Improvement of cardiovascular risk prediction using coronary imaging: subclinical atherosclerosis: the memory of lifetime risk factor exposure

Deaths from diseases of the heart are decreasing. Cardiovascular diseases (CVD) will be the main cause of morbidity and mortality in 2015 according to a WHO report. The main problem is related to the long-time delay between the start of the development of atherosclerosis in young adults and the manifestation many decades later. Despite a recent decline in a CVD mortality rate in men and women, the main problem is related to the acute manifestation as the acute coronary syndrome, which leads 30-50% of subjects to sudden and fatal outcomes. In addition, about 20% of first and recurrent acute myocardial infarctions are silent. The lifetime risk of coronary artery disease after 40 years is 49% for men and 32% for women. That means, we are confronted with a major health care problem. This is even more obvious, when the rate of coronary heart disease deaths out of the hospital are taken into account which amount to 70% in 2007. These data are confirmed for Europe despite a strong decline of hospital deaths. Another problem is related to the fact that the number of sudden cardiac death amounts to >300 000 in the general US population. It is about 10 times higher than in those patients who are defined as prone to sudden death due to low ejection fraction, ventricular arrhythmias, and acute myocardial infarction. For cardiologists, this general topic becomes even more obvious, because even well-known cardiologists experienced early (≤65 years) sudden cardiac deaths such as RW Campbell, JM Isner, PA Poole-Wilson, H Drexler, and recently the paediatric cardiologist from Hannover, A Wessels. These events underline again what has been emphasized 15 years ago by the MONICA study that two-thirds of patients die outside the hospital and that we have to concentrate on primary and secondary prevention, also in memory of these colleagues. This review will demonstrate the potential value of coronary artery calcification screening which can be used as a sign of subclinical coronary arteriosclerosis for improved risk prediction, the first step to prevention. Subclinical atherosclerosis represents the vessel memory of risk factor exposure.