Identification and management of patients at high-risk for cardiovascular disease in primary prevention.

Atherosclerotic cardiovascular disease (ASCVD) is a complex pathophysiological process and encompasses a broad spectrum of disease, from subclinical atherosclerotic plaque to acute events with lifelong morbidity or sudden mortality. Many identified risk factors for ASCVD include elevated blood pressure, elevated total cholesterol, diabetes mellitus, overweight status, smoking, dietary factors, physical inactivity, and inadequate sleep. The medical community has traditionally dichotomized patients into primary and secondary prevention, which may be too simplistic. Recent biomarker, imaging, and pharmacotherapy trials have highlighted the importance of recognizing and treating subclinical atherosclerosis to mitigate the progression of subclinical disease and reduce the risk for highly morbid or lethal ASCVD events. Here, we describe the patient with subclinical atherosclerosis and risk factors as a "high-risk primary prevention" patient. Employing an optimal therapeutic strategy over the lifetime of a high-risk primary prevention patient can mitigate ASCVD progression and prevent ASCVD events. This review highlights biomarkers for identifying high-risk primary prevention patients and reviews clinical trials in this population. We then describe current data that guide the management of these patients and discuss future directions for management.