Risk reduction.

In the 1950s, atherosclerosis, the disease process underlying coronary heart disease (CHD), was considered an inevitable, irreversible, and degenerative consequence of aging. Today we understand that coronary disease is treatable, that atherosclerotic plaque progression may be stabilized, and that prevention through risk factor modification can yield significant clinical benefits. Because atherosclerosis develops silently over several decades and begins as early as young adulthood,1 most investigators foresee a blurring of the distinction between primary and secondary prevention in the new millennium. However, asymptomatic patients may be unaware of their atherosclerotic burden and may undervalue the impact of an unfavorable risk profile.2,3 At the same time, physicians, concerned by a healthcare environment in flux, receive the consistent message that secondary prevention is the most cost-effective means of management.4 However, waiting until the patient has experienced a coronary event before intervening raises troublesome ethical concerns that must be addressed before excluding primary prevention altogether. Treatment of coronary risk factors is not as vigorous as it must be. For example, many physicians do not treat lipid disorders to the goals established by national guidelines.5 Although invasive revascularization procedures are sophisticated and may alleviate the physical symptoms of obstructive plaque and may improve survival in some patients with more severe disease,6 the majority of clinical coronary events arise from lesions that may be angiographically invisible and only moderately stenotic.7 Therefore, traditional interventional cardiology can only be part of the solution to the toll of cardiovascular disease. As we enter the 21st century, there is a clear mandate for aggressive promotion of primary prevention and risk factor control, a mandate long championed by the American Heart Association (AHA) and other groups. The last 50 years have seen rapid growth in the area of risk reduction and several important contributions from a large number of investigators and their laboratories. Table 1 describes a few of these major milestones that have influenced profoundly the course of clinical practice in the prevention of coronary disease.