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The Global Epidemic of Cardiovascular Disease – Diagnostic Standards
and the Role of the Clinical Laboratory in Primary and Secondary Prevention
and Risk Stratification
Professor M. J. McQueen
There is a global epidemic of atherosclerosis and the future disease burden is probably
underestimated because projections do not account for potential increases in risk factors
such as obesity, diabetes, dyslipidemia, hypertension, smoking, and urbanization.
Population based studies now suggest that 80% to 90% of CVD susceptibility can be
explained by a relatively small number of “classical” risk factors. However, myocardial
infarction occurs in up to 50% of people without significant lipid abnormalities and this
has led to the investigation of novel risk factors such as lipoprotein(a), ApoA1, ApoB,
homocysteine, inflammatory markers, infectious markers, and oxidative stress factors.
The clinical laboratory has a significant role in diagnosis, risk stratification, management
and prognosis in acute coronary syndromes, as well as the primary and secondary
prevention of cardiovascular disease.
Myocardial infarction has been re-defined, giving primacy to the rise and fall of
biochemical markers of myocardial necrosis (troponin/CK-MB) accompanied by at least
one of several symptoms and signs. This has created analytical issues for the clinical
laboratory. The biochemical markers may be cardio-specific but there is still not one
which is ischemic heart disease specific, so various markers for myocardial ischemia
have been investigated. Inflammatory markers have been shown to have prognostic
value in identifying those patients with acute coronary syndrome who are at greater risk
of death or myocardial infarction.
For primary and secondary prevention of cardiovascular disease, lipids and lipoproteins,
LP(a), homocysteine, and many inflammatory markers such as oxidized LDL, IL1,
TNF-α, ICAM, VCAM, selectins, IL6, SAA, and CRP have all been investigated. The
evidence for hsCRP as a risk marker for subsequent cardiovascular events is more clearly
demonstrated in primary prevention than secondary prevention cohorts. Data will be
presented from our Heart Outcomes Prevention Evaluation (HOPE) study relating to
inflammatory markers, multiple infection, heat shock proteins and their relative risk for
subsequent cardiovascular events. There is a need for more research to further define the
approach to therapeutic decision making, using markers of inflammation, infection, and
ventricular dysfunction (eg, natriuretic peptides).
File:shd.CV abstract