Cardiovascular care is the diagnosis, treatment, and prevention of cardiovascular disease. Cardiovascular disease includes pathology of the heart and the peripheral vasculature. It remains the number one killer in the United States. The 2010 overall rate of death attributable to cardiovascular disease was 235.5 per 100,000. On the basis of this death rate, more than 2150 Americans die of cardiovascular disease each day, which corresponds to 1 death every 40 seconds. However, the death rate attributable to cardiovascular disease has declined by 31% from 2000 to 2010.¹ The reasons for this include progress in preventive medicine as well as better treatment of risk markers like hypertension and hyperlipidemia, timely application of reperfusion therapy for acute myocardial infarction and better access to cardiovascular operations and procedures. This has correlated with a dramatic increase in the volume of cardiovascular care. For example, there were approximately 6,000,000 inpatient cardiovascular operations and procedures in 2000, which increased by 25% to approximately 7,500,000 inpatient cardiovascular operations and procedures in 2010.¹ As a result of these trends, cardiovascular care comes at a larger cost to society. The total direct and indirect costs of cardiovascular disease and stroke in the United States in 2010 were estimated at $315.4 billion.¹

Cardiovascular care is provided by a number of different cardiovascular subspecialties. This includes cardiac surgeons, cardiovascular physicians, interventional cardiologists, interventional and noninterventional radiologists, vascular surgeons, cardiovascular anesthesiologists, critical care specialists, and primary care physicians. Each of these subspecialties has evolved from very different historical roots. For example, cardiac surgery emerged from general surgery during the Second World War, when Dwight Harken successfully removed foreign bodies in and around the heart of some 130 injured soldiers.² In contrast, interventional cardiology emerged from radiology when Dr. Charles Dotter performed the first-ever angioplasty procedure in a leg artery at the Oregon Health and Science University in Oregon³ and, building on his work, Dr. Andreas Gruentzig performed the first balloon angioplasty procedure on a coronary artery.⁴ Similarly, each of the other subspecialties that contribute to cardiovascular care has evolved from distinct historical roots. As a result of these different historic roots, providers of cardiovascular care were originally organized in separate medical school departments according to the patient populations that their disciples historically served and the instruments that were historically used in their clinical practice.

The departments of early medical schools were initially formed by individual professors and their assistants. Subsequent expansion of the departments increased their organizational complexity but they continued to operate as separate units under the leadership of autonomous chairmen.⁵ Advances in medical research in the twentieth century resulted in the emergence of departmental subspecialists who predominantly treated one specific organ. Consequently, many medical school departments established divisions that focused on particular organ systems.⁵ As the divisions became ever more specialized, the clinical interests of individual divisions of separate departments began to overlap more with each other than with the rest of their respective departments. In particular, the emergence of cardiac surgery as a subspecialty resulted in a symbiotic relationship between cardiac surgeons and cardiologists.⁵ Moreover, cardiac surgeons and cardiologists increasingly relied on specialized cardiovascular radiologists and cardiovascular anesthesiologists. Over time, these relationships between the cardiovascular subspecialities evolved into formal associations and eventually dedicated cardiovascular centers were formed. These cardiovascular centers allowed physicians of different subspecialties to cooperate at an unprecedented level to optimally orchestrate the cardiovascular care of their patients.

Cardiovascular centers that integrate multiple cardiovascular subspecialties provide a number of important advantages. Firstly, integrated cardiovascular centers improve the clinical care for patients. For example, clinical care is improved by increasing patient volume. The relationship between patient volume and quality of care has been demonstrated in many areas of cardiovascular care. For example, a large body of evidence shows that increasing procedural volumes in cardiac surgery results in improved quality with decreased complication rates. Moreover, there is evidence that increased surgeon volume results in improved quality of care.⁶ Therefore professional organizations have recommended that cardiac surgery programs performing fewer than 125 coronary artery bypass graft (CABG) procedures annually consider affiliation with high-volume tertiary centers.⁷ A similar relationship between volume and quality of care exist in interventional cardiology. Among hospitals in the United States that have full interventional capabilities, a higher volume of angioplasty procedures was found to be associated with a lower mortality rate among patients undergoing primary angioplasty.⁸ On the basis of this and other studies, professional organizations recommended that patients with ST elevation myocardial infarction undergo primary angioplasty by cardiac catheterization laboratories performing at least 36 primary angioplasties as well as at least 200 total angioplasties per year.⁹ Integrated cardiovascular centers are ideally suited to deliver such high procedural numbers by concentrating cardiovascular care in dedicated centers, attracting referrals, co-marketing, and by sharing patients among the physicians. Higher quality of care can also be delivered by building up specialized expertise within narrow boundaries, multidisciplinary management of patients, and co-locating services. Finally, a substantial clinical research effort facilitates participation in multicenter trials that give patients access to the latest clinical treatment modalities.