Cardiovascular risk prediction in the real world. The discouraging evidences coming from literature

Risk prediction plays a leading role in cardiovascular (CV) prevention. Thus, several risk charts have been developed in different Countries in the attempt to identify subjects at high risk who might benefit from more aggressive and early interventions. However despite the availability of several risk charts, they are underutilized in clinical practice. Indeed risk charts show main limitations: they estimate absolute, but not individual risk; their performance is affected by changes on the incidence of CV diseases; they do not take into account the duration of risk exposure, which is related to the progression of atherosclerosis. Moreover, risk estimate might be less accurate in younger, in women, and in the elderly. Addition of novel risk markers have substantially failed to improve risk charts' discrimination power. Imaging has recently gained relevance in CV risk stratification for its ability to detect subclinical atherosclerosis. Among imaging techniques coronary artery calcium score(CACS) emerged as the most powerful and independent predictor of CV events. Hence, a CACS-based screening strategy have been proposed in all asymptomatic middle-aged people. However since CACS it is still quite expensive and not-radiation free, it is not recommended by most scientific guidelines. Conversely, detecting subclinical organ damage (SOD) like LV hypertrophy, carotid plaque, renal failure, microalbuminuria or the metabolic syndrome in subjects at intermediate risk is pretty cost-effective yielding to reclassification of subjects into higher-risk strata. Thus, merging information coming from different tools (risk scores, biomarkers, and non-invasive imaging) individual risk might be better stratified saving costs. In the next future, an integrated, semi-automated, high-reproducible and inexpensive ultrasound approach could represent a key point to approach the individual risk.