Introduction

Insull, William

doi:10.1016/j.amjmed.2008.10.012

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Volume 122, Issue 1, Supplement , Pages S1-S2, January 2009

Introduction

Section of Atherosclerosis and Vascular Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA

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Author disclosures
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Atherosclerosis is the major cause of death in industrialized countries and is becoming dominant in other countries as they assume similar adverse diets and health practices. The challenge to researchers and clinicians is to develop and clinically apply treatments, including lifestyle changes, to prevent both secondary events and primary events of atherosclerotic cardiovascular disease. The rationale for these treatments is to favorably change the size, cellular and chemical composition, and biological activity of atherosclerotic plaques, thus resulting in a more favorable clinical course.

Our knowledge and understanding of the pathology of atherosclerosis development have advanced significantly in 3 aspects over the past 5 years. In 2008, rational medical treatments, based largely on 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) available to every practitioner, can induce the regression of advanced-stage plaques of atherosclerosis and, concurrently, can reduce the risks of clinical disease. The rationale for these treatments is ultimately based on their effects on plaques, as documented by studies of plaque histopathology and morphology based on clinical imaging and on the results of clinical outcome studies.

The following 3 developments have been crucial to our enhanced understanding of the disease:

1.The histopathology of atherosclerotic lesions that cause sudden cardiac death (culprit lesions) has been described comprehensively. This fills the last gap in our knowledge of plaque development. It effectively completes our broad outline of the development of atherosclerotic lesions from early teenage years to terminal events of adulthood.

2.Numerous clinical trials have shown that statin treatments given to lower low-density lipoprotein cholesterol reduce the risk of clinical events by at least 33%.

3.The effects of statins on advanced human plaques include a significant and prompt reduction in the pathogenic processes of plaques and interactions between lipid metabolism and inflammation.

The purpose of this supplement to The American Journal of Medicine is to review for the practitioner major recent findings that support treatments to control advanced plaques of atherosclerosis, concluding with a checklist of key elements in the clinical management of atherosclerosis in 2008.

In the first article, Dr. William Insull, Jr., summarizes the pathology of lesions of atherosclerosis as they develop from initial lesions during the early teenage years to terminal events in late adulthood. The second article, by Dr. Borja Ibañez and colleagues, describes the role of clinical imaging in the diagnosis and evaluation of the burden of atherosclerosis for the individual patient.

In the third article, Dr. Harold E. Bays summarizes the practitioner's challenge to integrate the management of adipose tissue, obesity, and the metabolic syndrome into the management of atherosclerosis. In the fourth article, Dr. Sandra J. Lewis describes the practitioner's challenge to routinely and uniformly apply treatment for control of atherosclerosis in the office, aiming for the ideal of patient adherence to lifestyle changes and medical therapy.

The fifth article, by Dr. Michael H. Davidson and colleagues, provides a snapshot of medical treatment patterns in current clinical practice for the management of atherosclerosis and emphasizes the need for greater use of currently available treatments.

The supplement concludes with an article in which Drs. Insull and Lewis present a short checklist to aid the busy clinician in organizing and implementing an effective course of atherosclerosis evaluation and treatment for each patient.

Each article includes the authors' selected “clinical pearls,” which emphasize pivotal practical aspects of their topic. Two general conclusions are warranted:

1.Successful long-term management of atherosclerosis is the responsibility of each practitioner. This includes counseling patients about the need for lifestyle changes and, when necessary, instituting effective drug therapy, which is now available to every practitioner.

2.This series of articles provides the practitioner with a foundation for anticipating and evaluating future new treatments. This foundation is based on the newest pathology and treatment experiences through 2008.

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Author disclosures

The author of this article has disclosed the following industry relationships:

William Insull, Jr., MD, serves on the Speakers' Bureau for Abbott Laboratories, Merck & Co., Inc., and Schering-Plough Corporation and as a consultant/advisory board participant for Daiichi Sankyo, Inc., Merck & Co., Inc., and Merck/Schering-Plough, Inc. He is an investigator for Pfizer Inc and has received research support from AstraZeneca Pharmaceuticals LP, Kos Pharmaceuticals, Inc., Merck & Co., Inc., and Pfizer Inc. In addition, Dr. Insull has received honoraria from Merck & Co., Inc., and from Merck/Schering-Plough, Inc., and is an editor/writer for AstraZeneca Pharmaceuticals LP.

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