In the history of medicine, no other time has seen as rapid evolution as our time. By the time today’s consultants graduated from medical school, atherosclerosis was seen as a constantly progressive, mechanical, inevitable process associated with advancing age. The endothelium was portrayed as an inert barrier, and beta adrenergic blockers were the maximum we can do for patients who survived a heart attack. After the tremendous advance in our knowledge of risk factors and pathophysiology of vascular disease - as well as the miraculous evolution of our armamentarium to deal with all stages of atherosclerosis – the disease still spreads in a pandemic fashion, and its projected morbidity and mortality figures outnumber any other disease known to mankind.

The major challenges that have to be met by the profession – and the community – today are:

1. The evolving concept of risk: Cardiovascular risk estimation developed from just classification of patients to primary and secondary prevention situations into the use of advanced tools to detect subclinical disease progression (e.g. retinopathy, microproteinuria, intima-media thickness), and then to the dependence on different algorithms and risk charts to assess the probability of a cardiac event in 10 years time. These scores have facilitated risk calculation, but they have several limitations, the most prominent of which are the excess weight given to age, the use of risk factor levels as categorical rather than continuous variables, and the relative insensitivity of these algorithms in detecting the effects of therapeutic interventions. The estimation of the lifetime risk showed us that the 10 year risk calculation leads to a serious underestimation of reality. Risk factors do not just act for 10 years and then stop, they act for a lifetime. Similarly, therapeutic interventions do not just act for the period of the clinical trial, they act for a lifetime.

2. The change in demographics: The ageing of all populations, mainly due to improved health care led to more patients with vascular disease. The increased accessibility to high calorie, high fat, high salt foods, as well as the decreased need for physical activity led to an explosive spread of obesity, metabolic syndrome, and diabetes mellitus.

3. The profession is under continuous pressure to do more; treating at an earlier stage, giving more preventive care, and treating higher risk patients to more aggressive targets of blood pressure, lipid levels, blood glucose level, etc… The benefits of more aggressive therapy have to be carefully balanced against cost and adverse effects, particularly in a community that is much less forgiving to medical mistakes than it used to be two or three decades ago. This situation has led to serious under-treatment of some higher risk groups who are at an increased risk of both vascular disease and adverse drug effects, like elderly subjects, and those with chronic kidney disease.

4. The profession has to do its job as cost-effectively as possible. Even the richest communities face progressively increasing difficulties in making necessary medical services available to all those who need them. Resources more than science often decide what is to be done for patients. Each community has to set its own standards of care guided by both science and resources, since we obviously cannot afford to provide every useful therapy to every one who needs it.