December 7, 2012 | Returning to China in 1999, after a decade of cardiovascular research at two German university hospitals, Professor Junbo Ge turned his research into practice by helping to establish modern cardiology in a vast country that is experiencing rapid social change.
His research in the 1990s taught Professor Junbo Ge to ask questions. Asking questions can also be helpful when considering the future of cardiology: Which diseases will be predominant in times of demographic change and urbanization? Do patients need so many catheterizations? How can therapy be optimized? Medical Solutions discussed these issues with the current President of the Asian-Pacific Society of Interventional Cardiology not on the top of a modern skyscraper in Ge’s hometown of Shanghai but back in Germany, in medieval Forchheim.
The World Health Organization’s recent Global Atlas on Cardiovascular Disease Prevention and Control has once again identified cardiovascular diseases as the leading cause of death worldwide. And it says that this will remain the case until at least 2030. There are certain differences, though. In Europe and in the U.S., cardiovascular mortality is in fact falling. In many other countries, it is rising sharply. What is the situation in China?
Ge: We have been witnessing huge changes in the spectrum of disease over the last thirty years or so. Before China started to open up to the West in 1977, we had many infectious diseases. The open policy brought more wealth to an increasing share of the Chinese population, which is good, of course. But it also led to lifestyle changes. As a consequence, we are now confronted with lifestylerelated diseases that have already been prevalent in the West for some time. We have more obesity, more diabetes, more hypertension. And these diseases have similar consequences in China like everywhere else in the world: The occurrence of cardiovascular and cerebrovascular disease has increased dramatically, and it continues to increase substantially every year. To illustrate what I mean: 30 years ago, when I was a fellow at medical school, I remember a patient with myocardial infarction who had all the typical electrocardiogram signs and enzymes that you would expect. This really interested me because it was so rare at that time. I even asked a co-fellow to swap shifts so I could observe the patient longer. Today, we have patients with myocardial infarction practically every day. And if I go through the wards of our department, at least 60 percent of all patients present with coronary artery disease [CAD].
What are the main cardiovascular risk factors these days?
Ge: This again is very similar all over the world. We have many people with hyperlipidemia,
diabetes, and hypertension. Smoking has also become a big problem in China. In order to cope with the cardiovascular epidemic, we will have to tackle these risk factors sooner or later. Nations like, for example, the Scandinavian countries have shown how to do that. They have managed to stop the increase in coronary artery disease, mainly by reducing the risk factors.
How significant is the impact of global megatrends such as demographic change and urbanization on cardiovascular health?
Ge: These are big issues, obviously, and this again is very evident in China. Demographic change is leading to an increase in cardiovascular diseases. This is true for coronary artery disease, but also for other cardiovascular diseases like chronic heart failure and cardiac valve disease, and, of course, for cerebrovascular diseases. Take Shanghai, for example: The average life expectancy in Shanghai has now risen to 81 years. This comes with an increase in the occurrence of heart failure. I am the Principle Investigator of a big prospective epidemiologic study involving 20,000 people, very similar to the Framingham study. We did an analysis for the tenth Chinese five-year plan some years ago and found that the average occurrence of heart failure in adults is around one percent. This is quite a lot.
What about urbanization?
Ge: This is interesting, too. There are massive regional differences in cardiovascular morbidity in China. This at least partly reflects urbanization, but it also reflects other lifestyle differences. The number of cases of CAD, for example, becomes lower and lower the further south we travel in China. In Qingdao, where I come from, people eat more salt, smoke more cigarettes, and drink quite a lot. CAD incidence in Qingdao is around 230 per 100,000, whereas in the far south it is only 48 per 100,000. In Xinjiang, a region in the far northwest of China, we increasingly see severe three-vessel diseases in young people. The reason is that when people who were previously very poor become wealthy, the first thing they do is change their eating habits. They eat more fat and fast food, and they drink more. What we are realizing is that the very rich are actually vigilant about their health, and so are the very poor. The problem is the wealthy middle class, which is increasing year by year. When the western and central regions of China catch up with the east, we will see an explosion in cardiovascular diseases and heart attacks. It is simple: When you go to Shanghai, there is no longer a big difference from the west in terms of wealth and lifestyle. Therefore, the number of civilizationrelated diseases is also fairly similar. This will happen in other parts of China as well, and it is already happening in many parts of the world.
What does this mean for healthcare spending?
Ge: Healthcare spendin g is already rising. I am not aware of the latest data for China. But in the People’s Congress that takes place in March every year, the most common proposals that members of congress make to the government are related to education and medical care. The government is putting a lot of effort into improving medical care. It has defined 11 diseases that are covered by the state, including acute myocardial infarction and congenital heart disease. We would be happy to see heart failure added to the list as well. But this is a lot of money, and the government won’t be able to cover all the costs. What I consider to be at least as important, if not more important, is investing more money in healthrelated education. We have to tell people what a better and healthier life looks like, otherwise you become wealthy and throw all your money into hospitals afterwards. Many people are simply not aware of how to live healthily. And this is certainly not just a Chinese problem but a global one.
An increase in cardiovascular morbidity means that people need access to cardiovascular diagnostics and therapies, both medical therapies and interventional…
Ge: It does, and it is a challenge. When I was called back from Germany in 1999 there were around 4,500 cardiovascular interventions in China in total per year. Since then, this number has increased annually by around 25 percent. In 2011, we had 333,000 cardiovascular interventions, which means that China is now number two in the world behind only the U.S. There is no doubt that this number will increase further. At the moment, access to cardiovascular diagnostics and therapies is better in the metropolitan areas of the east than it is in Central China, for example. And indeed I think that companies like Siemens have a lot of responsibility here. They should not just be selling devices but they should also be training young doctors to use the technologies in the right way. The Chinese government is also active, of course. The Ministry of Health decided to build around 100 training centres all over the country. Young fellows now should be trained in one of these centres before they are given a license to perform interventions on their own in their respective local hospitals.
In western countries, there are increasing discussions on where interventional cardiology is or should be heading. Since the publication of the results of the COURAGE trial and other, similar trials, many people are arguing that there are too many diagnostic catheterizations and too many interventions. What is your opinion on this?
Ge: We are discussing these issues in China as well. We have to convince colleagues and patients of the benefits of new treatments. The COURAGE study showed no benefit of interventions in stable coronary artery disease in terms of prolonging patients’ lives. I was not too surprised about this result, because I think that normally nature is the determining factor in terms of prolonging lives. What COURAGE showed is that we can improve the quality of life of our cardiac patients substantially by performing interventions. And this is what our patients are looking for in the first place. This is similar to other diseases, by the way. If a patient comes to me and has a headache, I will give him medication to improve his quality of life. This is what I always tell my young fellows: You should not overuse the available technologies, but you can believe in these methods. We have more than enough evidence that we can improve ischemia and thus quality of life.
You have done extensive research in the field of intravascular ultrasound (IVUS) in your career. What role could imaging technologies play in making cardiology more targeted, more individualized?
Ge: First: If anything can be done noninvasively it should be done noninvasively because it is more comfortable and less painful for the patient. Second: In many ways, the existing noninvasive techniques are still not sufficiently accurate, so there is no way around invasive cardiology for the moment. There are some interesting noninvasive imaging technologies out there, for example multislice computed tomography or modern cardiac magnetic resonance imaging. I think that, with innovative software, it won’t be necessary to use invasive technologies like IVUS or interventional measurements of fractional flow reserve in order to decide on the optimal treatment for patients with, for example, ambiguous lesions. The importance of noninvasive imaging will increase. But invasive diagnostics will continue to exist for many years.
Before you returned to China in 1999, you worked at the university hospitals of Mainz and later Essen for almost a decade as a young doctor and researcher. In what ways are medicine and cardiology in Germany different from China?
Ge: It is hard for me to compare, because what I did in Germany was very different from what I do in China now. In Germany, I was an ambitious young researcher and tried to publish as much as I could. When I returned to China, I suddenly had to deal with the everyday reality of cardiology. In my department alone, we have more than 300,000 outpatients per year. This is an enormous number. It is really hard to cope with such a high workload and it doesn’t leave much time for research. What I learned in Germany and what I really consider to be very valuable is to ask the question: Why? Asking why is not only a big driver for research, it is also helpful in clinical routine. Asking why is what I always recommend to my fellows in Shanghai. And I also tell them that they should always respect their mentor, but never trust his opinion. It can sometimes be the case that outspoken experts are wrong.
Given that cardiology in China has matured, would you still advise younger Chinese doctors to spend time in other countries?
Ge: Absolutely. It is important to get to know how things are done in other countries. My son is studying medicine, and I have strongly advised him to go to Heidelberg for a fellowship. He can learn a lot in Germany. Germans take many things very seriously. You can learn how to solve a problem and to find the cause of the problem. I remember that I saw an elderly lady at a red light once. I thought, okay, she is having difficulty walking, so I asked her whether I could help her cross the road. She said, “How do you know that there isn’t a child in the building on the other side of the road who might see an adult cross the road in spite of the red light?” Germans think differently.
As in other fields of medicine, there are many new therapeutic methods popping up in cardiology at the moment as a consequence of genetic research and stem cell research. Is this “new cardiology” already playing a role in China?
Ge: It does exist. But it is far more challenging to get these kinds of study approved in China than it is in many western countries. We have built up a stem cell centre in Shanghai, and we do a lot of research there in animal models. When it comes to clinical studies, though, we are certainly behind countries like Germany.
One thing that Germany and China have in common is a high acceptance of traditional medicine. Do you include traditional Chinese medicine (TCM) in cardiology care in your hospital?
Ge: We don’t, no. I don’t understand much about TCM, so my view may be wrong. But I still think that if you want to prove that a method is useful you have to do clinical studies. You cannot say something is good based on personal experience. If you give patients water, 30 percent will say they feel better afterwards. But this does not make water a therapy. I am not against traditional methods. But I will not actively recommend them.
How do you see the future of cardiology? Today, we still distinguish between cardiology on the one hand and cardiac surgery on the other. In many places, there is competition between both disciplines, which is certainly not in the interest of the patient.
Ge: This is indeed a problem, but it is not restricted to cardiology. Today, we cut patients into pieces. We define diseases of the brain, the stomach, the heart, and so on, without trying to bring things together. I think this is not the right way to go. In the long run, we will have to reconsider medicine. We need to teach young doctors to take a more holistic approach to patients. An important point in this discussion is reimbursement. One of the roots of the current conflict between disciplines is that money is not pooled but paid per therapy. So when I think about the future of cardiology, I think about a different approach to patients, but I would also suggest a different approach to payment.