congestive heart failure is introduced to America; when it does not achieve acceptable outcomes, most hospitals discontinue its use.
- Beating-heart surgery techniques improve. Today 15 to 20 percent of all coronary artery bypass operations worldwide are performed on a beating heart.
- Large-scale, prospective, randomized, multicenter international trials demonstrate their power to assess and compare the effectiveness of a multitude of treatments. Studies led by Cleveland Clinic’s C5 Research (STAMPEDE, REVERSAL, EPISTENT, CAMELOT, GUSTO V and many more) define what works and what doesn’t.
- Carotid stenting emerges as a complementary alternative to endarterectomy for patients with carotid artery stenosis, offering outcomes similar to those with the surgical approach for many patients who are less well-suited to surgery.
- Surgeons develop blood-sparing and blood-free techniques for major cardiac procedures. Cleveland Clinic research shows that the risk of complications and mortality rises with blood transfusions.
- Branched endovascular stent grafts are successfully implanted to treat complex aneurysms in the aortic arch.
- Recognition mounts of the persistence of heart health disparities among socio-economic groups, with disadvantaged patient groups having greater disease burden and poorer treatment outcomes.
- Vest-like, wearable cardioverter defibrillators are successfully used in patients with heart rhythm disorders.
- High-volume cardiac surgery centers like Cleveland Clinic are able to repair 99 out of 100 cases of mitral valve regurgitation due to prolapse, with minimum mortality.
- New oral anticoagulants — i.e., direct thrombin and direct factor Xa inhibitors — join vitamin K antagonists like warfarin for the medical prevention of stroke-causing blood clots.
- Normothermic ex vivo perfusion-based organ care systems (“heart in a box”) enable procurement teams to travel longer distances to collect suitable hearts and lungs for transplant.
- Cleveland Clinic surgeons improve meticulous techniques for removal of infective endocarditis from heart tissue, neutralizing the formerly high risk of operating on a patient with an active infection.
- As more patients live longer with cardiac surgery, the number of reoperations increases at centers like Cleveland Clinic, where mortality rates for these challenging procedures are below 1 percent, even for second, third or fourth reoperations.
- Cleveland Clinic studies show that gut flora linked to consuming meat and eggs is associated with increased cardiac risk in humans, amplifying the negative cardiac effects of dietary cholesterol.
- Cleveland Clinic researchers develop an automated system that extracts the centerlines of the aorta and branch vessels from a patient’s CT scan and builds a complete mathematical model of the relevant vasculature for 3-D printing.
- A sealable cardiac port device (Kapsus) undergoes development at Cleveland Clinic to provide safe, transapical access to the heart chambers for percutaneous aortic and mitral valve replacement.
- 3-D echocardiography aids the diagnosis of complex valve problems for the surgical and percutaneous repair of structural heart conditions.
- Robotic catheter navigation helps improve the safety and effectiveness of complex catheter ablation procedures.
- Robotic arms developed for automobile assembly lines are adapted to hold X-ray equipment on C-arms in the catheterization lab.
- Increasing numbers of complex interventions begin to be performed percutaneously, including aortic valve replacement, mitral valve repair, and closure of patent foramen ovale, atrial septal defects and paravalvular leaks.
- The safety of percutaneous coronary intervention improves dramatically.
- Improvements in diagnosis and treatment contribute to a dramatic overall decline in STEMI in all age groups except younger women.
Tell us what we’ve missed
While old controversies are laid to rest, healthy debate continues on subjects of major importance to patients and physicians:
- What’s the role of coronary CT angiography in screening patients for cardiovascular disease?
- Which is better for stable angina — medical treatment or interventions like angioplasty, stenting and coronary artery bypass?
- Have recent studies permanently eroded confidence in renal ablation to treat resistant hypertension, or is there still hope for this once-promising technology?
Tell us what you think about these simmering debates or whether there’s a key development from the past 20 years that our list has missed. Weigh in using the Comments section below or at #CleClinicHeart50.