Should we screen asymptomatic individuals for coronary artery disease or implement universal lipid-lowering therapy?

The lifetime risk of developing coronary heart disease after age 40 has been estimated to be 49% and 32% in men and women, respectively. Including other diseases secondary to atherosclerosis makes the likelihood of developing cardiovascular disease even greater. Lacking an adequate screening test for subclinical cardiovascular disease, or for those in whom it will develop, our current national prevention and treatment strategy is to screen for risk factors of coronary artery disease (CAD), treating only those at greatest risk. Although pharmacologic lipid-lowering therapy has proven to be effective at reducing the development and manifestations of CAD, as well as remarkably safe, our current strategy withholds treatment of many in whom cardiovascular disease will ultimately develop. An alternate strategy is to implement universal lipid-lowering therapy, initiated in men at age 30 and at the time of menopause in women. Such a policy would not limit effective treatment to only those at greatest risk. While the cost of such a program would be substantial, although decreasing with the increasing availability of generic agents, this must be weighed against the direct and indirect costs of cardiovascular disease, estimated to be $368 billion in 2004. If such a strategy were implemented, the goal of screening would shift from CAD detection to detection of a disease burden such that therapies shown to decrease events among those with manifest CAD would be expected to benefit. Such treatments currently include aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and revascularization.