Heart disease may not feature as prominently in the press as other medical conditions, but in many respects, it is an even bigger problem, says Dr Ali Khavandi, consultant interventional cardiologist at the Royal United Hospital Bath NHS Foundation Trust. It “kills more than all cancers put together”.
Heart disease is also a growing problem, imposing the “largest financial burdens on healthcare systems around the world”. Fortunately, mounting demand for better treatments is sparking a revolution in the way we treat the condition, with the biotechnology and medical technology sectors changing everything from the way that we tackle the underlying risk factors to developing better pre-emptive measures.
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Heart disease has long been a huge problem in richer countries – 40% of the developed world’s population either has a cardiovascular condition or will develop one. However, it is increasingly also a problem for the developing world, says Khavandi. Note that “even in Africa more people now die of heart disease than of HIV, TB and malaria combined”. This is partly because longer life expectancies make an increase “inevitable” owing to the wear and tear on arteries as people age.
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For now, though, the more immediate concern is “metabolic syndrome”. This is the medical term for the health problems caused by bad eating habits, including eating too much ultra-processed food and drinking too much alcohol, and the lack of exercise associated with post-industrial life, which means that “most of us are carrying too much weight, especially around our vital organs”, says Khavandi.
There has been a “huge amount of interest” in the medical community around the link between poor nutrition and heart disease, with the World Health Organisation estimating that roughly 80% of cardiovascular disease could be prevented by making lifestyle changes.
Sadly, the message that being overweight can be bad for your heart doesn’t seem to be getting through to the wider population, who tend to view obesity in terms of “how it makes a person look rather than on their health”, says Matthew Renna, portfolio manager for the Harbor Health Care Ucits exchange-traded fund (ETF). Losing weight can also be difficult, while diet pills were traditionally “riddled with safety issues” and “didn’t work all that well”. But this has changed in the past few years with the development of the GLP-1 agonists. Originally developed to treat diabetes, these drugs work by enhancing the secretion of insulin, leading to “pretty significant weight loss” even in people without diabetes.
Almost as soon as these drugs were developed people began wondering whether the weight loss they promoted would “have a benefit on cardiovascular health”, says Renna. Last year, this was answered conclusively when a large-scale trial by Novo Nordisk involving 18,000 people showed that the weight loss drug Wegovy “reduced adverse cardiovascular events (strokes and heart attacks) by 20%”. This “amazing” result means these treatments are no longer merely weight loss drugs but have become what Renna considers “a major advancement for the treatment of cardiovascular disease”. Overall, he says, this is shaping up to be “the largest pharmaceutical market we’ve ever seen”.
Other promising heart disease treatments
Although important, anti-obesity drugs aren’t the only promising heart disease treatments coming through the pipeline. Until about 15 years ago, statins, a group of medicines that can help lower the level of low-density lipoprotein (LDL) cholesterol (or “bad cholesterol”) in the blood, were a big money-spinner for drug firms, say Ailsa Craig and Marek Poszepczynski of the International Biotechnology Trust. However, as the patents on most of these drugs have now expired, big pharma is seeking “new targets”. PCSK9 inhibitors, which also reduce cholesterol, are one promising category, with Amgen and Sanofi developing some that “work incredibly well in those who can’t tolerate statins or where LDL wasn’t lowered enough”.
Another group of drugs creating excitement among cardiologists are those targeted at Lp(a), another protein linked to heart disease. Around 20% of the population contains genes that lead to increased levels of Lp(a), even in otherwise healthy individuals. This may be because “in the distant past it actually conferred an advantage by helping the blood clot, useful at a time when there were no accident and emergency departments where you could go to patch up a wound caused by a bite from a sabre-toothed tiger”, says Craig. Unlike statins, which may even increase Lp(a) levels, these new drugs have been shown to inhibit the production of Lp(a).
Daniel Lyons, portfolio manager on the health care and biotech teams at Janus Henderson Investors, believes that if clinical trials being run by Novartis and Amgen around the link between lower Lp(a) and heart disease work out, it could “open up a new multibillion-dollar market”. Lyons also notes there are some other interesting areas, with biotech companies such as Rocket “working on gene therapies for rare forms of cardiomyopathy [disorders affecting the heart muscle] such as Danon disease”. What’s more, several firms “are working on improvements in cardiac diseases related to ageing, like TTR amyloidosis, with new therapies likely to be approved in the near term”.
The rise of the robot surgeons
Sadly, drugs can’t solve every heart-related condition. Many patients require some form of heart surgery. This can be time-consuming, expensive, come with various risks and even if successful can involve long recovery times. One technology that is starting to transform heart surgery is the use of robotic devices. Paul Modi, consultant cardiac surgeon at the Liverpool Heart and Chest Hospital, believes that robot-assisted surgery is particularly useful in “intra-cardiac” procedures (those that take place inside the heart), including the repair of two of the four main valves. It is also increasingly useful in extra-cardiac surgery, such as bypass surgery that involves a single graft.
Modi thinks that using robotic machines in heart surgery has “big advantages for both the patient and the surgeon”. For patients, robot-assisted surgery “reduces the amount of trauma and cuts recovery times”. Indeed, traditional surgery, which involves cutting open the front of the chest and breaking the breastbone, typically requires up to seven days in hospital, followed by a two-or-three-month period recovering at home”. However, robotic heart surgery involves a relatively tiny incision, “allowing the patient to resume normal activities within two to three weeks”. The need for post-operative care, including blood transfusions, is also dramatically reduced, while infections “are almost unheard of”.
Using a robotic system such as Intuitive Surgical’s Da Vinci also makes the surgeon’s overall job easier. The latest versions include “seven degrees of freedom”, which allows the user to manipulate the robot arm more precisely than ever before. Robotic systems also permit the surgeon to view the area being operated on in much more detail, with both three-dimensional vision and magnification of up to ten times on offer.
What’s more, robotic surgery isn’t necessarily the final destination. Modi quotes his American mentor, Wiley Nifong, who likens the automation (and miniaturisation) of heart surgery to climbing Mount Everest. So, “if conventional surgery is the base camp, then keyhole surgery (without robots) is a higher camp, and robotic surgery is even higher”, while the summit will be completely endovascular surgery, with procedures carried out by inserting a device into the bloodstream via a single pinprick.
“It’s becoming increasingly clear that using robotic systems in heart surgery, is delivering benefits for all stakeholders”, with the economic benefits, in particular seemingly “increasingly unassailable”, agrees Andrew Duncan, senior equity analyst at Killik & Co. Duncan accepts that the machines come with a high upfront cost, and the per-procedure expense is higher. However, this is far outweighed by the reduced need for post-operative stays in intensive care and extensive rehabilitation, as well as far fewer cases where the hospital will be required to repeat or redo procedures.
Killik’s Duncan says the machines are improving all the time. He is particularly impressed by the idea of augmented reality (AR), which projects computer-generated information onto real-world video images. With good visibility vital to successful outcomes, the AR systems starting to appear “will guide surgeons by highlighting areas they need to focus on, as well as the areas which they should avoid”. Force feedback (the simulation of physical touch in the real world) on the controls linking the surgeons and the robotic arms is another technology that could improve precision.
How to improve heart disease diagnosis
Better treatments for heart disease are only part of the solution. Like other conditions, heart disease is much easier to treat if caught at an early stage, but worsens if not identified until later. The problem is that it tends to be difficult to diagnose, especially using traditional methods, such as simple observation. This can lead to seemingly healthy adults, who Dr Khavandi refers to as “middle-aged men in Lycra”, being underdiagnosed. It’s also a particular problem for women, “as their incidence of heart disease is actually equal to that of men, but they tend to present differently in terms of symptoms”, says Adam Fine, co-founder and CEO of Windham Capital Partners. “This leads to delays in treatment as well as heart disease being mistaken for other conditions.”
The good news is that “the same miniaturisation trend that is transforming heart surgery is also taking place in diagnostics”, says Fine. Devices are being developed that monitor the wearer’s vital signs, flagging up potential problems. This reduces the need for more invasive testing such as right-heart catheterisation, where a surgeon measures how well the heart is pumping by inserting a catheter threaded into the pulmonary artery. Such testing requires a local anaesthetic and is uncomfortable for the patient “as well as being expensive and time consuming”.
Another non-invasive approach is to use an imaging device such as ultrasound, CT or MRI scans, or even simple chest X-rays. Sadly, human error and the limitations of the technology mean “many cases are missed”, says Mark Phillips, chief clinical officer of Annalise.ai. Set up only four years ago, with the aim of applying recent developments in artificial intelligence (AI) to medicine, Annalise has developed a system that identifies 124 different radiological findings on a typical chest X-ray. While it doesn’t replace a human radiologist, it reduces the time needed by the specialist by nearly half by flagging up areas of concern as well as prioritising cases in need of urgent attention.
This is important as some types of heart problems “require immediate intervention, while others can be dealt with by a visit to the doctor and some medication. Indeed, while the device has been clinically verified “to be at least as good as a human radiologist”, Phillips points to analysis suggesting that in a quarter of cases, it can help diagnose cases of heart disease a year earlier than a typical radiologist. Within a few weeks of radiologists being introduced to the system, even those previously sceptical were saying “they needed this to do their jobs properly”.
Integrating data to improve diagnosis
As well as advances in diagnostic methods, there are also moves to break down “informational silos”, says Jason Alan Snyder inventor and founder of SuperTruth. His company aims to integrate the data from various sources such as wearables, scans, cardiograms and even patient histories “to enable medical professionals to diagnose heart disease much more accurately than if they were looking at just one measurement”. He thinks that combining multiple sources can, in some cases, give doctors an “unbelievable” ability to predict heart disease at an early stage.
Snyder also thinks the increased integration of data and machine learning is improving the accuracy of diagnosing heart disease and making accessing medicine more convenient by encouraging the development of “telemedicine” and home-testing kits. Such kits, which analyse bodily fluids to see if they contain proteins consistent with heart-related inflammation, can prompt patients to come forward who think they might have a problem “but who otherwise wouldn’t want to trouble their doctors”.
How to invest in the battle against heart disease
While there are no exchange-traded funds (ETFs) that deal directly with heart disease, the Harbor Health Care Ucits ETF (LSE: WELL), due to be launched later this month, has several companies tackling it in its portfolio. They include Viking Therapeutics (Nasdaq: VKTX). Viking boasts an anti-obesity drug, VK2735, that showed strong results in a recent phase two trial (the second of three stages of clinical trials). It helped people lose weight, raising the possibility that it could become a major rival to the two main drugs now on the market. While Viking is still in the red, it has more than enough cash to help it get through the final stages of bringing the drug to market.
Matthew Renna, portfolio manager for the Harbor Health Care Ucits ETF, also likes Rocket Pharmaceuticals (Nasdaq: RCKT). Rocket specialises in developing gene therapies for various rare and life-threatening conditions, split between blood diseases and heart problems. While it is expected to win approval for its treatment for the blood condition Fanconi Anaemia (FA), Rocket’s most promising (and potentially lucrative) treatment is RP-A501, aimed at the heart problems associated with Danon’s disease, which affects around 45,000 people in the US and Europe alone. RP-A501 is undergoing stage-two trials. Like Viking, Rocket is unprofitable but could reap big rewards once its drugs get approved.
Amgen (Nasdaq: AMGN) is a more established biotech company. While its therapies are targeted at a wide range of conditions, one of its most lucrative drugs is Repatha, which aims to reduce the risk of heart attacks by lowering the amount of “bad” cholesterol in the blood. It also owns the GLP-1 anti-obesity drug MariTide, which has shown promise – and it only needs to be administered monthly, instead of weekly (as with the existing drugs). Amgen trades at 16.3 times 2025 earnings.
With a 99% market share, Intuitive Surgical (Nasdaq: ISRG) is the undisputed leader in robotic surgery. With the savings from reduced recovery times making hospitals “extremely happy”, and “tens of thousands of surgeons now trained to use its systems”, Killik’s Andrew Duncan thinks that Intuitive has an “unassailable position” in the field of robotic surgery. While Intuitive trades at a pricey 63 times 2025 earnings, this has to be viewed in the context of sales that are growing at 15% a year, along with strong operating margins and a double-digit return on capital employed. There have also been rave reviews for the Da Vinci 5, the latest version of its robotic operating system.
One established medical technology company that specialises in heart disease is Edwards Lifesciences (NYSE: EW). As well as making artificial replacement heart valves used in surgery, Edwards also produces monitoring software containing advanced algorithms that can predict the onset of hypotension (low blood pressure) during surgery. While sales have grown by around 60% over the past five years, and it produces a return on capital employed of just under 20%, it still only trades at 25 times 2025 earnings.
Boston Scientific (NYSE: BSX) is a medical device maker that derives 66% of its revenue from devices related to heart disease and cardiovascular health – everything from equipment used in heart surgery to wearable monitoring devices which allow doctors to track the health of patients with heart disease. Boston Scientific has a strong record of growing sales, now rising by 8%-10% a year, while offering high returns on capital, which more than justifies a rating of 30 times 2025 profits.
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