At heart of the matter, preventive care needs much more emphasis.

I differ with those who say nothing could have been done earlier to diagnose and reverse the plaque formation leading to former President Bill Clinton's bypass surgery (and before him. Vice President Dick Cheney's multiple heart attacks and bypass surgery).

Sophisticated techniques to diagnose and treat atherosclerosis are widely available, but they are not widely used because so few cardiologists understand them. Preventive treatment is not the locus of invasive cardiologists, who make their living putting in stents, or of cardiovascular surgeons, who do bypasses.

This is not to say that these specialists purposely avoid practicing prevention; only that there are only so many hours in the day. An invasive cardiologist or surgeon is called upon when the problem has advanced to crisis intervention. Their educational focus is on techniques, devices and pharmacology aimed at acute care, not prevention.

Many general practitioners, family practice doctors and even internists assume that they understand this area, and simply prescribe statins like Zocor or Lipitor when a patient's cholesterol is over 200. Although this is a start, it is often only the tip of the iceberg, which is why there are so ninny young and middle-aged patients whose first symptom is a fatal heart attack.

The medical insurance industry is also shortsighted. It pays well for invasive procedures, fancy devices and surgery, and pays little for office visits to prevent those procedures and keep patients well.

Although it is in the financial interest of HMOs to prevent heart disease, they appear unwilling to make the investment because so few patients stay in any one health plan long enough for prevention to "pay off" in terms of staving off bypasses and stents.

Over the past two decades, medical schools have reduced or eliminated programs to train cardiologists because of a perceived oversupply. At the same time, the specialty of lipidology has been growing, resulting in breakthroughs and refinements in our understanding of genetic and other factors of heart disease--America's largest killer by a huge margin.

Therein lies the paradox: As the economics of medicine converged to eliminate the focus of preventive cardiology, the science enhanced our understanding of what we can do to reverse heart disease. Clinton and Cheney presumably have the apparatus of government to give them the best that medicine has to offer. Why is it that they have both reached the point of acute care without an early diagnosis and treatment of their conditions?

Now there is a shortage of cardiologists available to treat acute cardiac problems, and even fewer available to treat the current epidemic of obesity, diabetes and the metabolic syndrome. The expertise exists to diagnose and reverse these deadly illnesses; we need a national refocusing of priorities to make it happen.

Dr. Michael J. Wong is past president of the greater Los Angeles affiliate of the American Heart Association.