The evolution and refinement of traditional risk factors for cardiovascular disease

Abstract

Traditional risk factors for cardiovascular disease such as systemic hypertension and hypercholesterolemia, all described more than half a century ago, are relatively few in number. Efforts to expand the epidemiologic canon have met with limited success because of the high hurdle of causality. Fortunately, another solution to current deficiencies in risk assessment-in particular, the underestimation of risk both before and after initiation of pharmacotherapy-may exist. Parallel to the investigation of novel biomarkers, such as high-sensitivity C-reactive protein, ongoing research has yielded improved metrics of known causative conditions. This evolution of traditional risk factors, heralded by measures such as ambulatory blood pressure, central hemodynamics, low density lipoprotein particle concentration, genetic testing, and "vascular age," may better address the detection gap in cardiovascular disease.

Figure 1. Discordance between ambulatory 24-hour blood pressure monitoring and clinic blood pressure assessment

For any given value of office systolic blood pressure, plotted on the horizontal axis, the observed mean daytime systolic blood pressure measured via ambulatory 24-hour monitoring may vary considerably. Data from the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale study.

Figure 2. Discordance between central blood pressure and peripheral blood pressure

For any given value of brachial systolic blood pressure, plotted on the vertical axis, the observed aortic systolic blood pressure may vary considerably. Data from the Anglo-Cardiff Collaborative Trial II.

Figure 3. Discordance between LDL-particle concentration and LDL-cholesterol

For any given value of non-HDL-cholesterol, plotted on the horizontal axis, the observed apolipoprotein B may vary considerably. Data from the National Health and Nutrition Examination Survey.

Figure 4. Association of LDL-particle concentration and LDL-cholesterol and adverse cardiovascular outcomes in the setting of discordance

Among the 1 in 5 patients with discordant LDL-P and LDL-C, LDL-P was strongly associated with outcomes while LDL-C had no relation. Data from the Framingham Offspring