Approach to Atherosclerosis as a Disease: Primary Prevention Based on the Detection and Treatment of Asymptomatic Atherosclerosis

Atherosclerosis is a pervasive and malignant disease of the arterial circulation. It is by far the most frequent cause of angina, heart attack (including sudden coronary death), and peripheral arterial disease and is responsible for many cases of stroke. Yet, many individuals, even those with advanced disease, are unaware because they have no symptoms. In 30–50% of these individuals, the first indicator of atherosclerosis is a heart attack, which often is fatal (sudden, unexpected death). Since there are many pharmacologic and non-pharmacologic therapies to reduce the risk of heart attack and stroke, early detection of atherosclerosis itself, before symptoms occur, can provide a major opportunity to prevent many such events. Since effective screening could confer great public health benefit, it may seem surprising that screening for subclinical atherosclerosis has not yet been incorporated into national and international clinical guidelines. Therapeutic strategies targeted to key at-risk vulnerable patients can reduce the heavy economic burden of symptomatic and end-stage care for cardiovascular disease (CVD). There have been two main reasons for this conservative strategy. Firstly, there has been a lack of data convincingly demonstrating that screening for subclinical atherosclerosis improves the assessment of risk beyond that provided by traditional risk factors, such as smoking, hypertension, hypercholesterolemia, and diabetes. Secondly, appropriate instruments for detection of subclinical atherosclerosis have not been widely available to clinicians. The authors of this chapter believe that recent developments have provided us with the requisite data as well as with the necessary methodology. Furthermore, highly effective and safe therapies against atherosclerosis and heart attack are available.