The National Heart, Lung and Blood
Institute (NHLBI) of the NIH is in the midst of developing a long-term plan –
or what they call “Visioning”.
Scientists, physicians and the general public are being given the opportunity
to offer opinions about future directions of research and implementation. The post below is the material sent as a
comment by Dr. Cooper.
I have grave concerns about the
outcome of the NHLBI “Visioning” exercise.
A vast array of new and important ideas have emerged from this exercise. At the same time, however, I am left
wondering whether we are still on course to extend the phenomenal success
achieved by the NHLBI and the cardiovascular community in reducing heart
disease and stroke over the last 50 years.
If anyone needed to be reminded, the figure below – charting a decline
in CHD death > 80% - demonstrates the greatest advances in control of a
major chronic disease ever observed. In
the US alone this trend represents ~ 600,000 fewer deaths each year. A similar
massive decrease in stroke has occurred.
As demonstrated by Ford et all in the NEJM in 2007, the majority of that
decline resulted from control of basic risk factors. While it is certainly true that better drugs
and better interventional tools have helped, particularly in the latter years,
there are still have huge potential gains in primary and secondary
prevention. It is hardly worth
mentioning that reductions in tobacco use have rapidly driven down rates of
lung disease – and is the primary reason death from cancer has fallen 30% in
the last 2 decades.
Unfortunately – as I read it – the
Visioning document does not adequately build on this unparalleled record of
success. A “word scan” retrieves topics
that are heavily weighted toward research on mechanisms rather than etiology
and prevention – viz, pathobiology,
‘omics, prevention linked to gene therapy, mechanistic interactions, systems
biology, developmental biology. I do
not want to enter into a debate over the relative merits of genomics – or all
‘omic’s – vs. population-based research, prevention and translation. I recognize that the case could be made that
we now know what we need to know about etiology, and in the words of Claude
Lenfant, Director of the NHLBI during the “golden age” captured in the figure, the
challenge is to “use what we know”.
Using medical knowledge in the care of patients is not the mission of
the NHLBI. However, while taking
advantage of the powerful new tools of genomics, we should not lose sight of
the needs of patients. Most patients at
risk of CVD will never benefit from genomics or the offspring of genomic
research. My point is simply to state
that the debate between “’omics” vs “prevention” is heavily weighted toward the
latter by the most fundamental evidence in biomedicine – the health experience
of our population over he last 50 years.
No matter what perspective one brings to planning for the future of CVD
science, extending the success of the past must rank as the highest
priority.
I, for one, do not see how the
proposals for genomics and system biology in this Visioning statement can
achieve that goal. As the erstwhile
Director of the NCI said, “genomics is a good way of doing science, but not
medicine.” I understand that population
cohorts and trials are expensive, and that we currently face a dearth of
exciting new ideas for prevention. But
the degree of difficulty of challenge does not diminish its importance. As I suggested before, the Institute appears
to have made a dramatic shift in direction from advancing prevention and
treatment to research on mechanisms and genomics. This shift from etiology to biology ignores
the lessons of success that we have learned from the period when we did make
huge progress toward reducing disease burden.
Basic research has a crucial role, there is no dispute on that point,
but the integrity of our enterprise requires that we evaluate the relative
merit of a field research against the potential to reduce disease burden. Control of heart disease, stroke and lung
disease are not, in my view, where they should be – at the center of any vision
of the future of the Institute.
Ford ES,
Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, Giles WH, Capewell S.
Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl
J Med. 2007;356:2388-98.
