From the Guidelines
The management of early subclinical atherosclerosis should focus on aggressive risk factor modification through lifestyle changes and pharmacological interventions, prioritizing statin therapy, blood pressure control, and lifestyle modifications to reduce morbidity, mortality, and improve quality of life. According to the most recent guidelines, patients should adopt a heart-healthy diet, such as the Mediterranean or DASH diet, and engage in regular physical activity, aiming for at least 150 minutes of moderate-intensity exercise weekly 1. Maintaining a healthy weight and completely avoiding tobacco are also crucial components of lifestyle modification.
First-line pharmacological therapy typically includes statins, with moderate-intensity options like atorvastatin 10-20mg daily or rosuvastatin 5-10mg daily for those with borderline risk, and high-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) for those with multiple risk factors or evidence of progression 1. Aspirin therapy (81mg daily) may be considered for selected higher-risk patients after weighing bleeding risks, although its use is recommended infrequently in routine primary prevention of ASCVD due to lack of net benefit 1. Blood pressure should be controlled to targets below 130/80 mmHg using appropriate antihypertensives, and diabetes should be managed to maintain HbA1c below 7% 1.
Key aspects of management include:
- Adopting a heart-healthy diet
- Engaging in regular physical activity
- Maintaining a healthy weight
- Avoiding tobacco
- Using statin therapy as first-line pharmacological treatment
- Controlling blood pressure and diabetes
- Regular monitoring with non-invasive imaging to assess progression and treatment efficacy. Regular monitoring with non-invasive imaging (carotid ultrasound or coronary calcium scoring) every 1-2 years helps assess progression and treatment efficacy, allowing for adjustments in the management plan as needed 1. This comprehensive approach aims to stabilize plaque, prevent progression to clinical disease, and reduce the risk of future cardiovascular events by addressing the inflammatory and lipid-driven processes that underlie atherosclerosis development.
From the Research
Management Approach for the Progression of Early Subclinical Atherosclerosis
The management approach for the progression of early subclinical atherosclerosis involves a combination of lifestyle modifications and pharmacological interventions.
- The focus is on early detection and prevention of atherosclerosis, as it is a major cause of death but preventable 2.
- Subclinical atherosclerosis can be detected using imaging techniques such as vascular echography and assessment of coronary calcium, allowing for early diagnosis and intervention 3.
- Statins have been shown to delay and even revert the progression of subclinical atherosclerosis, making them a key component of the management approach 3.
- Other lipid-lowering therapies, such as fibrates, ezetimibe, and PCSK9 monoclonal antibodies, may also be used to reduce plasma cholesterol levels and modulate lipid metabolism 4.
- Lifestyle modifications, such as controlling risk factors like high blood pressure, diabetes, and obesity, are also crucial in preventing the progression of subclinical atherosclerosis 5, 6.
Determinants of Progression and Regression
The determinants of progression and regression of subclinical atherosclerosis include:
- Higher low-density lipoprotein cholesterol (LDL-C) and elevated systolic blood pressure (SBP), which increase the risk of progression, particularly in younger individuals 5.
- The impact of LDL-C and SBP on subclinical atherosclerosis progression is more pronounced in younger participants, suggesting that tighter risk factor control at younger ages could enhance prevention and reduce the risk of clinical events 5.
- Regression of subclinical atherosclerosis is possible in early stages of the disease, highlighting the importance of early intervention and management 5.
Ongoing Research and Studies
Ongoing studies, such as the Progression of Early Subclinical Atherosclerosis (PESA) study, are investigating the trajectories of atherosclerosis and associated disorders from early stages to the transition to symptomatic phases 6.