Short-Term Progression of Multiterritorial Subclinical Atherosclerosis

There has been great interest in the evaluation of subclinical atherosclerosis to improve on

cardiovascular risk prediction. Several studies have focused on examining atherosclerosis 1 vascular territory at a time and they showed the presence of single or different  positive vascular territory is directly associated with the risk of subsequent CVD events.

In the  issue of April 14 2020 of the Journal of The American College of Cardiology, López-Melgar et al. reported report results from the PESA (Progression of Early Subclinical Atherosclerosis) study, in which thirty-five hundreds  participants underwent and extensive evaluation of the coronary (using CT detection of coronary arteries calcifications) and peripheral (using 2D and  3D vascular ultrasound) atherosclerosis.

The PESA investigators could observe that, from baseline to 3 years follow-up:

• Atherosclerosis progression occurred in in 41.5% of middle-aged individuals.
• Disease onset and progression occurred much earlier in noncoronary vessels than in coronary arteries, and coronary atherosclerosis progression, (estimated by coronary artery calcifications progression (CACS), was more common in individuals with detectable baseline peripheral atherosclerosis, reinforcing the evidence on the tight connection between progression of atherosclerosis in the coronaries versus other territories
• Atherosclerosis progression was associated with most conventional cardiovascular risk factors, being dyslipidaemia the most important modifiable one
• Although progression rates increased in parallel with estimated cardiovascular risk, even in those classified as low-risk status, more than one-third had at least some progression of atherosclerosis progression

There are some important points that could be of interest for investigators and clinicians that deals with aortic and peripheral artery disease:

1. Unlike coronary artery calcification evaluation, 3D vascular ultrasound can evaluate progression of overall atherosclerotic burden, which may be more sensitive for assessing changes in atherosclerotic plaque than assessing only calcified atherosclerosis. It will be important in the future to show whether atherosclerosis burden measured by this technique can be reproducibly assessed, whether it predicts future CVD events as strongly as CAC does.
2. We should always ask ourselves how both baseline atherosclerosis and rate of progression might affect how we manage the patient, a standard to which any imaging technique should be held. Currently, we have guidance on how and when to prescribe statins in the case of CACS,  it will be of use to have similar indications according to the presence and progression of atherosclerosis assessed by 3D vascular ultrasound.

Finally,  although a multisite evaluation of the atherosclerotic burden is appealing approach, further research is needed to clarify how these imaging modalities complement conventional risk stratification and confirm the association of progression of early disease with cardiovascular events during long-term follow-up.