Risky business: Understanding and managing residual CVD risk

Don’t let residual CVD risk go undetected. Enhance risk screening strategies this Heart Week.

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Despite advancements in managing modifiable risk factors, residual CVD risk persists. Novel biomarkers and risk predictors offer hope for more targeted prevention.

Optimal detection and control of known risk factors is the cornerstone of CVD prevention.¹

In recent decades, the management of modifiable risk factors, such as dyslipidaemia, hypertension and hyperglycaemia has undergone significant advancement.² New and more aggressive pharmacotherapy regimes have driven treatment targets to levels not previously achievable and led to improvements in cardiovascular outcomes.

Yet CVD remains a leading cause of death in Australia.³

Even when guideline-based preventative measures are implemented and target levels for modifiable risk factors are achieved, a significant risk of CVD events persists.

This is known as residual CVD risk.⁴

Several potential factors contribute to residual CVD risk. Beyond traditional risk factors, drivers of residual risk include inflammatory, pro-thrombotic and metabolic pathways, which are frequently undetected and not directly addressed through current management strategies.⁴

A recent meta-analysis involving over 31,000 people taking statins for dyslipidaemia found that residual inflammatory risk is more strongly associated with recurrent cardiovascular events and death than baseline LDL-C.⁵ However, the potential benefits of anti-inflammatory agents on cardiovascular outcomes are still being tested in clinical trials and results so far have been underwhelming. An ongoing challenge is to identify an optimal inflammatory biomarker that accurately reflects the risk and response to treatment.

Routine anticoagulation may have a role in addressing residual thrombotic risk in secondary prevention as an adjunct to aspirin for patients at high risk of a recurrent CVD event.²

Beyond LDL-C, there are other atherogenic lipoproteins that may contribute to residual CVD risk. Lipoprotein(a) levels are not significantly influenced by guideline-based management approaches, such as statin therapy, and are a strong risk factor for cardiovascular events irrespective of LDL cholesterol.⁶

Novel risk prediction strategies, such as polygenic risk scores, also have the potential to improve the accuracy of CVD risk prediction. ⁷ Utilisation of genomic information to anticipate lifelong trajectories of CVD risk may enable more targeted and timely prevention. Polygenic risk scores require further investigation, consensus and harmonisation before they can be widely used in practice.

Better understanding these drivers of residual risk will help target interventions that prevent recurrent CVD events and identify risk in people who are traditionally classified as low risk.

GPs wanting the latest evidence about managing residual CVD risk can register for the Heart Week 2023 clinical webinar. A panel of international and Australian experts will explore novel biomarkers, predictors and treatment for residual risk, supported by a case study to illustrate application in primary care.

During Heart Week (1–7 May), the Heart Foundation are encouraging GPs to prioritise prevention. Every 30 minutes, one Australian loses their life to heart disease. It takes 30 minutes or less to conduct a Heart Health Check.

Nearly 425,000 Heart Health Checks have been conducted as of 31 January 2023, bringing us close to our target of 450,000. These checks are projected to prevent 4,670 heart attacks, strokes or deaths related to cardiovascular disease within the next five years.

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This webinar is accredited by the RACGP for 1 Educational Activity CPD hour (activity no. 461157). Facilitated by Prof Garry Jennings, Chief Medical Advisor, Heart Foundation, the webinar’s expert panel includes:

• Prof Sandosh Padmanabhan, Professor of Cardiovascular Genomics and Therapeutics, University of Glasgow
• Assoc Prof Peter Psaltis, Co-Deputy Director, South Australian Health and Medical Research Institute
• Prof Sophia Zoungas, Head of School of Public Health and Preventive Medicine, Monash University
• Prof Jan Radford, Professor in General Practice and Director of the Launceston Clinical School, University of Tasmania.

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Despite being a critical tool in detecting and preventing heart disease, Heart Health Checks are due to expire on 30 June 2023.

These checks are the only Medicare items dedicated to CVD prevention and the sole health assessment MBS item for Australians aged 50–74, who represent more than half of heart disease hospitalisations each year.

We are urging the Australian government to extend the Heart Health Check Medicare items, ideally to make them permanent. Add your voice to save the Medicare Heart Health Check.

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_References:

1. _{Absolute CVD risk clinical guidelines. Available from: https://www.heartfoundation.org.au/bundles/for-professionals/fp-absolute-cvd-risk-clinical-guidelines [last accessed: April 2023].}
2. _{Prioritizing Health – Residual Cardiovascular Risk: Beyond Traditional Risk Factors, 25 February 2022. Available from: https://www.acc.org/latest-in-cardiology/articles/2022/02/12/01/42/prioritizing-health-residual-cardiovascular-risk-beyond-traditional-risk-factors-acc-2022 [last accessed: April 2023].}
3. _{Heart, stroke and vascular disease: Australian facts, 09 February 2023, Available from: https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/hsvd-facts/contents/all-heart-stroke-and-vascular-disease#deaths [last accessed: April 2023].}
4. _{Dhindsa DS, Sandesara PB, Shapiro MD, Wong ND. The Evolving Understanding and Approach to Residual Cardiovascular Risk Management. Front Cardiovasc Med. 2020 May 13;7:88. doi: 10.3389/fcvm.2020.00088. PMID: 32478100; PMCID: PMC7237700.}
5. _{Ridker PM, Bhatt DL, Pradhan AD, Glynn RJ, MacFadyen JG, Nissen SE; PROMINENT, REDUCE-IT, and STRENGTH Investigators. Inflammation and cholesterol as predictors of cardiovascular events among patients receiving statin therapy: a collaborative analysis of three randomised trials. Lancet. 2023 Mar 3:S0140-6736(23)00215-5. doi: 10.1016/S0140-6736(23)00215-5. Epub ahead of print. PMID: 36893777.}
6. _{O’Donoghue ML, Fazio S, Giugliano RP, Stroes ESG, Kanevsky E, Gouni-Berthold I, Im K, Lira Pineda A, Wasserman SM, ?eška R, Ezhov MV, Jukema JW, Jensen HK, Tokgözo?lu SL, Mach F, Huber K, Sever PS, Keech AC, Pedersen TR, Sabatine MS. Lipoprotein(a), PCSK9 Inhibition, and Cardiovascular Risk. Circulation. 2019 Mar 19;139(12):1483-1492. doi: 10.1161/CIRCULATIONAHA.118.037184. PMID: 30586750.}
7. _{Inouye M, Abraham G, Nelson CP, Wood AM, Sweeting MJ, Dudbridge F, Lai FY, Kaptoge S, Brozynska M, Wang T, Ye S, Webb TR, Rutter MK, Tzoulaki I, Patel RS, Loos RJF, Keavney B, Hemingway H, Thompson J, Watkins H, Deloukas P, Di Angelantonio E, Butterworth AS, Danesh J, Samani NJ; UK Biobank CardioMetabolic Consortium CHD Working Group. Genomic Risk Prediction of Coronary Artery Disease in 480,000 Adults: Implications for Primary Prevention. J Am Coll Cardiol. 2018 Oct 16;72(16):1883-1893. doi: 10.1016/j.jacc.2018.07.079. PMID: 30309464; PMCID: PMC6176870.}