Atherosclerosis is a disease in which plaque builds up within the wall of the arteries. Plaque is make up of cholesterol, fats, and inflammatory cells and substances. It is the underlying cause of both heart attack and stroke – the number one killer of both adult men and women in the U.S. The economic burden of cardiovascular disease is estimated at $500 billion annually. In just 5 years, it could add $2.5 trillion to our national debt. The country can’t afford it.
For many decades, the diagnosis is made and the treatment is started after the fact — when a person is already having a heart attack or a stroke.
Option 1: The presence of plaques not tested and appropriate medical treatment not given until hospitalization for unstable angina, heart attack, or stent is needed.
This is no longer a good approach to tackle a major public health problem. We have been putting expensive stents for a long time and its effectiveness was put to the test in a landmark clinical trial called COURAGE trial.
The prestigious New England Journal of Medicine (NEJM) published the conclusion from the trial in 2007 — in stable patients with advanced multi-vessel CHD, the addition of stents to already optimal medical therapy did not reduce cardiac death, non-fatal heart attacks and hospitalizations for acute coronary syndrome. This trial marks the turning point away from medically unnecessary stenting.
Option 2: The presence of plaques not tested and no medical treatment was given until the most fatal heart attack (called STEMI – ST segment elevation myocardial infarction) develops.
In 2013, the NEJM published another landmark study that analyzed over 98,000 STEMI cases, the most serious type of heart attack, from 2005 to 2009 nationwide and concluded that shorter door-to-balloon time (faster heart attack care) did not save more lives. All that expensive resources spent without improving clinical outcomes. There is another way. We have to rethink why we are not trying to identify more of these high risk populations years in advance and treating them optimally with evidence-based medical therapy to stop atherosclerosis, when in fact, we can.
In 2004, the president of the American College of Cardiology (ACC) Dr. Michael Wolk raised this question to its members – “So, why aren’t all cardiologists preventive?” There was too aggressive interventional therapy but not enough aggressive preventive medical therapy.
In 2015, the ACC President Dr. Kim Williams, when he was talking about the new historic CMS reimbursement program called The Million Hearts Cardiovascular Risk Reduction Model, said this: “It is time to turn off the faucet instead of just mopping the floor.” The ACC took a long time to take a more decisive and outspoken position on prevention. That is 14 years after I started incorporating preventive cardiology/lipidology in my practice in 2001.
Option 3: The presence of plaques is detected earlier by coronary calcium scan and appropriate medical treatment is given to stop plaque progression.
Residents, Medicare beneficiaries, employers and employees should get more informed about the risk of having a heart attack or stroke within the next 10 years and if they are at very high, high and even moderate risk, learn more and choose their treatment options.
On your next visit to your health provider, ask questions about your heart attack and stroke risk and if your medical treatment stops atherosclerosis progression.
For the full version of this article with slides, please visit www.princetonpreventivecardiology.com/us1.html.
Princeton Preventive Cardiology, 2 Capital Way, Suite 333, Pennington. 609-396-6363.