Cardiovascular disease is the number one cause of morbidity and mortality in the United States. The total cost of the disease is approximately $555 billion dollars per year.1 This staggering amount impacts individuals and their families. During the last decade, delineation of the pathogenesis and contributing risk factors of this disease have been elucidated.2 Furthermore, effective, inexpensive treatment is readily available.3 Atherosclerotic cardiovascular disease is both preventable at low cost and with minimal patient lifestyle change. This article proposes a realistic program to end cardiovascular disease. It is based on 6 tenets: 1) identification of atherosclerosis prior to cardiovascular disease events; 2) diagnosis of cardiovascular disease that is non-invasive, inexpensive, and safe; 3) treatment and reversal of cardiovascular disease when diagnosed; 4) periodic follow-up of cardiovascular disease-free individuals; 5) treatment only of individuals with proven cardiovascular disease; and 6) proposed program costs below current cardiovascular disease expenditures.
Why is this new program needed? Statistics show that the current approach is ineffective and has been ineffective for the past decade. There are approximately 600,000 heart attacks in the United States every year, and according to the American Heart Association, the prevalence of heart disease has been increasing since 2015.1 This grim statistic is true in spite of 555 billion dollars being spent each year on treatment, education, and prevention.1 There are at least 21 organizations that publish cardiovascular treatment guidelines, and there is little agreement among them.4 Their recommendations are obscure and challenging for both patients and caregivers. For example, the latest guideline from the American Heart Association is 118 pages in length.5 Without a change in strategy, cardiovascular disease will remain an under-treated national epidemic. However, no changes to the current approach are required during the phase-in period of this proposal.
Step 1. Identification of Atherosclerosis Prior to Cardiovascular Disease Events
This step will require the screening of most adult asymptomatic individuals between 30 and 50 years of age, and the timing will depend on the presence and severity of cardiovascular risk factors (hyperlipidemia, diabetes, smoking, hypertension, obesity, family history of cardiovascular disease, etc) Although atherosclerosis has been shown to be common in young soldiers killed in battle, atherosclerotic cardiovascular events are unusual before the age of 30. The presence of cardiovascular risk factors are major determinants of atherosclerosis.6 Therefore, the timing of the initial screening should be determined by the presence, absence, or degree of cardiovascular disease risk factors. Because age alone increases atherosclerosis, most individuals should be screened by age 50 (irrespective of risk factors).7 The timing of the initial screening should be determined by both the patient and his or her physician.
Step 2. Diagnosis of Cardiovascular Disease that Is Non-Invasive, Inexpensive, and Safe
A safe, inexpensive, non-invasive approach is now feasible with coronary artery calcium scanning.8 Extensive studies have demonstrated that this approach is an excellent predictor of future cardiovascular disease events.9 This approach is superior to both stress testing and coronary angiography and provides an accurate assessment of atherosclerotic burden. A positive scan indicates calcium in the coronary arteries and proves the presence of cardiovascular disease. The cost is modest, ranging from $50 to $150 in most US cities. The radiation exposure is less than 1 millisievert, which is equivalent to the background radiation received from living in Denver, Colo, for 3 months.8 If the coronary artery calcium scan is positive, then preventative treatment should be initiated as described.3
Step 3. Treatment and Reversal of Cardiovascular Diseases when Diagnosed
Current guidelines recommend treating all individuals with significantly elevated calculated risk scores, whether or not they have proven cardiovascular disease.5 This overtreatment approach has been unsuccessful, because taking medications without proven benefit exposes the patient to significant expense, adverse effects, and inconvenience. For example, it has been found that 50% of individuals aged 65 years and older who have been prescribed statins based solely on age, stop taking the medication within 6 months.10 Therefore, we propose to treat only individuals with cardiovascular disease proven by coronary artery calcium scanning.
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-David S. Schade, MDa,, S. Scott Obenshain, MDb, Barry Ramo, MDc, R. Philip Eaton, MDa
