Despite implementation of risk factor-based screening, deaths due to cardiovascular disease (CVD) continue to rise. The majority of CVD deaths occur in those with low to intermediate Framingham risk score (FRS). Risk based algorithms have served women particularly poorly. Imaging based methods of atherosclerosis [i.e. coronary calcium scan (CAC) and carotid intima media thickness (IMT) with plaque assessment] have proven to risk-stratify patients better and often demonstrate presence of atherosclerosis in those with low FRS ; however CAC and IMT have been given class IIb and class III indication respectively for CVD risk stratification. A shift in the liberalization of statin therapy serves the population better; however is still likely to undertreat some with and over treat others without atherosclerosis. Moreover, limited patient-physician dialogue on CVD prevention, unknown risk factors, side effects from therapy and lack of patient motivation remain barriers to implementation of preventive treatment.
The combined approach of risk factor based and imaging based assessment of atherosclerosis is feasible in today’s outpatient cardiology practice. In my own practice, I take the opportunity during outpatient visits to educate all of my patients on primary as well as secondary prevention of CVD. This includes increasing patient awareness of their risk factors for CVD, the recent changes in CVD prevention guidelines, and their CVD risk based on the new cohort risk equation. I also discuss the pathophysiologic link between “atherosclerosis” and cardiac, vascular, and cerebral disease that can be visualized by ultrasound assessment of thickness of carotid wall defined as intima media thickness and focal atherosclerosis as plaque due to the long dormant period before the disease becomes manifest as clinical events. Most, if not all, patients choose to “see” their atherosclerosis even if they have already been categorized as high risk by the risk calculator and despite dismal, if any, reimbursement on imaging tests to assess atherosclerosis. I perform carotid IMT and plaque assessment over about ten minutes using a dedicated ultrasound system in the same consultation room, or refer patients for an IMT evaluation by a sonographer as appropriate. I go over the images and the presence and severity of “atherosclerosis” or lack thereof and show patients their graph of IMT percentile relative to age, gender, and race-based norms. The patients are very intrigued and interested and become more receptive to lifestyle modification and initiation of statin therapy, or to increase existing dose of statins or restart statins they quit earlier due to myalgias or other side effects. For some patients—e.g. those with family history of premature CVD—demonstration of normal CIMT is a welcome relief. I know my patients are compliant with their statins based on the requests for medication refill and changes in their biomarkers on follow up. Figure 1 shows two patient examples from my practice.