Expanding the fight against heart disease

U.S. medical organizations are looking to reduce deaths caused by heart disease, the nation’s No. 1 killer, with new guidelines that reframe prevention as a lifelong battle that begins with testing in childhood.

The changes were made in clinical practice guidelines issued last month by the American Heart Association, the American College of Cardiology, and several other professional organizations.

In this edited conversation, Romit Bhattacharya, a Harvard Medical School instructor of medicine at Mass General and associate director of the hospital’s Cardiac Lifestyle Program, discusses the relevant science, the potential impact of new treatment thresholds, and more.

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How different are these guidelines from the 2018 recommendations?

They’ve 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.

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 — including South Asian and Filipino individuals, who are now explicitly named — 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.

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’t know before?

Apolipoprotein B and Lp(a) are additional types of cholesterol — or ways of measuring cholesterol that help us to refine risk. We’ve discovered that Lp(a) is a cousin of the LDL-C molecule and is atherogenic, meaning it leads to the development of atherosclerosis. It’s about six times stickier than LDL, but thankfully it isn’t 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’s inherited. You can’t eat healthier to lower it, you can’t 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 — eat better, exercise more, etc.

“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. ”

Are treatment thresholds lower than they were in the past?

Yes, and the mechanism is worth explaining. The old risk calculator — the pooled cohort equations — 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, 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.

This doesn’t mean that everyone above 3 percent automatically goes on medication — that’s where the conversation starts. Someone who comes in at 4 or 5 percent might find that targeted lifestyle changes — improving their diet, exercising regularly, losing weight, quitting smoking, getting better sleep — bring that number down on their own, without ever needing a pill. That’s actually the ideal outcome. Your doctor will weigh all of this alongside your family history and other test results before recommending treatment.

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’s health.

And the guidelines call for testing at a much younger age, right?

Yes. The guidelines now recommend that risk assessment starts at 30 — not 40 or 50 — and that for adults in their 30s with elevated cholesterol and sufficient predicted risk, pharmacotherapy is on the table. That’s a meaningful shift. The Cholesterol Treatment Trialists’ Collaborative — a massive pooled analysis of statin trials — showed that the absolute benefit of lowering LDL accumulates over time, which means earlier treatment translates to a much larger lifetime reduction in risk. The old message was, “You’re in your 20s. Don’t worry about it until you’re 50.” But cardiovascular disease doesn’t work that way. The investments you make early pay the biggest dividends, and by the time you’re 50 or 60, you’re playing catch-up.

Separately from that, in children, these guidelines recommend early testing to improve diagnosis of genetic conditions — like heterozygous familial cholesterolemia, which affects roughly one in 250 people and carries a two- to fourfold higher lifetime risk of heart disease, yet remains undiagnosed in up to 90 percent of those affected. Universal lipid screening is now recommended at ages 9 to 11, and cascade screening — testing close relatives of someone already identified — can start as early as age 2. The window matters because family history alone misses up to half of cases, and the earlier you catch it, the more lifetime risk you can take off the table.

“Close to 80 percent of cardiovascular disease is preventable through lifestyle and behavior change.”

Has the lack of a long-term approach been part of the reason it’s been so hard to knock down cardiovascular disease as a leading killer?

That’s a big element. Close to 80 percent of cardiovascular disease is preventable through lifestyle and behavior change. And these guidelines aren’t just for individuals, they’re for society: municipal governments, federal governments, and policymakers. They should be reading and thinking: “How can I support my population in a way that makes it easy to live this healthy life?” Americans are dealing with so much right now: extra jobs, the gig economy, taking care of kids, etc. I see in my clinic that people are struggling. When I say, “and also exercise two hours a week, and eat this, and cook your food at home” — that’s too much. We should think about how we can support our patients and our colleagues and our friends to make healthy decisions so that they don’t have to read the guidelines to know what to do.

My father had a coronary bypass years ago. How would have these guidelines helped him?

Sometimes we check in on someone’s health and a few months or a few years later, they have a heart attack and say, “I went to my doctor and everything looked good. How could this have happened?” That happens because we used to diagnose coronary artery disease only when someone came in with a heart attack or they had to have a stent or bypass surgery.

Imagine instead if you’re middle age and your doctor says that you may be in the intermediate risk class and suggests a coronary calcium scan to see what your arteries look like. The new guidelines have specified that when there’s any calcium present, you should be treated with preventive medication to lower your heart attack risk. And if calcium starts ticking up, we get aggressive and we treat you as if you’ve already had a heart attack. We want to lower your cholesterol to the floor and improve all your other risk factors. If your father had known about his coronary calcium years before his bypass, he may have been able to be on preventive medications and may never have had the procedure.