Providing Evidence for Subclinical CVD in Risk Assessment

Abstract

When the MESA (Multi-Ethnic Study of Atherosclerosis) began, the Framingham risk score was the preferred tool for 10-year global coronary heart disease risk assessment; however, the Framingham risk score had limitations including derivation in a homogenous population lacking racial and ethnic diversity and exclusive reliance on traditional risk factors without consideration of most subclinical disease measures. MESA was designed to study the prognostic value of subclinical atherosclerosis and other risk markers in a multiethnic population. In a series of landmark publications, MESA demonstrated that measures of subclinical cardiovascular disease add significant prognostic value to the traditional Framingham risk variables. In head-to-head studies comparing these markers, MESA established that the coronary artery calcium score may be the single best predictor of coronary heart disease risk. Results from MESA have directly influenced recent prevention guidelines including the recommendations on risk assessment and cholesterol-lowering therapy. The MESA study has published its own risk score, which allows for the calculation of 10-year risk of coronary heart disease before and after knowledge of a coronary artery calcium score.

Figure 1

The design of MESA allows the study the associations between risk factors, subclinical disease burden and progression, and clinical events.

Figure 2

Unadjusted Kaplan-Meier cumulative-event curves for coronary events among participants with coronary artery calcium Scores of 0, 1 to 100, 101 to 300, and >300.

Figure 3

Receiver operator characteristic curves showing area under the curve for FRS alone and FRS in addition to novel risk markers.

Figure 4

Relationship between pretest and posttest cardiovascular disease (CVD) risk after the knowledge of the negative result of each risk marker.

Figure 5

Impact of the absence of CAC in reclassifying risk below the threshold for statin consideration suggested by ACC/AHA cholesterol management guidelines, by estimated 10-Year ASCVD risk.

Figure 6

The MESA CHD Risk Score online calculator using two case examples.