A recent Washington Post article called for earlier detection of atherosclerosis and a shift from “ischemia-centric” thinking to an “atheroma-centric” model. That’s progress, but it’s still missing the most important piece: Plaque isn’t the root cause.

For 50 years, we’ve built a trillion-dollar cardiology machine around the cholesterol hypothesis. Statins, PCSK9 inhibitors, ezetimibe, inclisiran, Lp(a) drugs, all circling the same biochemical drain. LDL plays a role, yes. But LDL is the accelerant, not the arsonist.

The spark may be infectious.

This isn’t fringe. It’s been staring at us since the 1990s. Dr. J. Thomas Grayston and Dr. Allan Shor demonstrated Chlamydia pneumoniae inside atheroma using electron microscopy. Multiple labs confirmed it. And just this year, a Japanese pathology study found C. pneumoniae DNA and antigens in 100 percent of examined atheroma specimens. Not 20 percent. Not 50 percent. One hundred percent.

We keep treating cholesterol while ignoring the pathogen sitting in the wall.

If we’re serious about preventing the No. 1 killer of Americans, it’s time to run the trial that should have happened 30 years ago:

• Triple-therapy antibiotics modeled on TB, leprosy, and HIV protocols to hit all stages of C. pneumoniae’s life cycle.
• Target younger cohorts (20-40), where disease incubates silently.
• Use coronary CT angiography as a real-time, affordable, noninvasive outcome.

We don’t need another statin study. We need a TACTIC trial, one that actually targets the underlying infectious driver.

History keeps repeating: peptic ulcers (H. pylori), syphilis, TB, cervical cancer (HPV). Each time, the medical establishment clung to old dogma until someone finally treated the infection.

Why should atherosclerosis be any different?

A challenge to NIH and cardiology leadership

Fund the trial. Prove us wrong or prove us right. But stop pretending the cholesterol hypothesis is enough. The pathogen is sitting there in plain sight. We’re out of excuses.

Larry Kaskel is an internist and “lipidologist in recovery” who has been practicing medicine for more than thirty-five years. He operates a concierge practice in the Chicago area and serves on the teaching faculty at the Northwestern University Feinberg School of Medicine. In addition, he is affiliated with Northwestern Lake Forest Hospital.

Before podcasts entered mainstream culture, Dr. Kaskel hosted Lipid Luminations on ReachMD, where he produced a library of more than four hundred programs featuring leading voices in cardiology, lipidology, and preventive medicine.

He is the author of Dr. Kaskel’s Living in Wellness, Volume One: Let Food Be Thy Medicine, works that combine evidence-based medical practice with accessible strategies for improving healthspan. His current projects focus on reevaluating the cholesterol hypothesis and investigating the infectious origins of atherosclerosis. More information is available at larrykaskel.com.