Reducing the risk of heart attack: the key role of lipid profiling and atherosclerosis imaging.

Despite major improvements in primary and secondary prevention, a flattening in the improvement of survival curves of patients with or at risk of acute myocardial infarction has been reached in recent years. Pharmacological therapies that reduce LDL cholesterol (LDL-C) levels have shown incremental clinical and vascular benefits according to the achieved LDL-C levels. However, a non-negligible rate of events still occurs in patients achieving very low LDL-C levels. In addition to risk factors related to inflammatory pathways, emerging lipid-related factors seem to account for this residual atherothrombotic burden, with accumulative evidence establishing lipoprotein (a) (Lp(a)) as the single greatest emerging risk factor. Ongoing trials will evaluate whether the pharmacological reduction of Lp(a) levels reduces the incidence of cardiac events, and therefore may represent a novel therapeutic target. In addition, implementing atherosclerosis imaging may help improve traditional clinical scores to identify better patients at high risk of cardiovascular events who may benefit more from early and effective treatment strategies. In the era of tailored medicine, direct imaging of atherosclerosis can play a crucial role in helping clinicians better stratify patient risk and patients better understand the burden of their disease, ultimately improving medication adherence and goal attainment.