Most heart attacks are preventable, and that doesn’t make treatment the enemy

Key takeaways

• In a 2004 study of about 30,000 people in 52 countries, nine mostly changeable factors accounted for 90% of heart attack risk in men and 94% in women⁴.
• A structured lifestyle program cut new cases of type 2 diabetes by 58% in high-risk adults, nearly twice the effect of the drug metformin⁷.
• Prevention has four levels, and the third, managing a disease after diagnosis, includes treatments such as chemotherapy, so treatment is often prevention by another name¹.
• Fewer than 1 in 5 preventive measures in one large review saved money, about the same share as treatments, so ask whether something buys health at a fair price¹¹.
• Once disease is present, treatment matters: across 123 trials, each 10-point drop in the top blood pressure number cut major heart and stroke events by about 20%¹³.

In 2004, a team led by Salim Yusuf of McMaster University published one of the largest studies of its kind on heart attack risk⁴⁵. They compared 15,152 people who had just had a first heart attack with 14,820 people who had not, across 52 countries⁴.

Nine factors stood out. They were smoking, an unhealthy balance of blood fats, high blood pressure, diabetes, belly fat, stress, too few fruits and vegetables, and too little exercise. The ninth, regular alcohol use, went with lower odds of a heart attack in this study⁴.

Together, those nine accounted for 90% of heart attack risk in men and 94% in women⁴. Nearly all of them are things a person, a family or a town can change.

If you believe prevention beats cure, that reads like a vindication. It mostly is. But the same research carries a second message that natural-health readers hear less often.

Prevention and treatment are not rivals. They sit on one line, and the line bends at the moment disease appears. Knowing where you stand on that line is the whole skill.

Prevention has four levels, and only one comes first

Public health experts sort prevention by timing. The Centers for Disease Control and Prevention (CDC) describes three classic levels¹.

• Primary prevention acts before any harm occurs. Vaccines, quitting tobacco, eating better and banning harmful substances all count¹.
• Secondary prevention finds disease early, before symptoms show. Mammograms and routine blood pressure checks are examples¹.
• Tertiary prevention manages a disease after diagnosis, to slow it or stop it. The CDC lists chemotherapy and rehabilitation here¹.

Look closely at that third level. Chemotherapy is a treatment, yet public health files it under prevention, because it prevents death and disability. A blood pressure pill works the same way. It treats high blood pressure, and it prevents strokes.

A fourth level came later, from family doctors. Its first definition, written in 1986 and credited to the physician Marc Jamoulle, focused on spotting patients at risk of too much medicine and shielding them from needless interventions²³.

It is called quaternary prevention. WONCA, the global organization of family doctors, now has a working group devoted to it². The group describes its aim as sparing patients from medical care that brings no net benefit and might hurt them².

In 2018, a team writing in the European Journal of General Practice proposed widening the idea. They argued that every intervention a doctor suggests, at any stage of life, should be checked for more harm than good³.

Nine everyday factors tracked with most heart attacks

INTERHEART, as the 2004 study is known, used a measure called population attributable risk. It estimates the share of cases that would disappear, in theory, if a risk factor were removed.

Smoking, current or past, accounted for about 36% of heart attack risk. An unhealthy ratio of two blood-fat proteins, called ApoB and ApoA1, accounted for about 49%⁴. These shares overlap, so they don’t add up neatly. Together, smoking and the blood-fat ratio made up about two-thirds of the risk⁵.

The pattern held for men and women, younger and older people, and in every region studied⁴⁵. Yusuf’s team said the findings meant most premature heart attacks in the world should be preventable⁵.

There is a catch. INTERHEART was a case-control study, which means researchers looked back at people after their heart attacks and compared them with similar people who had not had one. That design shows strong links. It cannot prove each factor caused each heart attack.

A larger analysis in 2023 tested the question a different way. The Global Cardiovascular Risk Consortium pooled records on more than 1.5 million people from 112 cohort studies, which follow people forward in time, in 34 countries⁶.

It tracked five factors: body weight, the top blood pressure number, non-HDL cholesterol, current smoking and diabetes. Those five accounted for about 57% of new cardiovascular disease, such as heart attacks and strokes, in women and 53% in men over 10 years⁶.

That is less than INTERHEART’s 90%. But the newer study counted fewer factors, leaving out diet, exercise and stress. It also looked at all cardiovascular disease, not just first heart attacks. So the two numbers are not directly comparable.

Our reading is that “most” holds up, while the exact share depends on what you count.

One more detail deserves attention. The same five factors accounted for only about 1 in 5 deaths from any cause: 22% in women and 19% in men⁶. Preventing heart disease is powerful. It does not prevent everything.

A lifestyle program beat a drug at preventing diabetes

The Diabetes Prevention Program is the most famous test of lifestyle prevention. It enrolled 3,234 adults at 27 U.S. centers. Their blood sugar was raised but had not yet crossed into diabetes⁷⁸.

People were assigned by chance to a placebo pill, the drug metformin or a lifestyle program. The program’s goals were to lose 7% of body weight and to move at least 150 minutes a week⁸.

After an average of 2.8 years, the lifestyle group had 58% fewer new cases of type 2 diabetes than the placebo group. Metformin cut new cases by 31%⁷. For people 60 and older, the lifestyle program cut risk by 71%⁸.

In plain numbers, about 7 people had to follow the lifestyle program for three years to prevent one case of diabetes. For metformin, it took about 14⁷.

The effect faded but lasted. After 15 years, the lifestyle group’s risk was still 27% lower than the placebo group’s⁸. Our article on group health classes covers how the program moved into community centers.

Here is the detail that matters most for this topic. At the 10-year mark, all three groups had improved their blood pressure and cholesterol, but the lifestyle group needed fewer medicines to get there⁸. Prevention did not replace treatment. It shrank how much treatment was needed.

The prevention paradox: why success looks like nothing happened

The British epidemiologist Geoffrey Rose spotted an awkward truth about prevention. He named it in the BMJ in 1981¹⁰, and he built on that thinking in a famous 1985 paper, “Sick Individuals and Sick Populations”⁹.

Rose’s prevention paradox goes like this. A measure that brings large benefits to a whole population often offers very little to each person who takes part¹⁰.

Seat belts are a familiar illustration. Most drivers buckle up for a lifetime and never crash. Each person gains almost nothing on a given trip. Across a country, the lives saved add up.

Rose described two strategies⁹. The high-risk strategy finds the people at the top of the risk scale and treats them. The population strategy nudges everyone’s risk down a little, through things like cleaner air, smoke-free rooms or less salt in packaged food.

Each has trade-offs, as researchers revisiting Rose’s work in 2012 explained¹⁰.

• High-risk approach: advice fits the person, motivation tends to be higher, and benefits clearly outweigh harms for those at high risk. But finding those people is costly, and it can make healthy people feel like patients.
• Population approach: it can prevent more cases overall. But each person’s gain is so small that motivation is weak, and because so many people take part, any harm must be tiny.

Rose argued the two strategies usually work together. He put priority on controlling the causes that make a disease common in the first place⁹.

The CDC offers a real example. When smoking is banned in workplaces, restaurants and bars, hospital stays for heart attacks can drop by 8% to 17% within a year¹. No one can name the person whose heart attack never happened. That is the paradox in action.

It also explains why prevention can feel thankless in your own life. You will never meet the heart attack you prevented.

Prevention usually doesn’t save money, and it doesn’t have to

“An ounce of prevention” suggests a bargain. Health economists have tested that promise.

In a 2008 New England Journal of Medicine article, health economists Joshua Cohen, Peter Neumann and Milton Weinstein reviewed 599 cost studies published from 2000 to 2005¹¹¹². The studies held 279 comparisons of preventive measures and 1,221 comparisons of treatments¹¹.

Fewer than 20% of the preventive measures reduced medical spending. Treatments had a similar share¹¹. The authors concluded that good-value options exist in both camps, and that sweeping claims about prevention saving money were misleading¹².

Economists separate two ideas here. Cost-saving means something costs less than it saves. Cost-effective means it buys real health at a reasonable price¹¹.

Economist Louise Russell, in a 2009 talk on what these analyses have taught, gave examples from earlier studies. No blood pressure medicine saves money, but some are much better value than others¹¹. Chickenpox vaccine saves about 90 cents in medical costs for each dollar spent. Bigger savings claims count parents’ lost work time and children’s future earnings¹¹.

Counseling and screening tend to be better value in high-risk groups than in everyone¹².

So prevention is worth doing because it buys years of health, not because it pays for itself. Be wary of anyone, whether a politician or a product seller, who promises it will.

When treatment has to lead

Some situations call for treatment first, with healthy habits alongside.

High blood pressure. Almost half of U.S. adults have it¹⁴. A 2016 analysis in The Lancet pooled 123 randomized trials, studies where people are assigned by chance to one treatment or another, with more than 600,000 participants¹³.

For every 10-point drop in the top blood pressure number, major heart and stroke events fell by 20%. Strokes fell 27%, heart failure 28%, and deaths from any cause 13%¹³. The benefit was similar even in trials that included people starting below 130¹³.

The National Center for Complementary and Integrative Health (NCCIH) says meditation, tai chi, qigong and yoga may lower blood pressure a little¹⁴. Some foods and supplements, such as garlic and cocoa, show modest effects in limited studies¹⁴.

NCCIH also says that, in research so far, no supplement has matched the effect of blood pressure drugs¹⁴. Licorice root, bitter orange, ephedra and ginseng may even raise blood pressure¹⁴.

Curable cancer. In 2017, Yale researchers led by Skyler Johnson studied patients with breast, prostate, colorectal or lung cancer that had not spread¹⁵. Out of 1.68 million records, 281 people had turned down standard treatment in favor of alternative therapies¹⁵.

Over about five years, those with breast or colorectal cancer were about five times as likely to die as similar patients in standard care. For lung cancer, the risk was more than doubled¹⁵. Prostate cancer patients showed no drop in survival over that period¹⁵.

The researchers noted limits: they didn’t know which therapies people used, and those patients tended to be younger and healthier. Our companion article on complementary, alternative and integrative care looks at this research in more depth.

Sudden, severe symptoms. Chest pain, signs of stroke and trouble breathing need emergency care, not a lifestyle plan. Our article on symptoms that mean call 911 lists them.

Natural health got prevention right, but the risk is turning it into a creed

The natural-health instinct to put prevention first is well supported. So is the instinct toward the least intervention that works. Medicine’s own name for that second idea is quaternary prevention².

Trouble starts when prevention becomes an identity instead of a tool. Two traps are common.

The first is treating every medicine as failure. In the diabetes trial’s follow-up, the lifestyle group still used some medicine for blood pressure and cholesterol. It just needed less⁸. That is a win, not a loss.

The second is self-blame. In the 1.5-million-person analysis, five major risk factors accounted for a little over half of heart disease and stroke⁶. The rest came from causes the study didn’t measure, and some of those, such as age and family history, no one can change. Getting sick after years of good habits is not a moral failing.

Holding both ideas is a mature version of natural-health values: do the most you can upstream, and accept help downstream without shame.

Prevention, treatment or both: a decision guide

This guide is general education. Use it to plan a conversation with your clinician, not to replace one.

Where you are	What usually leads	Where natural approaches fit	A question to ask
Healthy, numbers in range	Primary prevention	Center stage: food, movement, sleep, no tobacco	Which screenings are due for my age?
Borderline numbers, such as prediabetes	Lifestyle first, with a recheck date	A structured program with clear goals	What number would make you recommend medicine?
Diagnosed condition that stays high	Treatment plus habits	Habits may let you lower doses over time	Can we reduce the dose if my numbers improve?
Cancer that can be cured	Standard treatment	Complementary care for symptoms, alongside	Which approaches are safe with my treatment?
Sudden, severe symptoms	Emergency care now	None until you are stable	Call 911 first
A test or treatment with unclear benefit	Quaternary prevention	Watchful waiting may be reasonable	What happens if we wait?

What the evidence says

Claim	Evidence level	What the research shows
A handful of changeable factors are linked to most heart attack risk	Strong evidence (large observational studies)	90% to 94% for nine factors in one study; about 53% to 57% of all cardiovascular disease for five factors in another46
Structured lifestyle programs prevent type 2 diabetes in high-risk adults	Strong evidence	58% fewer cases at about three years, 27% at 15 years78
Smoke-free laws prevent heart attacks	Strong evidence	8% to 17% fewer heart attack hospitalizations within a year1
Blood pressure medicine prevents heart attacks and strokes	Strong evidence	About 20% fewer major events per 10-point drop13
Mind-body practices lower blood pressure a little	Promising but early	Small possible benefits14
Supplements can replace blood pressure medicine	Not enough evidence	None shown to match drugs; some herbs raise pressure14
Prevention generally saves money	Evidence says no	Fewer than 20% of preventive measures studied did11
Alternative therapy instead of standard care for curable cancer	Evidence says no, or unsafe	About five times the death risk for breast and colorectal cancer15

Questions readers ask

The bottom line

Natural health’s faith in prevention is backed by some of the strongest evidence in medicine. A few changeable habits drive much of heart disease, and a structured lifestyle program prevents more diabetes than a pill.

But prevention has levels, and the later ones look a lot like treatment. Once a disease is present and serious, proven treatment is the step that keeps prevention possible. Use habits to need less medicine, use medicine when you need it, and question anything that offers more harm than help.

Related reading

• The preventive care that costs you nothing, and the exceptions
• Learning health skills together works when the group checks its facts
• When extra medical tests do more harm than good
• Complementary, alternative or integrative: one word carries most of the risk
• The symptoms that mean call 911 now

Sources

1. Centers for Disease Control and Prevention. “Prevention” (Picture of America series). CDC, about 2014. stacks.cdc.gov
2. WONCA Special Interest Group on Quaternary Prevention and Overmedicalization. “Quaternary Prevention.” World Organization of Family Doctors. globalfamilydoctor.com
3. Martins C, Godycki-Cwirko M, Heleno B, Brodersen J. “Quaternary prevention: reviewing the concept.” European Journal of General Practice, 2018. pubmed.ncbi.nlm.nih.gov
4. Yusuf S, et al. “Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.” The Lancet, 2004. pubmed.ncbi.nlm.nih.gov
5. McMaster University. “Global study shows nine factors identify majority of heart attack risk.” McMaster Daily News, 2004.
6. Global Cardiovascular Risk Consortium (Magnussen C, et al.). “Global Effect of Modifiable Risk Factors on Cardiovascular Disease and Mortality.” New England Journal of Medicine, 2023 (LSHTM repository). researchonline.lshtm.ac.uk
7. Diabetes Prevention Program Research Group. “Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin.” New England Journal of Medicine, 2002 (abstract via George Washington University Biostatistics Center). biostatcenter.gwu.edu
8. National Institute of Diabetes and Digestive and Kidney Diseases. “Diabetes Prevention Program (DPP).” NIH, reviewed 2021. niddk.nih.gov
9. Rose G. “Sick individuals and sick populations.” Reprinted in Bulletin of the World Health Organization, 2001 (originally International Journal of Epidemiology, 1985). scielosp.org
10. Burton H, Sagoo GS, Pharoah P, Zimmern RL. “Time to revisit Geoffrey Rose: strategies for prevention in the genomic era?” Italian Journal of Public Health, 2012. riviste.unimi.it
11. Russell LB. “What Have We Learned from Economic Analyses of Prevention?” Economics of Prevention Workshop, Sydney, 2009 (summarizing Cohen JT, Neumann PJ, Weinstein MC, New England Journal of Medicine, 2008). movendi.ngo
12. Greenberg DS. “Does Prevention Save Health-Care Dollars?” APS Observer, Association for Psychological Science, 2008. psychologicalscience.org
13. NIHR Evidence. “Lowering blood pressure reduces the risk of heart disease, stroke and death” (summary of Ettehad D, et al., The Lancet, 2016). National Institute for Health and Care Research, 2016. evidence.nihr.ac.uk
14. National Center for Complementary and Integrative Health. “High Blood Pressure (Hypertension).” NIH, updated 2018. nccih.nih.gov
15. National Cancer Institute. “Alternative Medicine Linked with Worse Survival for Curable Cancers” (on Johnson SB, et al., Journal of the National Cancer Institute, 2017). Cancer Currents blog, 2017. cancer.gov