Heart Disease and Stroke = Our # 1 Killers! What Went Wrong?

Last January the American Heart Association (AHA) reported its latest stats on heart disease and stroke (Circulation, Jan. 21, 2026; JACC, Jan. 12, 2026). The analysis revealed that 915,973 Americans died from cardiovascular disease (CVD). That is roughly one-fourth of all deaths in the United States annually. Why is CVD still our #1 killer after the billions that have been spent on statin-type cholesterol-lowering drugs?

We have been told repeatedly that the 4 BIG RISK FACTORS for cardiovascular disease disease are:

1. “Bad” LDL-Cholesterol
2. High blood pressure
3. Type 2 diabetes
4. Smoking

If we get blood pressure and blood sugar under control, lower LDL-cholesterol and stop smoking, we are supposed to be “good to go!” For most people that means taking medicine to control hypertension, diabetes and cholesterol. Over 50 million Americans are currently taking statin-type cholesterol-lowering drugs.

Yet despite amazing improvements in smoking behavior and an extraordinary number of pharmaceutical prescriptions, cardiovascular disease remains our number one killer! What’s up with that?

A Mind-Boggling Study Contradicts Standard Wisdom About Heart Disease and Stroke

An article published in the International Journal of Cardiology (January 15, 2023) has seemingly been ignored by many cardiologists. Perhaps that’s because it challenges conventional wisdom that “fixing” standard risk factors  provides the protection many healthcare professionals would have predicted.

First, you need to know what the word “SMuRF” means to cardiologists:  “Standard Modifiable Cardiovascular Risk Factors:

In doctor speak that means:

1. Hyperlipidemia
2. Hypertension
3. Diabetes
4. Smoking

These researchers reviewed data from 15 studies involving 1,285,722 patients who were experiencing symptoms of an imminent heart attack.

Here is their stunning conclusion:

“Our findings highlight an important group of individuals presenting with first-onset ACS [acute coronary syndrome] despite no standard modifiable risk factors for atherosclerosis. The global proportion of SMuRF-less patients with ACS presentations is substantial and they have excess early mortality compared with patients with at least one SMuRF.”

OK, I know that is confusing. What is a SMuRF-less patient? That is a person who does not have high blood pressure, diabetes, elevated LDL-cholesterol and is not a smoker! According to conventional medical wisdom they should have done much better than patients with one or more risk factors for CVD.

And yet these SMuRF-less patients “had increased in-hospital mortality” compared to patients with standard risk factors. How much greater “mortality?” The authors report that patients without the 4 big risk-factors were 57% more likely to die when compared to the higher-risk patients with one or more of the conventional concerns.

A fascinating article in Scientific American written by Melinda Wenner Moyer and published on April 14, 2026 was titled “The Hidden Cause of Heart Disease is Inflammation.”

Here is how she describes this research:

“Up to a quarter of the people admitted to hospitals for heart attacks don’t have any of these four risk factors…

“If the big known risk factors miss one in four patients, they still predict trouble as expected for the remaining three. That’s a good record. But it also means that of the roughly 920,000 Americans who die of cardiovascular disease every year, about 230,000 of them will have done so for no understandable reason.”

Melinda goes on to describe the research of cardiologist Paul Ridker. He blames chronic inflammation as the missing link. Finding the best way to calm chronic inflammation has been controversial. More about that shortly.

Modern Medicine Has Failed Us

According to the CDC:

“Heart disease has been the leading cause of death in the United States since 1921, and stroke has been the third leading cause since 1938.”

Fast Forward to 2026 and what do we learn from the American Heart Association (Jan. 21, 2026)?

“Heart Disease Is By Far the Leading Cause of Death in the US”

“Heart disease remains the leading cause of death in the U.S., while stroke has moved up to No. 4, replacing COVID-19, which fell to No. 10, according to the update.”

Please stop and consider what you have just read. More than 100 years ago, cardiovascular disease (CVD) was our number 1 killer in the United States. Now, over a century later, despite a massive (and successful) stop-smoking campaign and multiple drugs to lower the presumed cause of CVD, LDL-cholesterol, we have made surprisingly little progress.

A Quick Review of Heart Disease and Stroke

Smoking Cessation Stats:

During the 1950s it is estimated that roughly 45%-55% of American adults smoked. By 2022 the CDC estimated that fewer than 12% of the adult population were smokers. That’s huge because smoking is a major contributor to cardiovascular deaths.

Lowering Cholesterol:

Modern medicine has blamed cholesterol in general, and LDL-cholesterol in particular, for most of the heart disease and strokes that occur in the United States. The number one tool in the United States has been medications. We have spent billions and billions of dollars on drugs to lower cholesterol in general and LDL cholesterol in particular.

Cholesterol-Lowering Drugs:

1970s

• Cholestyramine (Questran)
• Clofibrate (Atromid-S)
• Niacin

1980s

• Lovastatin (Mevacor)
• Gemfibrozil (Lopid)
• Colestipol (Colestid)

1990s

• Simvastatin (Zocor)
• Pravastatin (Pravachol)
• Fluvastatin (Lescol)
• Atorvastatin (Lipitor)
• Fenofibrate (Tricor)
• Niacin / nicotinic acid (extended-release) (Niaspan)

2000s

• Rosuvastatin (Crestor)
• Ezetimibe (Zetia)
• Ezetimibe + simvastatin (Vytorin)
• Colesevelam (Welchol)
• Omega-3 acid ethyl esters (Lovaza)

2010s

• Pitavastatin (Livalo)
• Alirocumab (Praluent)
• Evolocumab (Repatha)
• Mipomersen (Kynamro)
• Lomitapide (Juxtapid)

2020s

• Bempedoic acid (Nexletol)
• Bempedoic acid + ezetimibe (Nexlizet)
• Inclisiran (Leqvio)
• Icosapent ethyl (Vascepa)

The most successful drugs have been the statins. As I write this, over 50 million Americans are taking statin-type cholesterol-lowering medications. Atorvastatin is the most prescribed medication in America. Nearly 30 million people fill more than 115 million prescriptions.

Why Haven’t Cholesterol-Lowering Drugs Cured Heart Disease and Stroke?

Most of these medicines work very well. That is to say they effectively lower total and LDL-cholesterol. Healthcare providers can get LDL-cholesterol below 100 mg/dL. If they increase the dose of statins or combine a statin with another medication they can get LDL-cholesterol below 50 mg/dL or even below 30 mg/dL. Keep in mind that there was a time doctors were happy if a patient were able to get LDL-cholesterol below 130 mg/dL.

To some extent, statins do have anti-inflammatory activity. They can lower C-reactive protein (CRP) levels. That is one of Dr. Ridker’s key markers for chronic inflammation. But statins do not seem to completely solve the problem of chronic inflammation.

Airplane Deaths Vs. Heart Disease and Stroke

Let’s put statistics into context. There are roughly 105 passengers on a typical airplane flight in America. If you divide 915,973 by 105 you get 8,723. That is how many metaphorical airplane crashes would occur each year to equate to the number of people who die from cardiovascular disease. How long would the airline industry last if there were 50 crashes a year? Even 10 airline crashes would drive America crazy.

If my calculations are correct and 915,973 people died in airplane crashes each year, that would represent about 23 commercial-airliner crashes daily. Would any sane person put up with such a number? Beyond that, would we allow the people running the Federal Aviation Administration or the National Transportation Safety Board to continue in their jobs? Would the CEOs of major airline companies be permitted to keep working?

And yet after 100 years and billions and billions spent on medications, CVD is still our number 1 killer. Why doesn’t anyone object? What is wrong with this picture? The answer, my friend, is blowing in the wind. You can read about another risk factor besides LDL-cholesterol at this link. It was ignored for decades.

Is Lp(a) the Best Kept Secret in Heart Disease?

Doctors rarely tested for Lp(a), even though 1 out of 5 people have high levels. Statins raise Lp(a) but a low-carb diet may lower this key risk factor a bit. There is some relatively new data to suggest that aspirin might be helpful for people with high Lp(a) levels. You can read more about that research at this link. No one should ever take aspirin regularly without medical supervision.

What Can People Do to Reduce the Risk of Heart Disease and Stroke?

There are a great many factors that contribute to heart disease in addition to LDL-cholesterol. In our eGuide to Cholesterol Control & Heart Health we list 26 possible risk factors that can contribute to heart attacks and strokes. When is the last time your cardiologist asked about depression, anger, stress or anxiety?  They can all contribute.

What about infection? Periodontitis (gum disease) can be a contributing factor. So can other infectious diseases. You can read more about the connection between pathogens and heart attacks and strokes at this link. Very few cardiologists have examined the connection between infection and chronic inflammation, yet we think it is important.

The Infection Factor: Rethinking Heart Disease and Dementia

Final Words:

Heart disease and stroke remain our No. 1 killers, even after a century of warnings and decades of cholesterol-lowering medications. That doesn’t mean the tools are useless. Statins and other therapies can help many people. But it seems pretty clear that we are missing important parts of the puzzle.

Lp(a), inflammation, infection, metabolic problems, stress, anger, sleep problems and other overlooked risk factors deserve far more attention than they get. For example, gout and high levels of uric acid may be an important contributing factor to chronic inflammation.

Here is an intriguing article published in the journal Clinical Therapeutics (March, 2026):

“Unseen but Impactful: Gout as a Neglected Comorbidity in Cardiovascular Care”

The authors suggest that an old gout drug such as allopurinol, that lowers uric acid levels, might also be beneficial for the cardiovascular system. Uric acid crystals can be among the most disruptive inflammatory factors in the body.

If you want to reduce your odds of becoming one more statistic, don’t assume a “normal” LDL number tells the whole story. Work with a knowledgeable clinician to look deeper, measure what matters, and tackle the risks that are too often ignored. You can learn more about many other cardiovascular risk factors than the the big 4 SMuRFs in our eGuide to Cholesterol Control & Heart Health. This online resource can be found under the Health eGuides tab.

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