Conceptual Framework for Addressing Residual Atherosclerotic Cardiovascular Disease Risk in the Era of Precision Medicine
This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
Until recently, therapies to mitigate atherosclerotic cardiovascular disease (ASCVD) risk have been limited to lifestyle interventions, blood pressure-lowering medications, high-intensity statin therapy, antiplatelet agents, and, in select patients, coronary artery revascularization. Despite administration of these evidence-based therapies, substantial residual risk for cardiovascular events persists, particularly among individuals with known ASCVD. Moreover, the current guideline-based approach does not adequately account for patient-specific, causal pathways that lead to ASCVD progression and complications. In the past few years, multiple new pharmacological agents, targeting conceptually distinct pathophysiological targets, have been shown in large and well-conducted clinical trials to lower cardiovascular risk among patients with established ASCVD receiving guideline-directed medical care. These evidenced-based therapies reduce event rates and, in some cases, all-cause and cardiovascular mortality; these benefits confirm important new disease targets and challenge the adequacy of the current standard of care for secondary prevention.
After years of treating our patients after an acute coronary syndrome event with the same core group of medications that have been proven to be safe, beneficial, and cost-effective, a diverse array of potentially beneficial options to address residual risk is now available. The near simultaneous development of these new approaches to secondary prevention disrupts existing paradigms regarding assessment and treatment of residual risk. For example, consider a hypothetical patient with obesity, hypertension, type 2 diabetes mellitus, and hyperlipidemia who had a non-ST elevation myocardial infarction and received an intracoronary drug-eluting stent. This patient would likely be …