[Biomarkers in primary cardiovascular prevention: rationale, premises, and promises]

Cardiovascular disease remains the leading cause of death worldwide, and this underscores the importance of primary prevention before the occurrence of its clinical manifestations. Actually, there is an important need for new ways to improve upon traditional risk assessment. Efforts to address the problem of better identifying persons at risk of developing a first cardiovascular event have largely focused on the use of new measurements - biomarkers - which could add to traditional risk scores to improve prediction. Hundreds of candidate biomarkers, mostly deriving from measurement of plasma levels of certain substances, have been proposed, and some of them have shown solid statistical associations with the incidence of future events in addition to traditional markers. However, in general they offer only a modest increase in the predictive value of current scores. On the contrary, assessment of subclinical atherosclerosis by multiple means clearly shows a substantial incremental return. Here we critically review the available literature for studies assessing the added value of new biomarkers, especially in multiple combinations, with a particular focus on non-invasive imaging markers of subclinical atherosclerosis, on top of traditional risk algorithms in primary prevention of cardiovascular disease.