Seeing the Fire or Measuring the Smoke? Risk Biomarkers of Inflammation

By Brittany Weber, M.D., Ph.D.

Assistant Professor of Internal Medicine and Dermatology
Director of Cardio-Rheumatology and Cardio-Dermatology

Inflammation plays a central role in all stages of atherosclerosis, from initiation to plaque rupture, prompting growing interest in incorporating inflammatory markers into cardiovascular disease (CVD) risk stratification. Both systemic biomarkers and advanced imaging techniques are increasingly recognized as valuable risk assessment tools. At the #AHA25 session on inflammation and CVD, I debated the relative strengths of systemic biomarkers versus imaging-based assessment of inflammation.

Systemic biomarkers, particularly high-sensitivity C-reactive protein (hs-CRP), are widely used due to their accessibility, affordability, and reproducibility. Emerging biomarkers such as IL-6 offer additional insights but remain impractical for routine clinical use. A major limitation of systemic markers, however, is their lack of cardiovascular specificity; elevations may reflect inflammation from other causes. As a cardio-rheumatologist, I discussed how the future of treatments with novel biologics requires the cardiovascular community to develop a critical approach to both risk stratification and longitudinal monitoring of response to anti-inflammatory drugs.

Imaging provides complementary, localized information about vascular structure, function, and inflammatory activity. Coronary artery calcium (CAC) identifies the burden of subclinical atherosclerosis. PET imaging with [18F] FDG evaluates metabolic activity in plaques, while cardiac MRI detects myocardial edema and fibrosis. One of the most promising tools is coronary CT-based assessment of pericoronary adipose tissue. Refining this approach with radiomics produces the fat attenuation index (FAI), which has shown strong predictive value for cardiovascular events.

Imaging’s strength lies in its ability to localize and monitor disease, though access, cost, and radiation exposure limit widespread use. A combined strategy – using biomarkers for broad screening and imaging for targeted evaluation – may improve precision in risk assessment and treatment monitoring. As novel biologics and anti-inflammatory therapies expand, cardiovascular prevention will increasingly require an integrated, biomarker-driven, precision-medicine approach bridging cardiology and emerging fields such as cardio-rheumatology.