Department Medicine, Division Endocrinology, Diabetes, Metabolism, University California, Irvine (UCI), School of Medicine, Irvine, CA, 92697, USA.
Diabetes Out-Patient Clinic, UCI Medical Center, Orange, CA, 92868, USA.
Curr Diab Rep. 2019 Jul 22;19(8):61. doi: 10.1007/s11892-019-1178-6.
To distinguish extreme and very high atherosclerotic cardiovascular disease (ASCVD) event risk based on prospective epidemiological studies and clinical trial results.
Clinical practice guidelines have categorized patients with either a history of one or more "clinical ASCVD" events or "coronary heart disease (CHD) risk equivalency" to be at "very high risk" for a recurrence or a first event, respectively. A 20% or greater 10-year ASCVD risk for a composite 3-point "major" atherosclerotic cardiovascular event (MACE) of non-fatal myocardial infarction (MI), non-fatal stroke, or cardiovascular death can serve as an arbitrary definition of those at "very high risk." Exclusion of stroke may underestimate risk of "hard" endpoint 10-year ASCVD risk and addition of other potential endpoints, e.g., hospital admission for unstable angina or revascularization, a 5-point composite MACE, may overinflate the risk definitions and categorization. "Extreme" risk, a descriptor for even higher morbidity and mortality potential, defines a 30% or greater 10-year 3-point MACE (ASCVD) risk. In prospective, epidemiological studies and randomized clinical trial (RCT) participants with an initial acute coronary syndrome (ACS) within several months of entry into the study meet the inclusion criteria assignment for extreme risk. In survivors beyond the first year of an ASCVD event, "extreme" risk persists when one or more comorbidities are present, including diabetes, heart failure (HF), stage 3 or higher chronic kidney disease (CKD), familial hypercholesterolemia (FH), and poorly controlled major risk factors such as hypertension and persistent tobaccoism. "Extreme" risk particularly applies to those with progressive or multiple clinical ASCVD events in the same artery, same arterial bed, or polyvascular sites, including unstable angina and transient ischemic events. Identifying asymptomatic individuals with extensive subclinical ASCVD at "extreme" risk is a challenge, as risk engine assessment may not be adequate; individuals with genetic FH or those with diabetes and Agatston coronary artery calcification (CAC) scores greater than 1000 exemplify such threatening settings and opportunities for aggressive primary prevention. Heterogeneity exists among individuals at risk for clinical ASCVD events; identifying those at "extreme" risk, a more ominous ASCVD category, associated with greater morbidity and mortality, should prompt the most effective global cardiometabolic risk reduction.
根据前瞻性流行病学研究和临床试验结果，区分极高危和高危动脉粥样硬化性心血管疾病（ASCVD）事件风险。
临床实践指南将有一个或多个“临床 ASCVD”事件史或“冠心病（CHD）风险等同”的患者分别归类为再次发生或首次发生的“极高危”患者。10 年内 ASCVD 复合 3 点“主要”动脉粥样硬化心血管事件（MACE）的非致死性心肌梗死（MI）、非致死性卒中和心血管死亡的 20%或更高的风险可以作为“极高危”的任意定义。排除卒中和添加其他潜在终点，如不稳定型心绞痛或血运重建住院、5 点复合 MACE，可能会低估 10 年“硬”终点 ASCVD 风险和风险定义分类。“极高危”，一个描述更高发病率和死亡率的术语，定义为 10 年内 3 点 MACE（ASCVD）风险为 30%或更高。在前瞻性、流行病学研究和随机临床试验（RCT）中，在进入研究后的几个月内首次出现急性冠状动脉综合征（ACS）的参与者符合极高危的纳入标准。在 ASCVD 事件后的第一年，当存在一种或多种合并症时，包括糖尿病、心力衰竭（HF）、3 期或更高的慢性肾脏病（CKD）、家族性高胆固醇血症（FH）和未得到良好控制的主要危险因素，如高血压和持续吸烟时，“极高危”仍然存在。“极高危”尤其适用于同一动脉、同一动脉床或多血管部位有进行性或多发性临床 ASCVD 事件的患者，包括不稳定型心绞痛和短暂性缺血发作。在“极高危”人群中识别无症状、广泛的亚临床 ASCVD 患者是一个挑战，因为风险评估引擎可能不够充分；有遗传 FH 的个体或糖尿病和冠状动脉钙化（CAC）评分大于 1000 的个体就是这种具有威胁性的情况和积极进行一级预防的机会。有临床 ASCVD 事件风险的个体之间存在异质性；识别“极高危”患者，即更严重的 ASCVD 类别，与更高的发病率和死亡率相关，应促使进行最有效的全球心脏代谢风险降低。
