High residual cardiovascular risk after lipid-lowering: prime time for Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive medicine

Abstract

As time has come to translate trial results into individualized medical diagnosis and therapy, we analyzed how to minimize residual risk of cardiovascular disease (CVD) by reviewing papers on "residual cardiovascular disease risk". During this review process we found 989 papers that started off with residual CVD risk after initiating statin therapy, continued with papers on residual CVD risk after initiating therapy to increase high-density lipoprotein-cholesterol (HDL-C), followed by papers on residual CVD risk after initiating therapy to decrease triglyceride (TG) levels. Later on, papers dealing with elevated levels of lipoprotein remnants and lipoprotein(a) [Lp(a)] reported new risk factors of residual CVD risk. And as new risk factors are being discovered and new therapies are being tested, residual CVD risk will be reduced further. As we move from CVD risk reduction to improvement of patient management, a paradigm shift from a reductionistic approach towards a holistic approach is required. To that purpose, a personalized treatment dependent on the individual's CVD risk factors including lipid profile abnormalities should be configured, along the line of P5 medicine for each individual patient, i.e., with Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive approaches.

Keywords: p5 medicine; personalized medicine; precision medicine; residual cardiovascular risk; residual inflammatory risk; residual thrombotic risk.

Figure 1

Future clinical practice with the patient centralized and an integral approach between healthcare professionals. CKD, chronic kidney disease; FH, familial hypercholesterolemia.

Figure 2

Risk factors contributing to CV risk. Risk factors highlighted in pink were discussed in this review, the ones not discussed in the review but identified through literature search are shown in soft orange. The risk factors considered in clinical risk assessment based on SCORE are depicted with red borders. (219) Apo, apolipoprotein; ADP, adenosine diphosphate; CKD, chronic kidney disease; HDL, high-density lipoprotein; hsCRP, high sensitivity c-reactive protein; ICAM, intercellular adhesion molecules; IL, interleukin; LDL, low-density lipoprotein; MetS, metabolic syndrome; MMP-12, metalloproteinase-12; NLRP3, nucleotide-binding leucine-rich repeat receptor family pyrin domain containing 3; OxPL, oxidized phospholipids; PLA2, phospholipase A2; sdLDL, small dense LDL; TG, triglycerides; TGRL, triglyceride-rich lipoprotein; VCAM-1, vascular cell adhesion protein 1.