As antibiotics became widespread after World War II, the specter of infectious disease subsided as the leading cause of death in the United States and was quickly overtaken by cardiovascular disease. This coincided closely with the founding of the American College of Cardiovascular Medicine, and given the urgency of the illnesses under its purview, the field rapidly expanded.1 Many sub-specialties of cardiovascular medicine have developed, including vascular and endovascular medicine. The innovations of research in these sub-specialties have drastically improved available methods of care for patients, and there are many exciting technologies still in development.
“In vascular surgery, no change for the better has occurred that wise and good men have not opposed. Such change is inevitable.”2
John J. Bergan, M.D., world-renowned vascular surgeon, a pioneer in organ transplantation.
A late 2023 article about new bioengineering discoveries being applied to vascular surgery declared that “the field of vascular medicine has witnessed the fifth cardiovascular revolution.”3 The first was the suturing of blood vessels and transplantation of organs, and the second was pioneering cardiovascular operations.4 The third would set the stage for angioplasty and interventional radiology, and the fourth was as recent as 1990, when the “first reported endovascular aortic aneurysm repair (EVAR) under epidural anesthesia” was performed in Argentina.5 Now, new bioengineering developments and technological skills are emerging in vascular medicine that stand poised to evolve the field once again.
Recent developments in bioengineering have galvanized the field of vascular medicine. Vascular bioengineering could also revolutionize organ transplantation, “creating artificial organs” such as hearts or blood vessels “that mimic the complex functions of the human circulatory system.”6 The creation of vascular biomaterials, both biological and synthetic, has laid the groundwork for many new treatments. Biological biomaterials can support cell growth and tissue regeneration for damaged vessels, while synthetic biomaterials provide mechanical strength for healing vessels and can then degrade naturally over time in a controlled way.7 In addition, surgeries are becoming less dangerous for patients through the use of minimally invasive procedures developed by vascular bioengineering, and to the benefit of everyone’s healthcare journey, through “advancements in genomics and biotechnology, healthcare providers can tailor treatments to each patient's unique genetic makeup, optimizing outcomes and minimizing adverse effects.”8
An especially exciting new development in vascular bioengineering is that of synthetic vascular neuronal networks. Essentially, artificial neural networks “mimic the autonomic nervous system's control over vascular functions,” integrating with the existing vascular system.9 They can “monitor and regulate real-time blood flow, vasodilation, and vasoconstriction.”10 These networks are also designed to adapt to the differing conditions in each individual. Artificial Intelligence (AI) algorithms begin to show the depth of their usefulness in optimizing these networks, being able to continuously analyze data from the sensors and make necessary adjustments.
AI and its related technologies are indeed some of the forces fueling the fifth revolution of cardiovascular medicine. AI, Machine Learning, Deep Learning, Natural Language Processing and Big Data Analysis are all terms that seem more at home in a pure computer science context, yet these are the technologies that are singled out as those that will “support, improve, and even revolutionize the healthcare industry” by cardiovascular specialists in an article about the fifth revolution in 2022.11 They argue that “knowledge and proficiency in technology will be an integral part of the skillsets required for clinical practice.”12
The integration and application of AI into the cardiovascular field demonstrate promise in several areas. First, predictive analysis synergized with the vascular bioengineering previously discussed “culminates in precision vascular medicine,” where tailored treatment plans can best serve each individual patient, minimizing risk and improving outcomes.13 “Data-driven insights” can be used “to optimize biomedical research, precision imaging, early public health primary intervention, and overall superior healthcare quality improvement.”14 And generally across healthcare, tasks that algorithms can execute with precision can be relieved from medical staff, allowing them to devote more time to caring for patients.15
Although concerns arise from the fact that AI algorithms may not always perform as planned, proponents within the cardiovascular speciality argue that this is why it must be “mandatory” for clinicians and researchers “to understand the way algorithms are created,” in order to “lessen the risks of entrenching biases in predictive algorithms.”16 AI, Machine Learning, and the like are already poised to “transform and disrupt how medicine works.”17 In the face of these innovations, becoming skilled in these new technologies is necessary to be successful in the future of post-fifth revolution cardiovascular medicine.
Much has been accomplished since cardiovascular disease overtook infectious diseases as the number one killer in the United States. Today, heart disease is still the leading cause of death in the United States.18 But the work that cardiovascular specialists and researchers have done has not been in vain by any measure. In the U.S., the rate of death from cardiovascular disease in 1950 “was over 500 per 100,000 people,” which has since “declined to less than 150 in 2020. This represents a reduction of almost three-quarters.”19 This latest revolution looks to a future where treatments for cardiovascular disease can be personalized and robust for each individual in ways never seen before. We may soon see the day where heart disease no longer sits at the top of that list.
“Technologies appearing in the short term are apt to be procedural in nature… 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.”20
Herbert Aronow, MD, MPH, FACC, chair of ACC’s Peripheral Vascular Disease Member Section.
1. "The Evolution of Vascular Medicine.” American College of Cardiology, September 30, 2015. https://www.acc.org/latest-in-cardiology/articles/2015/09/24/17/25/the-evolution-of-vascular-medicine
2. Sherif Sultan, Yogesh Acharya, Omnia Zayed, Hesham Elzomour, Juan Carlos Parodi, Osama Soliman, and Niamh Hynes. “Is the Cardiovascular Specialist Ready For the Fifth Revolution? The Role of Artificial Intelligence, Machine Learning, Big Data Analysis, Intelligent Swarming, and Knowledge-Centered Service on the Future of Global Cardiovascular Healthcare Delivery.” Journal of Endovascular Therapy 30, no. 6 (December 2023): 877-884. doi:10.1177/15266028221102660
3. Piergiorgio Settembrini, Sherif Sultan, and Alberto Settembrini. “Editorial: New Discoveries in Bioengineering Applied to Vascular Surgery.” Frontiers in Surgery 10 (October 2023). doi:10.3389/fsurg.2023.1293094
4. Sultan, “Is the Cardiovascular.”
5. Sultan, “Is the Cardiovascular.”
6. Settembrini, “Editorial: New Discoveries.”
7. Settembrini, “Editorial: New Discoveries.”
8. Settembrini, “Editorial: New Discoveries.”
9. Settembrini, “Editorial: New Discoveries.”
10. Settembrini, “Editorial: New Discoveries.”
11. Sultan, “Is the Cardiovascular.”
12. Sultan, “Is the Cardiovascular.”
13. Settembrini, “Editorial: New Discoveries.”
14. Sultan, “Is the Cardiovascular.”
15. Sultan, “Is the Cardiovascular.”
16. Sultan, “Is the Cardiovascular.”
17. Sultan, “Is the Cardiovascular.”
18. “Leading Causes of Death.” Centers for Disease Control and Prevention, January 17, 2024. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
19. Saloni Dattani, Veronika Samborska, Hannah Ritchie, and Max Roser. “Cardiovascular Diseases.” OurWorldInData.org, 2023. https://ourworldindata.org/cardiovascular-diseases?insight=death-rates-from-cardiovascular-diseases-have-declined-in-many-countries#key-insights
20. “The Evolution of Vascular Medicine.”