November 7th, 2012
Risk Prediction and Translation to Clinical Practice
Several Cardiology Fellows who are attending AHA.12 in LA this week are blogging together for CardioExchange. The Fellows include Tariq Ahmad, Reva Balakrishnan, Megan Coylewright, Eiman Jahangir, Amit Shah, and John Ryan (moderator). Read the previous post here. Find the next one here. For related CardioExchange content, go to our AHA 2012 Headquarters page.
The many sessions on epidemiology and prevention that I have attended over the last few days have had a unifying theme — risk prediction of CVD. In fact, my own study looked at risk prediction. Some may even call it the holy grail of cardiology. The discussions have been quite interesting….
Whether via a biomarker, imaging test, or other measure, there are many novel ways to predict risk. As to the current standard, there is something remarkable about traditional risk factors like high blood pressure and dyslipidemia; they have sound biologic mechanisms and are cheap and easy to measure. Also, many, many interventions have been proven to both improve these levels and reduce CVD mortality.
Will another measure ever compare to these? Clearly, coronary calcium has incredible predictive power. Nonetheless, it has the disadvantages of not being directly modifiable, of having some cost not routinely covered by insurance, and of radiation exposure. Biomarkers related to inflammation and oxidation also show promise, as with JUPITER, but showing the preventive value of interventions such as anti-inflammatory and antioxidant drugs has been challenging. The book is still open, however; hopefully, the Cardiovascular Inflammation Reduction Trial (CIRT) will give us some insight.
On another angle, however, we can appreciate the psychological benefit of risk predictors that can reduce risk by motivating behavioral change. Blood pressure is a silent killer and difficult for patients to grasp, but calcium on the heart may sound the alarm! If it can, for example, convince a patient to eat less fast food or drink less soda, then it can in fact be useful to get to the underlying risk of CHF. That to me is powerful.
We clearly have a lot to learn on this front. What are other people’s reactions to all of the risk prediction studies? Are we focusing on it too much? Or not enough?