The Heart of the Matter
In March 2025, when Eli Lilly announced positive results of an experimental drug, lepodisiran, that could significantly lower levels of the lipoprotein Lp(a) and thereby lower the risk of a heart attack for thousands, if not millions, of people, prominent cardiologists called the news “thrilling” and “a huge new frontier in cardiovascular medicine.” According to data presented by Eli Lilly at the 2025 meeting of the American College of Cardiology and cited in a New England Journal of Medicine article, some 20 percent of all Americans have elevated levels of Lp(a). Phase two of the trial involved 320 participants, all of whom were over the age of 40 (the mean age was 62.7). According to Martha Gulati, a cardiologist at Cedars-Sinai Medical Center in Los Angeles, just 0.8 percent of Americans have ever tested for Lp(a)—even though it was identified as a risk factor for heart disease back in 1974. Gulati urged all adults to test for this lipoprotein. If levels are found to be high—Lp(a) is controlled by genes, not by lifestyle or environment—doctors should look at other risk factors to help prevent cardiovascular events.
Researchers at Eli Lilly believe that lepodisiran could lower levels of Lp(a) by 94 percent; a large clinical trial, now underway, will conclude in 2029. And what if the trial confirms the drug’s efficacy? How many Americans with elevated Lp(a) levels will be tested and receive the new drug, and how many will have access to doctors who have the time to work with them to treat the other risk factors?
As I read the news about this potential breakthrough, I thought again of how fortunate I am to still be here, for in 1999, when I was 60 years old, I nearly experienced cardiovascular death. One day, when I found myself suddenly short of breath while swimming, I got out of the pool, went home, called my family doctor, and spoke with his nurse. She reminded me that I had not seen the doctor for more than two years and scheduled me for an appointment two and a half weeks later. At that checkup, my doctor thought the problem might be gastrointestinal—in addition to shortness of breath, I reported an occasional burning sensation in the middle of my back—but he recommended I undergo a stress test.
Two weeks later, I saw a cardiologist who talked with me briefly, looked at my EKG, thought I’d had a heart attack, canceled the stress test, and performed an echocardiogram. The results, he said, indicated a viral cardiomyopathy, and he told me to schedule an angiogram. The first appointment I could get would take place in three weeks.
In the meantime, I’d been talking almost every day with Rich Helfant, a high school friend who had recently retired as chief of cardiology at Cedars-Sinai. Although I had no conventional symptoms or risk factors—no chest pain, no high cholesterol, no high blood pressure, no worrisome family history—and had been swimming a mile a day and also regularly playing tennis and full-court basketball, I kept telling Rich that “I just didn’t feel right.” And when I called and told him the cardiologist’s diagnosis, he shouted into the phone, from 3,000 miles away, “It’s not viral, goddammit—I want you in the hospital as soon as possible!”
Two days later, I drove to Yale–New Haven Hospital, where another high school friend, Jerry Friedland, director of Yale’s AIDS research and clinical programs, had arranged an appointment for me with a cardiologist. An angiogram revealed that two of my three major arteries were 100 percent occluded, and the third, the left anterior descending artery (the infamous “widow-maker”), was 95 percent occluded. What had kept me alive, the cardiologist said, was the abundance of collateral blood vessels I’d built up by swimming a mile a day.
The next morning, I had emergency quintuple bypass surgery. Since then, lucky me, I’ve recovered into a life in which I have had no major or minor medical issues.
Despite the recent introduction of new drugs, new discoveries, and new tests, Americans are now dying of heart failure at a higher rate than they were in 1999. According to a study in the Journal of the American Medical Association, the increase is occurring most in individuals younger than 45, among whom there was a ninefold rise from 2012 to 2021; there was an almost fourfold increase during that period among individuals aged 45 to 64. Marat Fudim, a professor of cardiology at Duke University and coauthor of the JAMA study, suggests that the health system is at least partly to blame for this reversal because of shortages in primary care, where access to care is limited in many areas of the country, and prevention and chronic care are underemphasized.
It turns out that doctors, especially primary-care physicians, Fudim says, are spending less time with their patients. According to an article in Forbes magazine, one “study published in the Annals of Internal Medicine found that on average a physician spent 16 minutes and 14 seconds using the EHR (Electronic Health Record) for each patient that he or she saw”—which amounts to “one minute and 14 seconds longer than your typical 15-minute patient appointment slot.”
But a JAMA study states that the imbalance between the time primary-care physicians spent on an EHR compared with the length of a patient’s visit contributed to “emotional exhaustion and higher rates of physician burnout.” As a result, the continuity of a patient’s care can be affected. According to a 2025 study published in the Journal of the American Board of Family Medicine, patients at federally qualified health centers will, on average, have seen seven different primary-care physicians during a five-year period.
Although tests can be enormously helpful, a test cannot give a diagnosis. A doctor who takes a good medical history doesn’t need an echocardiogram to know that the sudden occurrence of exercise-induced shortness of breath and “referred” pain—for example, the burning sensation I had experienced in my back—in an otherwise healthy, fit individual are clear signs of an urgent medical situation.
Yes, lepodisiran may one day lower one of the many risk factors for heart disease. But my own experience with heart disease suggests that what we need, and what we are losing, is a health care system that affords doctors the time to interpret an increasing array of complex diagnostic technologies (genetic testing, elastography, magnetic particle imaging) and the time to know their patients well enough to be able to put their symptoms into the context of their histories.
Luck helps, too. “There’s no question that we wouldn’t be sitting here today,” Rich Helfant said when I visited him in California a year after bypass surgery, “if you hadn’t gone to high school with the right guys.”
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