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W2135498889 abstract "HomeCirculationVol. 121, No. 12Identifying Patients at High Risk of a Cardiovascular Event in the Near Future Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBIdentifying Patients at High Risk of a Cardiovascular Event in the Near FutureCurrent Status and Future Directions: Report of a National Heart, Lung, and Blood Institute Working Group Kim A. Eagle, Geoffrey S. Ginsburg, Kiran Musunuru, William C. Aird, Robert S. Balaban, Susan K. Bennett, Roger S. Blumenthal, Shaun R. Coughlin, Karina W. Davidson, Edward D. Frohlich, Philip Greenland, Gail P. Jarvik, Peter Libby, Carl J. Pepine, Jeremy N. Ruskin, Arthur E. Stillman, Jennifer E. Van Eyk, H. Eser Tolunay, Cheryl L. McDonald and Sidney C. SmithJr Kim A. EagleKim A. Eagle From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Geoffrey S. GinsburgGeoffrey S. Ginsburg From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Kiran MusunuruKiran Musunuru From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , William C. AirdWilliam C. Aird From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Robert S. BalabanRobert S. Balaban From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Susan K. BennettSusan K. Bennett From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Roger S. BlumenthalRoger S. Blumenthal From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Shaun R. CoughlinShaun R. Coughlin From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Karina W. DavidsonKarina W. Davidson From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Edward D. FrohlichEdward D. Frohlich From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Philip GreenlandPhilip Greenland From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Gail P. JarvikGail P. Jarvik From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Peter LibbyPeter Libby From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Carl J. PepineCarl J. Pepine From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Jeremy N. RuskinJeremy N. Ruskin From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Arthur E. StillmanArthur E. Stillman From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Jennifer E. Van EykJennifer E. Van Eyk From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , H. Eser TolunayH. Eser Tolunay From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author , Cheryl L. McDonaldCheryl L. McDonald From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author and Sidney C. SmithJrSidney C. SmithJr From the University of Michigan, Ann Arbor (K.A.E.); Duke University, Durham, NC (G.S.G.); Massachusetts General Hospital, Boston (K.M., J.N.R.); Beth Israel Deaconess Medical Center, Boston, Mass (W.C.A.); National Heart, Lung, and Blood Institute, Bethesda, Md (R.S. Balaban, H.E.T., C.L.M.); George Washington University Medical Center, Washington, DC (S.K.B.); Johns Hopkins University School of Medicine, Baltimore, Md (R.S. Blumenthal); University of California at San Francisco (S.R.C.); Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); Ochsner Clinic Foundation, New Orleans, La (E.D.F.); Feinberg School of Medicine, Northwestern University, Chicago, Ill (P.G.); University of Washington Medical Center, Seattle (G.P.J.); Brigham and Women’s Hospital, Boston, Mass (P.L.); University of Florida College of Medicine, Gainesville (C.J.P.); Emory University, Atlanta, Ga (A.E.S.); Johns Hopkins University, Baltimore, Md (J.E.V.E.); and University of North Carolina at Chapel Hill (S.C.S.). Search for more papers by this author Originally published30 Mar 2010https://doi.org/10.1161/CIRCULATIONAHA.109.904029Circulation. 2010;121:1447–1454The National Heart, Lung, and Blood Institute convened a working group to provide basic and clinical research recommendations to the National Heart, Lung, and Blood Institute on the development of an integrated approach for identifying those individuals who are at high risk for a cardiovascular event such as acute coronary syndromes (ACS) or sudden cardiac death in the “near term.” The working group members defined near-term as occurring within 1 year of the time of assessment. The participants reviewed current clinical cardiology practices for risk assessment and state-of-the-science techniques in several areas, including biomarkers, proteomics, genetics, psychosocial factors, imaging, coagulation, and vascular and myocardial susceptibility. This report presents highlights of these reviews and a summary of suggested research directions.Clinical Risk AssessmentNear-Term RiskThe proper deployment of preventive strategies requires an accurate classification system that allows the physician to target intensive treatments to the highest-risk patients. A commonly recommended approach is a multivariable assessment such as the Framingham Risk Score (FRS).1 Although the FRS is recommended in many guidelines on cardiovascular risk assessment,2 it has some limitations. It does not include several factors of the metabolic syndrome (glucose intolerance, central obesity, and hypertriglyceridemia), nor does it include family history. Moreover, the FRS classifies risk over a period of 10 years rather than in the near term (within 1 year). Indeed, no algorithm has been developed that accurately predicts near-term risk across diverse populations.The ability to forecast near-term risk of ACS or sudden cardiac death would represent an important advance in cardiovascular medicine because it would clarify which individuals are in most urgent need of intervention. It would help identify those rare asymptomatic, apparently healthy individuals who are in imminent danger of a cardiovascular event yet ordinarily would not receive therapy at all. In asymptomatic individuals judged to be at intermediate or high risk by the FRS, determining that they are at increased near-term risk could result in immediate (and perhaps temporary) intensification of therapy or other interventions. Among patients with known coronary artery disease and/or some degree of left ventricular dysfunction, those at high near-term risk would warrant the most aggressive level of treatment and monitoring.Post-ACS Risk PredictionTools to predict near-term cardiovascular risk after ACS are already available. For example, for patients presenting with ACS, the 7-point Thrombolysis in Myocardial Infarction (TIMI) risk score is an easy and valid tool for predicting risk of very-near-term events (eg, 14 to 30 days).3 However, risk stratification developed from randomized trial populations may lack generalizability to patients seen in usual clinical practice.4 The Global Registry of Acute Coronary Events (GRACE) risk score has been well validated as a risk prediction tool applicable for types of ACS patients encountered in clinical practice.4–6 Additionally, multiple biomarkers have been shown to have prognostic value in the post-ACS setting, both individually and in combination.7Many drugs have been proven to reduce near-term, post-ACS events in randomized trials (eg, angiotensin-converting enzyme inhibitors, aspirin and thienopyridines, supplements, aldosterone blockers, and statins). In some cases, interventions have been shown to be of particular value in patients at high short-term risk. For example, some studies have demonstrated improved post-ACS outcomes with the early intervention strategy compared with the early conservative strategy in patients presenting with high TIMI risk scores; no difference was seen among patients with low TIMI risk scores.8 Similarly, enoxaparin provided improved outcomes compared with unfractionated heparin exclusively in individuals with high TIMI risk scores.3 Thus, determination of near-term risk can help guide optimal therapy in post-ACS patients.Although much work is needed to perfect near-term risk prediction in the post-ACS setting, there is a relative wealth of information compared with the scant data available for asymptomatic individuals. A major unmet need is the development of risk scores akin to the TIMI and GRACE scores to forecast near-term risk in the primary prevention setting.Candidate Areas for New Risk Assessment ToolsClassic and Novel Risk FactorsSince the initial 4 risk factors underlying cardiovascular disease (CVD)—hypertension, hypercholesterolemia, left ventricular hypertrophy, and diabetes mellitus—were described in 1961 by Kannel et al,9 the list has grown to include many others. Additional clinical cardiovascular risk factors such as male gender, black race, advancing age, smoking, insufficient exercise, obesity, and family history are well recognized.10 However, all of these are fixed or chronic conditions that are better suited to predicting long-term risk than near-term risk. What are needed are novel risk factors that reflect acute processes influencing atherosclerotic plaque rupture, atherothrombosis, and electric instability in the myocardium. Of most value would be novel, easy-to-measure biomarkers that would make it possible to screen large numbers of individuals for near-term risk.Biomarkers are proteins or metabolites, individually or in combination, that correlate to pathological processes.11 A clinically useful biomarker should have specificity to the disease process; should differ quantitatively from controls, with this difference being larger than technical and biological variation combined; should be stable in blood or other body fluids; and should present in sufficient amounts for easy clinical measurement.12Some novel plasma-based biomarkers are associated with myocardial, renal, skeletal muscle, and brain involvement from atherosclerotic vascular disease, including brain natriuretic protein, bone morphogenic protein, transforming growth factor-β, and neuroprotein D1. These biomarkers may be related to damage of “target organs” and thus are potential risk factors. However, care must be taken to distinguish those that are truly predictors of future events from those that are secondary, downstream markers reflecting a prior event and have no predictive value. For example, the plasma level of troponin, a marker for myocardial damage, has little prognostic value in the primary prevention setting, where the test is principally used as a diagnostic marker to determine whether a symptomatic patient has suffered a cardiovascular event. In the secondary prevention setting, however, troponin has been demonstrated to be a useful biomarker for determining near-term risk and is a component of the TIMI risk score.Other biomarkers are associated with atherosclerosis, inflammation, endothelial cell dysfunction, plaque instability, thrombosis, and myocardial susceptibility and so are more likely to be causal risk factors. How these “new” biomarkers and “old” risk factors in" @default.
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W2135498889 date "2010-03-30" @default.
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W2135498889 title "Identifying Patients at High Risk of a Cardiovascular Event in the Near Future" @default.
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W2135498889 doi "https://doi.org/10.1161/circulationaha.109.904029" @default.
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