(Circulation. 1998;97:296.)
© 1998 American Heart Association, Inc.
Priorities in Heart Failure Research
Michael O'Rourke, MD, DSc
Medical Professorial Unit,
St Vincent's Hospital,
The University of New South Wales,
Sydney, Australia
To the Editor:
As a student of the circulation, of aging, and of heart failure
in the elderly, I was flabbergasted to read1 that
the NIH "Special Emphasis Panel on Heart Failure Research"
described priorities without mentioning the physical properties of the
circulation and of left ventricular load in the aged.
Priorities were cellular, molecular, genetic, and chemical, yet were
applied to a mechanical system in which arterial stiffening
with age markedly alters wave reflection and distorts the physical
tuning between pulsating heart and compliant arterial tree.
Though recognized as a priority area by the NIH for special
funding (NIH Guide, Vol 24, No 24, June 30, 1995), this area was
completely ignored in the present report, as were clinical trials.
An accompanying commentary from Dr Claude
Lenfant2 as NHLBI Director also concentrated on
subcellular mechanisms and made no mention whatever of
ventricular load in heart failure or the NHLBI's 1995
initiative. Lenfant's pronouncement ran counter to his own 1995 news
article in Circulation3 on "Integrative
Physiology: Remember the Big Picture."
In the Louis P. Bishop lecture delivered at the 1997 American College
of Cardiology annual meeting in Anaheim, Calif, a
previous NIH Director, Bernadine Healy, addressed "The impact of
health care reform on medical schools" and pointed out that community
pressures will force researchers to tackle community problems such as
the escalating problem of heart failure in the elderly. In 2 short
years, the NHLBI appears to be turning from the practical problem of
heart failure to the latest fashions in molecular biology. An observer
from afar might be permitted to ask what American
cardiology really sees as the "Big Picture" in
heart failure research.
Are the priorities described in the 1997 NIH panel's report
comprehensive and potentially most fruitful? Or is something
missing?
References
1.
Cohn JN, Bristow MR, Chien KR, Colucci WS, Frazier
OH, Leinwand LA, Lorell BH, Moss AJ, Sonnenblick EH, Walsh RA, Mockrin
SC, Reinlib L. Report of the National Heart, Lung, and Blood Institute
Special Emphasis Panel on Heart Failure Research.
Circulation. 1997;95:766–770.[Free Full Text]
2.
Lenfant C. Fixing the failing heart.
Circulation. 1997;95:771–772.[Free Full Text]
3.
Lenfant C. Integrative physiology: remember the big
picture. Circulation. 1995;91:1901.[Free Full Text]
Response
Leslie Reinlib, PhD
Health Scientist Administrator,
Heart Research Program,
Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute,
Bethesda, Md
Dr O'Rourke correctly recognizes that the report of the NHLBI
Special Emphasis Panel (SEP) on Heart Failure
Research1 is not all-encompassing. His remarks
concerning circulation, ventricular load, and aging are
well taken. For a complex disorder such as heart failure, the ideal
model would consider the various afflicted organs, neurohumoral
pathways, and physiological systems, as well as the
temporal alterations and interactions. Such broad consideration,
though, was beyond the scope of the SEP.
The SEP's report was not intended to review or comment on the
multitudinous parameters contributing to heart failure.
Such an ambitious overview was realized earlier by the NHLBI Task Force
on Research in Heart Failure, which provided a detailed blueprint of
suggestions for heart failure research.2 To avoid
generating an exhaustive wish list, the SEP was charged with
identifying and prioritizing research "gap areas" and practical,
new directions to serve as a guide to the NHLBI and the community.
Within the limitations imposed on it, the SEP performed admirably.
With regard to Dr O'Rourke's comments on the trendiness of the
recommendations, we attempted to select SEP members with broad
understanding of the nature of heart failure. I think most observers
will agree a reasonable array of research and clinical ideologies was
represented. Although several of the recommendations
emphasize cellular and molecular approaches, other ideas, such as
indicated by Dr O'Rourke, are included. For example, the third
priority was to "foster studies encompassing
physiological, molecular, biochemical, and
multiorgan factors." Another recommendation, to "study regression
of heart failure abnormalities with left ventricular assist
devices," was included specifically to encourage investigation of the
roles of ventricular load in cardiac remodeling,
dysfunction, and treatment.
Finally, although this particular report may not be as broad as
one would wish, the NHLBI and other institutes at the NIH do support a
comprehensive battery of basic and clinical research and clinical
trials addressing heart failure. The lion's share of this work is,
appropriately, investigator initiated. Where guidance appears needed,
the NIH has historically sought out experts in the field to serve on
advisory panels, such as this SEP, to assist in setting program
priorities or inviting proposals. An example of one such priority
communication, not from the NHLBI but from the National Institute on
Aging, is cited by Dr O'Rourke: the 1995 program announcement,
"Aging, Vascular Stiffness, and Cardiovascular
Function." We hope the recommendations of the SEP on heart failure
research will prove useful as a guide to researchers and be seen as a
contributing piece, if not the total "Big Picture," in the struggle
against heart failure.
References
1.
Cohn JN, Bristow MR, Chien KR,
Colucci WS, Frazier OH, Leinwand LA, Lorell BH, Moss AJ, Sonnenblick
EH, Walsh RA, Mockrin SC, Reinlib L. Report of the National Heart,
Lung, and Blood Institute Special Emphasis Panel on Heart Failure
Research. Circulation. 1997;95:766–770.
2.
Lenfant C. Report of the Task Force on Research in
Heart Failure. Circulation. 1994;90:1118–1123.[Free Full Text]
