4. •Prevention of
heart attacks must
be the primary
goal.
Treatment should
be regarded as
“locking the
barn door
after the
horse is
stolen”
Eugene Braunwald
Drug
Eluting
Stent
Lock!
5. What is new?
Shift in Paradigm:
- Atherosclerosis; an
inflammatory disease
- Non-flow limiting
plaque; the culprit in
most heart attacks
6.
7.
8. What is new?
Shift in Paradigm:
- Atherosclerosis; an
inflammatory disease
- Non-flow limiting
plaque; the culprit in
most heart attacks
49. 76.5 Million76.5 Million
AmericansAmericans
Have High CRPHave High CRP
Correlates of Elevated C-Reactive Protein Among Adults in the United States:
Findings From the 1999-2000 National Health and Nutrition Examination Survey
50. Greenland et al
JAMA August 2003, Vol 291 No7 P891-897
Major Risk Factors as Antecedents of Fatal and
Nonfatal Coronary Heart Disease Events
51.
52.
53.
54.
55.
56. Analogy of Smoking and Lung Cancer
Of course smoking is a strong risk factor for
lung cancer
but
in a town where almost everyone smokes,
smoking has no predictive value for
lung cancer.
Too many people have risk factors specially when
average cholesterol or high CRP is considered as risk
factors.
57. How Good Is NCEP III At Predicting MI?How Good Is NCEP III At Predicting MI?
JACC 2003:41 1475-9JACC 2003:41 1475-9 (Slide from J. Rumberger)(Slide from J. Rumberger)
222 patients with 1222 patients with 1stst
acute MI, no prior CADacute MI, no prior CAD
men <55 y/o (75%), women <65 (25%), no DMmen <55 y/o (75%), women <65 (25%), no DM
RiskRisk
>20%/>20%/
10 yrs.10 yrs.
RiskRisk
10-20%/10-20%/
10 yrs.10 yrs.
RiskRisk
<10%/<10%/
10 yrs.10 yrs.
NCEP GoalNCEP Goal
LDL<100LDL<100
NCEP GoalNCEP Goal
LDL<160LDL<160
NCEP GoalNCEP Goal
LDL<130LDL<130
Qualify for RxQualify for Rx
Not-Qualify for RxNot-Qualify for Rx
6%6% 6%6%
TotalTotal
12%12%
8%8% 10%10%
TotalTotal
18%18%
61%61%
9%9%
TotalTotal
70%70%
88% of these “young” patients who suffered a88% of these “young” patients who suffered a
first Myocardial Infarction were in thefirst Myocardial Infarction were in the
Low to Intermediate “risk” category accordingLow to Intermediate “risk” category according
To Framingham Risk AssessmentTo Framingham Risk Assessment andand
would have been missed as trulywould have been missed as truly
““High Risk” individuals who shouldHigh Risk” individuals who should
have been treated “aggressively”have been treated “aggressively”
59. •Screening for prevention of heart attack must be established as a
standard of practice in preventive cardiology.
•Comparing to most cancer with established screening guidelines,
screening for prevention of heart attack is more cost effective.
•Current risk factors are not desirable for screening and should NOT
be used as the first step
•High Prevalence
•Less than Desirable Predictive Value
•Numerous Risk Factors, More Emerging
•Risk factors are best for guiding and monitoring therapy
•Noninvasive tests capable of measuring the disease (structural
and or functional) at the arterial level should be considered as the
first step in screening.
Highlights from Santa Monica Meeting
60. This guideline has
been recently
released by the
three major
organizations.
Unlike for colon and
breast cancers in
which screening
tests for hidden
(subclinical) disease
are recommended,
for prevention of
heart attack, the
number one killer,
there is no such
recommendation for
screening and the
guideline is still
limited to the
assessment of
traditional risk
factors.
64. The Future Directions in SHAPE
(Screening for Heart Attack Prevention and Education -SHAPE)
Trajectory TestTrajectory Test
• Coronary Calcium
• Carotid IMT
• Coronary Calcium
• Carotid IMT
(-)(-) (+)(+)
Moderately
High Risk
Moderately
High Risk
High RiskHigh Risk
•Lifestyle
Modification
•Aggressive RF
Modification
•LDL<70
5 yrs
•Lifestyle
Modification
•Aggressive RF
Modification
•LDL<70
5 yrs
•Lifestyle
Modification
•LDL<100
•Reassess in 5
yrs
•Lifestyle
Modification
•LDL<100
•Reassess in 5
yrs
Asymptomatic Males ≥45y? and Females ≥55y? with no History of CVDAsymptomatic Males ≥45y? and Females ≥55y? with no History of CVD
•Follow “Very
High Risk” in
the 1st SHAPE
Guidelines
•Follow “Very
High Risk” in
the 1st SHAPE
Guidelines
Functional TestFunctional Test
• Noninvasive Molecular Imaging
of Plaque inflammation?
•Noninvasive Coronary
Endothelial Function?
• Noninvasive Molecular Imaging
of Plaque inflammation?
•Noninvasive Coronary
Endothelial Function?
≥?percentile?≥?percentile?
<?%?<?%?
≥?percentile?≥?percentile?
• Intravascular
VP Detection
for Safe and
Effective Local
Therapy
• Expensive
New Systemic
Therapies (Apo
A Injections...)
• Intravascular
VP Detection
for Safe and
Effective Local
Therapy
• Expensive
New Systemic
Therapies (Apo
A Injections...)
+?+?+?+?
Structural TestStructural Test
• Endothelial Dysfunction
•Carotid IMT
• Endothelial Dysfunction
•Carotid IMT
65. The Future Directions in SHAPE
(Screening for Heart Attack Prevention and Education -SHAPE)
Repeated
Trajectory Tests
Repeated
Trajectory Tests
• Endothelial Dysfunction?
•Carotid IMT?
• Endothelial Dysfunction?
•Carotid IMT?
(-)(-) (+)(+)
-RF’s-RF’s +RF’s+RF’s
•Lifestyle
Modification
•Aggressive RF
Modification
•Reassess in
5 yrs
•Lifestyle
Modification
•Aggressive RF
Modification
•Reassess in
5 yrs
•Lifestyle
Modification
•Reassess in 5
yrs
•Lifestyle
Modification
•Reassess in 5
yrs
Asymptomatic Males 20-45y? and Females ≥20-55y? with no History of CVDAsymptomatic Males 20-45y? and Females ≥20-55y? with no History of CVD
Genetic Tests for
Strong Genes
Genetic Tests for
Strong Genes
??
• Aggressive
Therapy and
Close
Monitoring
• Aggressive
Therapy and
Close
Monitoring
+?+?+?+?
-RF’s-RF’s +RF’s+RF’s
•Lifestyle
Modification
•Reassess in
5 yrs
•Lifestyle
Modification
•Reassess in
5 yrs
Genetic
Tests
Highly Predictive
Genetic
Tests
Highly Predictive
??