Circulation: The Beat Goes On
The American Heart Association (AHA) was founded in 1924 to promote the research and education of physicians in the emerging specialty of cardiology. Within months of its founding, the AHA took its first major step to support this core mission by publishing the first American journal in the field, the American Heart Journal. The editor-in-chief, Lewis B. Conner, was a founder and the first president of the AHA. The editorial board included such historic figures as Paul D. White, James B. Herrick, Henry A. Christian, and Carl J. Wiggers. In his opening editorial, Conner wrote of “the truly revolutionary advances made in our knowledge of the normal and pathological physiology of the heart and its beat, along with the advances in understanding of its diseases and their management” and of “the conviction on the part of the AHA that such a journal might be a potent factor in the furtherance of its purposes - the better education of the medical profession in matters relating to the diagnosis, treatment and prevention of heart diseases.”1
In 1948, the AHA was transformed from what then-president of the association H.M. Marvin described as a relatively “small organization of doctors interested in the purely scientific aspects of cardiovascular disease into a large, national voluntary health agency with wide interests and broad responsibilities.”2 This “new” AHA needed a new journal, and in 1950, Circulation was born. Marvin went on to write:
This first issue of Circulation, the official journal of the AHA, represents a major step toward the realization of an ambition long cherished by the Editorial Board and by many of our members; namely, the creation of a scientific journal that shall be acknowledged as foremost in the world among those devoted to a special field of medicine….It is the firm purpose of the Editor, the Editorial Board and the Publisher to avoid making it on the one hand a journal so exalted in its aims that only a handful of scientists could read it intelligently and, on the other hand, a purely clinical journal which would have little interest for the investigators who are advancing the boundaries of our knowledge so rapidly.2
A Legacy of Excellence
For more than 9 decades, first the American Heart Journal and then Circulation have flourished because the AHA has remained true to its mission. It has supported its 2 core journals and its outstanding editors-in-chief (Table), whose wisdom, clear thinking, fine judgment, and total commitment have ensured that the journals would honor the noble aspirations of their founders. It has been my privilege to serve on the Editorial Board of Circulation since 1960 and to chair the AHA’s Publication Committee in the late 1960s and early 1970s, overseeing the association’s several journals and selecting new editors. From these vantage points, it is clear to me that each editor-in-chief and editorial team brought new ideas and enthusiasm to their tasks, which have become progressively more demanding. Each has placed their personal stamp on the journal and has grappled successfully with the changing issues of the day. For example, James T. Willerson, editor-in-chief from 1993 to 2004, modernized the journal in many important ways as it entered the 21st century. He took over a monthly journal but, feeling the growing pressure for more rapid transmission of important information, converted it to a weekly journal while maintaining high quality. Other cardiology journals soon followed this practice.
Joseph Loscalzo, who served longer than any other editor-in-chief, built on this and provided almost simultaneous electronic publication of accepted articles weeks before their publication in print. He put together an outstanding team of associate editors from all branches of cardiovascular medicine and biology that met face to face weekly to review an incredible workload of manuscripts. This weekly discussion provided a level of review that was unique and that often went well beyond the conventional approach. Loscalzo’s primary goal has been to publish papers of the highest quality that would have an impact on the field, regardless of the size of the audience for these papers. He has been committed to the education of trainees and of practitioners, a key purpose of the journal, and established features and series that emphasized learning. He required the addition of a Clinical Perspective at the end of each original article; these perspectives have been especially useful in understanding the relevance of articles on cardiovascular science to clinical issues.
Loscalzo also recognized the increasing role of subspecialists within cardiovascular medicine and their growing communities and established daughter journals for 6 of them. Aware of rapidly evolving trends in academic publishing, he wholeheartedly supported the establishment of the AHA/American Stroke Association’s only Open Access journal, the Journal of the American Heart Association (JAHA). He nurtured and supported these “daughters,” which are now healthy adolescents. He committed much time, effort, and passion to the job of editor-in-chief, his many other responsibilities notwithstanding.
Looking to the Future
While celebrating the first 9 decades of AHA publications and expressing deep appreciation to the editors, editorial boards, reviewers, and publishing teams for their enormous contributions, we should now look ahead. I believe that the next decade is likely to be the most exciting one for cardiovascular science and practice since the birth of the specialty, because there are so many areas in which the basic work has been largely completed and many new concepts and technologies have been developed. Although these are enormously exciting and promising, they have not yet been adapted for clinical use and integrated into practice.
We are now moving to a much broader approach to patient care, referred to as precision medicine.3 Precision medicine makes use of the application of genomic and the other “omic” technologies to enhance diagnosis, the identification of individuals for diagnostic procedures, risk assessment, and specific management and preventive strategies. Management and preventive strategies are likely to include increasing emphasis on primordial prevention, the goal of which is to prevent the development of risk factors before their expression. Precision medicine will also make use of information derived from wearable and implanted sensors that continuously transmit measurement of physiological, biochemical, and physical activity and will use information derived from electronic medical records. It will introduce into clinical practice the rapid advances being made in pharmacogenomics.
Precision medicine has been discussed and written about for some time, and although many of the key components have been developed, they have not yet been combined and applied in any systematic way to clinical cardiology. Cardiologists will have to collaborate with bioinformatics specialists to store, interpret, correlate, and apply the enormous quantity of information, often referred to as “big data”, which is likely to alter significantly the practice of medicine and cardiology. Although precision medicine is, by its very nature, individualized, at the other end of the spectrum is the need to explore ways to reduce the incidence of cardiovascular disease in populations, especially in developing nations, in which its prevalence is rising at an alarming rate. The “polypill” has been suggested as an inexpensive approach to cardiovascular prevention in such populations, and the results of pilot trials have been encouraging, but its clinical impact has not yet been assessed.
Monoclonal antibodies to proprotein convertase subtilisin/kexin type 9 have been demonstrated to cause marked reductions in circulating low-density lipoprotein cholesterol in subjects both on and off statins. Definitive cardiovascular outcomes trials of these agents are nearing completion. If the results confirm those from the earlier trials and if no serious adverse effects are uncovered, it is possible, indeed it is likely, that further large reductions in atherosclerotic vascular disease will occur with their use. We will learn the long-term consequences of what we now regard as ultralow concentrations of low-density lipoprotein cholesterol. These monoclonal antibodies will probably be used first in patients with familial hypercholesterolemia and statin intolerance. The definition of the latter will be hotly debated, and the cost-benefit relation of adding proprotein convertase subtilisin/kexin type 9 inhibitors to various subgroups of patients will be elucidated.
Mechanical circulatory assistance has advanced considerably during the last decade, but its limitations have also become evident. Techniques for transcutaneous transmission of energy that eliminate the need for wires penetrating the abdominal wall are on the horizon and will improve patient management. Total replacement of the heart has been a dream for decades, and it is finally undergoing systematic testing.
There are some hopeful signs that cell therapy can be used to aid cardiac repair after acute myocardial infarction and in the treatment of chronic heart failure, but this approach has not yet become an approved mode of therapy. There are many unanswered questions about the optimum cell types, their appropriate processing, the optimum method of delivery, and even their mechanisms of action. Investigators around the world are hard at work to answer these questions. Several phase 3 clinical trials in this field are underway and will be reported in the next few years. Gene therapy for heart failure is not as far advanced as cell therapy, but the results of gene transfer in animal models are encouraging, and we can look forward to learning the results of early clinical studies in the next few years.
The topics mentioned above are just a small sample of those likely to cross the desks of Circulation’s new outstanding editorial group in Dallas. Led by Joseph Hill, this Texas team is likely to take us on a wild ride. The AHA can look forward with confidence and pride to the completion of the first century of publication of its core journal(s) by 2024, without missing a beat!
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
Circulation is available at http://circ.ahajournals.org.
- © 2016 American Heart Association, Inc.