Imaging Biomarkers Enhance Early Detection of Atherosclerotic Cardiovascular Disease

Imaging biomarkers can detect and quantify atherosclerotic cardiovascular disease (ASCVD) in its early stages, enhancing standard risk-prediction models and addressing their limitations. This advancement allows for earlier detection and more personalized prevention of ASCVD, a significant global health concern.

“Atherosclerosis often develops silently for years. The goal is to identify subclinical disease in appropriately selected patients before symptoms or an acute event occur and then connect the finding to an effective preventive strategy,” stated Prabhakar Rajiah, MBBS, MD, a cardiovascular radiologist at the Mayo Clinic in Rochester, MN.

In 2023, cardiovascular disease was responsible for about one-third of all deaths globally, totaling approximately 19.2 million fatalities, with ASCVD as a prominent contributor.

“For some patients, the first manifestation of ASCVD is a heart attack or stroke. Earlier, more accurate risk assessment will allow us to intensify prevention before that happens,” Dr. Rajiah noted.

In a recent article published in RadioGraphics, Dr. Rajiah and his co-authors explored the imaging biomarkers available for detecting and assessing ASCVD, including established methods like coronary artery calcium (CAC) scoring and coronary CT angiography, along with newer techniques.

The review highlights emerging coronary biomarkers, such as quantitative plaque analysis and pericoronary and epicardial adipose tissue assessments, as well as extracoronary markers like carotid plaque imaging, aortic plaque and wall imaging, and arterial stiffness. They also point out opportunistic biomarkers detectable through routine imaging, including incidental coronary and extracoronary arterial calcification and breast arterial calcification.

Dr. Rajiah and colleagues emphasized that traditional ASCVD risk-prediction models may not accurately reflect a patient's true risk, particularly in those at borderline or intermediate risk. These models might underestimate ASCVD risk in individuals with chronic inflammatory conditions such as rheumatoid arthritis and HIV.

“Short-term estimates may understate lifetime risk in younger adults and may not fully capture risk in some populations, including people of South Asian ancestry,” Dr. Rajiah added.

Imaging can reveal signs of ASCVD, including plaque burden, composition, vascular inflammation, and arterial remodeling. When used alongside traditional risk factors, these biomarkers afford a comprehensive risk assessment and facilitate earlier detection. Moreover, they can enable personalized care when the appropriate imaging test is chosen. Dr. Rajiah remarked, “There is no one-size-fits-all imaging test.”

He recounted a case of an asymptomatic patient initially assessed as low risk with a CAC score of 0. However, due to a significant family history, coronary CT angiography (CCTA) was conducted, uncovering substantial non-calcified coronary plaque associated with plaque rupture risk. “The CCTA findings materially changed the patient’s risk assessment and prompted intensification of preventive therapy,” Dr. Rajiah explained.

He also highlighted the significance of residual inflammatory risk, stating that even with controlled lipid levels and traditional risk factors, some patients may still be at heightened risk due to ongoing vascular inflammation. Emerging biomarkers of coronary inflammation could play a role in identifying this residual risk, although their application in guiding therapy is still being developed.