Dr falk's slides part ii
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This document summarizes key points from a task force report on identifying and treating asymptomatic patients vulnerable to heart attack. It introduces a new paradigm focused on outcomes studies, measuring disease activity, and identifying the vulnerable plaque and patient. The report was chaired by Morteza Naghavi and had writing contributions from experts in cardiovascular imaging, risk assessment, and prevention. It aims to advance the field beyond traditional risk factor assessment alone.
![From:From: Morteza Naghavi, M.D.Morteza Naghavi, M.D. [mailto:mn2@vp.org]
Sent:Sent: Thu 3/3/2005 1:29 AMThu 3/3/2005 1:29 AM
To: Erling Falk
Subject:
Erling, please note the yellow box is Lower Risk not Low Risk, … . Mort](https://image.slidesharecdn.com/qyglpvbus3e08f0kpz1q-signature-ff2318a174bfd4e5f1d417a23528cae62d8d53b9035de413ac0871ada57f583e-poli-160914033508/85/Dr-falk-s-slides-part-ii-52-320.jpg)
Dr falk's slides part ii
- 1. 96% of deaths from CHD or stroke occur in people aged 55 and over* *Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003;326:1419-
- 4. Circulation 2004;110:227-39Circulation 2004;110:227-39 § Almost all people with zero or 1 risk factor have a 10-year risk <10%,§ Almost all people with zero or 1 risk factor have a 10-year risk <10%, and 10-year risk assessment in people with zero or 1 risk factorand 10-year risk assessment in people with zero or 1 risk factor is thus not necessary.is thus not necessary.
- 5. Low riskLow risk • S-chol <200 mg/dlS-chol <200 mg/dl • BPBP <<120/80120/80 • No smokingNo smoking • No diabetesNo diabetes JAMA 1999;282:2012-8
- 6. Low riskLow risk • S-chol <200 mg/dlS-chol <200 mg/dl • BPBP <<120/80120/80 • No smokingNo smoking • No diabetesNo diabetes <10% of population<10% of population JAMA 1999;282:2012-8
- 7. Low riskLow risk • S-chol <200 mg/dlS-chol <200 mg/dl • BPBP <<120/80120/80 • No smokingNo smoking • No diabetesNo diabetes <10% of population<10% of population High negativeHigh negative predictive value!predictive value! JAMA 1999;282:2012-8
- 12. 96% of deaths from CHD or stroke occur in people aged 55 and over* *Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003;326:1419- Trajectory: How early?
- 13. Susceptibility VulnerableVulnerable PatientPatient ~10% risk/y~10% risk/y Risk factors: Categorical levels
- 14. Susceptibility VulnerableVulnerable PatientPatient ~10% risk/y~10% risk/y Vulnerability: • Relative • Absolute (VP) Risk factors: Categorical levels
- 15. Susceptibility VulnerableVulnerable PatientPatient ~10% risk/y~10% risk/y Vulnerability: • Relative • Absolute (VP) Risk factors: Categorical levels Tool- dependent
- 21. Madjid et al. ATVB 2004;24:1775-82
- 22. ThrombusThrombus Lipid-rich core Vulnerable Plaque + Thrombosis+ Thrombosis →→ Fibrous cap Inflammation (macr, MMP) smcsmc Expansive growth (remodeling) AngiogenesisAngiogenesis
- 24. Figure 1. Occurrence of a first coronary event within 10Occurrence of a first coronary event within 10 yearsyears, estimated by Cox proportional hazards models in percentages. Left, Percentage estimated by a model with FRS (5 categories) adjusted for survey. Right, Percentage estimated for each of 5 FRS categories by a model with CRP (3 categories) adjusted for FRS (continuous) and survey. Probability values indicate significance status of CRPCRP in the Cox model. Wolfgang Koenig, SHAPE Report 2005
- 26. Clinical utility of very high (>10 mg/L) as well as very low (<0.5 mg/L) levels of hsCRP among those with 10-year Framingham estimated risks <10% (left) and between 10% and 20% (right). Circulation 2004;109:2818-25
- 27. Pepe et al. Am J Epidemiol 2004;159:882-90Pepe et al. Am J Epidemiol 2004;159:882-90
- 28. CRPCRP MPOMPO !! Pepe et al. Am J Epidemiol 2004;159:882-90Pepe et al. Am J Epidemiol 2004;159:882-90
- 29. Pepe et al. Am J Epidemiol 2004;159:882-90Pepe et al. Am J Epidemiol 2004;159:882-90
- 30. Circulation 2004 Dec 14;110:e532
- 31. Targeted therapy, proportionate to the severity of the disease
- 32. Causal factors Targeted therapy, proportionate to the severity of the disease
- 33. Mosca L. N Engl J Med 2002;347:1615-7. Editorial
- 35. Table 1. Direct medical costs (not charges) for numerous cardiovascular imaging and cardiac diagnostic tests as based upon the published evidence and as synthesized in the recent 34th Bethesda Conference of the American College of Cardiology and from the recent European Society for Cardiology’s Consensus Panel Report on cardiovascular magnetic resonance imaging $39Outpatient Office Visit $712Added Cost of Intravascular Ultrasound $296Single Photon Emission Computed Tomography $67Exercise ECG $247Advanced Lipid Analysis $13C-Reactive Protein Laboratory Measurement $13Cholesterol panel Comparative Costs $1,810Right / Left Heart Cateterization $1,272Positron Emission Tomography $450Magnetic Resonance Imaging* $283Other Computed Tomography $91Rest Echocardiography $87Electron Beam Tomography / Computed Tomography Coronary Calcium Scan $71Carotid Ultrasound $61Ankle Brachial Index CV Imaging Costs *Costs vary widely from ~$200 to $1,100 depending upon the procedure. SHAPE: Cost-Effectiveness Leslee Shaw, SHAPE Report 2005
- 36. Screen Testing Evaluating the Cost and Effectiveness of Strategies for Atherosclerotic Detection and Prevention The SHAPE EquationThe SHAPE Equation N = nN = n00 ×× ffcc ×× ffss ×× ffdd ×× fftt ×× ffee N Number of prevented atherosclerotic events n0 Number of atherosclerotic events in the baseline population fc Fraction of candidates in the baseline population fs Fraction of candidates who are screened fd Fraction of screened candidates who are detected for treatment ft Fraction of detected subjects who are effectively treated fe Fraction of effectively treated subjects in whom events are prevented George A. Diamond, SHAPE Writing Group
- 37. Raymond Bahr, SHAPE Report 2005 Early Heart Attack Care (EHACEHAC) and Chest Pain Centers ED
- 40. Raggi et al. AHJ 2001;141:375-82Raggi et al. AHJ 2001;141:375-82
- 41. Fatal and nonfatal MI risk and OR for each decile of calciumrisk and OR for each decile of calcium score (CS)score (CS) Raggi et al. AHJ 2001;141:375-82Raggi et al. AHJ 2001;141:375-82 n=676, age ~52y
- 42. Author N Mean Age, y (years ) Follow-up Duration, y (years) Calcium Score Cutoff Comparator Group for RR Calculation Relative Risk Ratio Arad (11) 1,173 53 3.6 CAC >160 CAC < 160 20.2 Detrano (12) 1,196 66 3.4 CAC >44 CAC <44 2.3 Park (13) 967 67 6.4 CAC >142.1 CAC <3.7 4.9 Raggi (14) 632 52 2.7 Top Quartile* Lowest Quartile 13 Wong (15) 926 54 3.3 Top Quartile (>270) First Score Quartile 8.8 Arad (16) 5,585 59 4.3 CAC ≥ 100 CAC <100 10.7 Kondos (17) 5,635 51 3.1 CAC No CAC 10.5 Greenland (18) 1,312 66 7.0 CAC>300 No CAC 3.9 Shaw (19) 10,377 53 5 CAC >400 CAC <10 8.4** Pletcher (20) (meta-analysis) 3,970 56 3.3 CAC >400 CAC=0 10.0 Harvey Hecht, SHAPE Report 2005 Predictive studies: Characteristics and Risk Ratio for Follow- Up Studies Using EBCT in Asymptomatic Persons
- 43. NEJM 2003;NEJM 2003; 349:465-73349:465-73 RR>10RR>10 Office-basedOffice-based risk assessmentrisk assessment
- 45. O’Leary et al. NEJM 1999;340:14-22
- 46. O’Leary et al. NEJM 1999;340:14-22
- 47. Figure 2: B-mode imaging of right carotid artery, bifurcation and internal and external carotid arteries. Images are obtained with ultrasound beam perpendicular to the vessel wall showing near wall, lumen and far wall. Distal 1 cm of common carotid, 1 cm of carotid bulb and 1 cm of proximal internal carotid artery are imaged for IMT measurement and detection of plaque.and detection of plaque. Naqvi and Douglas, SHAPE Report 2005
- 48. Best Marker of Susceptibility to CHD prevalent arterial diseaseprevalent arterial disease CHD risk equivalentsCHD risk equivalents NCEP ATP III
- 49. 96% of deaths from CHD or stroke occur in people aged 55 and over* *Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003;326:1419- Future research: • Outcome studies • Disease activity • Search for the VP
- 51. From Vulnerable Plaque to Vulnerable Patient – Part III Introducing a New Paradigm for the Prevention of Heart Attack; Identification and Treatment of the Asymptomatic Vulnerable Patient Screening for Heart Attack Prevention and Education (SHAPE) Task Force Report Chairman… Editorial Committee… Writing Group … Advisors… Morteza Naghavi, …… Harvey S. Hecht, Jay Cohn, Michael Jamieson, Daniel Berman, Ole Faergeman, Matthew J. Budoff, Zahi Fayad, John Rumberger, George A. Diamond, Leslee Shaw, Tasneem Z. Naqvi, Pamela Douglas, Raymond Bahr, Wolfgang Koenig, Jasenka Demirovic, Dan Arking, Victoria L.M. Herrera, Juan Badimon, Sanjay Kaul, Juhani Airaksinen, Yoram Rudy, Arturo G. Touchard, Robert S. Schwartz, Daniel Lane, Henrik Sillesen, Roger Blumenthal, Roxana Mehran, Stephane Carlier, Allen J. Taylor, …… Prediman K. Shah.
- 52. From:From: Morteza Naghavi, M.D.Morteza Naghavi, M.D. [mailto:mn2@vp.org] Sent:Sent: Thu 3/3/2005 1:29 AMThu 3/3/2005 1:29 AM To: Erling Falk Subject: Erling, please note the yellow box is Lower Risk not Low Risk, … . Mort
- 53. Risk assessment and stratification Risk factor/office-basedNCEP , 10-year risk Intermediate Risk 10-20% High Risk >20% Low(er) Risk <10% RR ~2RR ~2 Pletcher et al Arch Intern Med 2004;164:1285-92