In the Cardiology Masters section of European Cardiology Review we bring you an insight into the career of a key contributor to the field of cardiology.
In this edition, we feature Dr Valentin Fuster, Mount Sinai Hospital, New York, USA
Growing up in a family of doctors – my dad was a psychiatrist, my grandfather was a general physician and my maternal grandfather was President of the University of Barcelona and medical school – you’d be forgiven for thinking that becoming a doctor was a natural progression for me. Actually I was more interested in the environment and researching plants. I wanted to study agriculture, but this wasn’t an option at the university in my hometown of Barcelona, and the tendency was to stay with your family.
I also had a passion for tennis and played at a national level, practicing 3–4 hours each day; it wasn’t until I was beaten in a tournament that I realised my future lay elsewhere and I stopped playing. Little did I know then that tennis would serve as a stepping-stone in my career on more than one occasion.
It was at a tennis club that I met Spain’s leading physician at that time, Pedro Farreras, who was author of the standard Spanish textbook of medicine. It was Dr Farreras who told me that I’d make a great doctor, so not knowing what I should do with my life I trusted him and followed his advice.
Move to the UK
Dr Farreras became my mentor, and it was when he had a heart attack in his 40s that he told me I should become a cardiologist; it was an area in which Dr Farreras felt he was weak. He then encouraged me to go to England to study pathology. He felt that to go to a small country would help to build my self-esteem as a professional. I ended up doing this for two summers. During the first summer I studied pathology specimens at the Middlesex Hospital in London, and I spent the second summer in Liverpool with a fantastic pathologist called Harold Sheehan, professor and head of pathology at the university, looking at slides from autopsies and biopsies.
The first day I worked with Professor Sheehan he showed me a slide that was a blood clot full of platelets; it was from a patient who had died of a heart attack. I asked what a blood clot had to do with a heart attack, and he said he didn’t know if it was the cause or the consequence. This was around 1963. Professor Sheehan suggested I investigate it for my thesis, so this is exactly what I did; I investigated the function of platelets to understand how heart attacks occurred.
This led me to investigate atherosclerotic disease of the vessel wall, and then visual imaging. It was at this time that we conducted the first randomised study with aspirin.1 We knew that aspirin was important in blood clots but this was a study about aspirin in the prevention of blood clots with saphenous vein bypass graft, which led to many other studies with aspirin and cardiac and arterial conditions.
I guess my tendency has always been to get to the root of the problem and it all started with that slide. I realise that a change in society’s lifestyle is key to most of our health problems, which is why I’m passionate about global health and why I have created SHE, a nonprofit foundation that, while focused on basic and clinical research (Science), is aimed at promoting healthy habits (Health) through communication and Education of the population.
Feeling unnoticed in Liverpool, I decided to enter another tennis tournament. I hadn’t picked up a racket for about 6 years. I won and became a hero overnight! After this, Professor Sheehan wrote letters of recommendation describing me as an investigator of the future and a sportsman. My tutor also advised me to move to the University of Edinburgh in Scotland, which then had one of the first coronary care units in the world. He also felt that because it was relatively small I wouldn’t get lost in a sea of people. The unit was led by Michael Oliver, a consultant of cardiology at the Royal Infirmary, and Desmond Julian, another consultant and head of the coronary care unit. It was here that I completed my thesis.
Move across the Atlantic
I was Professor Julian’s right-hand man on clinical matters and I stayed in Edinburgh for 3 years. I was curious about the United States, so I applied to San Diego to work with Eugene Braunwald and was accepted; however, at the last minute there was a problem with my visa. To cut a long story short, a friend contacted the Mayo Clinic where I didn’t need a green card and I got a job there that lasted 12 years! It was a great experience and I became involved with some great people including Dwight Mgoon, a cardiac surgeon who was a tremendous mentor to me and Bob (Robert) Frye and who was loved by us all.
Once I’d finished my training programme at the Mayo Clinic and become a member of staff, I wanted to carry out research and was fortunate to receive a National Institutes of Health grant. I began to work with people with Von Willebrand disease and this is where I learnt that platelets were important in vascular health because this patient group didn’t develop vascular disease.
Climb to Mount Sinai
My career really began to take off, which made it difficult to go back to Spain, and then one day I received a phone call from Dr Richard Gorlin, who was Chairman of Medicine at Mount Sinai Medical Center in New York. He wanted to recruit me as head of cardiology. I said no at first, but then my wife said the move would enable her to study art history at Columbia University, so I reconsidered. Finally we moved to New York and I spent 10 years at Mount Sinai before being recruited as Head of Cardiology at Massachusetts General Hospital. In 1995 I returned to New York to head the new Cardiovascular Institute at Mount Sinai, a unique venture for the United States, with all the specialties in cardiovascular disease pulled together under a single umbrella.
In terms of my academic achievements, I think the highlights so far have been understanding the closure of vein grafts and the use of aspirin, understanding how a plaque ruptures leading to a heart attack, and using MRI for the first time to address the arterial system; my team and I were pioneers in imaging and developed the technique to see how plaques that are not obstructed can rupture.
Then, through MRI, we learnt about the use of rapamycin in the prevention of restenosis following angioplasty. Rapamycin is the drug that has been used for drug-eluting stents and this led to the FREEDOM [Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease] trial that aimed to define the optimal revascularisation strategy for diabetic patients with multivessel coronary disease;2 it has had a significant impact in diabetic patients with coronary artery disease, which is why I’m very proud to have led the trial.
A more recent development I feel proud about is developing the polypill for heart attacks. It has been approved in 35 countries. Adherence to medication is much better as a result, and this highlights the importance of understanding human behaviour and psychology. In fact, acknowledging this has enabled me to make progress in global health. Motivating people to manage their health is possible, especially if you involve the wider community. I’ve been involved in a couple of projects that demonstrate this. One is in Kenya with Dr Rajesh Vedantan, where we are working in a poor area where people develop high blood pressure due to consuming food with too much salt. What we are doing is distributing automatic blood pressure machines to the communities and we’ve seen how this has motivated people to take their blood pressure and encourage their neighbours to do the same. Now we probably have one of the best registries of blood pressure we’ve ever seen in Africa. It’s all about motivating a community about a risk factor, in this case hypertension. We are replicating this psychology in a community in Catalonia, where my wife grew up, and in seven other communites. This time, we’ve divided people into groups of 10 and they help each other on exercise, obesity, smoking cessation and blood pressure. The groups meet every 2 months. The results are fascinating and demonstrate that between ages 25 and 50 there is no question that people in the community are motivating each other to change their behaviour.
I also work as an international advisor on Sesame Workshop’s Global Health Initiative. The goal of the initiative is to measure health improvements in children and build global partnerships to address critical health issues.
I first joined forces with the Sesame Workshop in 2006 to collaborate with Plaza Sésamo, the Latin American version of Sesame Street, to promote cardiovascular health and well being in Colombia. The series there encourages children, parents, teachers and caregivers to make informed nutritional and lifestyle decisions based on educational television content, community outreach and evidence-based research.
I was the inspiration for a Muppet doctor on Barrio Sésamo: Monstrous Supersanos, and my character Dr Valentín Ruster is helping to educate children to lead healthier lifestyles through exercise and healthy diet. This Spanish version of Sesame Street has just debuted on Spain’s Antena 3. I’m helping them to extend this initiative in the United States.
What we learnt through Sesame Street is that our behaviour develops by and large through our exposure to society aged between 3 and 5. We therefore used this window of opportunity to make health a priority with these children. Follow up after 9 years shows that it is really working. It will be interesting to see whether this intervention has an impact on the behaviour of the 75,000 children we are studying as they reach the age of 20.
I think the culmination of these projects and my work understanding human behaviour amongst the different age groups has led to my new appointment as Co-chair of the Consensus Committee on Global Health and the Future of the United States. The Committee will advise the next presidential administration on the role of the United States in the future of global health and I’m proud to be part of it. I cannot comment on what we’re working on now but I can say there is a tremendous drive from treating to promoting health. It’s an economic decision: the cost of treating cardiovascular disease in the United States last year was $300 billion, and this is increasing. The way science is advancing is fantastic but healthcare is becoming very expensive; we’re prolonging life at a tremendous expense and it’s impossible to continue like this.
Preventing disease is much less expensive and I’m proud to have been involved in so many projects that have looked at behaviour in children and in middle age, degenerative brain disease in later life, and how these health issues can be prevented and health promoted. We haven’t left science but are studying genetics and using imaging to help move the pendulum from treating disease too late to promoting health as early as possible; trying to see if we can change the behaviour of people we identify with disease.
I think the future of cardiology will continue to evolve scientifically but there will be a big driving force to understand disease before it evolves and to try to prevent it. The polypill to me is cosmetic. The answer to health isn’t to have a polypill after you’ve had a heart attack; the answer is to prevent a heart attack. We need to use technology to see who is at risk. If you look at the technology and apps from the likes of Google and Apple, for example, they are all trying to predict who might be at risk of disease and to act earlier. That said, I don’t think they’re paying enough attention to how we can help children.
Ten years ago our cardiologists-in-training didn’t think about promotional health and prevention at all; now the tide is turning and out of the 18 fellows that we are working with, six of them want to work in global health to make the world better. This is a huge change and I feel quite optimistic about it.
Motivating the young
Although I’ve been lucky enough to have witnessed and been involved in so many important developments in cardiology, I think one of the highlights for me has been the motivation of young people. Just as I have been mentored, now and in the past, I spend a lot of time trying to mentor young people and it’s a privilege. The world is becoming more complex and so it’s important to have more people around you. Young people sometimes have a hard time accepting this.
Young people need to ask themselves what they are good at, be it seeing patients or working with imaging technology, for example. Once they understand who they are, then they can put passion into it and push themselves, bearing in mind that there will always be ups and downs along the way. Life isn’t straightforward and as long as we acknowledge that, we can mentally prepare ourselves for the ride and exercise resilience.
It’s a bit like biking: as anyone who has experienced any of the world’s great mountain biking challenges such as the Giro d’Italia or the Tour de France will know, each mountain is different and needs to be tackled as a challenge in its own right. The same goes for each new path we take or corner we turn in life. We must face it head on, enjoy the journey, embrace the challenge and, hopefully, make a difference along the way.