Experts in the treatment of coronary artery disease have recommended reframing the perception of the disease, reclassifying the condition as atherosclerotic coronary artery disease in a move away from the traditional emphasis on ischaemia and acute cardiac events “towards a more systematic understanding of atherosclerosis”.
The call comes in The Lancet Commission on rethinking coronary artery disease, published this week. Subtitled “moving from ischaemia to atheroma”, the review, which was led by Rasha Al-Lamee (Imperial College London, London, UK), posits that reframing the disease will enable identification and treatment at an earlier stage.
“Coronary artery disease remains a major cause of death worldwide. It will only become more prevalent in most countries worldwide over the next 25 years. With this Commission, we aimed to highlight the most important strategies to reverse this trend,” comments Al-Lamee.
“At its essence, coronary artery disease is preventable. It is time that we recognised this and adapted our approach to healthcare and research to enable measures that will prevent, regress, and cure the disease. It is possible to imagine a world where heart attacks are rare events and seen as a failure of upstream care. I hope that the Commission will provide a platform for a change.”
In their introduction to the paper, Al-Lamee et al write that coronary artery disease has long been understood “through the paradigm of epicardial coronary obstruction, causing myocardial ischaemia”, but note that this model focuses on the “flawed” diagnosis and management of the disease based on ischaemia and cardiovascular events. Once ischaemia is present, this can often be too late for optimal intervention and limit the effective treatment options available, they note.
According to the authors, the focus on management of coronary artery disease needs to shift from late stages of the disease—coronary artery obstruction and resultant ischaemia and infarction—towards strategies aimed at early prevention, regression and cure.
Viewing the disease as a “lifetime continuum” from early life through to older age would move the focus from diagnosis after the development of ischaemia or a cardiovascular event towards defining lifetime risk for an individual or a population at the earliest opportunity.
Risk factor modification would serve to reduce the rate of death attributable to atherosclerotic cardiovascular disease, the Commission states, with effective strategies for early screening and detection needed to maximise the effect of therapies to delay, halt and revert the process of atherosclerosis.
“The Lancet Commission on Rethinking Coronary Artery Disease is a refreshing change that mandates a more rational approach, shifting the emphasis from ischaemia to atheroma—a desired direction that has not been articulated as emphatically before, even in authoritative clinical guidelines,” Y Chandrashekhar (University of Minnesota, Minneapolis, USA), George Mensah (National Heart, Lung, and Blood Institute, Bethesda, USA) and Jagat Narula (University of Texas Health-McGovern Medical School, Houston, USA) write in an accompanying editorial commentary.
The “relatively simple but crucial” reclassification of coronary artery disease to atherosclerotic coronary artery disease proposes to identify and modify the underlying disease rather than only find and treat flow-limiting disease, which traditionally forms the most actionable phenotype in current clinical practice, they add. “Such an approach promotes greater focus on prevention of disease—and possibly less downstream morbidity and mortality—and should help change the natural history of coronary artery disease and have a wider impact at the societal level.”
Four conceptual shifts could be anticipated as a result of the Commission’s recommendations, Chandrashekhar, Mensah and Narula state, including a greater emphasis on early detection, changes in the way that cardiologists test for atherosclerotic coronary artery disease, a move towards a “longitudinal process” of managing the disease, and a societal shift in support of earlier screening.
“The agenda proposed by this Commission is likely to reinvigorate the approach to coronary artery disease,” they write. “It will allow clinicians to focus our efforts on assessing and managing risk of adverse events rather than fixing a lesion or two periodically—a shift from considering only the anatomy of luminal compromise and physiology of flow limitation in the lumen to now including the biology of the disease in the vessel wall.”
