(Circulation. 2000;101:111.)
© 2000 American Heart Association, Inc.
AHA Scientific Statement |
Prevention Conference V
Beyond Secondary Prevention : Identifying the High-Risk Patient for Primary Prevention : Executive Summary
Key Words: AHA Conference Proceedings • prevention • atherosclerosis • coronary disease • lipids • risk factors • tests
Introduction
This conference, "Beyond Secondary Prevention: Identifying the High-Risk Patient for Primary Prevention," which was the fifth in a series of prevention conferences sponsored by the American Heart Association (AHA), was held October 26–28, 1998, in San Francisco, Calif. The need for this conference was precipitated by the remarkable advances in medical therapies for the prevention of coronary heart disease (CHD). The AHA has already set forth guidelines for aggressive medical therapy in patients with established CHD (secondary prevention). The major issue under consideration at this conference was the development of strategies to identify high-risk patients without established CHD who are candidates for aggressive medical therapies for primary prevention. Therefore, a central theme for the conference was the emphasis on establishing a prognosis for high-risk patients without clinical evidence of CHD. Three writing groups were established to report on the following areas: (1) medical office assessment, (2) tests for silent and inducible ischemia, and (3) noninvasive tests of atherosclerotic burden. Each working group reviewed research on existing risk-assessment strategies relevant to the prediction of risk in patients without clinical evidence of CHD.
The key findings of each working group are presented in this Executive Summary of the conference. The full conference report with references is available online at http://circ.ahajournals.org/ in the January 4, 2000, issue of Circulation. The recommended strategies will assist in expanding preventive therapies, including lipid lowering, blood pressure control, smoking cessation, diet, and exercise, to patients at high risk for developing CHD. The following briefly summarizes the major conclusions of the conference.
In the development of the Prevention V report, Writing Group I
outlined a strategy for initial risk assessment of the
asymptomatic patient to obtain an estimate of absolute
risk. On the basis of standard risk factors and related risk
correlates, the concept was set forth that asymptomatic
patients can be placed into 1 of 3 risk categories: low risk,
intermediate risk, and high risk (Table 1
). Low-risk patients can be
encouraged to adhere to healthy life habits. High-risk patients can
directly enter a regimen of aggressive risk reduction through a
combination of nondrug and drug regimens. Patients at intermediate risk
become candidates for further risk stratification through noninvasive
procedures that test for the presence of myocardial ischemia or
coronary atherosclerotic burden. The purpose of the latter
procedures is to assist the physician in better defining absolute risk
of intermediate-risk patients. Although these noninvasive procedures
have traditionally been used for diagnosis of coronary artery
disease for the purpose of invasive intervention, the emphasis of
Prevention Conference V was on their use to predict future major
coronary events (unstable angina and myocardial infarction).
This shift in emphasis from diagnosis to prognosis is illustrated by
differences in terminology between the 2 activities (Table 2).
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Writing Group II examined the potential of techniques for determining subclinical myocardial ischemia for risk prognostication in intermediate-risk patients. A review of the literature indicated that exercise electrocardiography (ECG) has independent predictive power beyond standard risk factors for patients of this type. Other techniques to detect subclinical ischemia may have utility for this purpose in selected patients, although literature related to this issue is sparse.
Writing Group III examined techniques used to estimate atherosclerotic burden for the purpose of risk prognostication. The ankle/brachial blood pressure index (ABI) emerged as a powerful, independent predictor of future coronary events. Several reports further indicate that measures of carotid intimal-medial thickness (IMT) by B-mode sonography provide an independent assessment of coronary risk. Finally, measures of coronary calcium by computerized tomography (CT) show a high correlation with extent of coronary atherosclerosis. Furthermore, preliminary studies suggest that coronary calcium scores provide an independent estimate of future coronary events; however, available studies are insufficient to define the magnitude of independent prediction. Overall, noninvasive procedures for assessing myocardial ischemia and atherosclerotic burden promise to improve the accuracy of risk prognostication for patients found to be at intermediate risk by office-based assessment.
Writing Group I: Medical Office Assessment
Writing Group I examined methods for estimating total
cardiovascular risk in the medical office. The emphasis
of this group was on the known risk factors for CHD. For some patients,
the presence of multiple risk factors is sufficient to confer a
high-risk status, and additional noninvasive testing for
coronary atherosclerotic burden or for subclinical myocardial
ischemia will be unnecessary. In patients found to be at
intermediate risk, however, additional testing may be indicated to
better stratify risk. Techniques for office assessment include history,
physical examination, laboratory testing, and ECG. The focus of the
examination is on detection of risk factors that can either be directly
modified or that will modify the overall intensity of risk-reduction
therapies. Patients should be examined for the presence of risk factors
listed in Table 3. The major causal risk
factors—cigarette smoking, elevated blood pressure, elevated serum
total cholesterol (and low-density lipoprotein [LDL]
cholesterol in particular), low high-density lipoprotein
(HDL) cholesterol, and diabetes—account for 
50% of the
variability in risk in high-risk populations and explain up to 90% of
the excess population risk for CHD. A patient’s age is a powerful
indicator of absolute risk because it reflects the total burden of
coronary atherosclerosis that has accumulated;
the probability of suffering a major coronary event (unstable
angina or myocardial infarction) is highly correlated with total plaque
burden. Conditional risk factors are those that have been correlated
with CHD risk, but their quantitative relation to major
coronary events remains to be defined adequately in large
prospective studies. The predisposing risk factors contribute to the
development of the causal and conditional risk factors. Two of these,
obesity and physical inactivity, have such a strong relationship with
the development of cardiovascular disease (CVD) that
they are designated as major risk factors by the AHA. Abnormalities in
the resting ECG (nonspecific ST-segment changes and left
ventricular hypertrophy) also carry predictive
power and can be called risk factors.
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Categories of Risk
To determine the risk for CHD, the coronary end point must
be specified. The Framingham Heart Study traditionally identifies total
CHD as its end point; this includes stable angina pectoris, major
coronary events (unstable angina and myocardial infarction),
and coronary death. Recently, Framingham investigators have
distinguished between total CHD and hard CHD, the latter consisting of
major coronary events and coronary death. Hard CHD
typically is the primary end point in clinical trials of risk factor
reduction. Risk estimates essentially are of 2 types, absolute risk and
relative risk. Absolute risk is the probability of developing CHD in a
finite period, whereas relative risk is the ratio of absolute risk for
a patient over a standard risk. The latter can be either the average
risk or the low risk associated with an absence of risk factors.
Global Risk Assessment
In the past decade, the concept has evolved that the intensity of
risk factor management should be adjusted by the severity of risk. This
concept has been adopted in the guidelines of the National
Cholesterol Education Program, the joint European
societies, and other organizations. Global risk assessment is the
estimation of absolute risk based on the summation of risks contributed
by each risk factor. Several methods have been used to sum risks.
Writing Group I favored a method recently proposed by Framingham
researchers in which the continuous relationship between risk factor
intensity and coronary risk is used. Framingham scoring uses
only the "standard" risk factors (smoking, blood pressure, serum
cholesterol, HDL cholesterol, blood glucose,
and age). Conditional and predisposing risk factors are not used in the
Framingham risk equation because of lack of evidence of a strong,
independent contribution to CHD risk. The writing group nonetheless
stressed that several of the conditional and predisposing risk factors
undoubtedly contribute to the development of CHD. Thus, the detection
and even therapeutic modification of these risk factors may be
appropriate in some patients.
Short-Term Versus Long-Term Risk
Global assessment for short-term (
10 years) risk is the
foundation of guidelines of the joint European societies. European
recommendations defined a high-risk state as a 10-year absolute risk
for developing CHD of 
20%. This level of risk was identified as one
that justifies management of risk factors in the clinical setting,
particularly for the pharmacological control of elevated blood pressure
and cholesterol. Writing Group I was attracted to the
European concept of applying increased intensity of therapy to a
category of patients at high short-term risk. However, the writing
group was reluctant to embrace the specific European definition of high
risk. This arbitrary definition derives from 3 factors: efficacy,
safety, and cost of therapy. Because efficacy and safety of
pharmacological therapy have improved progressively, the dominant
factor in the definition becomes cost-effectiveness. The writing group
hesitated to adopt a general definition of high risk without the
availability of extensive cost-effectiveness analyses.
Moreover, the writing group also expressed reluctance to allow
short-term risk estimates to drive all treatment decisions. Patients
who have intermediate risk in the short term may still be at high risk
in the long term. To exclude such patients from clinical management of
risk factors may not be prudent. For example, any single risk factor
can produce cumulative damage and thus lead to premature clinical
syndromes if left untreated for many years. Therefore, most members of
the writing group expressed the opinion that every causative risk
factor deserves modification under physician supervision once it has
reached a categorical level (Table 4).
Clinical judgment is required as to whether risk-factor reduction is
best carried out with nondrug or drug therapies.
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Finally, Writing Group I emphasized that risk assessment in the medical office is the backbone of global risk assessment. Even if risk estimates can be improved by noninvasive measures of coronary atherosclerosis, the selection of patients for noninvasive testing should issue from office-based risk assessment. Patients found to be at high risk through office-based assessment need not proceed to noninvasive testing. On the other hand, some asymptomatic patients who appear to be at intermediate risk on the basis of office assessment could be elevated to the high-risk category by the finding of advanced subclinical atherosclerosis or myocardial ischemia.
Writing Group II: Tests for Silent and Inducible Ischemia
Writing Group II addressed the question of whether tests that assess silent ischemia or inducible ischemia add to prognostic information gained from standard risk factors in asymptomatic patients without known coronary disease. The tests reviewed included exercise ECG, exercise and pharmacological (stress) echocardiogram (echo), exercise and pharmacological myocardial perfusion imaging, ambulatory ECG monitoring, and positron emission tomography (PET). These noninvasive tests detect myocardial ischemia associated with obstructive coronary artery disease. Their greatest application to date has been diagnostic, in the evaluation of patients with symptoms of angina or a previous clinical manifestation of CHD. A limitation of all methods used to detect stress (exercise or pharmacologically induced) myocardial ischemia is their dependence on the presence of flow-limiting coronary stenosis. As with all diagnostic studies, their predictive value is dependent on the prevalence of disease in the population tested. Also central to the Writing Group II discussions was the recognition that the majority of future events among patients with CHD are related to severity of obstruction, plaque instability, and total atherosclerotic burden. The group was specifically concerned with delineating the prognostic information available from these tests that could contribute toward identifying patients at higher risk for major CHD-related events.
Exercise ECG Testing
Among asymptomatic individuals, there is evidence that
the development of an ischemic ECG response at low workloads of
exercise testing is associated with a higher incidence of future events
such as angina pectoris, myocardial infarction, and sudden death.
However, the absolute risk of cardiac events in these populations
remains low.
The Multiple Risk Factor Intervention Trial (MRFIT) reported a nearly 4-fold increase in 7-year coronary mortality (7.6 versus 2.0 per 1000 person-years of risk) among middle-aged men with an abnormal exercise ECG versus those with a normal exercise ECG and suggested that the exercise ECG might serve to identify high-risk men who could benefit from risk factor reduction. There is a paucity of similar data regarding the use of the exercise ECG in women and the elderly (age >75 years).
In the Lipid Research Clinics Coronary Primary Prevention
Trial, of 3775 asymptomatic
hypercholesterolemic men, half of whom were taking
cholestyramine and half of whom were taking placebo, there was a 5.7
times greater risk of death due to coronary heart disease in the
placebo group among those with a positive exercise test result (1-mm
ST-segment depression or elevation on exercise testing) than among
those with a negative test result. Overall, during a mean follow-up
period of 7.4 years, there was a 6.7% mortality rate in the group with
a positive test result versus 1.3% in the group with a negative test
result.
The routine use of exercise ECG testing in completely unselected
asymptomatic populations before office screening for risk
cannot be recommended. In asymptomatic men >40 years of
age with 1 risk factor, exercise testing may provide useful
information as a guide to aggressive risk factor intervention or the
need to evaluate further the cause of myocardial ischemia. The
role of exercise testing in women and among the elderly (age >75
years) as a guide to identifying the high-risk patient for primary
prevention requires additional study.
Exercise and Pharmacological Stress Echocardiography
Stress echocardiography (SE) is based on
the premise that myocardial ischemia leads to left
ventricular dyssynergy that can be detected with
2-dimensional echo. Only limited data exist to support the use of SE as
a tool to elevate the intermediate-risk, asymptomatic
patient to a higher risk category. Also, the addition of
echocardiographic imaging to exercise ECG in
intermediate-risk patients increases the cost and complexity of the
examination. On the other hand, SE could be of value in the assessment
of women and elderly patients who fall into the intermediate-risk
category; nevertheless, additional studies are needed to define its
role for elevating such patients to the high-risk category for primary
prevention.
Exercise and Pharmacological Myocardial Perfusion Imaging
Myocardial perfusion imaging has evolved as an important clinical
tool in the evaluation of patients with symptoms suggestive of angina
pectoris or its equivalents. An important question is whether stress
thallium scintigraphy can be a useful addition to exercise
ECG for determining risk for major coronary events in
intermediate-risk asymptomatic patients. Limited data
suggest incremental value for this purpose in some populations. Such
populations might include postmenopausal women and elderly men (age
>75 years), in whom the use of exercise ECG testing is
problematic.
Ambulatory ECG Monitoring
Because of the low sensitivity and specificity of ambulatory
ECG monitoring for the diagnosis of multiple coronary arteries
with >50% occlusion, published recommendations suggest that it is an
inaccurate modality for use as a guide in the selection of patients for
invasive procedures. The guidelines for use of ambulatory ECG generated
by the American College of Cardiology/AHA Task Force
consider that its use for detecting myocardial ischemia in the
asymptomatic individual is a class III indication, ie,
there is general agreement that it is not a useful test in these
circumstances. The value of ambulatory ECG monitoring as a prognostic
indicator of major coronary events in intermediate-risk
patients has not been adequately evaluated. Whether it provides
incremental information over that obtained from a resting ECG is
unknown.
Positron Emission Tomography
The basis for detecting myocardial ischemia by PET is the
detection of flow heterogeneity during maximal
coronary hyperemia, and significant ischemia is
only detectable if coronary stenosis is
hemodynamically significant. Because PET is insensitive
for the detection of <50% coronary stenoses, its
incremental prognostic power over exercise ECG is doubtful. Moreover,
the test is expensive. Therefore, it was not considered to provide
additional quantitative risk prediction over exercise ECG in
middle-aged asymptomatic men in the intermediate-risk
category. Whether it would be more useful than exercise ECG in women or
elderly men (>75 years) remains to be determined. Although significant
issues exist surrounding the cost-effectiveness of PET in the
evaluation of asymptomatic patients at risk for CHD,
preliminary research suggests there may be future applications of this
technique in the detection of coronary
endothelial dysfunction and the noninvasive monitoring
of aggressive medical therapy and risk factor modification.
Conclusions
Data are quite limited regarding the prognostic utility of
noninvasive measures of inducing myocardial ischemia in
apparently asymptomatic people. Very few prognostic studies
have included adequate numbers of asymptomatic people. With
the exception of exercise ECG testing in asymptomatic men
with increased cardiovascular risk profiles, few data
exist to support the use of the noninvasive testing modalities
discussed by Writing Group II to screen asymptomatic
populations for high-risk subclinical CHD. Future research should
investigate the role of these techniques in association with global
risk assessment to further define prognosis, guide intensity of
therapy, and monitor the effectiveness of risk-intervention
strategies.
Summary
The purpose of noninvasive testing for subclinical myocardial
ischemia is to detect patients who have been found to be at
intermediate risk by office-based risk assessment and identify those
who are candidates for more aggressive risk-reduction therapies.
Several studies in middle-aged men in this category have documented
that exercise ECG has independent power for predicting major
coronary events and may be a useful adjunct in identifying
high-risk patients who otherwise would be classified as being at
intermediate risk. On the other hand, exercise ECG has little use in
the routine screening of young adults who as a group are at low risk
for developing CHD in the next decade. Furthermore, its predictive
power in older men (>75 years) and women is uncertain. Ambulatory ECG
apparently is less sensitive than exercise ECG for detecting myocardial
ischemia, and its use for risk adjustment cannot be recommended
at this time. SE appears to add little
prognostic/diagnostic information to exercise ECG in
middle-aged men but may have utility for adjusting risk assessment in
women and older men (>75 years), in whom the predictive power of
exercise ECG is uncertain. The same can be said regarding myocardial
perfusion imaging. PET scanning may detect myocardial ischemia
in the presence of less severe degrees of coronary
atherosclerosis than can be detected by exercise ECG;
however, its lack of availability and high cost seemingly do not
justify PET scanning of intermediate-risk patients whose exercise ECGs
are normal.
Writing Group III: Noninvasive Tests of Atherosclerotic Burden
Writing Group I considered the role of routine office-based measures for assessment of global risk in asymptomatic people. With the physician-directed office risk assessment as a foundation, further risk stratification may be valuable, especially when the risk estimate is neither clearly low risk nor high risk (intermediate risk). For the intermediate-risk patient, additional testing might include one or more noninvasive measures of atherosclerotic burden.
Pathology studies document that the levels of "traditional" risk factors are associated with the extent and severity of atherosclerosis. However, at every level of risk factor exposure, there is substantial variation in the amount of the atherosclerosis. Thus, subclinical disease measurements, representing the end result of risk exposures, may be useful in improving CHD risk prediction.
Noninvasive tests such as carotid artery duplex scanning, electron beam CT (EBCT), ultrasound-based endothelial function studies, ankle/brachial blood pressure ratios, and magnetic resonance imaging (MRI) techniques offer the potential for directly or indirectly measuring and monitoring atherosclerosis in asymptomatic people. High-sensitivity testing for C-reactive protein (hs-CRP) may also represent a measure of atherosclerosis "burden" and may therefore be considered another potential marker of atherosclerotic disease risk.
Ankle/Brachial Blood Pressure Index
The ABI is a simple diagnostic test for
lower-extremity peripheral arterial disease
(PAD). Among well-trained operators, test-retest reliability is
excellent, and the validity of the test for 50% stenosis in
leg arteries is high (sensitivity 90% and specificity 98%).
In population studies, people with a low ABI have been found to have a considerably higher prevalence of CVD (defined as history of myocardial infarction, coronary artery bypass graft, stroke, or stroke surgery or other measures of clinical CVD, such as angina or congestive heart failure) than those individuals with a normal ABI. These data confirm that atherosclerosis is a diffuse (ie, systemic) disease and that an abnormal ABI test (ie, low ratio) will often be indicative of significant atherosclerosis in other vascular beds. At least 3 studies have reported an increased combined incidence of CVD morbidity and CVD mortality in persons with PAD detected by ABI.
Conclusions
The ABI is a simple, inexpensive, noninvasive measure of PAD. Many
asymptomatic people 50 years of age will have abnormal
ABI values. Follow-up studies have shown that an abnormal ABI provides
incremental coronary and all-CVD risk-assessment information
over and above that provided by traditional risk factors. The writing
group concluded that the ABI might be a useful addition to the
assessment of CHD risk in selected populations, especially in people
aged 50 years and older or those who appear to be at intermediate or
higher risk for CVD on the basis of traditional risk factor assessment,
such as cigarette smokers or individuals with diabetes mellitus, who
have a particularly high risk for PAD. If a patient is found to have an
abnormal ABI, this patient can be elevated to a higher risk category.
The high relative risk in patients with abnormal ABIs is similar to
that of patients who qualify for the AHA secondary-prevention
regimen.
B-Mode Ultrasound
B-mode ultrasound is a relatively inexpensive and safe technique
that can noninvasively visualize the lumen and walls of selected
arteries, including carotid, aorta, and femoral arteries. B-mode
ultrasound has been validated for the measurement of IMT.
Cross-sectional associations between common carotid artery IMT and
cardiovascular risk factors have been demonstrated in
several studies. Similarly, common carotid IMT has been associated with
prevalent CVD in cross-sectional studies. Furthermore, at least 4
published studies found that carotid IMT measurement was a viable
predictor of the presence of coronary
atherosclerosis and its clinical sequelae. Thus,
carotid IMT defined by noninvasive B-mode ultrasound has been shown to
be an independent risk factor for CHD events and stroke.
Conclusions
Carotid artery B-mode ultrasound imaging is a safe, noninvasive,
and relatively inexpensive means of assessing subclinical
atherosclerosis. The technique can measure IMT, an
operational measure of atherosclerosis, in a valid and
reliable manner. The severity of carotid IMT is an independent
predictor of transient cerebral ischemia, stroke, and
coronary events such as myocardial infarction. The writing
group concluded that in asymptomatic individuals older than
45 years of age, carefully performed carotid ultrasound examination
with IMT measurement can add incremental information to traditional
risk factor assessment. In experienced laboratories, this test can now
be considered for further clarification of CHD risk assessment at the
request of a physician.
Coronary Calcium Scores in CAD Risk Assessment
Calcification within the coronary arterial
wall is a recognized marker of atherosclerosis. EBCT
and helical CT are highly sensitive means of detecting coronary
calcium and are being intensively evaluated as noninvasive means of
defining coronary atherosclerotic disease and identifying the
asymptomatic but high-risk CAD patient. There are, however,
relatively few prospective data linking coronary calcium scores
with risk of subsequent CHD events. Data concerning risk prediction
with EBCT in asymptomatic people (the primary focus of the
Prevention V conference) are sparse.
Conclusions
The presence of coronary calcium correlates strongly
with coronary atherosclerosis. Because the
severity of coronary atherosclerosis (from
pathological or angiographic studies) is well known to be associated
with risk of coronary events, coronary calcium scores
likewise should correlate with risk for coronary events.
However, the extent to which coronary calcium scores predict
coronary events independently of the traditional
coronary risk factors needs additional study. This latter
uncertainty must be weighed against the costs of measurement and the
risk that the results of the tests may create enough concern for
patients and their physicians to lead to inappropriate and invasive
coronary evaluation. Because of these uncertainties and
concerns, the writing group was reluctant to advocate the use of EBCT
for routine risk assessment in spite of the promise of the technique.
The greatest potential for coronary calcium scores would appear
to be in the detection of advanced coronary
atherosclerosis in patients at apparently intermediate
risk. Conversely, low or absent coronary calcium scores may
prove valuable in determining a low CAD event risk. Some clinicians and
researchers currently recommend use of the coronary calcium
score in risk assessment in these ways. However, the majority opinion
of the writing group was that until there is more definitive
information about the additive value of calcium scores in the
asymptomatic individual, coronary calcium
measurement should not be recommended for routine risk assessment in
asymptomatic populations. Selected use of coronary
calcium scores when a physician is faced with a patient with
intermediate coronary disease risk may be appropriate.
MRI and Atherosclerotic Disease
There has been increasing awareness of the importance of
composition of atherosclerotic plaque as a major risk factor for acute
coronary syndromes. MRI has been shown to characterize tissue
noninvasively in many different study systems. Therefore, research has
begun to focus on the use of in vivo MRI to evaluate the vessel wall in
several animal models and in humans.
Conclusions
MRI is a promising research tool, but its use appears
limited to only a small number of research laboratories at this time.
The writing group concluded that MRI is not ready for application in
the identification of patients at high risk for CAD.
Endothelial Function Studies and CAD Risk
The most frequently used endothelium-directed
vasodilator stimulus is an increase in blood flow. Investigators are
still seeking to improve the methods for ultrasonographic
analysis of brachial artery vasomotion. To achieve optimal
results, careful attention must be paid to details such as minimization
of patient stress or discomfort, recent fat intake, and cigarette
smoking and other transient exposures that may alter sympathetic tone.
The technique is skill and labor intensive and is not yet easily
applied to the routine clinical domain.
Conclusions
Although the assessment of endothelial function,
as measured most typically by flow-mediated brachial artery
vasodilation, is a promising technique that may reflect an independent
measure of CVD risk, additional prospective research is needed to
demonstrate that this technique can truly add to standard CVD risk
prediction. In addition, standardization and improvement of the
measurement technique are needed before this modality can become a part
of routine clinical assessment of CVD risk.
hs-CRP as a Marker of CAD Risk
A number of blood factors have received attention as potential new
markers of CAD and all-CVD risk. The list of potential candidates
includes total plasma homocysteine (tHcy), lipoprotein(a) [Lp(a)],
fibrinolytic function (as assessed by tissue plasminogen
activator and plasminogen activator
inhibitor-1 antigens), and inflammatory
parameters such as fibrinogen and CRP. Many of these
markers are not yet considered applicable for routine clinical CVD risk
assessment because of (1) lack of measurement standardization [eg,
Lp(a) testing, fibrinogen, and tHcy], (2) lack of
consistency in epidemiological findings from prospective
studies with CVD end points [eg, data for Lp(a) and tHcy are
inconsistent], and (3) lack of evidence that the novel marker
adds to risk prediction over and above that already achievable through
the use of established cardiovascular risk factors.
Laboratory evidence and findings from pathological studies suggest that
the inflammatory process plays an important part in the atherosclerotic
process. CRP is a sensitive marker for vascular inflammation, and it
has been suggested that hs-CRP may provide a novel method to assess CVD
risk that is additive to the assessment of traditional CVD risk
factors.
Conclusions
hs-CRP has been shown to predict future coronary events in
several prospective studies and may add to the predictive value of
lipid testing alone. hs-CRP testing may become commercially available
in the near future. The writing group concluded that additional studies
of this approach to risk prediction are warranted and should be
undertaken before this measurement can be advised for addition to the
routine assessment of coronary risk.
Appendix
Prevention V Conference Writing Group Members
Sidney C. Smith, Jr, Prevention V Conference Chair
Writing Group I: Scott M. Grundy, Chair; Terry Bazzarre, James Cleeman, Ralph B. D’Agostino, Sr, Martha Hill, Nancy Houston-Miller, William Kannel, Ronald Krauss, Harlan M. Krumholz, Ronald M. Lauer, Ira S. Ockene, Richard C. Pasternak, Thomas Pearson, Paul M. Ridker, David Wood.
Writing Group II: Sidney C. Smith, Jr, Chair; Ezra Amsterdam, Gary J. Balady, Robert O. Bonow, Gerald F. Fletcher, Victor Froelicher, Gregory Heath, Marian C. Limacher, Jamshid Maddahi, David Pryor, Rita F. Redberg, Edward Roccella, Thomas Ryan, Lynn Smaha, Nanette K. Wenger.
Writing Group III: Philip Greenland, Chair; Jonathan Abrams, Gerard P. Aurigemma, M. Gene Bond, Michael H. Criqui, Luther T. Clark, John R. Crouse, Lawrence Friedman, Valentin Fuster, David M. Herrington, Lewis H. Kuller, Paul M. Ridker, William C. Roberts, William Stanford, Neil Stone, H. Jeremy Swan, Kathryn A. Taubert, Lewis Wexler.
Footnotes
A single reprint of this article is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0181.
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