New Delhi: The first signs of plaque build-up in arteries should be warning enough to hit the panic button and start appropriate measures rather than adopting the wait-and-watch approach to prevent a heart attack or stroke, say the latest Lancet Commission recommendations on rethinking coronary artery disease, signalling the need for a major shift in the treatment of heart disease.
Coronary artery disease (CAD) continues to be a leading cause of morbidity and mortality globally.
The recommendations that focus on preventing blockages in arteries that develop due to accumulation of fat, cholesterol etc are in line with a recent school of thought that moves the focus to early diagnosis, prevention, and management for most diseases, with the ultimate objective being to save more lives and reduce the massive financial cost involved in treating end-stage diseases.
The recommendations say the current approach, “which focuses on diagnosing and managing coronary artery disease based on ischaemia (restricted blood flow to the heart) and cardiovascular events, is flawed”. “By the time ischaemia manifests, it is often too late for optimal intervention, limiting the effectiveness of treatment options… The focus of medical care has predominantly been on the recognition of symptoms and treatment of acute events, missing opportunities for early detection and prevention of disease…,” it adds.
Instead, the Commission suggests “reclassifying the condition as atherosclerotic coronary artery disease (ACAD), moving away from the traditional emphasis on ischaemia and acute cardiac events towards a more systematic understanding of atherosclerosis”. It adds that the new approach could potentially save “ millions of lives worldwide.”
Experts said the reclassification was much-needed.
“The Lancet Commission’s rethinking of prioritizing preventive aspects of atherosclerotic coronary artery disease (ACAD) from focusing on the detection and prompt management of the end stage of atherosclerosis leading to heart attacks and sudden death to basics of preventing the building up of the plaque in the arteries, makes lot of sense,” said Upendra Kaul, chairman cardiology and dean academics and research, Batra Hospital and Medical Research Centre. “The emphasis needs to shift from spending colossal amounts on diagnosing the end product of advanced ACAD and managing it to prevent the development of atheroma which is the root cause of advanced atherosclerosis.”
Ashok Seth, chairman, Fortis Escorts Heart Institute, said, “It’s a very important way forward as advances in cardiac treatment has led to the focus moving away from prevention and early-stage management, when it can bring down the financial burden considerably. While we may have specialised treatments available for various conditions, still those can be cost-prohibitive for many. This Lancet Commission’s focus on prevention will be important especially for the Asia pacific region where the CAD burden is massive.”
For a country like India, the shift is also significant because of the growing cases of non-communicable diseases, especially cardiovascular diseases . Studies have established onset of cardiovascular events 10 years earlier than standard norms in the Indian population.
“These preventive measures need to start at very early stages preferably during their primary education to ensure low incidence of getting high blood pressure, high cholesterol and diabetes in adulthood. All this would lead to minimal chance of getting fat deposition in the arteries of the heart and prevent atherosclerosis,” added Kaul.
The Commission argues that if behavioural and metabolic risk factors, such as smoking, hypertension, high cholesterol, and poor diet, were eliminated or controlled early in life, the global burden of ACAD could be dramatically reduced. Eliminating these risk factors by 2050 could decrease the rate of ACAD deaths by 82.1%, potentially saving 8.7 million lives annually.
The risk of ACAD develops over a lifetime, beginning in utero, progressing through childhood and adolescence, and continuing into older age. The early stages of disease, which involve the formation of atherosclerotic plaques (inside arteries), are often undetected.
“A major shift is needed from acute event-centred care to strategies focused on early diagnosis, prevention, and management of atherosclerosis. In this new framework, ACAD should be recognised across all stages, from the earliest signs of atheroma formation to the advanced stages of disease,” the Commission said.
The goal, they suggested, should not just to be to manage symptoms and events but to prevent the disease from developing in the first place and, where possible, reverse its course.
The implementation of screening strategies to identify individuals at risk of developing ACAD is also crucial as between 2022 and 2050, mortality rates from ACAD are forecasted to increase by 19.2% in lower-middle-income countries and 4.2% in upper-middle-income countries, said the Commission.
“Targeted screening programmes, integrated into healthcare systems, can detect early signs of atherosclerosis and enable timely intervention. Such interventions, if applied early, have the potential to halt, delay, or even reverse the progress of the disease, reducing the risk of cardiovascular events in later life,” it said.
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