Risk Stratification in Secondary Prevention

Prevention and risk management of atherosclerotic vascular disease remain major health challenges. Coronary heart disease (CHD) and other cardiovascular diseases remain the primary causes of mortality and morbidity in developed countries. Improvement of risk stratification by identification of new biomarkers has been extensively investigated in both primary and secondary clinical settings in the past decade. A substantial number of biomarkers, representing various stages of atherogenesis and impaired cardiac function, have been evaluated against modifiable traditional risk factors, such as cholesterol, blood pressure, smoking status, and diabetes.1–4 However, whether these various biomarkers add incremental prognostic information to that provided by traditional risk factors is still controversial, and the clinical implications of “high” biomarker levels have yet to be determined. A multimarker strategy of combining biomarkers may theoretically help clinicians to stratify subjects into risk categories, but data on this subject are scarce.5,6Article p 201 In this issue of Circulation , Blankenberg and coauthors7 evaluate the prognostic value of multiple biomarkers compared with that of traditional risk factors on cardiovascular events in a large subgroup of the Heart Outcomes Prevention Evaluation (HOPE) study. The biomarkers examined cover a broad range of inflammation and endothelial activation, including C-reactive protein (CRP) and cellular adhesion molecules, as well as the cardiac neurohormone N-amino terminal of the prohormone brain natriuretic peptide (NT-proBNP). The well-known HOPE study was a randomized, clinical trial investigating ramipril and vitamin E in patients with CHD, peripheral vascular disease, diabetes, or previous stroke. A total of 3199 patients with available blood samples for subsequent biomarker analyses were enrolled in the subgroup examined by Blankenberg et al. Patients were followed up with respect to recurrent cardiovascular events, including myocardial infarction, stroke, and cardiovascular mortality as the primary end points of the HOPE study. As expected from existing literature among …