Franz Weidinger, MD
Frank Bengel, MD, a professor at the Hannover Medical School (Hanover, Germany), and Johannes Czernin, MD, editor-in-chief of The Journal of Nuclear Medicine (JNM) and a professor at the David Geffen School of Medicine at UCLA, talked with Franz Weidinger, MD, president of the European Society of Cardiology (ESC), about his career of leadership in cardiac medicine. The ESC represents more than 105,000 individuals in the field of cardiology from Europe, the Mediterranean Basin, and beyond and includes 28 cardiovascular subspecialty communities of clinicians and researchers.
Dr. Weidinger is head of cardiology at the Klinik Landstrasse (previously the Rudolfstiftung Hospital), a teaching hospital affiliated with Vienna Medical University in Austria. He previously served as deputy head of the Division of Cardiology at the Medical University of Innsbruck (Austria; 1997–2007). His clinical focus is on percutaneous coronary interventions (PCIs) and acute coronary syndromes, with more than 200 peer-reviewed publications. He has been active as a leader in numerous medical societies, including as president of the Austrian Society of Cardiology (2013–2015).
Dr. Czernin: Thank you very much for taking the time to talk with us. It has been a long time since we both trained in cardiology at the University of Vienna. You have had a remarkable career culminating in your current role as president of the ESC. Let’s start with the early days of your research career. You spent 2 years at Brigham and Women’s Hospital (Boston, MA) working on coronary vasomotion. Why did you pick Boston?
Dr. Weidinger: At that time, we were supposed to first train in clinical cardiology. Toward the end of our training, we were encouraged to go to the United States for a research fellowship. I read a paper in The New England Journal of Medicine (1986;315:1046–1051) that described paradoxical vasoconstriction in response to acetylcholine in human coronaries, from the group led by Peter Ganz, MD, and Andrew Selwyn, MD, at Brigham and Women’s. This sounded very exciting and translatable. That’s why I applied.
Dr. Czernin: Can you describe the setup of the research there? You did animal experimental work without having prior experience. How did you learn this?
Dr. Weidinger: It was there that I discovered the beauty of science and how to do research. I spent my first 2–3 months writing the proposal for my project. This was a big project, because it dealt with endothelial dysfunction after balloon angioplasty in a rabbit iliac artery model. I had to learn how to anesthetize and operate on New Zealand White rabbits. I was trained by the fellows in the cath lab and the animal lab. I developed my own project looking at dysfunction of regenerated endothelium after balloon angioplasty, which at that time was quite interesting, because we didn’t yet have stents. We could distinguish what the mechanical injury of balloon angioplasty did to the endothelium and the underlying smooth muscle cells.
Dr. Czernin: How did the mentoring with Ganz and Selwyn work? How often did they interact with you?
Dr. Weidinger: At that time, I would have appreciated seeing them more often. We had rounds once or twice a week with all the fellows, who discussed progress. I gradually became acquainted with a group of specialists in pathology, vascular biology, physiology, and, of course, catheter techniques. The great thing was that for every question, a relevant specialist could be found either in the same building or just across the street.
Dr. Czernin: How did you apply your research later on in your career, and did it translate into patient care?
Dr. Weidinger: Together with other colleagues, we started working with the same rabbit model at the University of Vienna. Later on, we were able to study endothelial dysfunction in humans noninvasively with ultrasound methods. The topic of endothelial dysfunction remained important for a long time. I don’t think that endothelial function testing has been established as one of the office tests to screen for early atherosclerosis or progression of atherosclerosis, but it remained an important research tool.
Dr. Czernin: Did it inform any risk factor modification strategies?
Dr. Weidinger: I think so. Look at the effects of lowering cholesterol with statins or the effects of vitamin E and other antioxidants on endothelial function. It’s a nice way to demonstrate that at least part of vascular dysfunction in early atherosclerosis can be reversed.
Dr. Czernin: Before I turn the discussion over to Frank, I have a political question. You lived in the American and the European health-care systems. Are there advantages of the American over the European system or vice versa?
Dr. Weidinger: I once had to go to an emergency department. Nothing serious, but I needed to go there and couldn’t even pass the entrance without showing my credit card. “Are you insured? Are you entitled to be here?” This is unlikely to happen in our system. Most European systems are still based on socially supported health care, based on mandatory health insurance. In Austria, everyone gets good treatment and care. The hospital doors are perhaps too wide open, which drives health-care costs; nevertheless, I do prefer the Austrian and European healthcare systems.
Dr. Bengel: I’m going to get back to your research and its clinical translation. You’ve been working in animal models using pharmacologic interventions. You have also reported on the effects of mechanical manipulation of arteries. This is the dichotomy of cardiovascular care, where we have catheter-based interventions on the one hand and pharmacologic and lifestyle interventions on the other. If you had to define the most important aspect of cardiovascular care today, would it be intervention or drug therapy? Or both?
Dr. Weidinger: It’s certainly both. And maybe we are at something of a turning point, because at least with chronic stable angina or chronic coronary syndrome (as we call it now), things have changed since the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and other trials have shown the limitations of too much intervention. At least in stable patients with few symptoms, we have very powerful pharmacologic approaches to improve patient outcomes. On the other hand, primary PCI in the acute setting of myocardial infarction can save lives. There is no doubt that we need rapid restoration of blood flow and stenting. More recently, we can also save lives in structural heart disease by noninvasive transcatheter aortic valve implantation for aortic stenosis. Progress and innovation come from both interventional and pharmacologic therapies.
Dr. Bengel: How do you view the current role of functional testing for myocardial ischemia? How is that going to guide therapy?
“The best way to reach a good decision, whether in a clinical team or on the board of the ESC, is to convince with your arguments.”
Dr. Weidinger: We have to deal with the discrepancies between the amount of ischemia, the impact of the invasive strategy, and the outcome. What the ISCHEMIA trial put into question is whether we can improve outcome by intervening in those patients with extensive ischemia independent of symptoms. In the many patients in whom symptoms are not so clear, perfusion imaging still has a strong role, at least in my clinical setting. It remains well established here in Austria and Europe.
Dr. Bengel: In Germany, the numbers of nuclear perfusion imaging procedures are going up almost every year, despite the success of alternative noninvasive tests using MRI and CT. Clearly there is a role for noninvasive testing, but the question is: What kind of therapy will imaging guide in the future? Everyone is talking about precision medicine. How would you define precision cardiology?
Dr. Weidinger: That’s an interesting question, because the term comes from oncology, where targeted drug therapies are guided by biomarkers to the right patients. We like to talk about personalized medicine and precision medicine in cardiology, too. However, those are buzzwords that should be filled out with more content. It’s still too early to say how precision medicine in cardiology can change clinical practice. It will involve “omics” technologies and demonstrate how these could better guide us in both preventive cardiology and in choosing the right treatment. The latest prevention guidelines of the ESC already talk about lifetime risk and better ways of assessing cardiovascular risk in individual patients.
Dr. Czernin: Are any predictive or prognostic imaging biomarkers already on the horizon for precision cardiology?
Dr. Bengel: Yes, cardiac amyloidosis is a nice example in which imaging, including bone scans, is specifically used to guide application of novel and highly effective disease-modifying drugs—which are also very expensive.
Dr. Weidinger: I agree. The search for amyloidosis has really surged in the last few years. We should be realistic and not expect that every patient in whom we have a suspicion for the presence of amyloidosis will be a good candidate for these very costly treatment strategies. However, I think it’s an important new avenue for refining our search for causes of cardiomyopathies or poor ventricular function, and it serves as a role model for where novel targeted therapies can go in cardiology.
Dr. Bengel: I have two more questions before I hand the ball back to Johannes. You talked about buzzwords; have you heard of the buzzword “theranostics”?
Dr. Weidinger: Yes, I have, because my wife is a nuclear medicine physician. I think it’s a way to visualize a target and then treat the target with a similar molecule labeled with a therapeutic isotope.
Dr. Bengel: Indeed. I was asking this because the JNM associate editors have recently discussed how we as nuclear physicians would define theranostics. The terminology is a mixture of therapy and diagnostics, and it could be expanded beyond the use of a radiopharmaceutical for diagnosis and subsequent therapy toward a more general setting in which a specific, targeted therapy is informed by a diagnostic test. Perhaps cardiology is a very early example of that, because you perform coronary angiography followed immediately by coronary intervention guided by that angiography.
Dr. Weidinger: Another example would be the vulnerable plaque that we have been following for decades, investigating whether it’s possible to distinguish stable from unstable plaque and whether we can intervene more effectively, perhaps using nuclear techniques as well. I think that’s fascinating.
Dr. Bengel: We are getting new technology, such as total-body PET imaging, that will increase sensitivity for small lesions. Thus, vulnerable plaque may be detectable in the not-so-distant future using this advanced technology.
Theranostics is currently a driving force in nuclear medicine, leading to much greater interest in our methods from industry. Major companies, such as Novartis, are now getting involved. Industry and the scientific and clinical cardiology communities have for a long time collaborated very closely. However, certain risks are involved. Could you share with us a little bit about how you’re managing this as president of the ESC while still maintaining independence in clinical and scientific decisions?
Dr. Weidinger: That’s a great challenge. Large, randomized trials are increasingly expensive, and larger numbers of patients are needed to show meaningful benefits for a given therapy. Industry and medicine must collaborate to get this done. We have to be very careful to determine and establish the most independent way of guiding these interactions. We need the support of industry both in discovery of new treatments as well as to interact with the scientific and clinical communities. It’s a delicate balance to preserve unbiased, independent research. We have established cardiovascular roundtables at which industry partners interact with experts in a given field of cardiovascular medicine to then publish papers on potential collaborations.
Dr. Czernin: Another field of the future is artificial intelligence (AI). Radiologists have feared that AI could take away their jobs. How do you see the role of AI in cardiology in interpreting test results or creating algorithms?
Dr. Weidinger: Just today I have on my desk an issue of The New England Journal of Medicine (2023;388:e49) with a review article on AI in medicine and what it’s about. AI provides a huge opportunity in cardiology. In the ESC, we try to find the right experts who already have experience with AI in their subspecialty areas, such as imaging or arrhythmia. We have to manage big datasets, and that’s where AI has a bright future. However, if you don’t combine the clinician with the data scientists and the AI experts you will get more garbage than useful data. We don’t know what we can expect in terms of decision support from these new technologies. Probably the best use for AI is that it should liberate us from too much bureaucratic work so that we gain time for our patients.
Dr. Czernin: How much time do your young colleagues want to spend in research, given the quest for a life/work balance?
Dr. Weidinger: The younger generation often sees doing research as a phase of their careers, and then they leave it. Our congresses more and more focus on educational than purely scientific content, including basic research. A recent paper in Nature (2023;613:138–144) showed that “disruptive” science has declined over the past decades. We have to offer ways to stimulate interest in discovery research.
Dr. Czernin: Frank, how do you create interest in fundamental research in your department?
Dr. Bengel: It is mostly about reserved time for research. Young students respond well if you offer them structured programs that lead to publications and to their MD theses. Later, during clinical training, they may enroll in a clinician scientist program, which gives them 50% research time and 50% for clinical work. We still need to find better ways to integrate clinical and research training. If you want to find motivated young people, this is what you have to offer to them.
Dr. Czernin: Franz, when I learned that you had become president of the ESC, I wondered what motivated you.
Dr. Weidinger: I was on the board of the ESC for about 6 years, and some colleagues tried to convince me to run for the presidency. I talked to my family, because I anticipated that this would be a lot of work—and it is! But it’s still gratifying, because I interact with a very international community, learn much about different health systems, and also have the opportunity to appreciate different points of view and cultures. I can also introduce new ideas and try to influence the course of the ESC in Europe. It is a great privilege and opportunity to work with so many bright people from different countries.
Dr. Czernin: This series is called Discussions with Leaders: What is your leadership style in your hospital and in the ESC?
Dr. Weidinger: I prefer to listen rather than to speak too much—to integrate others’ opinions rather than dictate. The best way to reach a good decision, whether in a clinical team or on the board of the ESC, is to convince with your arguments. Listening to the opinions of others and then arriving at a synthesis to provide solutions is the best way of governing and leading a society and its board. It is important to stay humble but have a clear vision communicated in the right way to stimulate interest in our common topics and concerns.
Dr. Czernin: What is the most impactful thing you have done in your professional career?
Dr. Weidinger: I like to think back to my years in Innsbruck. This was the time when primary PCI for acute myocardial infarction started. I was very deeply involved in the regional ST-segment elevation myocardial infarction (STEMI) network that we established there. It was gratifying to see how much we could improve outcomes of acute myocardial infarction by doing primary PCI. To be able to interact with the emergency physicians to convince them to bring in patients very quickly by helicopter, rather than doing thrombolysis in the field, was a very impactful thing.
Dr. Czernin: My final question for you: What kind of advice do you have for the next generation, not only cardiologists, but physicians in general?
Dr. Weidinger: We have to be mindful. We are often dealing with elderly patients, and we should spend more time explaining, in very simple terms, what we can provide and offer. We need to maintain a high interest in documenting detailed medical histories and listening carefully to the patients entrusted to us. These communication skills that we learned before smartphones should also be taught to the young. My advice would be to communicate in a very understandable, simple, and convincing way with patients after carefully listening to their stories.
Dr. Czernin: Thank you, Franz. We are grateful to you for spending time with us and for sharing your experiences and insights with our readers.
- © 2023 by the Society of Nuclear Medicine and Molecular Imaging.
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