In the ongoing effort to shift the paradigm from REACTIONARY to PREVENTIVE when it comes to atherosclerosis, the results from the REACT study were recently presented at the European Society of Cardiology congress.
This study enrolled nearly 17,000 patients aged 18-70 in Spain and Denmark who hadn’t previously experienced a cardiovascular event. These folks underwent baseline imaging with three different imaging techniques:
- Femoral ultrasound (notably, this was the most common site of initial atherosclerosis in the PESA study)
- Carotid ultrasound (notably, in that same PESA study, carotid plaque was present 31% of the time even when coronary plaque was absent)
- Coronary CTA (which is basically a CAC on steroids)
And there were many different provocative findings, but I’ll provide a Plaque Snack sample platter below:
- 57.1% of the study participants had “Silent Atherosclerosis,” defined as
sneaky and introvertedidentifiable plaque in a vascular bed on one or more imaging techniques. - Even in those aged 18-29, 6.7% of females and 8.7% of males had identifiable plaque.
- This finding is consistent with the recently coined term “Primordial Prevention” and the notion that “atherosclerosis begins at a young age.” And indeed, fatty streaks in blood vessels have been found in stillborn babies with Familial Hypercholesterolemia, and the PDAY study also showed fatty streaks and plaques in those aged 15-34. Additionally, autopsies of young soldiers who made the ultimate sacrifice in battle have demonstrated similar pathology in prior studies.
- I would be curious to see subanalyses of those with obesity, those with a strong family history of premature vascular disease, and those who were active smokers in this younger age demographic…I would theorize these factors may have had something to do with the “early evidence of a break-in.”
- Very rarely was coronary plaque present without identifiable plaque in other vascular territories (less than 10% of the time in men and <5% of the time in women).
- 52-58% of participants age 30-39 with coronary plaque had a CAC>0…the rest had identifiable coronary plaque, but a CAC of zero.
- This highlights that a CAC above zero in a young person is VERY useful and warrants aggressive intervention. But in a young person with either a disastrous Home Security System, rough Lipid Neighborhood, raging family history, or all of the above, CAC=0 still doesn’t make you feel amazing.
- The SCORE2 Risk Calculator was highly specific for identifying Silent Atherosclerosis (99.8% of those in the High Risk category had plaque) but had incredibly low sensitivity (1.9%). Those in the “Moderate to High” risk category had a specificity of 87.9% and an abysmal sensitivity of 34.1%. Essentially, if the Risk Calculator places you at “High Risk, you probably have some plaque. But even if you’re somewhere below “High Risk,” especially if you’re younger, you very well may have Silent Atherosclerosis. Even in Europe, which is generally ahead of the USA with preventive diagnostics and certainly superior when it comes to quality of bread and pasta, you can still find crappy Risk Calculators.
So what does this really mean? Should we statinize babies the moment they take their first steps? Rather than teach infants the ABCs, should we first be teaching them the letters L-D-L? And given that people with CAC zero from the recent SCAPIS study have a 0.5% chance of having a cardiovascular event over 10 years, is the solution to any identifiable plaque blitzing everyone with high doses of lipid-lowering medication? And what about the 8% of people in PESA who, after initially having identifiable non-coronary plaque, had zero plaque on follow-up after getting their acts together from a lifestyle standpoint? The answers to these questions will likely vary depending on the person you ask and the specific patient context.
So maybe, just maybe, we have to individualize our approach. And I 100% agree that, rather than take a laissez-faire approach to atherosclerosis, we should emphasize early identification of the various factors that can result in vascular disease…maybe something like Home Security System and Lipid Neighborhood😊
