Personalized Approach to Statin Selection in Primary Prevention: Genetic Risk Scores Vs Imaging Risk Scores

Abstract

This review addresses how assessment of coronary artery calcium (CAC) and information on genetic profile can guide statin therapy in primary prevention of atherosclerotic cardiovascular disease (ASCVD). CAC provides information beyond that given by standard risk factors, improving discrimination and risk reclassification, especially in the intermediate-risk stratum. A substantial proportion of individuals in primary prevention have CAC = 0 and very good prognosis over 10 years (ASCVD risk 100 is usually associated with 10-year ASCVD risk >7.5%, even in individuals considered to be at low risk by traditional risk factors. Recent studies have reported genetic risk scores (GRSs) for prediction of coronary artery disease (CAD), composed by a variable number (up to millions) of genetic variants. The most recent GRSs have shown to improve prediction of CAD over conventional risk factors. GRSs may also identify a subset of individuals (1 in 53) with risk of early-onset CAD as high as those with familial monogenic hypercholesterolemia. CAC score has a definite role in reclassifying individuals in primary prevention to more accurate risk strata, which may help decisions regarding statin initiation. CAC testing is appropriate in individuals aged 40–75 years with intermediate 10-year ASCVD risk (5–20%) and in selected cases of low risk. GRSs are rapidly evolving and recent data on CAD risk prediction are encouraging. More detailed information on ability to reclassify individuals and further validation are needed before their routine implementation. Nevertheless, a potential clinical utility can be envisioned, especially at younger ages, before the emergence of risk factors.