May 28th, 2015
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No Easy FixesMs. D., a middle-aged Jamaican-American woman from the Hyde Park neighborhood of Boston, sits amidst many other patients in the waiting room. It's not evident from her outward appearance, but her coronary arteries house 10 drug-eluting stents. Six of them had been placed over the course of a year, now 6 years ago, when she underwent seven cardiac catheterizations at the age of 49. Yes, Ms. D. has terrible coronary artery disease. Yes, with a body-mass index of 41, she is morbidly obese, with type 2 diabetes, high blood pressure, and high cholesterol. Nonetheless, given that she was a nonsmoking and relatively young woman, her initial 10-year risk for developing coronary heart disease, as predicted by the original Framingham risk score,1would have been considered low. We now know that these estimates are imperfect at best, particularly for certain subgroups of patients with heterogeneous risk, and studies are under way to permit more accurate and meaningful risk stratification of patients. Yet though it is tempting to assume that Ms. D. must harbor an uncommon cluster of genetic defects contributing to an aggressive and refractory atherosclerotic phenotype, her d

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