The Future of Cardiovascular Biomedicine
The Future of Cardiovascular Epidemiology
Ramachandran S. Vasan, MD; Emelia J. Benjamin MD, ScM
C ardiovascular disease (CVD) is a major cause of mor-
bidity and mortality worldwide, with the lifetime risk
exceeding 60%.1 More than 2200 Americans die of CVD daily,
1 death every 40 seconds. A third of CVD deaths occur before
75 years of age, which is less than the average life expectancy
of 78.8 years.1 Thus, prevention of CVD is a public health
priority. Major advances in cardiovascular epidemiology over
the last 4 decades have improved our understanding of the
pathogenesis of CVD, with the identification and treatment of
several major risk factors.2
However, several factors are worth highlighting to place
these past achievements in appropriate perspective.
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1. There remains a substantial societal burden of risk
factors. Data indicate that 1 in 3 Americans reports
no leisure-time physical activity and is likely to
have high blood pressure, prediabetes, or high blood
levels of low-density lipoprotein cholesterol.1 A
majority of adults in the United States are over-
weight or obese; about one fifth have low levels
of high-density lipoprotein cholesterol; one sixth
smoke; and about 1/10th have diabetes mellitus.1
2. Projections indicate that the prevalence of CVD in
the United States may escalate by 10% between 2010
and 2030.3 The estimated increase stems in part from
the aging of the population and is fueled by the recent
trends for increasing obesity rates and the concomi-
tant rising rates of hypertension (8% increase over the
next decade) and diabetes mellitus (100% increase
over next 3 decades).1 These projections indicate that
past achievements potentially may be challenged by
some of the recent adverse trends in some risk factors.
3. There is a glaring 14-year difference in life expec-
tancy between select population groups in the United
States, as identified in the Eight Americas Study,4
with CVD emerging as the greatest source of differ-
ence in life expectancy. Indeed, it is estimated that
blacks have a higher burden of usual CVD risk fac-
tors, are 2- to 3-fold more likely to die of heart dis-
ease compared with whites, and have higher rates of
premature death resulting from CVD.1 Thus, major
declines in CVD mortality accrued over decades of
advances in population health have not effaced the
racial and ethnic gaps in CVD morbidity and mortality.5
From National Heart Lung and Blood Institute’s and Boston University’s Framingham Heart Study, Framingham, MA (R.S.V., E.J.B.); Evans Department
of Medicine, Whitaker Cardiovascular Institute (R.S.V., E.J.B.) and Preventive Medicine and Cardiology Sections, Department of Medicine (R.S.V.,
E.J.B.), Boston University School of Medicine, MA; and Department of Epidemiology, Boston University School of Public Health, MA (R.S.V., E.J.B.).
Correspondence to Ramachandran S. Vasan, MD, Framingham Heart Study, 73, Mt. Wayte Ave, Ste 2, Framingham, MA 01702. E-mail vasan@bu.edu
(Circulation. 2016;133:2626-2633. DOI: 10.1161/CIRCULATIONAHA.116.023528.)
© 2016 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
2626
4. There is increasing emphasis that key research, includ-
ing cardiovascular epidemiological research, must trans-
late directly to improvements in public health, focus on
diverse populations, and engage communities actively.
Indeed, the utility of cardiovascular epidemiological
research has been periodically questioned in the past
and more recently.6 Dr Michael Lauer (National Heart,
Lung, and Blood Institute) noted in a recent Journal of
the American Medical Association editorial that “the
answer to the question ‘what has epidemiology done
lately’ suggests two answers: much and not enough.”6
Thus, cardiovascular epidemiology is confronted by a dual-
ism: unprecedented opportunities for new research directions
amid a growing uncertainty about its potential value and a pres-
sure to do more and be more accountable. Additionally, the
notion that a great deal of epidemiological research results in
false-positive findings has gained momentum,7 thereby raising
the bar for both study quality and the necessity for replication
as a sine quo non for all future epidemiological investigations.
Overall, thought leaders have underscored the importance of
consequential8 and translational epidemiology9 in the decades
ahead for the science to remain relevant in the face of greater
expectations that epidemiological research must affect public
health more directly.
Given this background, we identify key transformative direc-
tions that the field of cardiovascular epidemiology will undergo
over the next decade. The specific areas we highlight in our
review include the changing framework of population health and
disease, including a greater integration of individual and com-
munity approaches, and the combination of health promotion
strategies with traditional disease prevention/treatment goals
(cHealth); recognition of the social determinants of health and
their incorporation into the biomedical model of CVD (sHealth);
better characterization of the exposome, including the built envi-
ronment and via the “quantified” self, fueled aptly by the digi-
tal data age revolution (mHealth); the integration of electronic
medical records (EMRs; eHealth) resources into the monitoring
and maintenance of the health of individuals and populations;
and harnessing of the power of the genomic revolution toward
better precision cardiovascular medicine delivery (gHealth);. We
also address related challenges that require reconfiguration of
traditional cardiovascular epidemiology training and the devel-
opment of the public health workforce of this century.
DOI: 10.1161/CIRCULATIONAHA.116.023528
 Vasan and Benjamin   Future of Epidemiology   2627
Recognition of the Essential Role
of Community-Based Approaches
to Cardiovascular Health Over
the Life Course: cHealth
It has been well recognized for decades that CVD is a life-
course and lifestyle disease. Traditional approaches to pre-
venting CVD have focused on the assessment and treatment
of key risk factors at the individual level. Sir Geoffrey Rose10
elegantly articulated the debate between individual and pop-
ulation-based approaches to the prevention of disease. He
underscored both the complementarity of the 2 approaches
and the fundamental importance of not ignoring population-
level interventions. However, these concepts languished as
most cardiovascular guidelines and position papers have
emphasized targeting of individuals for screening and man-
agement of CVD risk factors. More recently, there has been
increased recognition that it is critical both to target individ-
ual-level behaviors and to treat the associated levels of mea-
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sured biochemical risk factors for CVD for preventing CVD
successfully.
In parallel, studies in the United States have demonstrated
that sustained, community-wide programs targeting CVD risk
factors and behavior changes to improve population health at
a county level (eg, Franklin County, Maine) were associated
with concomitant reductions in hospitalization and mortality
rates over a 40-year period (relative to the rest of the counties
where similar programs did not exist).11 This was reminiscent of
the experience from North Karelia in Finland.12 Of note, these
community programs were integrated with primary care, which
may explain the difference from prior experiences in the United
States with 3 other programs (the Stanford Five-City Project13
and the Minnesota Heart Health Program14 and Pawtucket
Heart Health Program15); these 3 programs had shown relative
improvements in CVD risk factors yet no concomitant mortal-
ity impact, possibly because these programs were not integrated
well with primary care.16,17 A major underlying and emerging
theme is that community programs with primary care involve-
ment alter the default health-related behavioral decisions of
individuals, thereby proving to be more effective and less costly
in shifting the entire distribution of CVD risk factors, consistent
with the “health impact pyramid.”18
Supporting the vital importance of community health
promotion, the American Heart Association has developed
a community guide19 that integrates optimal health behav-
iors, community settings, and public health interventions to
improve cardiovascular health. A wide range of public health
strategies help promote optimal levels of CVD health factors
over the entire life course, including dietary salt restriction,
limits on food portion size, tobacco laws (including taxes)
to promote smoking cessation and to mitigate secondhand
tobacco exposure, and changes to the built environment to
enhance physical activity.19 Additional steps such as taxation
of sugar-sweetened beverages and subsidies on fruits and veg-
etables may potentially influence behavior favorably, a prem-
ise warranting more research.
In parallel with community efforts, awareness has
increased within the academic medical school communities to
move toward the “third curve” representing entire populations
(compared with the first 2 curves representing patients seek-
ing care and the managed-care populations).20 Over the next
decade, we foresee a greater emphasis on cardiovascular
health promotion and CVD prevention within and across com-
munities, with greater engagement of the entire community,
maintenance of surveillance, and partnerships in the actual
physical settings where people live, work, and study. Future
studies of CVD risk factors and their burden will move from
the traditional focus on individuals and cohorts to greater
attention to the central role of communities in which individu-
als live and work.
Recognition of the Social Determinants of
Cardiovascular Health and Disease: sHealth
As noted above, the benefits of major advances in cardiovascular
epidemiology and the pathogenesis and treatment of CVD have
not trickled down uniformly across all strata of the US popula-
tion. Specifically, select socioeconomic, racial, and ethnic groups
in the United States have a much greater prevalence of CVD risk
factors and a higher CVD incidence and mortality.18 Linguistic
differences and cultural beliefs and practices have been demon-
strated to influence the behavior of individuals, including their
health-seeking behaviors, their access to care, and their compli-
ance with preventive treatments. However, major contributors
to disparities are socioeconomic deprivation, implicit bias, and
racial stereotypes, which affect both cardiovascular health pro-
motion and disease prevention and exacerbate disparities in the
access to and delivery of cardiovascular care.18
On a parallel note, the traditional biomedical model of
CVD has embraced the notion that individual-level risk fac-
tors, both behavioral and biological, mediate CVD risk. Such
a model ignores the environmental contexts that actually
shape and determine the evolution of the CVD risk factors
themselves.18 Recent work has also thrown the spotlight on
social networks and their impact on the clustering and devel-
opment of behaviors (eg, smoking,21 alcohol,22 and physical
activity23) and their association with spread of obesity through
the community.24 There is also a greater acknowledgment that
diminished social support contributes to CVD risk.18
Recent research has highlighted the fundamental role of
the neighborhood built/physical environment in influencing
CVD risk. Thus, features of one’s residential area such as
urban design and public spaces, land use patterns, street con-
nectivity, access to parks and exercise/recreational facilities,
air and noise pollution levels, and access to public transpor-
tation systems all seem to contribute to both health behav-
iors and the levels of the CVD risk factors.18 Additional built
environment indicators may capture features of social norms
and connectivity, as well as psychosocial stressors (eg, safety,
violence, and social cohesion). Thus, investigators from the
Multi-Ethnic Study of Atherosclerosis (MESA) have eluci-
dated how CVD risk factors are linked to the built physical
environments, including neighborhood healthy food access
and resources for physical activity.25,26
The coming decades will see greater efforts to capture con-
tributions of socioeconomic position (as reflected by income,
education, and occupation) to CVD risk and to identify the
mechanisms by which social networks and forces affect
 2628  Circulation  June 21, 2016
cardiovascular health outcomes. Additional research will char-
acterize the contributions of perceived racism27,28 and other
psychosocial stressors in contributing to the burden of high
blood pressure and vascular reactivity. It is likely that future
studies will use a comprehensive framework for capturing the
exposome, including delineating the built environment, to fully
characterize the propensity for developing CVD risk factors
and overt disease and to promote an understanding of how best
to influences factors at the neighborhood and individual levels.
Future cardiovascular epidemiological studies will evaluate the
key role of culturally appropriate educational and other inter-
ventions aimed at improving cardiovascular health care.
Role of Digital Technology and mHealth
Major advances in the miniaturization of computer chips and
Bluetooth wireless technology have enabled the development
of biosensors that convert physiological sensing inputs into
a measurable and interpretable signal.29 Wearable devices are
on- or in-the-body digital elements that transduce physiologi-
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cal signals. The combination of biosensors and wearables can
provide a substantial window into the exposome and has revo-
lutionized mHealth, the use of portable digital devices to obtain
clinical data that can then be used to identify, monitor, and
guide the management of various health outcomes. Examples
of mHealth technology include smartphone health “apps,”
devices that can connect to a smartphone, wearables and bio-
sensors, and handheld imaging platforms.30 Quantitative bio-
sensor and wearable data have been used in epidemiological
studies for some time (accelerometry is a good example), and
newer waves of data collection, including physiological mea-
sures (heart rate and rhythm, blood pressure, weight, physi-
cal activity, etc), are accruing via projects such as the Health
eHeart Study at the University of California at San Francisco,
a National Patient-Centered Clinical Research Network
(PCORnet). Apple’s open-source ResearchKit is already facil-
itating smartphone-based medical research, and collaboration
between Duke University, Stanford University, and Verily Inc
(formerly Google Lifesciences) will gather extensive “physi-
ome” data through wearable sensors for the National Institutes
of Health’s (NIH’s) Precision Medicine Initiative Cohort of
1 million US participants. A pilot program at the Vanderbilt
University Medical Center will launch the Direct Volunteers
Pilot Studies under the aegis of the federal Precision Medicine
Initiative Cohort Program, in partnership with Verily, with the
additional dimension of developing a biobank capable of stor-
ing and managing blood, urine, and saliva samples for analy-
sis of the Precision Medicine Initiative Cohort Program.
Over the next decade, we anticipate major headway in our
assessment of the plethora of m-health devices and apps to
develop quality standards for such data and comparability of
devices, to define processes for their integration into the clini-
cal decision support systems, and to establish regulatory pro-
cedures for devices used for this purpose. It has been estimated
that by the year 2020, 90% of individuals >6 years of age in the
world will possess a smartphone.31 The ability to gather health
data via smartphones on virtually everyone worldwide poses a
mind-boggling opportunity and a challenge and undoubtedly
will influence the field of cardiovascular epidemiology over
the next decade. Issues of data harmonization, data security,
data integration, and individual privacy concerns will require
substantial investment of efforts, followed by the incorpora-
tion of streams of real-life continuous data on select traits into
the research portfolios of scientists. Traditionally, epidemiol-
ogy has focused on limited phenotyping obtained in a state
of rest and repeated periodically over a period of years. The
ability to phenotype individuals on a wide array of physiologi-
cal measures in real time and for prolonged periods of times
is an unprecedented development rendered feasible by digital
technology. Additionally, such “deep phenotyping” will cap-
ture human responses to perturbations, thereby increasing the
granularity of the human phenome. However, using informa-
tion on the “quantified self” for research purposes is a rela-
tively new occurrence and will likely require implementation
of machine learning tools (support vector machines, random
forests, etc) that have traditionally been used in industry for
commercial purposes.
Role of EMRs and eHealth
Hospitals in the United States received a mandate to transi-
tion their patient clinical information to an electronic format
under the Patient Protection and Affordable Care Act of 2010
enacted by President Barack Obama. The expectation was that
medical information about patients’ past histories and cur-
rent illnesses would be captured digitally, thereby facilitating
better health care across various institutions and healthcare
systems, and would simultaneously open up new avenues for
clinical research. The widespread use of EMRs introduces
challenges related to the interoperability of different plat-
forms and a relative lack of standardization of various data
elements across systems. There was also a federal mandate
to invest in large data infrastructure projects such as the NIH
Collaboratory and the National PCORnet, which facilitates the
linkage of multiple EMR data, thus harnessing medical infor-
mation on millions of patients for clinical investigators across
numerous institutions and healthcare systems. EMR data also
enable large-scale postmarket surveillance studies and recruit-
ment of patients into pragmatic clinical trials. However, the
EMR captures the exposome imperfectly because a substan-
tial proportion of exposures (eg, behavioral, socioeconomic,
environmental factors) are not captured within the current
EMR systems. Nonetheless, initial attempts at linking EMR
to genome-wide data have born fruition, with the confirmation
of some known “hits” demonstrated in large-scale genome-
wide association analyses and with the additional yield of new
associations.
We expect over the next decade a consolidation of efforts
to standardize and harmonize data elements within EMRs and
greater use of these data for research purposes.32 As noted
above, the Precision Medicine Initiative Cohort Program
involves recruitment of a cohort of nearly a million individu-
als, and integration of research with their EMRs is one of the
central features of this project. We also anticipate greater inte-
gration of EMRs with genomic data (epigenome-wide asso-
ciation studies noted above),33 paralleled with evolution of the
quality of EMR data, including enhanced interoperability of
the various platforms. EMR data will also likely see greater
use for recruitment of patients into pragmatic trials and for
the development of community-based research networks.
 Vasan and Benjamin   Future of Epidemiology   2629
It is also likely that healthcare data will become accessible
via standardized open software interfaces (apps) to research-
ers (and patients) with a focus on “efficacy, accuracy, utility,
safety, privacy and security” features.34
Exposome-Phenome-Diseasome
Associations: Genomic and Biomarker
Revolution and Impact on Cardiovascular
Epidemiology (gHealth, bHealth)
The molecular revolution, marked by the HAPMAP,35 1000
Genomes,36 and ENCODE37 projects and the -omics tool
box,38,39 is reshaping current concepts of CVD.
New technologies developed through the Human Genome
Project and related initiatives have radically altered both the
types of data that quantitative scientists now work with and
the types of questions epidemiologists ask using the available
multidimensional data. The -omics tool box has expanded our
ability to measure numerous biomarkers and to characterize
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genetic, epigenetic, transcriptomic, microRNA and noncod-
ing RNA, proteomic, metabolomic, and microbiome profiles.
Understanding genomics is now a critical element in cardio-
vascular epidemiology because of our enhanced ability to iden-
tify common and rare genetic variants, to use genomic markers
in adaptive clinical trial designs, and to evaluate circulating
molecules originating in the gut microflora that influence car-
diometabolic and vascular risk. The parallel developments in
better characterization of the exposome (as noted above), the
phenome (dynamic characterization, including in response to
perturbations such as exercise and glucose challenge), and the
diseasome itself (better delineation of disease networks, sub-
sets, and endophenotypes)40,41 will transform our understand-
ing of the molecular epidemiology of CVD.
The genomic revolution will juxtapose concepts of per-
sonalized medicine and comparative effectiveness research
(CER; see below) as a result of the increased realization that
interindividual variations in the genome and the genomic
and epigenomic responses to exposures and pharmaceutical
agents are varied, thereby identifying more homogeneous
molecular subsets to collate and in which to perform CER
studies. There will be renewed and sustained interest in the
synthesis of the evidentiary basis for exposome-phenome-
diseasome associations through efforts such as the Human
Genome Epidemiology Network42 and Evaluation of Genomic
Applications in Practice and Prevention43 initiatives.
The focus of risk prediction will veer more and more
toward prevention over the life course, with a consideration
of both a short-term (the traditional 10-year time window)
and a much longer time (20- to 30-year time window) hori-
zon.44,45 Therefore, the biomarker revolution (b-health) will
herald the measurement of different panels of biomarkers at
various ages that capture the complexity and evolution of risk
factors themselves and reflect more accurately the anteced-
ents of these risk factors (eg, better nutritional and adiposity
biomarkers), as well as indicators of subclinical disease mea-
sures over the entire life course. Targeted interventions will
be based on both an individual’s genotype and the exposome
as reflected by biomarker profiles and will likely be highly
individualized. Elucidation of the molecular epidemiology of
diseasomes will mean that treatment may be highly personal-
ized and based on an individual’s trajectory of changes along
the spectrum of disease states. Indeed, the choice of treatment
may be facilitated by both a person’s genomic profile and the
response of his/her induced pluripotent stem cells in vitro. The
coming decade will also witness advances in our understand-
ing of pharmacogenetics testing, the reporting of genetic vari-
ants identified, and their plausible molecular pathogenicity (or
lack thereof).
Another specific advance that will gain firm ground is
the integration of cardiovascular epidemiology with chronic
disease epidemiology, with the emerging refrain of a shared
commonality of risk factors across several forms of noncom-
municable diseases, including cancer and pulmonary disease.
Thus, the prevention of CVD will be integrated within the
broader framework of prevention of noncommunicable dis-
eases in the upcoming decades.
Transformative Vision for Epidemiology
in This Century: Extension of Big Data
Into Cardiovascular Epidemiology
Khoury et al46 proposed a transformative vision for epi-
demiology in this century with 8 overarching thematic
recommendations:
(1) extend research beyond traditional domains of
discovery and etiologic research to include multi-
level analysis, interventions, implementation, and
outcomes research; (2) greater access to and shar-
ing of protocols, metadata, and biosamples, fostering
collaboration, ensuring replication, and accelerating
translation; (3) expand cohort studies to collect diverse
exposures across the life course to examine multiple
health-related endpoints; (4) develop and validate reli-
able methods and technologies to quantify exposures/
outcomes on a massive scale; (5) integrate ‘big data’
science; (6) use knowledge to drive research, policy,
and practice; (7) transform training of 21st century
epidemiologists to address interdisciplinary and trans-
lational research; and (8) optimize resources and
infrastructure for epidemiological studies.
Each of these recommendations is very relevant to the
field of cardiovascular epidemiology.
In 2013, the NIH unveiled the Big Data to Knowledge
Initiative with $200 million committed to research in this
domain.47 The development of systematic approaches to
robustly manage, integrate, analyze, and interpret large,
complex data sets is crucial. Overcoming the challenges of
developing the architectural framework for data storage and
management may benefit from the lessons learned and the
knowledge gained from other disciplines. Adaptation of tech-
nological advancements such as cloud-computing platforms,
already in use by private industries (eg, Amazon Cloud Drive
and Apple iCloud), can further facilitate the virtual infrastruc-
ture and transform biomedical research and health care. With
high-powered computers and advances in computing software,
complex methods for analyzing massive data sets are becom-
ing more feasible. The advent of “big data” has resulted in
 2630  Circulation  June 21, 2016
questioning the importance of meticulous sampling designs,
greater acceptance of misclassification in the tradeoff for more
data, and a movement away from traditional causal inferences
and hypothesis testing to more agnostic approaches of enquiry
and generation of new knowledge.
Big-data trends and scientific advances emphasize both the
challenges and opportunities for restructuring cardiovascular
epidemiology over the next few decades, which may increas-
ingly be informed by CER.48 The last 5 years has witnessed
an unprecedented emphasis on CER with a view to identify-
ing the most effective health interventions for diseases and to
achieve best health outcomes, including CVD, propelled in
part by the American Recovery and Reinvestment Act of 2009
that appropriated $1.1 billion for CER ($400 million allocated
to the NIH and the remainder to the Agency for Healthcare
Research and Quality and Office of the Secretary of the
Department of Health and Human Services). New CER stud-
ies over the next decade will likely use “different trial designs,
very large sample sizes, high-throughput technologies, routine
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utilization of electronic medical records, and adaptations that
reflect the infrastructures of integrated health care systems.”48a
Simultaneously, new CER studies must be complemented by
randomized trials that can verify the results of observational
data and suitable inroads in implementation science to ensure
that the best interventions can be adequately implemented in
the clinical domain.
There is an increasing emphasis on interventionist
approaches in epidemiology, along with the notion of conse-
quential epidemiology emphasized by Galea,49 in an attempt
to keep the science more directly relevant to public health.8
Newer methods such as critical time windows, directed acy-
clic graphs, marginal structural models, g-health, and time-
varying social networks are likely to see increased use in
epidemiology.50 In parallel with methodological advances,
there will be a greater globalization of cardiovascular epi-
demiology with emphasis on steps to quantify the global
burden of disease, to characterize regional burden, and to
elucidate steps to implement primordial, primary, and sec-
ondary prevention over the life course across the various
regions.51,52
Cohort Studies in Cardiovascular
Epidemiology at a Crossroads
As noted, the field of cardiovascular epidemiology is under-
going a revolution as a result of the burgeoning amounts of
genetic and genomic data, a plethora of biomarkers, and the
emergence of systems biology and collaborative science.
Paralleling these major scientific advances is the spawning of
the notion that epidemiological studies, especially traditional
cohort studies, have limited utility in today’s era because of
high costs, modestly incremental knowledge, an inherent
inability to innovate at reasonable cost, and a failure to identify
and answer contemporary research questions. Additionally,
the concept of decentralized large cohort studies (eg, the
UK Biobank and the Precision Medicine Initiative Cohort
Program, as currently envisaged), the notion of large data and
biorepositories with ease of access, and the possibility of free
and open sharing of federated data sets53 have become firmly
ensconced in science today. The imperative to perform innova-
tive research addressing the most meritorious question, nim-
bly and cost-effectively, has never been greater.54 Therefore,
the future of cohort studies has been debated actively in sev-
eral scientific forums.55,56 The concept of embedding clinical
trials within pre-enrolled cohorts has gained traction recently,
and novel approaches such as genotype-based phenotyping of
cohort subsets have been envisaged.
We anticipate that the notion of multicohort studies across
the human life span will witness a major rise over the next
decade as it becomes clearer that elucidating risk factor–
disease associations within different race/ethnic and age- and
sex-based groups will assume critical importance. These
cohort studies will see a rise in use of m-health and EMR-
based phenotyping, and key innovations in the creative analy-
ses of such cohort data will likely bear fruition. The recently
created Cross-Cohort Consortium57 of National Heart, Lung,
and Blood Institute–supported studies is an example of the
kind of the transconsortial collaborations that are likely to
assume prominence in the decade ahead.
The Multidisciplinary Workforce
in Cardiovascular Epidemiology
in This Millennium
The cardiovascular epidemiologist of the future will undoubt-
edly be working as part of a multidisciplinary team of
scientists including data scientists, bioinformaticians, physi-
ologists, geneticists, molecular biologists, and mathemati-
cians, and this list of disciplines is by no means complete.
The concept of team science will be critical to the success of
all scientific endeavors,48,58–61 and open access to data will be
key, along with the need for built-in replication strategies for
all scientific studies.
A recent Institute of Medicine report noted that “critical
to the implementation of big data science is the need for high-
quality biomedical informatics, bioinformatics, and mathemat-
ics and biostatistical expertise.”62 Indeed, successful analysis
and integration of massive and heterogeneous data sets require
new quantitative skills, supported by a deep understanding of
the biological and experimental processes underlying the data
and an ability to appropriately use the information available
from public databases. New quantitative skills include the
ability (1) to model complex systems using statistical machine
learning methods for the intelligent search of large databases;
(2) to develop the different network formalisms, ranging from
regulatory networks to gene expression mechanisms; (3) to
use graphical models and bayesian networks; (4) to describe
complex multivariate associations; and (5) to use scale-free
networks to relate genotypes to phenotypes. Additionally, the
Institute of Medicine report62 emphasized the importance of
(1) transdisciplinary training, with the development of quan-
titative skills, as noted above; (2) translational research; (3)
competency-based approaches to training and evaluation;
(4) evolving notions of team science and research network-
ing and their critical role in academic careers; (5) individual-
ized development plans in career planning and mentoring; (6)
alternative pathways in careers, including collaborations with

Table.  Training needs for the Epidemiology Workforce in This Millennium: A Synthesis of Major Reports
Khoury et al46*
Multilevel analysis, interventions, implementation, and outcomes research
Greater access to and sharing of protocols, metadata, biosamples; fostering
collaboration; ensuring replication; and accelerating translation
Collect diverse exposures across the life course to examine multiple health-
related end points
Develop and validate reliable methods and technologies to quantify
exposures/outcomes on a massive scale
Integrate big-data science
Use knowledge to drive research, policy, and practice
Transform training to address interdisciplinary and translational research
Optimize resources and infrastructure
COL indicates Council on Linkages; and IOM, Institute of Medicine.
*Focus is on transforming epidemiology in the 21st century.
†Focus is on core competencies.
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‡Link between academia and public health practice.
industry, and policy; and (7) diversity barriers in biomedical
research and required shifts in recruitment strategies.
On a parallel note, a group of leading epidemiologists
recently reviewed 12 macro-level trends that will shape the
future of epidemiology, including the training of its workforce
(Some of these trends are reviewed in the present article).63 The
required new skill sets and the impending big-data changes sug-
gest that training programs for the cardiovascular epidemiology
workforce for this millennium will need to be redesigned dramat-
ically, emphasizing skill sets that are multidimensional and itera-
tively acquired over the course of one’s career (Table).46,62,64–66
Conclusions
The current vision of cardiovascular epidemiology empha-
sizes an ecological approach that incorporates the full range
of biological, environmental, and social determinants of
cardiovascular health across the life course. This approach
leverages emerging sciences (genetics and genomics), infor-
mation and digital technology, and communication sciences
and underscores the importance of the social determinants of
health. Indeed, determinants of CVD “act within complex,
often scale-free networks made up of a small number of ‘hubs’
that are extensively linked to many more relatively isolated
determinants and that are similar in structure and function at
the genetic, molecular, cellular, clinical, environmental, and
societal levels.”6 Likewise, a wide spectrum of environmental
and physiological measurements can be made with portable
devices and mobile technology, applying increasingly sophisti-
cated sensor technologies to people and biosamples. A plethora
of biomarkers will become available to better characterize the
evolution of CVD over the adult life span. The coming decades
will see the integration of cHealth, sHealth, mHealth, eHealth,
gHealth, and bHealth into cardiovascular epidemiology and
the generation of a multiplicity of data sets in publicly acces-
sible biorepositories for scientists to evaluate and test novel
hypotheses. The aforementioned developments will require
the retooling of the existing workforce in cardiovascular epide-
miology and a redesigning of training programs to meet these
Vasan and Benjamin   Future of Epidemiology   2631
IOM Report62† COL64†‡
8 New core competencies: Informatics Develop skills: Analytic/assessment
Genomics policy development/program planning
Communication Communication
Cultural competence Cultural competency
Community-based participatory Community dimensions of practice
research
Global health Basic public health sciences
Policy and law Financial planning and management
Public health ethics Leadership and systems thinking
newer needs. Our hope is that these advances in cardiovascular
epidemiology will translate into better cardiovascular health
of the global community and promote the primordial, primary,
and secondary prevention of CVD worldwide.
Sources of Funding
This work was supported by the National Heart, Lung, and Blood
Institute, Framingham Heart Study (National Heart, Lung, and Blood
Institute/NIH contracts N01-HC-25195 and HHSN268201500001I),
1P50HL120163, and the Boston University School of Medicine
Evan’s Scholar Award (Dr Vasan).
Disclosures
None.
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Key Words: cardiovascular diseases ◼ epidemiology
 The Future of Cardiovascular Epidemiology
Ramachandran S. Vasan and Emelia J. Benjamin

Circulation. 2016;133:2626-2633
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