The most common cause of death in the U.S. is heart attacks. For 20 percent of victims, the first symptom is the last: sudden death, with no obvious evidence of heart disease before this tragedy occurs. Heart attacks can strike people as young as their 30s and 40s.

Heart attacks occur when plaque (atherosclerosis, aka hardening of the arteries) in a coronary artery ruptures. The risk factors for developing atherosclerosis were discussed in last week’s column. Most cardiologists aren’t into heart attack prevention, but Dean Ornish, M.D., is an exception and proved over 25 years ago that heart disease can be prevented and reversed by a plant-based, whole (unprocessed) food diet with avoidance of salt, sugar and added oil. Caldwell Esselstyn, M.D., conducted studies at the Cleveland Clinic that confirmed Dr. Ornish’s work. He is featured in the documentary “Forks Over Knives,” available on Netflix and You Tube, and he wrote the book “Prevent and Reverse Heart Disease.” Dr. Esselstyn calls atherosclerosis a “food borne illness,” related to the S.A.D. (standard American diet).

Fifteen years ago the Berkeley Heart Lab put me in touch with Brad Bale, M.D., a family physician who got into heart attack prevention before anyone else was doing it other than Dr. Ornish and Dr. Esselstyn. Dr. Bale has been my mentor in heart attack prevention, and he and his nurse practitioner Amy Doneen, FNP, PhD, wrote a book a few years ago called “Beat The Heart Attack Gene.” Bale and Doneen have patients from all over the country, and some from other countries, who have severe atherosclerosis. They have an amazing track record of preventing heart attacks in these people and have published papers in prestigious medical journals. My only criticism of the Bale-Doneen Method is that they advocate the Mediterranean diet, about which Dr. Esselstyn says “moderation kills,” by which he means that people on the Mediterranean diet still die from heart attacks and strokes whereas they don’t on a plant-based diet. This is a good example of how physicians tell their patients to do only what they do themselves — Dr. Bale is a big guy from Kentucky with some heaviness around the middle, and he isn’t going to give up his fish or olive oil.

So we know that atherosclerosis can be prevented and reversed, and that essentially all heart attacks can be prevented. Why, then, isn’t this happening? As is often the case, follow the money: In America we don’t have a health care system — instead we have a disease management system. We wait until diseases occur and then we spend a lot of effort and money trying to manage them. Because of our dysfunctional and money-driven health care system, people continue to die from preventable diseases such as heart disease. Big Pharma, Big Food, the hospital industry, the cardiology and cardiac surgery specialty societies all are benefiting financially from the status quo and resist change (read “Mistreated,” by Robert Pearl, M.D.).

Based on Bale and Doneen, here’s how to prevent heart attacks:

• Identify people at an early age who are at risk, not only based on risk factors but also by identifying atherosclerosis by carotid IMT, as discussed in last week’s column.

• If people have atherosclerosis, treat their risk factors aggressively: get blood pressure < 120/80; get their total cholesterol < 150, LDL (bad cholesterol) < 70; if they smoke get them to stop; encourage at least 30 minutes of exercise a day; encourage consumption of more fruit and veggies and whole grains.

• If atherosclerosis is present, consider an advanced cholesterol test that includes Lp(a), a particularly harmful type of LDL; LDL particle number (more meaningful than the usual level of LDL); LDL particle size (big is better).

• Look hard for inflammation, which is a major cause of atherosclerosis and of plaque rupture. Markers for inflammation include hsCRP, MPO and LpPLA2. If any of these blood markers are elevated, look for inflammatory diseases such as ulcerative colitis and rheumatoid arthritis; and inflammation from dental and gum disease. Lauren Roper, DDS, is a local dentist who has attended the Bale-Doneen preceptorship and understands the mouth/vascular connection.

• Identify people with insulin resistance (aka pre-diabetes) or diabetes, because these conditions drive 70 percent of heart disease and can be reversed if caught early. Most people with insulin resistance have central obesity and many have high triglycerides and low HDL (good cholesterol). Even if fasting blood sugars are normal, these people need a two-hour glucose tolerance test (one-hour blood sugar > 125 or two-hour > 120 mean insulin resistance).

• Be sure the patient is getting seven to eight hours of good sleep a night. Screen for sleep apnea and treat if present.

• Repeat the carotid IMT a year after starting appropriate treatment — it should look better.

Plant-based physicians would add the following:

• Heart attack-proof lipid values are those that people on a lifelong plant-based diet have — who never get atherosclerosis. Their total cholesterols are < 150, LDLs in the 30s and 40s, triglycerides < 70. Ask any cardiologist what they’d like their own LDL to be and most say 40 — but that’s not their goal for their patients.

• We need our patients to understand that many studies show that a plant-based diet is 98 percent effective in preventing heart attacks, in contrast to statins, which are 30 percent effective (some people do need both).

Dr. Feinsinger, who retired from Glenwood Medical Associates after 42 years as a family physician, has a nonprofit Center For Prevention and Treatment of Disease Through Nutrition. He is available for free consultations about heart attack prevention and other medical issues, and to help people with hospital or other medical bills they don’t understand or think are too high. Call 970-379-5718 for an appointment. For questions about his columns, email him at gfeinsinger@comcast.net.