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

Summary

This Commission reframes coronary artery disease as atherosclerotic coronary artery disease (ACAD), advocating a shift from event- and ischaemia-centric care to early detection, prevention, and disease modification. Modeling suggests that eliminating major behavioral and metabolic risk factors by 2050 could reduce ACAD deaths by 82.1%, while highlighting widening burdens in lower- and upper-middle-income countries without equitable access and screening.

Key Findings

• Proposes reclassifying CAD as atherosclerotic coronary artery disease (ACAD), shifting focus from ischaemia to early atheroma detection and prevention.
• Modeling forecasts that eliminating/controlling major behavioral and metabolic risk factors by 2050 could reduce ACAD deaths by 82.1% (~8.7 million lives annually).
• Disparities: projected ACAD mortality increases by 19.2% in lower-middle-income and 4.2% in upper-middle-income countries without equitable prevention and screening; calls for expanded research funding and early detection.

Clinical Implications

Prioritize early atherosclerosis detection (e.g., risk stratification, imaging for plaque), aggressive risk-factor control, and systematic screening programs; reorient guidelines from ischaemia to atheroma biology.

Limitations

• Commission framework without new primary data; relies on modeling and synthesis.
• Implementation feasibility and effectiveness will vary across health systems and require local validation.

Future Directions

Develop scalable early atheroma screening, validate risk-guided imaging strategies, invest in transformative anti-atherosclerotic therapies, and deploy equitable prevention programs in LMICs.