Cardiovascular disease: is it time to finally recognise it as a complex, chronic life-span illness?

Cardiovascular disease (CVD) is the leading cause of death and disability globally. Success in reducing mortality has been seen in developed nations such as North America, Europe and Australia1. The technological advancements of recent decades, in particular interventional cardiology and pharmaceutical innovation, have contributed to this phenomenon. Yet nations experiencing economic development are now reporting increases in the burden of CVD, particularly heart failure. The above is typical of many introductory paragraphs to papers in the CVD literature. They report numerous prevalence and incidence data to support the severity and impact of the disease. Yet there persists an intense focus on one of two components of the patient journey: the acute event and its management; and/or heart failure. Far too little attention is given to the processes leading up to the acute event and to the period between the acute event and heart failure. What is missing is recognition of the complex yet unitary nature of the person’s lifetime cardiovascular journey. Conceptually, there is a shift from focusing predominantly on the presenting disease, to illness and sickness roles: with disease being a medical aspect of the experience, illness a personal and sickness a socially determined construct2. The impact of all three need comprehension as the interaction between them influences health and health outcomes. What is therefore needed is a way to contextualise the comprehension of these complex processes within a person-centred approach, as it is important for truly understanding their interaction. The person is situated within a broader social context where all the barriers and enablers to improving their health outcomes merge3. As such, the dominant focus of our efforts needs to shift from disease and diagnosis to illness and its management through partnership with patients, families and communities4. In attempting to stimulate scholarly debate, this editorial seeks to challenge some of the assumptions inherent in cardiovascular practice and research including: The domination of an acute care/event/diagnosis focus in CVD management. The mistaken notion of ‘cure’. A linear approach to health behaviour change. The dominance of a ‘disease’ model rather than illness management. To date, health service systems have focused attention on the acute medical management of cardiac events; with myocardial infarction or a diagnosis of acute coronary syndrome being the foundation for treatment. While length of hospital stay in the past was higher, ample opportunity existed to engage the patient, carer and/or family in health education and support. In contrast, a person admitted today for primary PCI may be out of hospital within 3 days: such is the impact of technological innovation. This shortened hospitalisation all but eliminates the opportunity to commence a meaningful dialogue and partnership with patients, carers and families with the end goal of positively influencing health-behaviour change. The poor uptake of ‘secondary prevention’ strategies, such as comprehensive cardiac rehabilitation5, underscores the need to rethink the approach to CVD management given the substantial increases in chronic illness burden being currently experienced; something projected to increase for the foreseeable future1. Technological advancements have reinforced this acute-care orientation, resulting in distorted ideations of ‘cure’. The sense of ‘cure’, while greatest with many patients who are looking for the ‘quick fix’, is underscored by clinicians using similar language when discussing treatment with patients6. The simplistic nature of this approach to treatment belies the very nature of the underlying disease: atherosclerosis. Far from simple, the myriad of bio-psycho-social interactions7 over the course of a person’s lifetime form a web of complexity which science is still unravelling. By way of example, it is recognised that vascular changes due to atherosclerosis can begin in utero8. Given the immense variation in ways CVD risk factors impact upon individuals, it makes little sense to remain singularly focused on either the acute care event or the ‘chronic’ debilitating end-of-life phase, heart failure, to the exclusion of other essential periods of the person’s CVD trajectory9. Prevention would likewise be approached in a more unitary fashion, rather than the current distinctions between primary, secondary and tertiary prevention10. The use of these categorisations, while arguably helpful to clinicians, is of little help to patients. For instance, the advice given to someone found to have a risk for CVD who is yet to have ‘an event’ is largely the same as that given to someone in cardiac rehabilitation. It is ironic that a fourth level of prevention has emerged (‘quaternary’), to deal with the over-medicalisation of patients and the threats of iatrogenic causes of illness7. An example of this is the trend where risk factors are progressively being redefined as diseases, as in the case of obesity11. While such an approach may be warranted, the potential of further disintegration of the complex interaction may only serve to exacerbate rather than ameliorate the risk. In part, the labelling of such a risk factor as a disease potentially removes the person from the process as ‘diseases’ are objective classifications imposed by a health professional, thereby potentially dislocating the person from their broader social context12. In addition, the perceptions of patients needing to make lifestyle adaptations needs to be understood13. Prevention should therefore engage individuals, families and communities on a whole-of-lifespan basis, with context-specific strategies tailored to the presenting need. One positive trend is growing awareness of the need for collaboration between cardiovascular healthcare disciplines: physicians, nurses and allied health professionals. Strong inter- and trans-disciplinary practice and research is required in order to strengthen the healthcare system’s capacity to successfully engage the diverse and complex issues it faces14. Consequently, a fundamental shift in how clinicians conceptualise the patient journey through the CVD trajectory is vital15. Rather than seeing the person as a passive recipient of treatment in response to an event, emphasising the patient journey and the person as the ‘centre’16 will assist in the necessary realignment of healthcare delivery15. The next logical step is a chronic disease management approach, such as the Chronic Care Model by Wagner and colleagues17. Such an approach would provide a framework to operationalise the patient journey: from initial atherosclerosis formation to death from heart failure. Yet it must start with collaboration between healthcare disciplines and partnership with patients, families and communities. Healthcare delivery would need to become more seamless, allowing greater flow of people and information between providers including public, private, primary, acute and community healthcare sectors. The system prevailing in much of the world places barriers to innovation with people falling through the gaps between existing services. Achieving seamless integration of health information systems cannot be underestimated in ameliorating the effects of these barriers. Yet it will require significant political will and collaborative interdisciplinary engagement to be realised. Realising a more integrated approach to CVD management requires an essential comprehension of the complex behavioural factors involved in health decision making. For example, adherence to treatment, with its associated constructs of health-behaviour modification and quality of life, remain two areas of practice and enquiry that continue to confound healthcare delivery in terms of measurement and improvement in outcomes. The nature of these issues illustrates the complexity inherent in contemporary cardiovascular healthcare. To quote Plesk and Greenhalgh’s highly cited paper18 which emphasised: “…the limitations of reductionist thinking and the ‘clockwork universe’ metaphor for solving clinical and organisational problems. To cope with escalating complexity in health care, we must abandon linear models, accept unpredictability, respect (and utilise) autonomy and creativity, and respond flexibly to emerging patterns and opportunities.” Such a notion could be deemed a ‘dangerous idea’ as it demands so much from clinicians, researchers and policy makers. A chronic disease management approach, from the outset, challenges clinicians and researchers alike to rethink the way the patient experience is constructed, policy written, and care planned and delivered. The acute care approach is groaning under the weight of fiscal and demographic factors. Meanwhile, the chronic illness burden is a tsunami looming on the horizon. With CVD only showing signs of increasing, new approaches that appreciate the true complex nature of the phenomena being faced are needed now.