Disrupting clinical inertia: Personalizing cardiovascular risk to transform cardiometabolic care in the real world

Disrupting clinical inertia: Personalizing cardiovascular risk to transform cardiometabolic care in the real world People with type 2 diabetes (T2D) have a 2-to 4-fold higher risk of cardiovascular disease (CVD) than the general population [1].This risk is reduced to levels similar to those of the general population when all major cardiovascular risk factors (hemoglobin A1c, blood pressure, LDL-C level, albuminuria, and smoking) are treated to target [2].Additionally, cardiovascular outcomes trials (CVOTs) of glucose-lowering agents glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i), along with nonstatin lipid-lowering therapies such as proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), have revolutionized CVD risk reduction in this high-risk population.To this end, society guidelines and consensus statements recommend these therapies for use in people with T2D, yet few people with T2D meet cardiovascular risk factor targets or are started on cardioprotective agents.In NHANES 2017-2020, only 11.1 % of adults with T2D met A1c, blood pressure, cholesterol, and smoking goals [3], and only 5.8 % and 4.4 % were on an SGLT2i or GLP-1 RA, respectively [4].A global survey found that 67 % of primary care providers were aware of recent CVOTs in people with T2D, and 81.6 % agreed that early intensification of therapy is clinically beneficial.However, 46.1 % delayed prescribing GLP-1 RA or SGLT2i until later in patients' clinical courses, and 23.9 % would not intensify with cardiometabolic therapy if a patient achieved glycemic control [5].This therapeutic inertia persists despite relatively low-cost or well-covered interventions to address the basic ABCs of T2D CVD risk reduction (A1c, Blood pressure, Cholesterol).In this issue of the American Journal of Preventive Cardiology, Gill et al. report the effect of patient and provider awareness of a blood-based proteomic Residual Cardiovascular Risk (RCVR) score on cardioprotective therapy prescriptions (SGLT2i, GLP-1 RA, and PCSK9i) and cardiovascular risk after 6 months in adults with T2D [6].Those in the informed arm had a significantly higher rate of cardioprotective therapy prescriptions (32.1 % vs 9.6 %, respectively) with risk-concordant prescribing seen only in the informed arm: 38.6 % of those with high risk by RCVR score, 35.7 % of those with medium-high risk, and 27.1 % of those with medium-low risk (vs 12.1 %, 6.4 %, and 11.3 % in the uninformed arm, respectively).Furthermore, RCVR scores at 6-12 months decreased significantly in informed participants who started therapy.This study shows the behavioral impact of a proteomic risk score and provides evidence of its potential to break clinical inertia.RCVR scores predict cardiovascular events within 4 years in adults 40 years or older with one or more causes of elevated CVD risk (including T2D) [7].This score uses a 27-protein model, encompassing 10 pathways related to vascular pathology and 12 proteins with causal genetic traits.Although this model has a higher C-statistic for 4-year