Carotid ultrasonography improves residual risk stratification in guidelines-defined high cardiovascular risk patients
Georgios Georgiopoulos1,2, Georgios Mavraganis1, Dimitrios Delialis1
1Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens Medical School, 80 Vas. Sofias Str, Athens 11528, Greece.
Insights
Carotid atherosclerosis markers like maximal wall thickness improve risk prediction for cardiovascular events in high-risk patients. Specific thresholds can identify those needing further risk reduction or having a very low event probability.
Area of Science:
- Cardiology
- Vascular Medicine
- Medical Imaging
Background:
- Clinical value of carotid atherosclerosis markers for residual risk stratification in high atherosclerotic cardiovascular disease (ASCVD) risk patients is not established.
- Current guidelines-defined risk stratification may not fully identify all patients requiring intensive management.
Purpose of the Study:
- To derive and validate optimal values of carotid subclinical atherosclerosis markers for improving risk stratification in patients at high ASCVD risk.
- To assess the incremental prognostic value of carotid intima-media thickness and plaque characteristics over clinical risk scores.
Main Methods:
- Analysis of high or very high ASCVD risk patients from a CV prevention registry (n=751) and the ARIC study (n=2,897).
- Assessment of intima-media thickness (maxWT, avg.maxWT) and carotid plaque presence.
- Primary endpoint: composite of cardiac death, myocardial infarction, and revascularization.
Main Results:
- Maximal wall thickness (MaxWT) > 2.00 mm and average maximal wall thickness (avg.maxWT) > 1.39 mm significantly improved risk reclassification (P < 0.05).
- MaxWT < 0.9 mm predicted a very low probability of cardiovascular events (NPV = 97% and 92%).
- Findings were confirmed for long-term events and across derivation and validation cohorts.
Conclusions:
- Carotid ultrasonography markers provide incremental prognostic value beyond clinical risk scores.
- Integration of carotid imaging can refine risk stratification, identifying very high-risk patients for intensified management or very low-risk individuals.
- These markers aid in optimizing residual cardiovascular risk reduction strategies.
Aims:
The clinical value of carotid atherosclerosis markers for residual risk stratification in high atherosclerotic cardiovascular disease (ASCVD) risk patients is not established. We aimed to derive and validate optimal values of markers of carotid subclinical atherosclerosis improving risk stratification in guidelines-defined high ASCVD risk patients.
Methods And Results:
We consecutively analysed high or very high ASCVD risk patients from a cardiovascular (CV) prevention registry (n = 751, derivation cohort) and from the Atherosclerosis Risk in Communities (ARIC) study (n = 2,897, validation cohort). Baseline ASCVD risk was defined using the 2021 European Society of Cardiology guidelines (clinical ESCrisk). Intima-media thickness excluding plaque, average maximal (avg.maxWT), maximal wall thickness (maxWT) and number of sites with carotid plaque were assessed. As primary endpoint of the study was defined the composite of cardiac death, acute myocardial infarction and revascularization after a median of 3.4 years in both cohorts and additionally for 16.7 years in the ARIC cohort.
Results:
MaxWT > 2.00 mm and avg.maxWT > 1.39 mm provided incremental prognostic value, improved discrimination and correctly reclassified risk over the clinical ESCrisk both in the derivation and the validation cohort (P < 0.05 for net reclassification index, integrated discrimination index and Delta Harrell's C index). MaxWT < 0.9 mm predicted very low probability of CV events (negative predictive value = 97% and 92% in the derivation and validation cohort, respectively). These findings were additionally confirmed for very long-term events in the validation cohort.
Conclusion:
Integration of carotid ultrasonography in guidelines-defined risk stratification may identify patients at very high-risk in need for further residual risk reduction or at very low probability for events.
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