Personalizing Treatment: Between Primary and Secondary Prevention

Current American College of Cardiology/American Heart Association guidelines for the management of patients with elevated blood cholesterol increasingly emphasize assessment of atherosclerotic cardiovascular disease (ASCVD) risk in deciding when to initiate pharmacotherapy. The decision to treat is based primarily on mathematical integration of traditional risk factors, including age, sex, race, lipid values, systolic blood pressure, hypertension therapy, diabetes mellitus, and smoking. Advanced risk testing is selectively endorsed for patients when the decision to treat is otherwise uncertain, or more broadly interpreted as those patients who are at so-called "intermediate risk" of ASCVD events using traditional risk factors alone. These new guidelines also place new emphasis on a clinician-patient risk discussion, a process of shared decision making in which patient and physician consider the potential benefits of treatment, risk of adverse events, and patient preferences before making a final decision to initiate treatment. Advanced risk testing is likely to play an increasingly important role in this process as weaknesses in exclusive reliance on traditional risk factors are recognized, new non-statin therapies become available, and guidelines are iteratively updated. Comparative efficacy studies of the various advanced risk testing options suggest that coronary artery calcium scoring is most strongly predictive of ASCVD events. Most importantly, coronary artery calcium scoring appears to identify an important subgroup of patients with advanced subclinical atherosclerosis-who are "between" primary and secondary prevention-that might benefit from the most aggressive lipid-lowering pharmacotherapy.