Coronary artery disease (CAD) is largely preventable through risk factor optimisation. CAD incidence remains high due to poor services to move these risk factors into the optimal range and due to lack of regenerative treatments (i.e. non surgical (e.g.) stenosis reversal interventions or availability of economically viable tissue engineered biological/bioprosthetic/prosthetic hearts or vasculature).
How to optimise QALY:£ (i.e. save costs, promote quality)?
- Online program, telemedicine, nurse consultation>doctor, artificial intelligence: Alexa/Jarvis?
Should there be a recommended integrated CAD/ARD prevention protocol for age (60?)+?
- Calorie restricted “Food Hourglass” diet? Precision diet & supplements? Stricter and broader risk factor targets?
- Self funded option? NHS will never afford all investigations and therapies despite evidence base?
- Does informed consent for CAD prevention really exist?
Is money better spent on preventive therapies & education straight up, as most investigation results are predictable? Which populations?
Is money needed to be spent on (which?) modifiable risk factor investigations?
- 24/hr glucose monitors, vitamins A-K, blood/hair minerals, pseudo-vitamins, fatty acid profile, IGF-1/BUN, micro/macronutrient tracking and analysis software, TC, LDL, HDL, TG, hsCRP, thyroid, BMI, WHR, 3D avatar body composition imaging, BP, 24Hr BP, HbA1c, FPG, OGTT, hsTroponin
Does low (x?) mSv CACS/CTA or stress echo have a place in screening/“motivational screening”?
- What population (X% CAD likelihood?) (QRISK2 score?) do you screen? With what frequency?
- What added benefit in clinical outcomes (predicted reduction in clinical event, symptoms or % stenosis/vulnerable plaque change) VS motivational interview with pure CAD likelihood /QRISK2 score?
- Is there a cut off for mSv exposure to justify screening use in population? 1 mSv combined CTA/CACS per scan? 0.5 mSv?
- Invest in MRI, ultrasound or digital stethoscope hardware and software for PPV & cost to rival CTA?
Is it necessary to validate reduction in stenosis/CACS and or other measured risk factors? At what interval? For which populations?
Environmental engineering policy?
- Increase (triple?) the price of junk foods and beverages? Subsidise validated CAD preventive foods or related entrepreneurship/innovation? Vending machines full of CAD preventing foods? Ban all unhealthy ingredients above x proportion? Food engineering - what if all food (even macaroons, croissants, bacon) was healthy? More scientifically accurate food labeling system? GDP effect? Moral duty? Good nanny state? Bad nanny state?
First published Feb 25 2017