Cardiovascular risk stratification in inflammatory-driven conditions: how far have we come?

Atherosclerotic cardiovascular disease (ASCVD) risk stratification has predominantly relied on conventional risk factors such as hypertension, hyperlipidemia, diabetes mellitus, smoking, and family history of premature ASCVD. These features, while important, often fail to capture the complex interplay of contributors to ASCVD. Inflammation is involved in the initiation, progression, and destabilization of atherosclerotic plaques. However, it has not been consistently included in cardiovascular risk stratification tools which are crucial to trigger interventions and prevent events. Thus, there has been a growing interest in incorporating inflammatory biomarkers into ASCVD risk assessment. Two researchers entered the search terms: "cardiovascular" AND "risk stratification" AND "inflammation" AND alternately the following aditional terms: "primary prevention" OR "secondary prevention" OR "residual risk" OR "inflammatory disease" in the PubMed and Open Evidence platforms. In total, 25 studies were analysed and discussed: 1 meta-analysis, 15 cohort studies, 9 cross-sectional studies. Other studies were included to support the evidence and provide context. Inflammatory-driven conditions can lead to a 24% to almost three-fold increase in cardiovascular mortality risk compared with the general population even in the absence of traditional risk factors. Furthermore, stratification of inflammatory-driven risk is largely unexplored in primary and secondary (residual risk) prevention. Traditional scores are least effective in the intermediate-risk group where a proportion of over 50% of individuals are misclassified. In secondary prevention, estimates show that 38% of individuals persist with elevated high-sensitivity C-reactive protein and these patients exhibit higher all-cause mortality, myocardial infarction and stroke rates at one year. In this review we aim to gather and appraise studies presenting alternatives to traditional risk assessment that consider the inflammatory contribution to cardiovascular events in primary and secondary prevention levels, as well as, in populations living with inflammatory-driven diseases.