The Rationale for a Different Approach to Preventing Cardiovascular Disease

摘要

The Problem: We have previously suggested that an alternative approach to preventing cardiovascular disease is necessary because atherosclerotic cardiovascular disease (ASCVD) has been increasing for the last 50 years and has now reached epidemic status. Since the year 2000, approximately 600,000 heart attacks and ASCVD related deaths have occurred annually in the United States. It is the most common cause of death in the U.S., more than all cancers combined. The financial costs are staggering, amounting to 555 billion dollars per year in direct and indirect costs. Outlook for an improvement in these statistics is not encouraging as the U.S. population continues to become more obese and to develop diabetes. The Question: Why is ASCVD continuing to be a major challenge to healthcare providers when the pathogenesis is known and inexpensive preventative treatment is available? The reasons are multiple and complex. First, present financial reimbursement policies of healthcare organizations reward treatment of a disease and its complications instead of preventing the disease. Second, professional guidelines and treatment goals are often too complex, subject to interpretation, and time-consuming to be useful in the clinical setting. Third, no specific follow-up of patients at risk for ASCVD is recommended when the risk assessment changes. Fourth, many expensive cardiovascular diagnostic tests are utilized without meeting appropriate guidelines for their use. Fifth, treatment of individuals without first proving the presence of disease results in poor adherence to therapy. The Solution: This article describes the rationale for a new approach to the prevention of ASCVD in asymptomatic individuals. It is based upon preventing ASCVD by identifying all asymptomatic individuals with subclinical disease before an ASCVD event occurs. It recommends that all adults be screened for ASCVD on or before the age of 50 using a non-invasive atherosclerosis specific coronary artery calcium heart scan. Further recommendations include treating all calcium positive individuals to reverse their atherosclerotic coronary artery plaques with a combination of a low cholesterol diet, rosuvastatin 10 mg/day, and ezetimibe 10 mg/day. The therapeutic goal is a low-density lipoprotein cholesterol below 50 mg/dl to ensure regression of atherosclerosis. For individuals who have a zero calcium score, a repeat scan in 3 to 5 years is recommended. This new approach can easily be integrated into ongoing heart disease prevention programs to reduce the burden of ASCVD within the next five years. Conclusion: The mortality, morbidity, and cost of ASCVD have reached unacceptable levels. Reducing this disease to a rare condition will require the efforts of many individuals to organize, educate, and facilitate the goal of identifying all individuals with subclinical ASCVD. Once identified, aggressive therapy is required to reverse their atherosclerotic plaques in order to prevent heart attacks and atherosclerotic strokes. If successful, within 5 years the majority of the patients with asymptomatic ASCVD can be identified and if treated appropriately, reduce the prevalence and cost of ASCVD by 90%.