Manesh Patel, MD, chief of the Division of Cardiology at Duke University School of Medicine and the new president of the American Heart Association (AHA), used his presidential address at the AHA’s Scientific Sessions on November 8 to argue that medicine’s next great challenge is not only making discoveries, but getting them to the people who need them.
He called it “science’s last-mile problem.”
“Too many times in my career, I have met people for the first time on the cath lab table, while they are having a heart attack,” Patel said. “And I see that they have not been treated with therapies we know could’ve helped prevent their disease.”
Patel illustrated the problem with an example close to his own work. In 2025, direct-acting oral anticoagulants (DOACs) were prescribed worldwide more often than warfarin for stroke prevention. Patel was part of the team whose 2011 research, published in 2011, showed DOACs were better than warfarin.
“It took over 14 years for these proven therapies to finally reach most of the people who needed them,” he said. “We could and should be doing better. Not enough discoveries from our incredible investigators are reaching patients, particularly in countries and regions where there’s less access to health care.”
Closer to personalized biology
Cardiology has moved to more precise therapies for thrombosis prevention and away from chronic anti-platelet therapy, he said, bringing cardiologists closer to patients’ personalized biology while keeping the focus on proving interventions that make people feel better, live longer, and avoid unpleasant events.
“However, therapies to prevent thrombosis, reduce cholesterol, and control blood pressure aren’t reaching many of the people who need them most,” Patel said, citing barriers including cost, limited access to healthcare, difficulty adhering to therapies and health behaviors, and clinicians and patients not knowing about or believing in new advances.
Patel also showed a map of amputation rates among people with peripheral artery disease across the United States, including in his home state of North Carolina, where limb loss varies dramatically between neighboring counties. He said the pattern shows that “a person’s zip code can have a greater impact than their genetic code.”
Projections from the Lancet Commission and the AHA suggest that, without substantial change, cardiovascular disease will worsen worldwide. The answer, Patel said, lies in better implementing solutions that already exist and work, including the AHA’s Get with the Guidelines program, which over nearly 20 years has improved the use of proven therapies for heart attack and heart failure, and Mission: Lifeline, which lowers door-to-needle and door-to-balloon times for strokes and ST-elevation myocardial infarctions.
Patel expressed optimism about emerging therapies, including long-acting biologics that could improve adherence and gene-editing technologies, as care shifts from intervention toward prevention. But a question, he said, “nags” him: How do we get new proven therapies to patients if they can’t get the old ones?
This is why, to improve health today and prepare us for the breakthroughs of tomorrow, solving the last-mile problem must be prioritized, Patel said.
“If managed properly, I’m convinced AI could be transformative for cardiovascular health – both for discovery and implementation of proven therapies, and AI could and should reduce the friction patients face in getting care, and we face in delivering care,” he added.
AI, with guardrails
Since September 2026, Patel has led a team selected by the Advanced Research Projects Agency for Health (ARPA-H) to carry out the ADVOCATE program, which aims to create a first-of-its-kind, FDA-authorized clinical AI system that serves around the clock as a digital member of the care team in real-world settings.
Such AI “agents” could help engage patients, schedule appointments, coordinate care and obtain medications, and help research teams rapidly review genomic, metabolic and physiologic data to identify new therapeutic targets.
But Patel cautioned that without care, these tools could widen the gaps they are meant to close. His answer is the two-step process he learned as an intern: AI tools should help patients feel better, live longer or avoid unpleasant events, and they must show the evidence.
That means building clinical standards beyond regulatory ones, Patel said. The AHA and others have created AI testing “sandboxes” where developers can compare tools against gold-standard outcomes across multiple data sets. For tools that help monitor patients, detect deterioration or escalate care, rigorous studies, even randomized outcomes trials, will be needed.
He also called for national implementation and evidence-generation networks, such as the SYMPHONY Consortium created through the ARPA-H grant, and for tools housed and monitored on a trusted platform such as the AHA Precision Health Platform.
“Just like we once had a golden era of the open artery hypothesis,” Patel said, “we now have the responsibility to make this the golden era of AI improving health.”
“It’s science”
Patel thanked his Duke colleagues, Duke cardiology mentors Robert Califf, MD, Pamela Douglas, MD, and Robert Harrington, MD, and his family, including his parents, who were born in India. He noted that he is the first South Asian president of the AHA, and that his address fell on the day of Diwali, the Hindu holiday celebrating the victory of light over darkness, knowledge over ignorance and hope over despair.
Reflecting on how far cardiac care has come since 1997, when he began his training, Patel said what once might have seemed like magic is science: “It’s what happens when we pair the best discovery science with the best implementation science.”
He closed with a call to action. “Of course, we will never sacrifice scientific accuracy or safe monitoring for the sake of speed,” he said, adding that whatever AI’s role plays, evidence must drive actions and, whenever needed, a human must be in the loop.
“This is how we shorten the last mile,” Patel said, “so that the greatest discoveries in health reach people where they are.”