In the interest of disease prevention and risk stratification, a global shift from the emphasis on ischemia to emphasis on atherosclerosis is needed in the management of coronary artery disease (CAD), a new Commission in the Lancet proposes. This was reported by Rasha K. Al-Lamee, MD, of Imperial College London, on behalf of the investigators in the Commission. The Commission was published online in the Lancet on Monday. CAD is one of the leading causes of mortality across the world, and this is still rising. By 2050, it is forecasted that there will be 10.5 million deaths from CAD and a 19% rise in the diagnosis of CAD in lower-middle-income countries, Dr. Al-Lamee told CRTonline in an interview on Thursday. Atherosclerosis is the cause of CAD and often results in myocardial infarction (MI) that occurs as the disease progresses. Current medical care focuses on recognizing symptoms and treating acute events. Because of this, clinicians miss opportunities for early disease prevention and protection. By the time ischemia shows up in a patient, it is usually too late for optimal interventions. This limits treatment options and prognosis. Risk factors for the disease start early and exposure can even start before birth and clinicians should focus on treating these risk factors to, hopefully, prevent the disease from even manifesting. “We come to the disease very late in most patients because we frame it around the idea of ischemic heart disease,” she said. “We propose a new way of thinking about it focused on atheroma and not an end-stage disease. In our modeling, we saw that if we just adequately implement just what we know already know, we can reduce the burden of the disease by around 80%.” Dr. Al-Lamee said that she wants people to consider this: every time someone has acute coronary syndrome, it is a failure of upstream care and we have missed the opportunity to prevent disease. The Commission focused on ten key messages, the primary messages were based on early screening for coronary disease, implementation of early prevention measures, viewing the disease as a continuum along the life course of an individual, increased research funding and addressing regional disparities that we see around the world. The Commission proposed a change from the ischaemic heart disease label to ACAD: atherosclerotic coronary artery disease. In terms of industry and technologies, she said the team wants to encourage the discovery of novel treatments and new therapies for the disease. “Maybe we will have a vaccine for atherosclerosis one day,” she said. So, what can clinicians do? Dr. Al-Lamee said clinicians can be more intensive about the therapies they know work. For example, controlling hypertension, lipid levels, diabetes and smoking are all interventions that can be carried out early-on for patients. Patients can also prevent disease by taking actionable steps for their health, such as eating a healthy diet, addressing medical concerns early and advocating for themselves when they are discussing their health with their clinicians. “It is not uncommon for patients to come in with an acute coronary syndrome, and tell us that they’ve had elevated cholesterol for some time, but were told that they were too young or not high risk enough for treatment,” she said. Since 2023, in the UK, patients can be offered lipid controlling therapies at a younger age and lower risk threshold. “Patients should advocate for themselves and understand that this is a preventable disease, and in most patients, heart attacks are avoidable,” said Dr. Al-Lamee. In an accompanying editorial, Y Chandrashekhar, MD, of the VA Medical Center, Minneapolis; George Mensah, MD, of the National Heart, Lung and Blood Institute; and Jagat Narula, MD, of the University of Texas Health-McGovern Medical School, Houston, discussed the importance of early detection and prevention of CAD. The editorialists wrote the Commission is a “refreshing change that mandates a rational approach” when it comes to shifting the emphasis from ischemia to atheroma in CAD by reclassifying CAD as ACAD. Ron Waksman, MD, Director of Cardiovascular Research and Advanced Education at the MedStar Heart Institute, Washington, DC, also spoke with CRTonline about the Commission. “The Lancet Commission is timely and focuses on early detection and prevention but should not discount efforts to continue improving the treatment pathways for those who missed the boat and are presenting with ischemia,” said Dr. Waksman. “Early detection of the disease is important, but it remains to be seen which therapies will have an impact on later outcomes, and this will require mega trials.” Source: Zaman S, Wasfy J, Kapil V, et al. The Lancet Commission on rethinking coronary artery disease: Moving from ischeamia to atheroma. Lancet. 2025 March 31 (Article in press). Chandrashekhar Y, Mensah G, Narula J. From coronary artery disease to atherosclerotic coronary artery disease: What is in a name? Lancet. 2025 March 31 (Article in press). Image Credit: sorapop - stock.adobe.com