YEAR IN CARDIOLOGY SERIES
The Year in Atherothrombosis
Javier Sanz, MD, Pedro R. Moreno, MD, FACC, Valentin Fuster, MD, P
H
D, FACC
New York, New York
The present review aims to summarize relevant studies
published during the last year in the field of atherothrom-
bosis. A special emphasis was placed on the promotion of
cardiovascular health worldwide, as well as on the need for
a progressive shift from the treatment of advanced disease to
early detection and enhanced prevention.
Epidemiology and Public Health Impact
Important information on the magnitude of the burden of
cardiovascular disease (CVD) became available in 2007.
During the last 2 decades, coronary heart disease (CHD)
age-specific death rates fell by Ͼ40% in high-income
countries (1,2). Prolonged survival has translated into grow-
ing disease prevalence and number of hospitalizations, with
much smaller reductions in absolute mortality and stagger-
ing financial burden: the estimated annual cost of CVD in
the U.S. is $431 billion (1,3). The 1-year incidence of death,
myocardial infarction (MI), stroke, or hospitalization for an
atherothrombotic event is 14% for patients with established
atherosclerotic disease, and 5% for patients with multiple
(Ͼ2) risk factors, according to an international registry (4).
With continuing increase in expenditure and progressive
aging of the population, the present healthcare system
appears unsustainable in the long run (5). The importance
of considering CVD a global health priority was empha-
sized: CVD is the main killer also in low- and middle-
income countries, and causes 3 times more deaths than the
most lethal infectious diseases combined. In developing
countries, CVD affects younger people of working age and
has additional economic impact (6).
Up to 50% of the reduction in age-adjusted mortality
from CHD can be attributed to the application of evidence-
based therapies rather than to effective prevention (1,2,7).
Although the remaining improvement in survival can be
explained by reductions in some risk factors, obesity and
diabetes markedly increased, as well as the burden of CVD
attributable to diabetes (2,8). Of major concern, risk profile
worsened in children and adolescents: hypertension, obesity,
diabetes, and physical inactivity escalated, whereas choles-
terol levels and tobacco use remained unchanged (9). In
developing regions, the prevalence of traditional risk factors
is on the rise in both adults and the young (6). According to
a survey in Ͼ168,000 primary care patients in 63 countries
worldwide, Ͼ60% of men and Ͼ50% of women are either
overweight or obese in all regions except southern and
eastern Asia (10). Approximately 25% of the world popu-
lation smokes, with two-thirds living in 15 low- and
middle-income countries (11). Tobacco smoke exposure
was shown to cause dose-dependent endothelial dysfunc-
tion in children (12). Smoking and obesity/inactivity
have become the 2 leading modifiable causes of prema-
ture death (13).
Early Detection and Risk Assessment
Traditional risk factors. Traditional risk factors continued
to be the cornerstone of prevention and risk stratification. A
report from NHANES (National Health and Nutrition
Examination Survey) estimated that the percentages of
adult Americans falling into the low, moderate, moderate-
to-high, high, and very-high risk categories are 61.1%,
17.2%, 5.4%, 10.6%, and 5.7%, respectively (Fig. 1)(14).
These findings suggest that the “intermediate-risk” group
may be smaller than previously thought. The European
Society of Cardiology updated region-specific charts for
predicting the 10-year risk of a first fatal atherosclerotic
event based on age, gender, smoking habit, systolic blood
pressure, and total cholesterol (15). In an attempt to
improve primary prevention worldwide, the World
Health Organization proposed the use of similar simpli-
fied region-specific charts that also consider the presence
of diabetes (16).
A number of studies evaluated the roles of lipids in
cardiovascular risk. The relationship between age, lipid
profile, and incident fatal MI was evaluated in Ͼ128,000
subjects followed for a mean of 10.3 years. Most of the
excess risk associated with age could be attributed to
long-term exposure to a proatherogenic lipid environment,
thus suggesting that it is potentially modifiable (17). Inde-
pendent, long-term associations with MI, CHD, and death
were also described for nonfasting concentrations of serum
triglycerides in both men and women (18).
Several studies addressed the relationship between obesity
and CVD. The waist-to-hip ratio was independently asso-
ciated with the presence of coronary calcium by computed
From The Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josee and
Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine,
New York, New York.
Manuscript received November 12, 2007; accepted December 13, 2007.
Journal of the American College of Cardiology Vol. 51, No. 9, 2008
© 2008 by the American College of Cardiology Foundation ISSN 0735-1097/08/$34.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2007.12.018