Can the first cardiovascular event be prevented?

Risposta: In the era of precision medicine, the concept of cardiovascular prevention has undergone a significant evolution. Cardiovascular diseases continue to be the leading cause of death and disability worldwide, with a consequent significant clinical, social and economic impact; preventing them therefore means taking action not only on the disease itself once it has manifested, but above all on the risk factors that precede its onset, often by many years.

The current approach no longer consists of a uniform and undifferentiated correction of individual risk factors, but rather in determining an individual’s overall cardiovascular risk, on the basis of which the intensity and objectives of treatment can be tailored. The management of high blood pressure and high cholesterol is a prime example of this: similar blood pressure or LDL cholesterol levels do not necessarily indicate the same prognostic outlook in all individuals – whose clinical profiles may differ – and, consequently, do not require the same intensity of treatment.

The stratification of cardiovascular risk is therefore based on an integrated assessment of demographic data (age, sex and geographical area of origin), traditional risk factors – such as smoking and clinical parameters including blood pressure and lipid profile – and comorbidities such as diabetes mellitus, chronic kidney disease and familial hypercholesterolaemia, as well as the presence of organ damage or previously documented cardiovascular disease. In apparently healthy individuals, validated tools such as the SCORE2 and SCORE2-OP scoring systems enable the probability of developing a major cardiovascular event over a 10-year period to be estimated. This process enables a person to be categorised into different cardiovascular risk classes – low, moderate, high or very high – each corresponding to preventive strategies of varying intensity and progressively more stringent treatment targets.

In cases where the risk profile assessment is borderline, it is advisable to evaluate those clinical parameters known as ‘risk modifiers’. These include elevated levels of biomarkers – such as lipoprotein (a) – and subclinical atherosclerosis, which can be documented using imaging techniques such as colour Doppler ultrasound of the supra-aortic trunks or, in selected cases, coronary CT angiography.

The ultimate aim is therefore to translate the prognostic assessment into a tangible clinical benefit. The challenge of cardiovascular prevention today thus lies in the ability to combine the right timing, appropriateness and proportionality of the intervention.