Risk prediction and prevention in patients with advanced subclinical atherosclerosis

BACKGROUND: Cardiovascular diseases (CVD) continue to be the leading cause of global mortality. Despite the alarming statistics, effective prevention of CVD remains a significant challenge in practice. The available risk stratification tools have critical limitations in the early detection of CVD. To address these gaps, it is crucial to integrate additional risk detection methods for more accurate identification of at-risk patients. OBJECTIVES: This article addresses the limitations of conventional CVD risk factors and emphasizes the need for individualized risk evaluation. Additionally, it evaluates the role of imaging techniques in the early detection of CVD and the personalized use of aspirin therapy when subclinical atherosclerosis becomes advanced. METHODS: This article is based on an expert literature review and reflects the outcomes of a medical advisory board meeting that was held in the Middle East (ME) region. A multidisciplinary group of experts discussed the "cardiac risk continuum" concept and the importance of advanced subclinical atherosclerosis detection beyond traditional binary CVD classification. Experts evaluated the clinical feasibility of utilizing carotid ultrasound and coronary artery calcium (CAC) scoring, and assessed the role of aspirin in primary prevention for at-risk patients. RESULTS: The need for tailored risk assessment strategies and individualized preventive measures was highlighted. The experts agreed on the practical use of CAC scoring and/or carotid ultrasound to identify at-risk patients and quantify subclinical atherosclerosis. Data suggest that aspirin estimated benefit increases proportionally with atherosclerosis burden and becomes a net-positive at CAC > 100 or carotid plaque score above 2. CONCLUSIONS: The experts emphasized the importance of individualized screening strategies tailored to the Middle Eastern population, considering the challenges and resource limitations in the region. They recommended selective use of CAC and carotid ultrasound to improve risk stratification and to guide a more personalized approach to managing CVD. The experts stressed the need for standardized protocols, healthcare providers' education, and infrastructure development to ensure the effective implementation of these approaches.