The 2006 William Feinberg lecture: shifting the paradigm from stroke to global vascular risk estimation

Abstract

By the year 2010, it is estimated that 18.1 million people worldwide will die annually because of cardiovascular diseases and stroke. "Global vascular risk" more broadly includes the multiple overlapping disease silos of stroke, myocardial infarction, peripheral arterial disease, and vascular death. Estimation of global vascular risk requires consideration of a variety of variables including demographics, environmental behaviors, and risk factors. Data from multiple studies suggest continuous linear relationships between the physiological vascular risk modulators of blood pressure, lipids, and blood glucose rather than treating these conditions as categorical risk factors. Constellations of risk factors may be more relevant than individual categorical components. Exciting work with novel risk factors may also have predictive value in estimates of global vascular risk. Advances in imaging have led to the measurement of subclinical conditions such as carotid intima-media thickness and subclinical brain conditions such as white matter hyperintensities and silent infarcts. These subclinical measurements may be intermediate stages in the transition from asymptomatic to symptomatic vascular events, appear to be associated with the fundamental vascular risk factors, and represent opportunities to more precisely quantitate disease progression. The expansion of studies in molecular epidemiology and detection of genetic markers underlying vascular risks also promises to extend our precision of global vascular risk estimation. Global vascular risk estimation will require quantitative methods that bundle these multi-dimensional data into more precise estimates of future risk. The power of genetic information coupled with data on demographics, risk-inducing behaviors, vascular risk modulators, biomarkers, and measures of subclinical conditions should provide the most realistic approximation of an individual's future global vascular risk. The ultimate public health benefit, however, will depend on not only identification of global vascular risk but also the realization that we can modify this risk and prove the prediction models wrong.

Figure 1

Determinants of global vascular risk.

Figure 2

Primordial, primary, secondary, and tertiary prevention stages for global vascular risk.

Figure 3

Study design of the Northern Manhattan Study.

Figure 4

Relationship between (a) systolic blood pressure (mm Hg) and (b) diastolic blood pressure (mm Hg) and the log-hazard for stroke (solid line), and stroke, myocardial infarction, and vascular death (dotted line) from the Northern Manhattan Study.

Figure 5

Shifting the global vascular risk score through the (a) mass approach and (b) high-risk approach. The histogram depicts the distribution of the global vascular risk score in our NOMAS cohort.