Cardiovascular imaging to guide primary prevention

### Learning objectives Coronary heart disease is the most common cause of death across the world. The WHO estimates it accounts for nearly a third of all global deaths each year and since 1990, more people have died from cardiovascular disease than any other cause.1 So how can we prevent this inexorable tide of cardiovascular morbidity and mortality? The concept of primary prevention is rooted in history with the old adage ‘prevention is better than cure’ being attributed to Desiderius Erasmus, the 15th century Dutch philosopher. Prevention of cardiovascular diseases, such as myocardial infarction and stroke, is a major goal of the medical community and is embodied in current international guidelines. Indeed, the use of cardiovascular risk scores to identify individuals at risk is the current standard of care across the world.2–6 The rationale for this practice is to select those individuals at greatest risk to maximise the cost-effectiveness of treatment, without recommending therapy in the entire population. This is especially important given that the majority of cardiovascular events are unheralded, and the prognosis in those suffering myocardial infarctions without preceding symptoms of angina is worse.7 However, there is considerable debate surrounding whether this is something that risk scores can accurately do. In an area of practice that requires significant improvement, this article aims to look at whether cardiovascular imaging can be used to optimise the process of primary prevention. ### The birth of risk scores Although many different risk scores are used throughout the world, the Framingham Score is perhaps the most famous. Inspired by the death of President Roosevelt in 1945 and on the back of a pandemic of the then ‘untreatable’ cardiovascular …