Primordial prevention of cardiovascular disease: from mirage to mission

Cardiovascular disease (CVD) remains the leading cause of death worldwide, responsible for nearly one in three deaths globally, with the greatest burden borne by low- and middle-income countries (LMICs).1 Despite substantial progress in therapeutics, imaging, and risk prediction, global incidence has not declined in parallel with advances in treatment.1 The persistent rise in CVD burden invites an uncomfortable possibility: that modern preventive cardiology may be constrained by interventions applied only after risk has already taken hold. Preventive cardiology has traditionally been organized around two stages. Primary prevention focuses on identifying and treating established risk factors such as hypertension, dyslipidaemia, and diabetes, while secondary prevention attempts to prevent recurrence in those with manifest disease. Both have transformed outcomes. Yet both largely begin after pathological processes are underway. Decades ago, Strasser proposed a different approach- primordial prevention, defined as preventing the emergence of risk factors themselves.2 The idea is intuitively appealing but difficult to operationalize. In clinical practice, prescribing a statin or intensifying antihypertensive therapy has clear ownership and measurable results. By contrast, primordial prevention shifts attention toward the social, environmental, and economic conditions that shape behaviour long before a patient meets a cardiologist. For this reason, it has often been viewed as conceptually important but practically remote. The question is whether this perception reflects genuine impracticality or a misalignment between the scale of the problem and the level at which we attempt to address it.