Análise crítica da estratificação de risco cardiovascular / Critical analysis of cardiovascular risk stratification

A doença aterosclerótica cardiovascular é a principal causa de morte em todo o mundo e em muitos dos casos o evento fatal é sua primeira manifestação. Educar mudança de hábitos à população e identificar e tratar precocemente os indivíduos de alto risco é a única forma de reagir. Nesse contexto, diversos escores marcadores de risco têm sido desenvolvidos para auxiliar a identificação e orientar a terapêutica preventiva. A complexidade da aterogênese e sua multiplicidade de fatores de risco limitam, no entanto, a eficácia destas ferramentas e impõem estratégias sequenciais de investigação. Nesta revisão, serão apresentadas as principais características e limitações dos escores clínicos, com que frequência eles podem falhar em indivíduos de alto risco na população brasileira e que estratégias estão sendo usadas para atenuar estas limitações.

Atherosclerotic cardiovascular disease is the leading cause of death worldwide and in many cases the fatal event is its first appearance. Educating the population to change of habits and lifestyle identifying and promptly treating the high-risk individuals are ways of fighting against this disease. In this context, several risk markers and scores have been developed to help identify and guide preventive therapy. Their effectiveness, however, is affected by the complex interactions among multiple risk factors involved in atherogenesis and strategies involving the combined use of clinical scores and laboratory or imaging tests are necessary. This review will cover the main features and limitations of clinical scores, which often can fail in high-risk individuals in our population, and in strategies which are being used to mitigate these limitations.

Most of the patients presenting myocardial infarction would not be eligible for intensive lipid-lowering based on clinical algorithms or plasma C-reactive protein.

OBJECTIVE: The study we assessed how often patients who are manifesting a myocardial infarction (MI) would not be considered candidates for intensive lipid-lowering therapy based on the current guidelines. METHODS: In 355 consecutive patients manifesting ST elevation MI (STEMI), admission plasma C-reactive protein (CRP) was measured and Framingham risk score (FRS), PROCAM risk score, Reynolds risk score, ASSIGN risk score, QRISK, and SCORE algorithms were applied. Cardiac computed tomography and carotid ultrasound were performed to assess the coronary artery calcium score (CAC), carotid intima-media thickness (cIMT) and the presence of carotid plaques. RESULTS: Less than 50% of STEMI patients would be identified as having high risk before the event by any of these algorithms. With the exception of FRS (9%), all other algorithms would assign low risk to about half of the enrolled patients. Plasma CRP was <1.0mg/L in 70% and >2mg/L in 14% of the patients. The average cIMT was 0.8±0.2mm and only in 24% of patients was ≥1.0mm. Carotid plaques were found in 74% of patients. CAC ≥100 was found in 66% of patients. Adding CAC ≥100 plus the presence of carotid plaque, a high-risk condition would be identified in 100% of the patients using any of the above mentioned algorithms. CONCLUSION: More than half of patients manifesting STEMI would not be considered as candidates for intensive preventive therapy by the current clinical algorithms. The addition of anatomical parameters such as CAC and the presence of carotid plaques can substantially reduce the CVD risk underestimation.