Introducing Cardiovascular Precision Diagnostics in the 21st century: ready for Prime Time? - Christa Cobbaert

Christa Cobbaert, Professor and Chair of the IFCC Scientific Division

Leiden University Medical Centre, Leiden, the Netherlands

The delivery of healthcare to the highest standard without a further increase in cost, requires that clinical practice should become more effective and efficient. The current clinical care pathway for cardiovascular risk assessment is suboptimal, in that there remains considerable unexplained residual cardiovascular risk, even if LDL-C on treatment targets are met. It is time for a paradigm shift from traditional reactive medicine, often based on statin therapy and a one- size-fits-all-strategy, to proactive ‘P4 medicine’ (i.e. Preventive, Predictive, Personalized, Participatory) in which disease mechanisms and systems biology allow for a targeted and patient centric approach. To accomplish this, laboratory medicine should move towards a molecular definition of Health and Disease.

In the case of cardiovascular disease (CVD), measurements of traditional serum lipids do not fully capture biochemical residual CVD risk in all patients, whereas a serum apolipoprotein panel in addition to the lipid profile has the potential to provide more detailed information about a person’s risk for CVD. According to the state of science, apolipoprotein B (apo B) testing is recommended in the EAS/ESC guideline since 2019. In addition, since 2022 the latest EAS lipoprotein(a) (Lp(a)) consensus statement recommends to incorporate Lp(a) testing in clinical practice at least once in a patient’s lifetime. If the serum Lp(a) level is not considered, the absolute CVD risk might be underestimated substantially. For adequate assessment of a patients’ CVD risk accurate molar measurement of Lp(a) is a key requirement. 

Beyond apo B and Lp(a) testing, more relevant apolipoproteins (e.g. apo CIII) that provide insight in the pathophysiology of the dyslipidaemia are under investigation in clinical trials. These developments will facilitate the refining of diagnoses and therapeutic targets and will allow the use of more targeted therapies which will help reduce residual cardiovascular risk. When clinical and cost effectiveness of a comprehensive apolipoprotein panel is proven in the nearby future, a transition from promising apolipoprotein biomarkers to medical tests is anticipated with defined test roles in the CVD care pathways.