Abstract :
The reactions of Health Authorities, the public and industry to the concept of “Evidence-based medicine” and socio-economic changes have major implications on the future of cardiovascular research.
The experimental models of coronary artery ligation, subtotal nephrectomy or carotid artery ballooning have been either confirmed (Save, Diabetic Nephropathy) or contradicted (Mercator) by randomized clinical trials, reminding us that animal models and human diseases are not similar. Cast, Promise and Sprint have demonstrated that physiopathological reasoning is not sufficient to provide the evidence necessary to recommend a treatment. Consequently, the drug registration process will become more stringent.
The extension of anti-hypertensive treatment into the elderly expanded 20 years before the SHEP results, which illustrates the fact that physicians are obliged to perform in a situation of uncertainty. This contributes to the variability in their practices, in conjunction with patient variability. Economic analysis superficially considers these difficulties as a waste of limited resources. Indeed, in an economically-driven society, the search for “productivity gains” leads the economic powers that be to consider health expenditures as potentially limiting to profits, while governments consider them as an unpopular reason for rising taxes. The percentage of the GNP attributed to health care is considered as unacceptable, whatever its value between 7 to 13%. Moreover, these expenses did not avoid increasing inequalities in access to care.
Pharmaceutical industries were mainly attracted by long term therapies for common conditions, occurring in “mature”, socially-secure people, (menopause, hypertension, dyslipidemia, osteoporosis), creating overpopulated classes of drugs, and extending prescriptions by aggressive marketing. Consequently, cost-containment policies started by looking at drug pricing, and reimbursement, even if drug prescription only represents 15% of health expenditures. The non-innovative generic business is now encouraged and new profits are expected in managed care systems. The vicious circle is completed by the message “cheap is beautiful”, with the support of recommendations by “expert committees.
In this context, research in vascular medicine, presently based on cell biology and molecular genetics, will have a difficult time, because it offers promises and intellectual advances in a time when short-term views are predominant, up to the point where it has been forgotten that all cardiovascular deaths below a certain age should be considered as an unacceptable failure of our Society.
