Strategies to reverse atherosclerosis: an imaging perspective.

Several treatment strategies, including lowering low-density lipoprotein cholesterol with intensive statin therapy, reducing triglycerides with fibrates, and raising high-density lipoprotein cholesterol with nicotinic acid, have the potential to induce atherosclerosis regression. Atherosclerosis imaging techniques including intravascular ultrasound, carotid ultrasound to measure carotid intima-media thickness, and cardiovascular MRI are established modalities for describing longitudinal changes in the quantity and quality of atherosclerotic plaque. An increasing number of clinical trials are using radiologic measures of subclinical atherosclerosis as surrogate end points in lieu of the traditional "hard" end points of myocardial infarction and death. This approach has great appeal, as improvements in atherosclerosis imaging now enable the characterization of early atheromas and positive remodeling within the vessel wall before the plaque becomes obstructive. Additional prospective data correlating these surrogate end points with hard outcomes are needed to determine whether atherosclerosis regression will be the major determinant of future treatment strategies.

Primary prevention for patients with intermediate Framingham risk scores.

Coronary heart disease (CHD) is the leading cause of mortality in the industrialized world. Proper identification of individuals at risk for CHD is challenging. The Framingham Risk Score, the most widely accepted tool for quantifying 10-year risk, fails to identify a great proportion of future CHD. Because of the health and economic consequences of CHD, there is a need to develop better prognostic tools for primary prevention. Coronary artery calcium scoring, C-reactive protein measurement, and heart rate recovery and exercise tolerance during exercise stress test may be useful tools for better risk stratification of intermediate-risk patients.