Cardiovascular Disease — 10

There’s also the ability to determine high-risk, vulnerable plaque (without significant narrowing or limiting of blood flow) more directly by imaging inside the coronary arteries. A randomized trial of sixteen hundred patients with these vulnerable plaques compared intervention (with a balloon angioplasty or stenting) versus medical therapy and found a substantial reduction of major cardiac events during two years of follow-up. These results have challenged dogma that stenting should only be done for significant flow-limiting, arterial narrowing, often colloquially referred to as “blockages.”

Figure 5.7. Relationship of inflamed arteries (by AI of CT scan) and heart-related death. Adapted from Kenneth Chan et al., “Inflammatory risk and cardiovascular events in patients without obstructive coronary artery disease: The ORFAN multicentre, longitudinal cohort study,” Lancet 403, no. 10444 (June 2024): 2606–18, https://doi.org/10.1016/s0140-6736(24)00596-8.

From a synthesis of all these trials, we can acknowledge that body-wide or heart artery inflammation is a risk factor for major adverse cardiovascular events, and that anti-inflammatory drugs can improve outcomes. Yet, the cardiovascular community has not moved on to change practice, acknowledging our ability to detect inflammation and to do something about it. Perhaps that will eventually sink in when we have better anti-inflammatory drugs.

FORECASTING AND PREVENTION

The longtime window it takes for atherosclerosis to build up provides an opportunity to determine who is at high risk for developing coronary artery disease, closely follow these individuals, and intervene early to modify any risk factors, which now, as we just reviewed, include inflammation (fig. 5.8). Assessment of an individual for risk should now go well beyond the traditional clinical factors of diabetes, obesity, smoking, lack of physical activity, and high LDL cholesterol.

The insights derived from these heart inflammation reports helps add another way to forecast a person’s entanglement with heart disease. Besides the well-established clinical risk factors, there are many other results that can help pinpoint high-risk individuals. The list includes polygenic, gut microbiome, and proteomic risk scores; heart aging clock; CHIP; inflammation biomarkers such as hs-CRP, along with AI interpretation of the retina photo, and if available, chest X-ray. The retina and chest X-ray are examples of what has been called “opportunistic medical imaging,” since getting a handle on heart disease risk isn’t the reason why the tests were ordered. But with AI, the heart artery calcium score can be accurately determined from the retina or the chest X-ray. The retina photo can also be used to predict the risk of heart attack and stroke. Epigenetic age (DNA methylation) clocks that indicate accelerated body-wide aging are correlated with increased risk of adverse cardiovascular outcomes.