U.S. medical organizations are looking to reduce deaths caused by heart disease, the nation\u2019s No. 1 killer, with new guidelines that reframe prevention as a lifelong battle that begins with testing in childhood.<\/p>\n
The changes were made in clinical practice guidelines<\/a> issued last month by the American Heart Association, the American College of Cardiology, and several other professional organizations.<\/p>\n In this edited conversation, Romit Bhattacharya<\/a>, a Harvard Medical School instructor of medicine at Mass General and associate director of the hospital\u2019s Cardiac Lifestyle Program, discusses the relevant science, the potential impact of new treatment thresholds, and more.<\/p>\n How different are these guidelines from the 2018 recommendations?<\/p>\n They\u2019ve done a fantastic job and now integrate the newest data from the last 10 years, incorporating information that cardiologists have been using for some time.<\/p>\n The big changes are the formal integration of coronary artery calcium scoring, the formal integration of polygenic risk scoring, the explicit recommendation for Lp(a) screening, and a more formal involvement of apolipoprotein B as a risk measure. These guidelines also call out special populations that might benefit from additional care: individuals with obesity and diabetes, individuals with chronic kidney disease, individuals with hypertensive disorders of pregnancy and other reproductive risk factors, individuals with high genetic risk, and individuals of high-risk ancestries \u2014 including South Asian and Filipino individuals, who are now explicitly named \u2014 among other groups. This is an attempt to move toward more holistic care based on an understanding of the risk that most people encounter, and then to address, in a more personalized fashion, groups that are at additional high risk.<\/p>\n Some of these new measures, including Lp(a) and coronary artery calcium, might be unfamiliar to patients. What do they tell us that we didn\u2019t know before?<\/p>\n Apolipoprotein B and Lp(a) are additional types of cholesterol \u2014 or ways of measuring cholesterol that help us to refine risk. We\u2019ve discovered that Lp(a) is a cousin of the LDL-C molecule and is atherogenic, meaning it leads to the development of atherosclerosis<\/a>. It\u2019s about six times stickier than LDL, but thankfully it isn\u2019t very high in most people. Lp(a) is, however, elevated in 20 percent of the population and that elevation causes increased cardiovascular risk. Unfortunately, it\u2019s inherited. You can\u2019t eat healthier to lower it, you can\u2019t exercise it away, or stop smoking to make it go down. But when I check Lp(a), it helps me see when I should lower my treatment thresholds and treat you more aggressively to improve your prevention outcome. We have multiple new therapeutics in clinical trials that will help patients with high Lp(a) reduce their risk. And if I can tell you that you have high Lp(a), then you are empowered to make better decisions about your health \u2014 eat better, exercise more, etc.<\/p>\n \u201cIf someone is 35 today, I want to know what their arteries are likely to look like at 65, not just in the next decade. \u201d<\/p>\n Are treatment thresholds lower than they were in the past?<\/p>\n Yes, and the mechanism is worth explaining. The old risk calculator \u2014 the pooled cohort equations \u2014 was overpredicting risk by roughly 40 to 50 percent for many patients. The new guidelines switch to a better-calibrated tool called the PREVENT calculator<\/a>, trained on more than 3 million contemporary Americans, and lower the treatment threshold accordingly: the old cutoff was a 5 percent predicted 10-year risk; the new one is 3 percent.<\/p>\n This doesn\u2019t mean that everyone above 3 percent automatically goes on medication \u2014 that\u2019s where the conversation starts. Someone who comes in at 4 or 5 percent might find that targeted lifestyle changes \u2014 improving their diet, exercising regularly, losing weight, quitting smoking, getting better sleep \u2014 bring that number down on their own, without ever needing a pill. That\u2019s actually the ideal outcome. Your doctor will weigh all of this alongside your family history and other test results before recommending treatment.<\/p>\n For an individual patient these numbers can sound abstract, but at a population level, this recalibration matters. And crucially, PREVENT also predicts 30-year risk, which is the time horizon where prevention really pays off. If someone is 35 today, I want to know what their arteries are likely to look like at 65, not just in the next decade. We have the most power to prevent disease if we think about 20 or 30 years, where even moderate interventions can dramatically change the trajectory of someone\u2019s health.<\/p>\n And the guidelines call for testing at a much younger age, right?<\/p>\n