Clinical Pathway for Coronary Atherosclerosis in Patients Without Conventional Modifiable Risk Factors: JACC State-of-the-Art Review

Gemma A Figtree; Stephen T Vernon; Jason A Harmer; Michael P Gray; Clare Arnott; Eric Bachour; Giannie Barsha; David Brieger; Alex Brown; David S Celermajer; Keith M Channon; Nicholas W S Chew; James J H Chong; Clara K Chow; Peter A Cistulli; Patrick T Ellinor; Stuart M Grieve; Tomasz J Guzik; Emil Hagström; Alicia Jenkins; Garry Jennings; Anthony C Keech; Katharine A Kott; Leonard Kritharides; Mamas A Mamas; Roxana Mehran; Peter J Meikle; Pradeep Natarajan; Kazuaki Negishi; John O'Sullivan; Sanjay Patel; Peter J Psaltis; Julie Redfern; Philippe G Steg; David R Sullivan; Johan Sundström; Birgit Vogel; Andrew Wilson; Dennis Wong; Deepak L Bhatt; Jason C Kovacic; Stephen J Nicholls; CRE for CAD Collaborators

doi:10.1016/j.jacc.2023.06.045

Clinical Pathway for Coronary Atherosclerosis in Patients Without Conventional Modifiable Risk Factors: JACC State-of-the-Art Review

J Am Coll Cardiol. 2023 Sep 26;82(13):1343-1359. doi: 10.1016/j.jacc.2023.06.045.

Authors

Gemma A Figtree¹, Stephen T Vernon², Jason A Harmer³, Michael P Gray⁴, Clare Arnott⁵, Eric Bachour⁶, Giannie Barsha⁴, David Brieger⁷, Alex Brown⁸, David S Celermajer⁹, Keith M Channon¹⁰, Nicholas W S Chew¹¹, James J H Chong¹², Clara K Chow¹³, Peter A Cistulli¹⁴, Patrick T Ellinor¹⁵, Stuart M Grieve¹⁶, Tomasz J Guzik¹⁷, Emil Hagström¹⁸, Alicia Jenkins¹⁹, Garry Jennings²⁰, Anthony C Keech²¹, Katharine A Kott²², Leonard Kritharides²³, Mamas A Mamas²⁴, Roxana Mehran²⁵, Peter J Meikle²⁶, Pradeep Natarajan²⁷, Kazuaki Negishi²⁸, John O'Sullivan²⁹, Sanjay Patel³⁰, Peter J Psaltis³¹, Julie Redfern³², Philippe G Steg³³, David R Sullivan³⁴, Johan Sundström³⁵, Birgit Vogel²⁵, Andrew Wilson³⁶, Dennis Wong³⁷, Deepak L Bhatt³⁸, Jason C Kovacic³⁹, Stephen J Nicholls⁴⁰; CRE for CAD Collaborators

Collaborators

Affiliations

¹ Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia. Electronic address: Gemma.figtree@sydney.edu.au.
² Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
³ Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia.
⁴ Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia.
⁵ The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
⁶ Consumer Representative, Agile Group Switzerland AG, Zug, Switzerland.
⁷ Department of Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia.
⁸ National Centre for Indigenous Genomics, Australian National University, Canberra, Australian Capitol Territory, Australia; Telethon Kids Institute, Nedlands, Western Australia, Australia.
⁹ Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
¹⁰ British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.
¹¹ Department of Cardiology, National University Heart Centre, National University Health System, Singapore.
¹² Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.
¹³ Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.
¹⁴ Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
¹⁵ Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA; Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, Massachusetts, USA.
¹⁶ Department of Radiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Imaging and Phenotyping Laboratory, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia.
¹⁷ Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom; Department of Internal Medicine and Omicron Medical Genomics Laboratory, Jagiellonian University Medical College, Krakow, Poland.
¹⁸ Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.
¹⁹ National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia; Diabetes and Vascular Medicine, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.
²⁰ Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
²¹ National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia.
²² Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
²³ Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia; The ANZAC Research Institute, Concord Repatriation General Hospital, Concord, New South Wales, Australia.
²⁴ Keele Cardiovascular Research Group, Centre for Prognostic Research, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom.
²⁵ The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
²⁶ Baker Heart and Diabetes Institute, Melbourne, Vicotria, Australia.
²⁷ Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA; Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
²⁸ Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Kingswood, New South Wales, Australia.
²⁹ Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Precision Cardiovascular Laboratory, University of Sydney, Camperdown, New South Wales, Australia; Heart Research Institute, University of Sydney, Camperdown, New South Wales, Australia.
³⁰ Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Heart Research Institute, University of Sydney, Camperdown, New South Wales, Australia.
³¹ Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, SAHMRI, Adelaide, South Australia, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia.
³² The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia; Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.
³³ Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris, France.
³⁴ Department of Chemical Pathology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
³⁵ The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia; Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
³⁶ Menzies Centre for Health Policy and Economics, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.
³⁷ Monash Cardiovascular Research Centre, Monash University, Clayton, Victoria, Australia; MonashHeart, Monash Health, Clayton, Victoria, Australia.
³⁸ Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA.
³⁹ The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia.
⁴⁰ Victorian Heart Institute, Monash University, Clayton, Victoria, Australia.

Abstract

Reducing the incidence and prevalence of standard modifiable cardiovascular risk factors (SMuRFs) is critical to tackling the global burden of coronary artery disease (CAD). However, a substantial number of individuals develop coronary atherosclerosis despite no SMuRFs. SMuRFless patients presenting with myocardial infarction have been observed to have an unexpected higher early mortality compared to their counterparts with at least 1 SMuRF. Evidence for optimal management of these patients is lacking. We assembled an international, multidisciplinary team to develop an evidence-based clinical pathway for SMuRFless CAD patients. A modified Delphi method was applied. The resulting pathway confirms underlying atherosclerosis and true SMuRFless status, ensures evidence-based secondary prevention, and considers additional tests and interventions for less typical contributors. This dedicated pathway for a previously overlooked CAD population, with an accompanying registry, aims to improve outcomes through enhanced adherence to evidence-based secondary prevention and additional diagnosis of modifiable risk factors observed.

Keywords: atherosclerosis; cardiovascular risk; clinical pathway; coronary artery disease; primary prevention; secondary prevention.

Publication types

Review
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Atherosclerosis*
Coronary Artery Disease* / epidemiology
Critical Pathways
Heart Disease Risk Factors
Humans
Myocardial Infarction*

Abstract

Publication types

MeSH terms

Grants and funding