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Swiss Cheese Model: A Cardiologist’s perspective.

Posted on Sunday January 28, 2024 in Health Screening

Written by Dr Edward Leatham Consultant Cardiologist

Since my research on ‘coronary thrombosis’ in 1996 and 25 years as an interventional cardiologist, I’ve pondered why heart attacks occur unpredictably across individuals with varying levels of coronary plaque and risk factors. The answer seems to lie in the role of chance in heart disease, akin to accidents that result from a series of underlying causes, not just isolated incidents.

This concept is well illustrated by the Swiss Cheese Model of system accidents. The model describes a stack of spinning disks, each representing a layer of defence with holes. An accident, like a heart attack, occurs when these holes align, allowing hazards to reach victims. In heart disease, the ‘layers’ are biological processes affecting the coronary arteries. A heart attack happens when the ‘holes’ in at least four layers align by chance. Understanding this model helps us realise that heart attack prevention involves more than dealing with just one factor, such as by taking a statin.

Fig 1. Four identifiable ‘risk’ layers contribute to a heart attack in an individual patient, where the risk of a heart attack can be linked to the number and size of the holes in each layer. Whereas the holes in the first layer can change over many years those in the latter layers vary day by day and even hour by hour. The four layers are spinning and the holes in three of the four distinct layers constantly vary in size as they open and shut thus only align infrequently by chance, explaining the random timing of a heart attack as well as why one patient, even left untreated can have their second event decades after their first.

The Story of Cholesterol

High LDL cholesterol is a known risk factor for heart disease. Coronary artery disease (CAD) builds up layer by layer, starting in our 20s with fatty streaks in the arteries. Over years, LDL cholesterol causes an inflammatory response, leading to plaque accumulation and calcification. The first layer in the Swiss cheese model is the development of plaque, which affects future heart attack risk.

The Thin Line between Stability and Disaster

As plaque builds up, the area becomes vulnerable to plaque rupture. Plaque vulnerability can lead to temporary thinning of the fibrous cap, increasing the risk of rupture. High blood pressure can exert shear stress on a weakened fibrous cap, causing it to rupture. This concept helps explain cardiac events linked to sudden physical exertion.

Thrombosis and Platelets: The Silent Guardians

When plaque ruptures, platelets form a plug to seal off the area, protecting against larger thrombotic proteins. However, the effectiveness of this response varies. During periods of high platelet activation, even minor plaque ruptures can trigger a more aggressive platelet response, leading to clot formation. Antiplatelet drugs like aspirin reduce this risk.

Body’s Fibrinolytic Defence: Our Natural Clot Busters

Our arteries have a clot-busting pathway, the fibrinolytic pathway, which is finely balanced to deal with arterial thrombosis. Factors like statin therapy and exercise improve our ability to handle arterial thrombosis, whereas a sedentary lifestyle and diabetes increase the risk.

Cardiac Arrest

Sudden occlusion of a major coronary artery is a common cause of sudden death, with considerable variation in individual response.

Preventive Measures

Understanding heart attacks through the Swiss Cheese Model emphasises the need for a multifaceted approach to prevention. This includes focusing on cholesterol-lowering, inhibiting platelets, encouraging exercise, and considering beta-blockers in high-risk patients.


The Swiss Cheese Model provides insight into how multiple factors, when aligned, can lead to catastrophic events like heart attacks. By identifying and reducing these risks through education, intervention, and awareness, we can work towards preventing such tragedies.


1/ Reason J. Human error: models and management. BMJ. 2000;320:768–70. doi: 10.1136/bmj.320.7237.768. [PubMed]

2/ Subclinical Coronary Atherosclerosis and Risk for Myocardial Infarction in a Danish Cohort

3/ Cardiovascular computed tomography imaging for coronary artery disease risk: plaque, flow and fat: Keith M Channon, David E Newby, Edward D Nicol, John Deanfield

4/ Does Exercise Influence the Susceptibility to Arterial Thrombosis? An Integrative Perspective

5/ The Acute and Chronic Effects of Resistance and Aerobic Exercise in Hemostatic Balance: A Brief Review

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