Integrating Coronary Atherosclerosis Burden and Progression with Coronary Artery Disease Risk Factors to Guide Therapeutic Decision Making

IMPORTANCE: Although atherosclerosis represents the primary driver of coronary artery disease, evaluation and treatment approaches have historically relied upon indirect markers of atherosclerosis that include surro-gates (cholesterol), signs (angina), and sequelae (ischemia) of atherosclerosis. Direct quantification and char-acterization of atherosclerosis may encourage a precision heart care paradigm that improves diagnosis, risk stratification, therapeutic decision-making, and longitudinal disease tracking in a personalized fashion.OBSERVATIONS: The American College of Cardiology Innovations in Prevention Working Group introduce the Atherosclerosis Treatment Algorithms that personalize medical interventions based upon atherosclerosis findings from coronary computed tomography angiography (CTA) and cardiovascular risk factors. Through integration of coronary CTA-based atherosclerosis evaluation, clinical practice guide-lines, and contemporary randomized controlled trial evidence, the Atherosclerosis Treatment Algorithms leverage patient-specific atherosclerosis burden and progression as primary targets for therapeutic inter-vention. After defining stages of atherosclerosis severity by coronary CTA, Atherosclerosis Treatment Algorithms are described for worsening stages of atherosclerosis for patients with lipid disorders, diabetes, hypertension, obesity, and tobacco use. The authors anticipate a rapid pace of research in the field, and conclude by providing perspectives on future needs that may improve efforts to optimize precision preven-tion of coronary artery disease. Importantly, the Atherosclerosis Treatment Algorithms are not endorsed by the American College of Cardiology, and should not be interpreted as a statement of American College of Cardiology policy. CONCLUSIONS AND RELEVANCE: We describe a precision heart care approach that emphasizes atherosclerosis as the primary disease target for evaluation and treatment. To our knowledge, this is the first proposal to use coronary atherosclerosis burden and progression to personalize therapy selection and therapy changes, respectively. DISCLOSURE: The American College of Cardiology Foundation has made an investment in Cleerly, Inc., mak-ers of a software solution that utilizes coronary CT angiography findings to evaluate coronary artery disease.(c) 2023 Elsevier Inc. All rights reserved. center dot The American Journal of Medicine (2023) 136:260-269

Automated summary

This article introduces a precision heart care approach that focuses on atherosclerosis as the primary target for evaluation and treatment. By directly quantifying and characterizing atherosclerosis, it aims to improve diagnosis, risk stratification, therapeutic decision-making, and personalized disease tracking. The American College of Cardiology has introduced the Atherosclerosis Treatment Algorithms, which personalize medical interventions based on coronary computed tomography angiography findings and cardiovascular risk factors, leveraging atherosclerosis burden and progression as primary targets for therapeutic intervention.