TITLE:
The Rationale for a Different Approach to Preventing Cardiovascular Disease
AUTHORS:
David S. Schade, Barry Ramo, S. Scott Obenshain, Ron Schrader, R. Philip Eaton
KEYWORDS:
Cardiovascular Disease, Preventing, ASCVD
JOURNAL NAME:
World Journal of Cardiovascular Diseases,
Vol.9 No.7,
July
31,
2019
ABSTRACT:
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%.