By: Matt Gurney

Late last month, attending the Halifax International Security Forum, I was having the damndest feeling. Can you have déja vu for something that you only experienced via fiction? Because it was kind of like that.

The fiction in question was a novel by an Australian, published during the Second Iraq War. Anti-American sentiment was running rampant all over the world. The premise of the novel is out there in the realm of sci-fi — America disappears. Specifically, Americans disappear — some mysterious wave of energy scours most of North America clean of life. Virtually all of the U.S. is wiped out; most of Canada and Mexico, too. Somewhat to the surprise of the anti-Americans, this does not result in an improvement in life on Planet Earth.

Standing around at the forum, eating the delicious snacks and drinking the good coffee and chatting with friends old and new, that was what I kept thinking about. Where are the Americans? And what the hell are we going to do without them?

And, in case you’re wondering what’s up with that headline, here’s another question — what will we do if they one day try and come back?

The forum is an annual gathering of senior military officers, defence and intelligence officials from across the free world, and representatives from the media, think tanks, large companies and civil society organizations whose work relates to defence and security issues or in some way seeks to promote and preserve a healthy democratic world. Funded by NATO, the Canadian government and private-sector sponsors, the event is a major part of Canada’s “soft power” offering to our allies — we host the big party and show everybody a good time. The actual schedule is split between on-the-record panel talks or presentations, off-the-record sessions, and informal time for mingling and schmoozing. I am grateful to have been invited to participate again this year.

Especially this year. I’ve been going to the forum for years, and the event always had a strongly American flavour.

Not anymore! Yankee went home.

Like, literally. He was ordered to go home, or stay there. Secretary of Defense Pete Hegseth ordered the Pentagon to avoid a series of high-profile annual defence summits. That includes Halifax, and others in places like Munich and Singapore, and even inside the United States itself. The reason, according to the Pentagon’s press apparatus, was that, and I swear to God this is the actual quote, such events promote “the evil of globalism, disdain for our great country and hatred for the president of the United States.”

Oh. Well, then.

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That’s what made the forum so fascinating this year. As I told my colleague Jen Gerson while I was in Halifax, the entire event felt a little bit like the first Thanksgiving after a divorce. It’s great to see everyone, but there’re some notable absences, is the thing.

Let me be clear about one thing: there were indeed a great many Americans at the forum in Halifax. I don’t want to suggest otherwise. There was a large Congressional Delegation, or a “CODEL,” present at the forum, as there is every year. If anything, I think this year had an unusually large CODEL. And it was a bipartisan one, too. But I noticed something interesting. They were all senators. No House reps. I can’t help but suspect that’s because they’re either planning to retire (some have said already they will) or because the longer six-year term afforded senators gives them some ability to withstand White House anger that House reps, with two-year terms, don’t have.

There were plenty of other Americans from private companies, think tanks, academia, and many former and retired U.S. government officials. And I’m going to be extremely careful in how I describe this: I have a pretty good hunch that some U.S. military officers were indeed in attendance, because — gosh! what a coincidence! — they just happened to be in Halifax on vacation at the exact same time the forum was taking place.

I was glad to see these Americans and had many fascinating chats with them. But I have to tell you all, dear readers, that the lack of official U.S. military and government representation was very obvious. And those brave Americans who did attend did not have an easy time. There was some pretty strong talk aimed at America, either directly or in absentia. And I think that many of the American visitors were surprised by the vehemence of some of the comments and questions directed their way.

Let me give you an example from an on-the-record session that I can quote directly. Sen. Jeanne Shaheen (Democrat-New Hampshire) was the head of this year’s CODEL and had a one-on-one chat with moderator Nick Schifrin, an American journalist from PBS. You can see it all here. But things got really interesting when Canadian senator Stan Kucher got up to ask a question. It’s at the 18-minute-ish mark of the video linked to above. Kucher rattled off various criticisms of the “peace deal” that has been proposed for Ukraine, a deal that was dismissively described at the forum as a real estate transaction. After making his own views on the proposed deal clear (he’s not a fan), Kucher said this to Shaheen: “We’ve talked about allyship. What should the allies, who uphold democratic values, in the reality that the United States has walked away from them … what should the allies do?”

Pretty blunt by the standards of most Canadian senators I’ve ever talked to. I expected Shaheen to reject the premise of the question.

She didn’t.

She noted that other allies had already rejected the terms of the proposed peace, and reiterated that she agrees with them. And fair enough. But, wow. The question was about Ukraine, but it raised a much deeper point — America has “walked away” from its allies. And the leader of the CODEL took no issue with that characterization.

Here’s another example, again from an on-record part of the proceedings. David Zapolsky, chief global affairs and legal officer from Amazon, was giving remarks. (Amazon is one of the forum’s sponsors.) He was being interviewed by Jamie Tarabay, a Bloomberg reporter. You can see their conversation here, but as the panel was wrapping up, Tarabay dropped a humdinger of a question on Zapolsky. Here’s the quote (slightly cleaned up for clarity): “We’re in an age where there’s a government that puts pressure on companies [and] people for [Trump’s] own gain. You have been so steadfast in your support for Ukraine. What will Amazon do if your government says ‘Stop’?”

Zapolsky replied that the company has contracts with foreign governments and NATO allies and said that Amazon would only change those relationships if it was legally forced to do so via something like a sanction.

There were two fascinating things about that exchange (it starts around the 17-minute mark of that video). The first was the question itself; it alone was a signal of how much things have changed.

The second interesting thing is that Zapolsky’s answer was, with respect, bullshit.

I can see why he’s a legal officer! He gave an answer that was legally correct — the only way that the U.S. government can officially bar Amazon from providing cloud services for a foreign military, for example, would be by sanctions or some comparable legislation.

But that’s not how it could go. What would happen is that someone senior at Amazon, maybe Jeff Bezos himself, would get a call from some golf partner or drinking buddy in the administration, and the message will be simple: “Stop, or you won’t get contracts. We’ll arrange some hearings into your operations. Your little spaceflight company will find itself under way more levels of regulatory review than your Musk-owned competitor. This is what the boss wants. Make it happen.”

Amazon or any other U.S.-based company will then make the decision that best promotes and protects long-term shareholder value. And that decision will be, in every case, to submit and comply. Everyone in the room knew that. America is different, now. It’s inescapable.

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Those are some examples from the on-the-record sessions. The most dramatic one by far — and yes, we’re finally getting to the headline you all clicked on — was in a session that was covered by Chatham House rules — I can directly quote what was said, but I cannot identify the speaker. The session, over dinner, was a small group. It was about America’s moral leadership in the world. Our moderator was a now-former American official. She was pretty frank and clear-eyed about how America’s allies currently view the country’s place in the world, but also expressed some hope that after the midterms next year or maybe the next presidential election, things would start to get more back to normal. We were assured that a lot of people in America are still with us. Some of the other Americans present nodded their heads.

And, like, gosh. Boy. I confess to readers that due to extenuating circumstances, my reserves of both patience and charm are largely exhausted at present. I informed the moderator, probably more bluntly than I might have normally, that that wasn’t going to happen. The damage is already done. I know firsthand that a great many Americans who really do believe in the post-1945 global order, and of America’s prior role in the world and the value of that role to America and Americans, are still inside the U.S. government. But I also know that many of them are retiring, or seeking early retirement, or switching to consulting gigs. They can’t stomach what U.S. foreign policy is becoming, and they won’t be a part of it.

Good for them. But every single person who departs is being replaced by someone who is totally fine with the new U.S. foreign policy. And sometimes is actually quite enthusiastic about it. That will accelerate the process that’s already underway. And those new people are going to have long careers, shaping things both in public and behind the scenes. And the damage to America’s soft power — the shutting down of aid programs and things like Voice of America — can’t be undone rapidly no matter who wins the midterms. U.S. troops that are pulled out of bases where the U.S. no longer sees a strategic reason for their presence aren’t likely to come back.

And, this is the critical part, wouldn’t necessarily be welcomed even if they did.

I worry that I might have been a bit brash with my American dining companions that night. (If any of them are reading this and if I was, sorry. Lot goin’ on over here.) But before I could worry about it too much, a senior military officer from a major (non-American) allied nation drove a stake right through the heart of the matter.

America has blown 80 years of accumulated goodwill and trust among its allies, our American moderator was told. A rock-steady assumption of allied defence and security planning for literally generations has been that America would act in its own interests, sure, but that those interests would be rational, and would still generally value the institutions that America itself worked so hard to build after the Second World War. America’s recent actions have destroyed the ability of any ally to continue to have faith in America to act even within its own strategic self-interest, let alone that of any ally.

The officer then said that even a swift return of America to its former role won’t matter.

Because “we will never fucking trust you again.”

The Americans at the table seemed somewhat startled by the heat of that pronouncement. I agreed with it entirely. So, it seemed to me, did most of the non-Americans.

This wasn’t the only such moment at the forum this year, but it was, to me, the most interesting. And it was still being talked about the next day. “Thank God,” one allied official said to me. “Someone had to tell them.”

If there’s one thing I think people should take from my visit to Halifax, it’s that. America’s former role is gone. And I think that Americans themselves are having the hardest time of all coming to terms with what that might actually mean in the long run.

Stay tuned for more from Halifax in the coming days.

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For fifteen years, I've tracked the flow of political money in America—who gives, who gets, and what it buys. After all that, I can say this with confidence: the narrative most Americans hear about money in politics largely misses the real story.

The real story isn't about the ads you see but the power you don't. It's about the candidates who never run, the policies that never get debated, and the slow, systemic drift of our democracy away from the will of the majority.

We tend to imagine corruption as a transaction: money buying votes, quid pro quos in backrooms. But money's real power is quieter and deeper. It decides which candidates get to run, which policies are thinkable, and whose voices get amplified or ignored. It has rewritten the rules of self-government—slowly, invisibly, and almost entirely within the law.

The Supreme Court has locked the front doors to reform, but the side doors remain open. To see where to start, we need to understand how money actually works inside the system—ranked from least to most consequential.

Here's what surprises everyone: the billions spent on campaign ads during general elections have remarkably little power to change voting behavior.

For decades, political scientists have rigorously studied this question, and the findings are overwhelmingly consistent. General election advertising—whether television or online, positive or negative—barely moves the needle when it comes to persuading voters to switch parties. Think about your own experience. How many attack ads would you need to see before abandoning your party and voting for the other side? Five? Ten? A thousand? If you're like most voters, the question itself sounds absurd.

Most people's political identities aren't built on flimsy preferences; they're powerful and durable. Your party affiliation acts as a social and psychological anchor. For most voters, a 30-second ad is like a paper airplane thrown against a brick wall—like running a commercial during the Super Bowl to convince Eagles fans to start rooting for the Cowboys. Their identity is tied to the team; they are unmovable.

A landmark meta-analysis by Joshua Kalla and David Broockman found that spending on campaign outreach—including Super PAC spending and online advertising—has essentially zero persuasive effect on voter choice in general elections. More recently, a massive 2020 study involving over 60,000 Facebook users found that removing all political ads from their feeds had no measurable impact on candidate favorability or vote choice. My own analysis of 1.2 million precinct-level results confirms this: doubling an opponent's Super PAC spending typically shifts the vote share by just 0.02 percentage points—roughly 75 votes in a typical congressional district.

Political advertising is the wellness vitamin of the campaign world—a pricey remedy backed more by faith than evidence. A vast industry of political consultants profit by convincing candidates they can't win without ever-increasing doses, turning them into endless fundraisers. The other beneficiaries are the media companies generating billions in revenue selling ad space. For candidates and voters, however, the return on investment is vanishingly small. The real influence of money lies elsewhere.

If ads designed to persuade voters are largely ineffective, what about voter mobilization? Here, money does have a more tangible effect. Candidates and parties invest in sophisticated get-out-the-vote operations that demonstrably increase turnout. But the data shows surprisingly modest results for huge expenditures.

Decades of research consistently find that traditional canvassing, phone calls, and mailers typically increase turnout by only one to three percentage points. In a close election, that can be decisive. A two-point bump in a congressional district with 400,000 voters is 8,000 votes—more than enough to swing a tight House race. This is why campaigns pour millions into their ground games; in a battle of inches, every inch matters.

However, these efforts are incredibly expensive and their impact is dwarfed by larger structural forces. The single biggest determinant of turnout isn't a last-minute phone call but the perceived importance of the election itself. Turnout in presidential years always exceeds midterms. Voters in battleground Wisconsin are far more likely to vote than those in safe states where the outcome is foregone.

The most significant barrier to voting has little to do with campaign spending: it's voter registration. Unlike most democracies, the U.S. places the burden of registration on individual citizens. Every time you move, especially across state lines, you must re-register—a process that can be confusing and cumbersome. Policies like automatic voter registration have far greater impact on turnout than any get-out-the-vote campaign ever could.

So if money doesn't persuade voters and only modestly mobilizes them, where does its real power lie?

Before a single vote is cast, candidates must survive what insiders call the "money primary." This invisible, high-stakes contest demonstrates the ability to raise substantial funds. Because of partisan sorting and gerrymandering, the winner of the general election in most districts is a foregone conclusion. This makes the primary election the place where money truly matters, and as former White House Chief of Staff Rahm Emanuel famously put it, that contest is about "money, money, money."

Candidates without early financial backing from wealthy networks struggle to hire staff, gain media attention, and establish credibility. Many promising candidates drop out due to lack of funds before voters ever get a chance to evaluate them.

This financial gauntlet fundamentally skews who can realistically compete for office, resulting in a political class that looks nothing like America.

The median net worth of a member of Congress exceeds $1 million—roughly 12 times the median American household. While blue-collar and service-industry Americans comprise the majority of the workforce, they hold fewer than 3 percent of congressional seats.

There is a reason for that and it's not because voters prefer wealthy candidates. Running for office means months of unpaid campaigning, a luxury mostly only the financially secure can afford.

But having personal wealth isn't enough; what matters more is access to other people's wealth. This explains the dominance of the legal profession. While lawyers make up less than half of a percent of the American workforce, they hold nearly half of all congressional seats.

The scale of this imbalance is hard to overstate: relative to the average citizen, a millionaire is 10 times more likely to serve in Congress. Lawyers, by comparison, are nearly 100 times more likely. This is largely because of the money primary. My research finds that lawyers running for the House raise twice as much money in the critical first 90 days of a campaign as candidates from other backgrounds. This cash doesn't come from the public at large—about half comes directly from other lawyers. It is a closed loop of professional influence that filters out those who can't tap into a similar network.

Our elections operate less as a meritocracy producing the best leaders and more as a filter isolating the most financially connected ones. The result is a Congress where the daily economic grind of most Americans is understood only in the abstract by the people writing the laws.

The same filter that screens out working-class Americans also screens out younger ones—and for related reasons. My recent research with Jake Grumbach reveals how the campaign finance system acts as a pillar of American gerontocracy. The average political dollar now comes from a 67-year-old donor—up from 61 just eight years ago. Meanwhile, the median American is 38. Our democracy speaks with a voice nearly three decades older than its people, and that gap is widening. This creates a massive structural disadvantage for younger candidates: a 65-year-old challenger raises, on average, $207 more per early donor than a 35-year-old running in the same district. When political money talks with a 67-year-old voice, it's no wonder our policies so often look backward rather than forward. In his other research, Grumbach has shown that these fundraising pressures act similarly with respect to race as they do age.

Even for those who make it through the filter, the pressure only intensifies. Many members of Congress spend hours most day in call rooms, dialing for dollars for their next campaign. Imagine landing your dream job, only to discover that half your workday will be spent not on the work itself but on cold-calling strangers to beg for money.

This constant fundraising diverts enormous time and energy away from the actual work of governing. But the damage is deeper. It filters for a specific personality type: not necessarily the most thoughtful public servant but the one most comfortable with relentless solicitation. And it poisons the relationship between parties and their own supporters.

This desperation has spawned what I've called the fundraising-industrial complex. In 2024, campaigns burned through $3 billion just asking for more money, nearly as much as they spent on advertising. The result is increasingly manipulative appeals—subject lines screaming "BETRAYAL" or "Last Chance"—that treat supporters like ATMs rather than allies and erode trust in parties and the political process.

While the public fixates on corporate campaign donations, this is often misdirection. The real action happens after the election is over, and its primary vehicle is lobbying.

Corporations and their trade groups have spent over $30 billion on federal lobbying since 2015. Sophisticated companies deploy a coordinated assault to shape policy. They use lobbying expenditures to influence the specific language of legislation; they exploit the "revolving door" to hire former government officials with insider knowledge and access; and they use strategic campaign donations not to buy votes but to buy goodwill, ensuring their lobbyists get a meeting when key decisions are being made.

Consider the pharmaceutical industry. During the 2022 election cycle, while public attention focused on PAC contributions totaling around $14 million, the industry spent $776 million on lobbying. This army of lobbyists, many of them former congressional staffers, didn't just oppose drug-pricing reform; they rewrote it from the inside, ensuring that even reform legislation preserved their profit margins.

The pattern repeats across industries. During the Dodd-Frank financial reform debates, Wall Street firms spent millions on campaign contributions but poured hundreds of millions into lobbying—and into hiring former regulators and congressional staffers who knew exactly which provisions to target. The result was a law riddled with carve-outs and loopholes, its rulemaking process stretched over years as lobbyists fought line-by-line battles over implementation. By the time the regulations took effect, they had been hollowed out in ways the public never saw.

The real corporate money isn't spent trying to sway your vote; it's spent in the halls of Congress, ensuring that by the time a bill comes up for a public vote, it has already been molded to serve their interests.

Here we arrive at money's most dangerous influence, where the political system becomes fundamentally detached from the will of the majority and tethered to the preferences of a tiny, wealthy elite.

When the policy preferences of wealthy Americans conflict with those of everyone else, the wealthy always win. Not sometimes. Not on certain issues. Exposed to the same debates, offered the same choices, average and low-income citizens simply do not see their preferences reflected in policy outcomes at anywhere near the same rate.

This isn't a partisan story—my analysis of the Forbes 400 richest Americans shows their wealth tends to grow faster under Democratic administrations than under Republican ones. The real goal of mega-donor influence isn't to secure a specific party’s victory but to ensure that the political system, regardless of who is in charge, remains friendly to the interests of extreme wealth. It's about creating a "heads I get a subsidy, tails I get a tax loophole" policy environment.

This goes beyond lobbying; it's about the direct, personal power of mega-donors to shape government itself. After spending over $250 million to help elect Donald Trump in 2024, Elon Musk was rewarded with something unprecedented: a seat at the table of federal power. Through the Department of Government Efficiency, the world's richest man was granted extraordinary access to reshape the federal bureaucracy—inserting himself into decisions about which agencies to cut, which contracts to cancel, and which regulations to eliminate. Many of those decisions directly affected his own companies. That the relationship later soured doesn't diminish the point: a quarter-billion dollars purchased not just access, not just influence, but a quasi-governmental role that no voter elected him to fill.

Consider another example: When Vice President Kamala Harris's campaign endorsed a budget proposal including a 25 percent minimum tax on unrealized gains over $100 million—a policy affecting perhaps 10,000 of the wealthiest Americans—billionaire Mark Cuban publicly threatened to oppose her. The campaign, which had officially endorsed the policy, suddenly went silent and refused to comment when pressed by reporters. For context, 10,000 people is roughly the number of Americans who own pet tigers. A presidential campaign would not immediately backtrack if Joe Exotic claimed the country would never financially recover from a tax on tiger breeding. But when Mark Cuban made essentially the same self-interested argument, it carried real political weight.

Or consider the 2017 Republican tax bill—the signature legislative achievement of unified GOP government. The bill delivered a massive corporate rate cut and passed-through business deductions that overwhelmingly benefited the wealthy, while providing modest, temporary relief to middle-class families. Republican donors were explicit about the stakes. As Representative Chris Collins admitted at the time: "My donors are basically saying, 'Get it done or don't ever call me again.'" Senator Lindsey Graham warned that failure to pass the bill would mark the end of the GOP as a party. The legislative priority wasn't shaped by public demand—polls showed the bill was deeply unpopular—but by the financial threat from mega-donors who expected a return on their investment.

This dynamic is warping our political parties. In the 2024 election cycle, an astonishing 56 percent of all contributions to Republican federal campaign committees came from mega-donors giving over $1 million each. When a major party becomes so dependent on such a tiny sliver of the population, it inevitably drifts from "one person, one vote" toward "one dollar, one vote."

Here lies the ultimate irony, the thread that connects the surprising ineffectiveness of campaign advertising to the alarming power of oligarchs: mega-donors' influence doesn't primarily come from their ability to sway voters. As we've seen, advertising has remarkably limited persuasive effect. Instead, their leverage comes from convincing politicians that they need mega-donor money to win. Politicians become dependent on the wealthy not because the money actually delivers votes, but because they believe it does. This belief becomes a self-fulfilling prophecy, creating a vicious cycle where the perceived need for big money gives billionaires outsized influence over the entire system, even when their campaign contributions don't meaningfully affect electoral outcomes. The oligarchs' real power isn't buying elections; it's buying the faith of the political class.

Overturning Citizens United has become a rallying cry for reformers, and it's a worthy goal—corporations shouldn't be able to spend unlimited sums on elections. But the honest truth is that Citizens United is not the root of the problem, and simply overturning it would be far from sufficient.

The foundational damage was done in 1976, when Buckley v. Valeo established that spending money is constitutionally protected speech. That's the decision that put campaign finance reform in a legal straitjacket. And here's what most people miss: corporations were already content to spend most of their political money on lobbying before Citizens United, and they largely still are. With a few notable exceptions like the cryptocurrency industry's recent electoral spending spree, corporate America has not rushed to dominate elections directly. The explosion of super PAC money comes overwhelmingly from ultra-wealthy individuals, not corporations. Even if the Court reversed Citizens United tomorrow, the oligarchs would remain.

The front doors to reform are locked. But that doesn't mean nothing can be done.

First, there's growing evidence that public financing works. Seattle's democracy voucher program gives every resident $100 in vouchers to donate to local candidates, fundamentally changing who can afford to run. New York City's matching funds program amplifies small donations, reducing candidates' dependence on wealthy donors. The results are visible in this year's mayoral races in both cities, which feature more diverse candidates from more varied economic backgrounds than the traditional money primary would ever allow. These programs don't require the Supreme Court's permission. They can be enacted by states and cities right now.

Unlike Republicans, who would face financial collapse without their billionaire backers, Democrats would not. With only 18 percent of their funds coming from mega-donors, Democrats claim a sizable fundraising advantage among grassroots supporters that enabled them to comfortably outraise Republicans in 2024. Yet the party continues to court billionaires while campaigning against oligarchy, a tension that undermines their credibility.

Democrats should act now to leverage this strength. They should voluntarily limit contributions from wealthy individuals and reject corporate PAC money entirely. In a previous analysis, I showed they could do this while still out fundraising Republicans. They can afford to walk away. And doing so would give them something money can't buy: the credibility to make corruption the central issue of the next election.

The benefits would be immense: the moral authority to attack Republican corruption without the crippling retort of "both sides do it," and the freedom to pursue policies that benefit working Americans without donor interference.

The choice isn't between winning with big money or losing without it. It's between perpetuating a broken system that only serves to hold them back and becoming the party they claim to be. Democrats have the fundraising strength to choose the higher ground. They should take it.

For the 4 decades that I’ve been a cardiologist, we’ve been obsessed with obstructive, blood flow-limiting narrowings and blockages in the coronary arteries, and using procedures like stenting and bypass surgery to fix them. This year we’ve gotten signals that a major shift is ongoing, from fixation on obstructive coronary artery disease (simply put “blockages”) to the focus on non-obstructive arterial disease (simply put “atheroma”), as visualized non-invasively to be high-risk, so-called vulnerable atherosclerotic plaque, and/or exhibiting inflammation (Figure below). This Ground Truths edition will take you through the evolution of the thinking and capabilities, with new non-invasive A.I. imaging, and new drugs, that may ultimately lead to a major reduction in heart attacks.

The dream of eradicating heart attacks was articulated in 1996 in a Science editorial entitled: ”Heart Attacks: Gone with the Century?” It was written by Michael Brown and Joseph Goldstein, awarded the Nobel Prize in 1985 for their groundbreaking cholesterol metabolism work that led to statins. Although statins have helped reduce the risk of heart attack, we still have over 800,000 each year in the United States, which is similar to the data spanning 2012 to 2022, and heart disease remains the number 1 killer despite a marked reduction in death rates over the past 2 decades. Even with 1 in 4 Americans taking statins now, it’s clear we’re far away from their disappearance. One prescient note in the Science editorial was “The challenge is to develop noninvasive screening methods to detect coronary atherosclerosis in its earliest stages.”

We’ve long known that it takes decades for atherosclerotic plaque to develop, as visualized to be prevalent (albeit not obstructive, i.e severe narrowing, blood flow-liming) at significant frequency in teenagers and young adults (Figure). Yes, it’s an age-related disease, but it typically starts very young.

The pathology studies from post-mortem studies have provided clearcut features of arteries in heart attack victims. Chief among them is the thin fibrous cap of the atheroma (TCFA) plaque (Figure) which leaves it prone to erosion, cracking or rupture, the immediate event (usually accompanied by a blood clot) that precedes a heart attack. A lipid-rich necrotic plaque (dead cells, cellular debris, cholesterol and other lipids) is typically underneath the thin cap, and inside the plaque there is inflammation with accumulation of macrophages and T cells. Unlike stable plaque, the vulnerable plaque does not contain dense calcification. (This one of the reasons I have never ordered a CT calcium score for any patient since they are often highly misleading). The minimal lumen area (MLA, channel for blood) is reduced. The artery can enlarge outwardly, known as positive remodeling, to compensate for accumulation of plaque.

But until there were ways to image inside the coronary artery, we relied on angiograms, a 2-dimensional silhouette of the lumen—the channel through which the blood flows. The 1995 paper I co-authored entitled “Our Preoccupation With Coronary Luminology” reviewed the serious problems and limitations of relying on angiograms. That was near the time when intracoronary imaging was receiving increasing attention for illuminating what was going on inside the artery wall, not just in the lumen. Both intravascular ultrasound (IVUS, middle images below) and optical coherence tomography (OCT) (left images below) provide exquisite images from within the artery, that is they require a catheter to be inserted into the artery being assessed, thus considered a form of invasive imaging.

From intracoronary imaging we learned the natural history of atheroma progression. As seen below from a prospective study of nearly 700 patients, subsequent major cardiovascular events during 3.4 years of follow-up were mostly in atheroma that were mild by angiogram (non-obstructive) but by IVUS had thin-cap fibroatheroma (TCFA), high plaque burden (PB) or small luminal area (MLA). Features that would not be picked up by an angiogram.

So now that we could identify these high-risk atheroma—vulnerable plaques—there was thought they might be stabilized or “sealed” with ballon angioplasty. Bernhard Meier advanced this idea, as did an insightful perspective by Kern and Meier.

That concept hung is suspension, unproven, for a number of years until a recent randomized trial was conducted in South Korea, Japan, Taiwan and New Zealand of plaque sealing known as PREVENT, demonstrating for the first time that intervention of vulnerable plaque (determined by IVUS) with optimal medical therapy led to reduced major events compared with optimal medical therapy alone (Figure). The study concluded “These findings support an expansion of the indications for percutaneous coronary intervention to include non-flow-limiting, high-risk, vulnerable plaques.”

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In June 2024, here at Ground Truths, I wrote about the Big Miss: Inflammation and Cardiovascular Disease emphasizing the need to detect arterial inflammation and acknowledge the importance, redirecting our attention to non-obstructive coronary disease. In April 2025, The Lancet Commission, Rethinking Coronary Artery Disease: moving from ischemia to atheroma” highlighted the opportunity to save 8.7 million lives per year globally by focusing on early detection of atheroma (Cover of that issue below).

More recently, in September 2025, the American College of Cardiology published a scientific statement on inflammation and cardiovascular disease. A key conclusion:

“The time is also ripe for the development of strategies to promote increased physician awareness of the crucial role of inflammation in CVD and accelerate the adoption of evidence-based, guideline-directed anti-inflammatory therapy through dissemination and implementation research.”

Taken together, these recent papers are indicative of the shift of thinking and embracement of the need to detect vulnerable, inflamed, high-risk plaque if we are going to make further progress for avoiding heart attacks and cardiovascular deaths.

Detection of the high-risk atheroma has been made possible without a catheter placed into the artery using CT imaging with an injection of contrast dye (angiography), known as CCTA (for coronary computed tomography angiography) There are 4 companies that have used A.I. of the images obtained to identify high-risk, non-obstructive plaque. I’ve made this Table below to summarize what each company does, since they are quite different. CLEERLY, which as a tag line on its website “Creating A World Without Heart Attacks,” detects plaque features with the ground truths (reference markers) shown below, and has a clinical validation study to link their detection to events. ELUCID focuses on plaque composition, using histology as the reference marker, but has no clinical event validation. HEARTFLOW uses fluid dynamics and 3D plaque reconstruction and has published a paper for clinical event validation. CARISTO, which is pending but not yet FDA-cleared (the other 3 are), uses the fat attenuation index (FAI), the peri-vascular fat tissue when by histologic study to be rich indicative of inflammation and rich in T cells (see also Top Figure of this post). This is the only technology that has thus far been linked to cardiac mortality.

Below are data from 40,000 consecutive patients with CCTA in 8 centers in the UK with up to 10 year follow-up using the CARISTO FAI. Even 1 inflamed artery raised the risk of death 13-fold compared with no inflamed arteries! Take a look a the paper for data partitioning obstructive and non-obstructive lesions, inflamed or non-inflamed.

Last week it was announced that Medicare will reimburse for the FDA-cleared non-invasive coronary imaging A.I. companies more than $1,000 per scan. Another sign of a big shift.

Besides the new non-invasive image algorithms, last week’s American Heart Association presentations were noteworthy for many new drugs emerging for treating abnormal lipids and preventing progression of atherosclerosis. This Wall Street Journal article below provided a useful summary. The toolkit is rapidly expanding with the anticipated introduction of potent oral PCSK9 blockers, Lp(a) inhibitors, more ANGPTL3 blockers, along with anti-inflammatory drugs such as different interleukin blockers and the possibility of using GLP-1 drugs for this purpose. GLP-1 drugs have already been shown to reduce heart attacks in people with obesity and we recently learned that only about a third of the benefit was weight-loss dependent.

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We’ve gone from the miscue of statins ending heart attacks to now A.I. purportedly “creating a world without heart attacks.” The problem, once again (besides exuberance), is that there is far too much fixation on just the atheroma, the vulnerable plaque, instead of on the high-risk patient. We have far better ways to identify vulnerable patients and we’re not doing it. I wrote extensively in SUPER AGERS about the many missed opportunities to do this, such as polygenic risk scores (PRS) for coronary artery disease. They are the most extensively validated of all PRS common diseases, available from more than 10 companies, getting initial uptake in some health systems, but have not reached general use. The value of PRS for assessing risk is independent of family history or risk factors of diabetes, smoking, hypertension, high cholesterol, sedentary behavior, or obesity. We don’t generally measure blood inflammation markers such as high-sensitivity C-reactive protein, and have no assay for clonal hematopoiesis of indeterminate potential (CHIP) even though they CHIP is clearly linked with risk of cardiovascular disease. The protein organ clocks that quantify the pace of aging a person’s arteries and heart are prime candidates to add to the way of finding high-risk individuals. A retina photo or OCT, easy and inexpensive to obtain during an eye exam, can be used with A.I. interpretation to detect subclinical coronary artery atherosclerosis (figure below), or predict heart attacks. The latter report concluded: “Our results indicate that one could identify patients at high risk of future myocardial infarction from retinal imaging available in every optician and eye clinic.” Importantly, each layer of data about heart risk can be corroborated and integrated with the other layers.

In a recent Ground Truths I reviewed the Delphi2m large health model which predicted over 1,200 diseases and health events at the individual level for the next 20 years, not just what events but when. That was just from the electronic health record without the other layers of data I allude to here, and with a GPT-2 model with very low parameters compared to current models.

The accurate and comprehensive identification of high-risk individuals needs to be inexpensive, so it can be applied globally. The cost of obtaining and interpreting a person’s data for their genomics, proteins, biomarkers and eye grounds could be extremely low.

I do think there is a highly promising way forward to markedly reduce heart attacks. Even with new reimbursement, we cannot do CCTA and A.I. in most people, no less on a serial basis. But by accurately determining who are the individuals at high-risk—with multiple layers of data— genes, proteins, inflammation markers, imaging—the way to get ahead of their progression of atherosclerotic disease has never been more impressive. And an expansive array of drugs adds to the mix. Medications not just to address high LDL cholesterol but also Lp(a), for which we’ve never had a drug, and ways to suppress arterial inflammation that is not just mediated by abnormal lipids. While we’ve recently seen a big shift in thinking, we have no indication of any shift in action. That’s highly warranted. That’s what we need.

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