A Less than Provocative Approach for the Primary Prevention of CAD

Coronary artery disease (CAD) risk increases in proportion to the magnitude and duration of exposure to plasma low-density lipoprotein cholesterol (LDL-C), doubling every additional decade of exposure. Early primary prevention is three times more effective than initiated later. Several clinical trials show plasma LDL-C of 15-40 mg/dL is more effective and equally safe as the Current Cardiovascular Clinical Practice Guidelines (CCCPG) recommended target of 70mg/dL. The cholesterol in the blood is the excess synthesized by the cells and secreted into the blood for disposal in the liver. The CCCPG is inadequate since traditional risk factors (TRF) are not detectable until the sixth and seventh decade. The genetic risk score (GRS) evaluated in 1 million individuals as a risk stratifier for CAD is superior to TRF. Genetic risk for CAD was reduced by 30-50% by statin therapy, PCSK9 inhibitors, and lifestyle changes. The GRS does not change during one's lifetime and is inexpensive. Incorporating genetic risk stratification into CCCPG would induce a paradigm shift in the primary prevention of CAD.