Francesco Tona’s open-access viewpoint in Open Heart (published December 23, 2025) offers a reflective critique of modern cardiology. He argues that rapid technological advancements—such as transcatheter valve replacements (e.g., TAVR), advanced imaging (CT, MRI, echocardiography), AI-driven tools, and remote monitoring—have delivered remarkable benefits, including improved survival, reduced hospitalizations, and better quality of life for many patients. Key examples include:

• TAVR transforming outcomes for high-risk aortic stenosis patients.
• Percutaneous interventions revolutionizing acute coronary syndrome management.
• AI aiding arrhythmia detection and risk prediction.
• Wearables enabling early atrial fibrillation detection.

However, Tona warns of a “quiet crisis”: these capabilities have shifted practice from physiologic, question-driven reasoning (“why intervene?”) to feasibility-driven action (“it can be done safely”). This leads to:

• Overtreatment in vulnerable groups: Routinely offering procedures like TAVR to frail nonagenarians where anatomical suitability trumps clinical benefit, potentially yielding minimal gains in survival or quality of life.
• Commercial pressures: Industry influences conferences, guidelines, and research, prioritizing procedural volume over evidence.
• Erosion of restraint: Training emphasizes technical mastery and protocols, sidelining pauses for patient values, frailty, or futility.
• AI risks: Outsourcing reasoning to opaque algorithms shortens cognitive engagement, turning physicians into “validators.”
• Research shifts: Focus on surrogate endpoints and technology validation rather than discovery or patient-centered outcomes.

Tona invokes the Latin maxim: Quod fieri potest, non continuo faciendum est (“Not everything that can be done must be done”). He calls for reform: better training in judgment and uncertainty, guidelines incorporating frailty/patient preferences, investigator-initiated trials, transparent industry boundaries, and multidisciplinary deliberation.

A Balanced Perspective

Tona’s concerns resonate with ongoing debates in medicine about overmedicalization and the need for restraint. Evidence supports caution in certain scenarios:

• In very elderly/frail patients undergoing TAVR, outcomes show higher mortality and complications compared to younger cohorts, with shared decision-making emphasizing quality of life over procedural success.
• Guidelines (e.g., ACC/AHA) increasingly stress appropriateness criteria, integrating frailty assessments to avoid futile interventions.
• AI holds promise but risks bias, overreliance, and “deskilling” clinicians if not transparently integrated.
• Industry sponsorship can shape research agendas, though guidelines aim for independence.

Yet, these technologies have undeniably advanced care when applied judiciously—extending life meaningfully for many once-inoperable patients. The key is balance: technology as a servant to humanistic, evidence-based judgment, not a driver of reflexive action.

Tona’s piece serves as a timely reminder to reclaim the “why” amid capability’s allure, ensuring cardiology remains profoundly patient-centered. It’s a call for cultural evolution, not rejection of progress.