Preventing Heart Disease in the 21st Century

We could prevent 90% of heart attacks. Such a claim would have seemed outrageous in the 1960s, as the coronary heart disease (CHD) epidemic reached new heights and accounted for one third of all deaths in the United States and most other developed countries.1 The identification of conditions that predicted the probability of CHD (known as “risk factors”) stimulated hope that modification of these risk factors would reduce the frequency of CHD. Long before this idea was validated in clinical trials, individual physicians2,3 and voluntary health agencies4 began in the 1960s to promote the concept to the public. Many individuals accepted the idea, and many physicians adopted the recommendations in their practices.The US CHD mortality rate declined to approximately half its former level by 1990.5 The associated favorable changes in risk factors accounted for about half of this decline, whereas improved treatment of CHD accounted for the other half.6 The extent and severity of atherosclerosis also declined during this period.7,8 CHD mortality continued to decline after 1990 but at a slower rate, and CHD remained the leading cause of death in the United States.9A convergence of evidence from diverse sources in the last 2 decades now indicates that the claim that we can prevent 90% of CHD should no longer be thought of as outrageous but as achievable. For example, the absence of the major established CHD risk factors at 50 years of age has been shown to indicate a 90% lower lifetime risk (to age 95 years) for men and a 79% lower risk for women.10,* Subjects in several large cohorts without any of the major risk factors who were followed up for 16 to 22 years had 77% to 92% lower (men) or 79% lower (women) …