Primary Prevention of Coronary Heart Disease

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Abstract
The concept that coronary heart disease (CHD) can be prevented has increasingly become a driving force in cardiovascular medicine. For many years, the field gave lip service to prevention but neglected to take it seriously. The possibility of effective prevention was met with skepticism from many quarters. Gradually, however, the tide has turned, and prevention is getting the upper hand. Widespread acceptance of the benefits of prevention came first in the area of secondary prevention, ie, preventing recurrent coronary events in patients with established CHD.1 Secondary prevention stands at the boundary between prevention and treatment. Many cardiologists consider secondary prevention to be treatment of coronary artery disease; others see it as prevention of recurrent coronary events. There is a more uniform agreement that prevention of new-onset CHD should be called primary prevention. This article examines some of the major issues currently under scrutiny for primary prevention of CHD. Without question, the area of primary prevention is complex and contentious; some of the issues will not be easily resolved. However, if the burden of CHD in industrialized and developing societies is to be substantially reduced, effective strategies for primary prevention must be put in place. Major advances have recently been made in understanding the pathogenesis of acute coronary syndromes (unstable angina, myocardial infarction, and coronary death). Of great importance was the recognition that rupture of vulnerable plaques leading to coronary thrombosis accounts for most acute coronary syndromes.2 3 Equally important was the discovery that the risk of plaque rupture and its consequences can be substantially reduced by medical intervention. For example, cigarette smoking almost certainly predisposes to plaque rupture, and smoking cessation rapidly lowers risk for coronary thrombosis.4 Meta-analysis confirms that lowering blood pressure in hypertensive patients will reduce acute myocardial infarctions.5 Low-dose aspirin therapy likewise lowers …