Multimodality Strategy for Cardiovascular Risk Assessment

Study Questions:

Does a combination of biomarker improve cardiovascular disease (CVD) risk assessment among adults without known CVD?


Data from two studies, MESA (Multi-Ethnic Study of Atherosclerosis; n = 6,621) and DHS (Dallas Heart Study; n = 2,202) were used for the present analysis. Participants were included in the current analysis if they were free from CVD and had the following measures (left ventricular hypertrophy by electrocardiogram [ECG-LVH], coronary artery calcium [CAC], N-terminal pro–B-type natriuretic peptide [NT-proBNP], high-sensitivity cardiac troponin T [hs-cTnT], and high-sensitivity C-reactive protein [hs-CRP]). Associations of test results with the global composite CVD outcome (CVD death, myocardial infarction [MI], stroke, coronary or peripheral revascularization, incident heart failure, or atrial fibrillation) and atherosclerotic CVD (ASCVD; fatal or nonfatal MI or stroke) were assessed over >10 years of follow-up.


Mean age at enrollment was 62 years for MESA and 44 years for DHS. Over a median of 11 years of follow-up, a total of 1,026 CVD events occurred in MESA and in DHS 179 global CVD events occurred over a median of 10.3 years of follow-up. Each test result was independently associated with global composite CVD events in MESA after adjustment for the components of the base model and the other test results (p < 0.05 for each). When the five tests were added to the base model, the c-statistic improved from 0.74 to 0.79 (p = 0.001), significant integrated discrimination improvement (0.07, 95% confidence interval [CI], 0.06-0.08; p < 0.001) and net reclassification improvement (0.47, 95% CI, 0.38-0.56; p = 0.003) were observed, and the model was well calibrated (X2 =12.2; p = 0.20). Using a simple integer score counting the number of abnormal tests, compared with those with a score of 0, global CVD risk was increased among participants with a score of 1 (adjusted hazard ratio [HR], 1.9; 95% CI, 1.4-2.6), 2 (HR, 3.2; 95% CI, 2.3-4.4), 3 (HR, 4.7; 95% CI, 3.4-6.5) and >4 (HR, 7.5; 95% CI, 5.2-10.6). Findings replicated in DHS and were similar for the ASCVD outcome.


The authors concluded that among adults without known CVD, a novel multimodality testing strategy using ECG-LVH, CAC, NT-proBNP, hs-cTnT, and hs-CRP significantly improved global CVD and ASCVD risk assessment.


This study suggests that additional criteria obtained from lab work and an ECG may be useful for identifying higher-risk adults who have no clinical CVD. Confirmation of the risk assessment in addition to the cost-benefit of such testing suggests that further evaluation is warranted prior to widespread adoption.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Atherosclerosis, Atrial Fibrillation, Biological Markers, C-Reactive Protein, Electrocardiography, Heart Failure, Hypertrophy, Left Ventricular, Myocardial Infarction, Myocardial Revascularization, Natriuretic Peptide, Brain, Peptide Fragments, Plaque, Atherosclerotic, Primary Prevention, Risk Assessment, Risk Factors, Stroke, Troponin T

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