Q.1- Data indicates that over 50% of first-time heart attack victims die with a sudden cardiac arrest mostly before reaching hospital, and this has been the case since 1950s. Doesn’t it mean that cardiovascular medicine is fundamentally handicapped in reaching most of its target population? Is there any other disease you can think of with such a limitation? How can we break this long-standing statistic, by doing more of what we have done or it’s time for new strategies?
Q.2- Heart attack and stroke cause more deaths in the US than all cancers combined. Despite this sobering fact, the entire panel of CVD screening measurements such as blood pressure, serum lipids and glucose all together cost less than $300 whereas cancer screening with only colonoscopy and mammography alone costs over $3,000, a 10-time advantage. Knowing that atherosclerotic CVD is much more preventable than cancer, how can we address such a disparity?
Q.3- Autopsy series, IVUS and carotid ultrasound studies, as well as coronary calcium studies have all shown that about 50% of middle age populations have significant atherosclerosis. This highly prevalent condition is reminiscent of tooth decay which affects half of adults and resulted in water fluoridation policy. Do you think such an approach is warranted for low dose statin? If not nationwide, how about for counties with ASCVD rates above national average? Over a decade ago polypill was viewed as a potential panacea, is there any hope for polypill in primary prevention or the hope is dead? Hypothetically, if PCSK9 inhibitors were completely free would you have recommended a monthly or semi-annual injection to all over 40 or 50?
Shall we take a contrarian view and consider atherosclerosis a benign disease that needs no therapy but we should focus on the dangerous, malignant, or “vulnerable” types of atherosclerosis? If so do you think that risk factors of vulnerable plaques might be different from risk factors of atherosclerosis? Does pursuing vulnerable plaque still make sense or we should move on to the “vulnerable patient”, and treat an individual with atherosclerosis in any vascular bed as high risk regardless of focal pathology?
Q.4– We know that a significant number of patients with coronary artery disease do not have an alarmingly high level of traditional risk factors, and on the other hand some people with very high cholesterol and other risk factors (including smoking) live a long life (over national life expectancy) and do not experience coronary events. What does this mean to you? Does it mean that not all individuals with risk factors are susceptible to them? Or does it mean that some people have protective factors that we don’t know about? Therefore, a personalized risk assessment is needed? What is the best method for personalization? Do you think that the hype of genomic profiling will deliver a breakthrough for personalized risk assessment? Do you recommend health-conscious individuals to take genetic tests such as 23&Me? If cost was not an issue for a health-conscious asymptomatic individual,l would you recommend getting full genome sequencing? How about getting a coronary calcium test? Which one would serve as a more personalized risk assessment tool?
Q.5- Imagine instead of the existing daily weather forecasts and weekly hurricane alerts we were told the probability of a storm within the next 10 years! As you know this is how we predict CVD events today. We tell our patients that their 10-yr risk of a CVD event is for example 8.5% and expect them to change life style and religiously take their medications. Some believe that such long term predictions do not trigger immediate preventive actions. Asymptomatic people are complacent until symptoms occur or feel a serious threat like a lump, a positive biopsy, or a very high PSA. Imagine if we had a similar situation in CVD and could alert people months, weeks, or even days before a heart attack and trigger immediate preventive actions. SHAPE proposed looking for such predictors in subjects from longitudinal cohorts who shortly after an office exam with a blood draw experienced an event (asymptomatic vulnerable patients). The idea is to search for a characteristic pattern among these individuals using machine learning. Do you think such a vision can be realized? If yes where do you think such a powerful predictor could come from, circulating or systemic markers, imaging modalities of focal pathology, wearable data monitors, or a combination with artificial intelligence? Do you think the NIH would fund such an ambitious project? If such a predictor is developed with an accuracy of a mammogram or a biopsy, would it open doors to a new era of acute preemptive interventions in cardiology? What would such preemptive interventions be like? Bypass and other aggressive PCI procedures analogous to surgical removal of tumors? Hyper-intensive medical therapies analogous to chemotherapy?
Q.6- Do you think heart attacks can be eradicated one day, like polio and smallpox, or peptic ulcer, are today? What major development do you think would pave the way for such a future?
Final and Personal Question:
As a leader in cardiovascular medicine, do you think you might be a vulnerable patient?! If not, what makes you confident and how can we make ordinary people similarly confident about their CVD risk?