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Atherosclerotic coronary heart disease (CHD), perhaps more than any other chronic condition, is ideally suited for strategies aimed at prevention (Table 51–1). CHD is extremely common and contributes to more than 1.2 million myocardial infarctions (MIs) and nearly 500,000 deaths in the United States each year.1 It is caused by numerous modifiable risk factors with high prevalence, including physical inactivity, overweight and obese states, dyslipidemia, hypertension, diabetes mellitus, and tobacco use. CHD is also associated with profound societal economic cost, with estimates of $165 billion being spent on this condition in 2009 alone.1

Table 51–1. Why Is Atherosclerosis Ideal for Prevention?

Central to the treatment of CHD is the recognition that its incidence is readily modifiable by behavior. Although this is particularly true when healthy lifestyles are adopted early, there are nonetheless barriers to adoption of such behaviors. CHD is a slowly progressive disease that produces few symptoms until late into its course, thus providing ample time for prevention but limited motivation for earlier lifestyle changes. In contrast, when CHD becomes evident, there is often a short duration between symptom onset and disability, leaving less time to initiate preventive strategies. Despite vast improvements in the treatment of patients with acute CHD, such therapies are associated with tremendous cost, and affected patients remain at high risk. The consequence of the above is an unnecessarily high number of patients in the population that face increased cardiovascular (CV) risk.

The central concept of preventive cardiology is that early identification of CHD risk factors and treatment of the associated risk will result in improved survival. Many risk factors begin accumulating at a young age, often while individuals are asymptomatic.2 In fact, pathologic evidence of atherosclerosis can be identified as early as the second and third decades of life,3,4 with even higher prevalence in those with multiple risk factors.5 In some studies, risk factors measured during youth predict atherosclerosis better than those emerging during adulthood.6 For these reasons, the focus of preventive cardiology must be centered on youngsters, adolescents, and young adults because the global epidemic of childhood obesity and diabetes mellitus threatens to reverse the gains that have occurred over the past several decades.

The core science of preventive cardiology is clinical epidemiology. Observational data from prospective cohort studies and interventional data from randomized controlled trials (RCTs) underlie modern risk assessment and preventive care. Beginning in the late 1940s, the Framingham Heart Study advanced the notion of traditional "risk factors" and identified smoking, hypertension, and elevated ...

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