The Lancet Commission on rethinking coronary artery disease: moving from ischaemia to atheroma

Reported from ACC.25

Background

As interventional cardiologists, or otherwise, we often consider coronary artery disease as stenosis of the epicardial coronary arteries and ischemic burden. As such, strategies have largely focused on reperfusion and damage control rather than addressing the root cause. The economic repercussions have stained the healthcare systems and are likely not sustainable in the future. The Lancet Commission advocates for a more proactive definition that permits earlier recognition of triggers for atherosclerosis and prevention. A blueprint has been elaborated to redirect research away from management of acute events towards prevention and regression of atherosclerosis as the fundamental goal. (Figure 1: Adapted from The Lancet)

Figure 1: Opportunities and strategies to prevent atherosclerotic coronary artery disease over the life course. Early life defined as age 0–3 years. Young life defined as age 4–17 years. Adult life defined as age 18 years and older. ACAD=atherosclerotic coronary artery disease. 
Source: The Lancet

Figure 1: Opportunities and strategies to prevent atherosclerotic coronary artery disease over the life course. Early life defined as age 0–3 years. Young life defined as age 4–17 years. Adult life defined as age 18 years and older. ACAD=atherosclerotic coronary artery disease. 
Source: The Lancet

Blueprint Key Messages

1. Effective strategies for early screening and detection should be identified. Therapies to delay, halt, and reverse the process of atherosclerosis by using targeted screening and detection during the early years of life require further investigation.
2. Implementation of evidence-based knowledge lacks standardization and contributes to the rising cardiovascular death, disability, and waste of resources. Stakeholders should support implementation efforts to maximise the uptake of studied strategies for the prevention and treatment globally and equitably.
3. Research remains a challenge with poor representation of diverse populations which is not transferable to all populations and economies. A global standard of data collection and dissemination to inform population-based decision-making.
4. Research funding should focus on the development of new therapies to prevent, reverse, and eradicate atherosclerosis. Transformative therapies underscoring the emerging role of imaging are crucial.
5. New therapies to eradicate atherosclerosis must be developed and applicable to the global community. A systematic international approach to making data accessible for research and policy will permit a standardized and unified approach to atherosclerosis prevention and treatment.
6. The current focus on diagnosis and treatment is considered late-stage disease. As such, resources should be redirected towards the delivery of care to prevention, detection, and management of earlier stages.
7. Current research resources and investments are not commensurate to the global burden of morbidity and mortality attributable to atherosclerosis. Reallocation of funds to Research funding must increase to address the challenge. 

Clinical Relevance

One wonders what are the implications for individual operators in 2025? It is incumbent upon each of us to push the boundaries and ask more questions. Some we have in fact already started asking: The vulnerable plaque and the vulnerable patient. Our role ought to extend beyond finding the best stent technology and reducing stent failure (or graft failure). We should be addressing conventional and non-conventional risk factors such as smaller particle lipids, genetic predisposition and inflammation. Defining severity beyond per cent stenosis through advanced imaging technologies that permit a longitudinal assessment of plaque progression (or hopefully regression) should be a priority. Perhaps lifestyle modification is an urgent early intervention we should be advocating.

Research Relevance

At this time we are focused on therapies such as the duration of dual antiplatelet therapy, imaging for optimization of percutaneous revascularization and the guideline-directed medical therapy for heart failure. We ought to be evaluating earlier interventions to understand the atherosclerotic process and the response to targeted therapies, for example. The role of immunomodulation or gene therapy.

Dilemma

The question in 2025: We are still seeing patients at a late stage. How do we reconcile the reality with an ambitious transformation in fundamental research and clinical concepts? Perhaps it should be a collective effort: journals, health authorities, advanced health & research centers and individual clinicians/researchers’ calling to action.

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Author

Mirvat Alasnag

@mirvatalasnag

Interventional cardiologist / Cardiologist

Jeddah, Saudi Arabia

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