Preventive cardiology: what lies ahead?

Despite increased knowledge of the leading causes of cardiovascular diseases, we continue to observe rather than to control the rise and fall of their incidence. Research needs to be more oriented toward current uncertainties of policy: Is a high-fat diet acceptable so long as its polyunsaturated to saturated fat ratio is high? What are the long-term adverse effects of the powerful new cholesterol-lowering drugs? Should people eat more polyunsaturates? Can new understanding of clotting factors help to prevent heart attacks? How can we lower the average blood pressure of the population as a whole? How do maternal and child health influence the next generation's cardiovascular health? The new research to answer such questions requires that epidemiologists abandon the "black box" approach (which ignores mechanisms); instead, basic scientists need to explain the actions of environmental agents. A new style of preventive clinical practice is emerging, but its future success depends on changes in the medical care system (involving structure, rewards, and staffing), changes in medical education, and on the willingness of physicians to negotiate shared responsibility with their patients. Physicians can identify and help high-risk individuals; but because the incidence of heart disease depends on how people live, it follows that progress in prevention ultimately depends on social, economic, and political decisions. By successful communication of knowledge and impartial advice, physicians can assist in those decisions.