Cardiac imaging and circulating biomarkers for primary prevention in the era of precision medicine

Introduction: Current primary prevention guidelines do not strongly support the use of cardiovascular imaging and circulating biomarkers in risk assessment. Still, an increasing body of evidence suggests that important prognostic information can be obtained from imaging and biomarker measurements.Areas covered: In this review, we describe the most important imaging modalities (coronary computed tomography, myocardial perfusion imaging, carotid intima media thickness, echocardiography and cardiac magnetic resonance imaging) and circulating biomarkers (cardiac troponins, B-type natriuretic peptides and C-reactive protein) for risk prediction in people without known cardiovascular disease. We discuss both the prognostic performance and clinical utility of these biomarkers in the era of primary prevention with increased focus on precision medicine. Finally, we comment on the use of cardiac biomarkers in screening for additional work-up with cardiac imaging and the combination of the entities in risk prediction.Expert opinion: We believe future primary prevention should, to a larger extent, integrate measurements of cardiovascular biomarkers and non-invasive imaging to enhance the precision of subclinical disease detection and risk stratification. The use of cardiovascular biomarkers as a screening tool for further testing with non-invasive imaging may be a cost-effective strategy.