Abstract

Prevention of progression of atherosclerosis is the best approach to reduce incidence of myocardial infarction, sudden coronary heart disease (CHD) death, stroke and peripheral vascular disease. Research over the past 40 years has identified the risk factors for atherosclerotic disease, noninvasive methods for measuring the extent of atherosclerosis in multiple vascular beds and very efficacious therapy to reduce the level of risk factors and prevent cardiovascular diseases. Cardiovascular incidence and death rates have declined. Nevertheless, rates of CHD and other vascular disease remain much higher in many countries and within select regions of certain countries than necessary. Prevention of atherosclerosis depends on 4 key steps: 1) a much more aggressive effort to lower modifiable risk factors, especially apolipoprotein-B (ApoB)-containing lipoproteins, low density lipoprotein (LDL) particles, LDL cholesterol, blood pressure, obesity, and smoking during adolescence and young adult years; 2) identify and treat elevated ApoB lipoproteins, diabetes and smoking cessation of very high risk young adults as early as possible; 3) use of imaging to identify atherosclerosis of coronary and other arteries for appropriate segments of the adult population and treatment of risk factors for those with identifiable atherosclerosis; and 4) improved approaches to deliver prevention of cardiovascular disease to large numbers of asymptomatic individuals identified by non invasive imaging to maximize adherence to therapies. The major missing piece is better methods to identify vulnerable coronary plaques on the verge of an atherothrombotic transition and better treatments to prevent “acute” events. However, the four steps above will still lead to very substantial reductions in CHD incidence and mortality.