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0.5 mg, can reduce cardiovascular events in individuals with The SMART (Secondary Manifestation of ARTerial dise-
poor risk factor control or recurrent events despite optimal ase) model estimates the individual residual risk for recu-
therapy . rrent myocardial infarction, stroke, or vascular death (Table
8
2). The study included a cohort of patients in Utrecht, and
Residual thrombotic risk Table 1. Clinical parameters necessary for calculating residual risk
using the EUROASPIRE model
8, 33, 34
Acetylsalicylic acid is indicated for all patients with si- Country - (Serbia is included in the calculator)
gnificant coronary artery disease for lifelong use, in the ab- Cardiovascular risk (1 or 2 years)
sence of contraindications, at doses of 75-100 mg per day. Age
Dual antiplatelet therapy (aspirin + potent P2Y12 receptor
inhibitor, such as ticagrelor or prasugrel) is an essential Diabetes mellitus (DM and value HbA1c < 7%, DM and value HbA1c ≥ 7%)
component of optimal medication therapy within the first Previous CVI, HF, PAD, PCI, depression, anxiety
year of acute coronary syndrome in the absence of contrain- Non-HDL cholesterol
dications. In specific clinical cases (assessment of ischemic/ Glomerular filtration (eGFR)
thrombotic risk and bleeding risk, presence of comorbidi- Legend: CVI - Cerebrovascular Insult; HF - Heart Failure; PAD - Peripheral Arterial
ties such as atrial fibrillation requiring oral anticoagulant Disease; PCI - Percutaneous Coronary Intervention; DM - Diabetes Mellitus; HbA1C -
glycosylated hemoglobin or hemoglobin A1c.
therapy), antiplatelet therapy may be shortened (< 12 mon-
ths), extended (> 12 months), or modified . the results obtained were validated in several external clini-
4, 8
cal studies. However, the model included patients enrolled
before 2010 who were followed for 4.7 years, so it could not
Do models for estimating the residual reliably be applied to assess the ten-year risk. Additionally,
risks contribute to better clinical practice? it did not include parameters related to regional differences
in CVD incidence, as well as other diseases that may lead to
To define individual risk more closely within a universally fatal outcomes unrelated to CVD.
defined group of patients with very high cardiovascular risk,
several risk assessment models have been formulated. The SMART 2 model was developed by enhancing the
These models are based on easily “measurable“ clinical cha- mentioned parameters and included 377.399 patients with
racteristics of patients. Identifying patients with high and coronary, cerebral, and peripheral atherosclerosis aged 40
very high risk provides clinical guidance for the necessity of to 80 years, with 64.513 new events 35-37 . It is formulated in
implementing more intensive treatment and interventions such a way that using an online calculator, the residual risk
within a clearly defined period of follow-up. Table 2. Clinical parameters necessary for calculating residual risk
using the SMART model for countries with low and moderate risk 8,
The EUROASPIRE (European Action on Secondary Pre- 35
vention through Intervention to Reduce Events) initiative on Gender
secondary prevention began in the mid-1990s and has since
been conducted in five different studies. The results have Age
been incorporated into numerous clinical guidelines. They Time since cardiovascular event (number of years)
Type of cardiovascular event
have highlighted the high prevalence of smoking, diabetes, (coronary, peripheral or cerebrovascular arterial disease, aortic aneurysm)
obesity, and central obesity in the European population 33,
34 . Despite numerous therapeutic possibilities, target lipid Diabetes mellitus (yes/no)
and blood pressure levels are not being achieved. For this Value of systolic blood pressure
reason, EUROASPIRE IV (78 centers from 24 European coun- Creatinine
tries) and V cohorts of patients with coronary heart disease Hs CRP*
from 27 European countries were integrated to develop a Lipid profile: Total cholesterol, HDL cholesterol and LDL cholesterol
risk assessment model for patients younger than 75 years. Antiplatelet therapy (yes/no)
A prospective study included 12.484 patients followed for Legend: Hs CRP - High-sensitivity C-reactive protein.
approximately 1.7 years. The primary outcome - fatal car- * if values are not available, automatic calibration is applied using mean values from the
diovascular disease or recurrent hospitalization due to non- original cohort.
fatal myocardial infarction, stroke, heart failure, coronary and the possibility of its reduction through the optimization
artery bypass grafting (CABG), or percutaneous coronary in- of individual parameters can be calculated. It is expected to
tervention (PCI) - was recorded in 1,424 patients. The model be available for clinical use soon.
was validated in 20,148 patients after AMI from the SWED-
HEART registry. A calculator has been developed to estimate The SMART REACH model indeed estimates both the
the risk within the first and second year following the index ten-year residual and lifetime risk 37-39 . The model has been
event (Table 1), and Serbia is included in the model. developed and validated in the prospective SMART and
34
REACH cohorts: 14.259 (REACH Western Europe), 19.170
(REACH, North America), and 6.959 (SMART, Netherlands)

REVIEW PAPER Galenika Medical Journal, 2024; 3(9):42-47. 45