替代風險標記在心血管風險評估中的角色

The Role of Surrogate Risk Markers in Cardiovascular Risk Assessment of ASCVD

傳統心血管風險評估，主要依賴年齡、性別、血壓、血脂、糖尿病與吸菸等危險因子，並以Framingham或Pooled Cohort Equations等族群模型，推估10年動脈粥樣硬化性心血管疾病（Atherosclerotic Cardiovascular Disease，ASCVD）風險。然而，在「低～中度風險」個體中，僅用危險因子，常不足以反映個別病人的實際動脈粥樣硬化負擔，導致治療強度不足或過度治療。替代（替代終點）或次臨床動脈粥樣硬化標記（surrogate／subclinical markers），能直接量測血管病變或血管老化程度，提供增量預測（incremental prognostic value）、改善風險分層與治療決策。本文系統性回顧3類臨床可用的替代標記：冠狀動脈鈣化（coronary artery calcium，CAC）、頸動脈超音波，含頸動脈內膜中層厚度（carotid intima-media thickness，cIMT）與斑塊／斑塊負荷、以及動脈硬度，以脈波傳導速度（pulse-wave velocity，PWV）為代表，並討論其測量要點、證據強度、指引建議與在台灣族群的實務應用方向。

Traditional cardiovascular risk assessment primarily relies on major risk factors such as age, sex, blood pressure, lipid profile, diabetes mellitus, and smoking status. Population-based models, including the Framingham Risk Score and the Pooled Cohort Equations, are commonly used to estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). However, in individuals classified as having low to intermediate risk, risk factor–based estimation alone may not adequately reflect the true burden of atherosclerosis. This limitation can lead to either undertreatment or overtreatment in clinical practice. Surrogate endpoints or subclinical atherosclerosis markers provide direct assessment of vascular pathology and vascular aging, offering incremental prognostic value beyond traditional risk factors. These tools can enhance risk stratification and support more individualized therapeutic decision-making. This article systematically reviews three clinically applicable surrogate markers: coronary artery calcium (CAC), carotid ultrasonography (including carotid intima–media thickness [cIMT] and plaque/plaque burden), and arterial stiffness (with pulse-wave velocity [PWV] as the representative measure). We discuss key measurement considerations, strength of evidence, current guideline recommendations, and practical implications for implementation in the Taiwanese population.