The treatment of cardiovascular diseases has advanced at an extraordinary pace over the past half-century resulting in an age-adjusted 60 percent reduction in heart disease death rates. This dramatic decline is directly attributable to primary and secondary preventive therapies such as statins and small interfering messenger RNAs along with disruptive technologic advances in procedural techniques. New pharmacologic options for thromboprophylaxis and novel therapies for heart failure further underscore the field’s rapid and transformative progress in drug development. On the device side, transcatheter aortic valve replacement (TAVR) has revolutionized valve disease care in the US. TAVR provides life-saving treatment options for US adults over the age of 80 and even among nonagenarians with severe aortic stenosis who would otherwise be ineligible for open-heart surgery. Similarly, drug-eluting stents are now routine in managing obstructive coronary disease, with modern designs offering exceptional safety, durability, and treatment options for patients ineligible for coronary artery bypass surgery.
Nevertheless, rather than looking ahead to the next generation of cardiovascular innovations and therapeutics, the European Society of Cardiology, American College of Cardiology, American Heart Association, and the World Heart Federation issued a “special communication” (“Environmental Stressors and Cardiovascular Health: Acting Locally for Global Impact in a Changing World”) redirecting their attention toward environmental risk factors (ERFs), such as noise pollution, artificial light at night, and urbanization. They offer that cardiovascular risk from ERFs surpasses traditional risk factors, like smoking, hypertension, and diabetes, yet none of the cited references substantiate this claim. More so, in these studies, causality with respect to cardiovascular risk is not established, confounders are not reliably controlled, and the relevance to clinical cardiology is effectively nonexistent.
Still, health care professionals are being asked to take urgent action to mitigate environmental stressors through advocacy, education, and guidelines. It is a striking pivot for a field defined by transformative scientific progress, which has delivered some of the most consequential, population-level gains in modern medicine.
Environmentalism rebranded as cardiology
The pattern, unfortunately, is familiar. Last year the Journal of the American College of Cardiology published Sustainability in Electrophysiology, criticizing electrophysiology laboratories as “resource- and energy-intensive” and urging that they be remade into models of “climate-conscious cardiology.” Yet beyond modest cost-saving measures, such as reducing HVAC use during off-hours, the paper offers no truly transformative recommendations. And any proposal to scale back atrial fibrillation ablation or implantable cardiac defibrillators would, in fact, expose high-risk patients to a greater risk of death.
Surprisingly, the purported solution to this perceived energy-overuse is “primordial and primary prevention,” not because these measures have inherent clinical benefit but because they are cast as advancing “environmental, social, and financial sustainability.” This emphasis on political advocacy, environmentally-focused guidelines, and “environmental cardiology” shifts clinicians’ attention away from the individual patient physicians are sworn to serve and toward a broad policy agenda that appears more concerned with emissions than with mortality.
The call to activism is unmistakable, with the signatories of the special communication urging clinicians to shape policy and press for regulatory reform, extending even to “equitable technology transfer” and “integrated urban planning.” Should cardiologists now be expected to concern themselves with urban design? Should fellowship training expand to include zoning codes, planning frameworks, and environmental development? And, if so, at what cost to an already demanding curriculum?
Reasserting cardiology’s proper domain
No one disputes the health harms of pollution or the value of clean air and water. But this special communication has forgotten that cardiology is a medical discipline, and cardiologists have neither agency nor the expertise to operate outside their professional domain. More so, cardiologists should be proud; their field has brought extraordinary benefit to humanity. It need not reinvent itself as the Sierra Club. Turning toward planetary-health advocacy raises the question of what cardiologists are being asked to do and should do. This call for environmental advocacy reads more like a feel-good appeal than a substantive contribution to cardiovascular science.
It also idealizes a pre-industrial “holistic” past, overlooking how difficult and disease-burdened life was before modern technology and economic development. We would do well to remember that economic progress has raised living standards so dramatically that today’s poorest citizens enjoy comforts unimaginable to the kings of centuries past.
This special communication, however, loses sight of these gains. Its narrative gravitates toward an idealized notion of “natural” environments, minimizing the extent to which modern innovations, advanced diagnostics, revolutionary devices, and targeted therapies, have dramatically improved human well-being. The scientific and industrial progress of the West has greatly extended life expectancy, a reality the paper sidesteps.
The future of cardiovascular medicine depends not on activists’ desires to have clinicians achieve an environmentalist’s dream. Rather, it is linked to the great ingenuity and genius of physicians and scientists who continue to push the bounds of innovation as well as strengthening what we know works, early detection, precision therapeutics, advanced imaging, minimally invasive procedures, and aggressive management of modifiable risk factors. Diverting attention toward broad policy agendas risks diluting medicine’s core mission and for that we will all inevitably suffer.
Kurt Miceli is an internal medicine and psychiatry physician.
