The magnitude and composition of the residual risk vary substantially between patients and are influenced by numerous factors with partly synergistic effects ( Figure 1). Despite growing evidence and wider dissemination of intensive treatment in the setting of secondary prevention patients with established CVD remain at dramatic residual risk. Most of these risk factors can be altered and need to be treated aggressively in patients with established CV disease ( 9). Increasing age, higher body mass index, male gender and impaired renal function as well as classical risk factors like hypertension, smoking, hyperlipidemia, diabetes and genetic predisposition are associated with an increased risk for subsequent events. The onset of atherosclerosis is complex and multiple factors drive further progression of the disease ( 8). Residual risk and the need for novel options in secondary prevention This includes medical and non-medical interventions, both confirmed in randomized clinical trials resulting in strong evidence ( 7). Nevertheless, although relevant prognostic improvements can be achieved by modifying the CV risk profile ( 5, 6), secondary prevention needs to be optimized in order to reduce the global burden of the disease as well as the incidence of secondary events. Therefore, primary prevention will be key to address this growing problem. Moreover, CV disease has an important impact on medical resource utilization and associated costs ( 4). Patients with established cardiovascular (CV) disease are prone to suffer from subsequent events including stroke, myocardial infarction (MI) and death ( 1- 3). Keywords: Secondary prevention cardiovascular disease coronary artery disease (CAD) Against this background, individual efficacy, risk, and costs have to be considered when identifying patients for each new regime. It seems that a combination of an aggressive lipid-lowering treatment in combination with antithrombotic therapy could improve prognosis significantly (at least for distinct subgroups). Secondary prevention in coronary artery disease (CAD) holds a strong potential to reduce subsequent CV events, even CV death. Although life-style modifications and better utilization of established medical treatment options will remain first-line strategy, new medication is just about to enter the market. As of now, evolocumab, alirocumab and ticagrelor are on the market, while rivaroxaban and canakinumab are not yet licensed for the treatment of secondary prevention in CV disease. All of the trials reviewed included patients with stable CV disease on optimal medical treatment with a surprising similar mortality. Three main therapeutic targets are addressed: residual cholesterol, residual inflammatory and residual thrombotic risk. This review focuses on new options in secondary risk prevention as presented by these five major randomized controlled trials (RCT): PEGASUS-TIMI 54, COMPASS, FOURIER, ODYSSEY and CANTOS. Abstract: Patients with established cardiovascular (CV) disease remain at dramatic residual risk for subsequent events, despite growing evidence in secondary prevention and wider dissemination of intensive treatment.
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