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Problems with Prevention: A Clinical Perspective

Problems with Prevention: A Clinical Perspective. Michel Accad, MD October 17, 2011 GABA Panel Discussion.  Prevention is bound to be difficult. Ann Intern Med 1961. Commonly Identified RFs. Disease. Risk Factor. Compatible with well-being over a wide range of values Continuum of risk

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Problems with Prevention: A Clinical Perspective

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  1. Problems with Prevention:A Clinical Perspective Michel Accad, MD October 17, 2011 GABA Panel Discussion

  2.  Prevention is bound to be difficult

  3. Ann Intern Med 1961

  4. Commonly Identified RFs

  5. Disease Risk Factor Compatible with well-being over a wide range of values Continuum of risk Risk is target for therapy (risk reduction) Statistical • Symptoms • Sharp demarcation from normal • Disease is target for therapy • Deterministic (present or not)

  6. Risk Factor ≠ Disease

  7. T H ED I S T I N C T I O NB E T W E E NR I S K F A C T O RA ND D I S E A S EH A SB E E NB L U R R E D

  8. Risk Assessment:A Fluid Concept • Imperfect Quantitative Models • Doctor’s perspective • Patient’s perspective • Patient’s means

  9. Treating Populations:The Paradox of Prevention

  10. Risk Factors:Disease by fiat • Cut-off numbers “define” disease • Numbers selected by super-committees • Changing cut-off numbers creates millions of patients overnight

  11. Risk factors as disease… …doctors as weathermen?

  12. 118 CVD Risk Factors And counting…

  13. Risk factor as disease • The problem of the J-curve Bad outcome Risk factor

  14. Public Awareness Campaigns… (the answer is most certainly yes…)

  15. “It is not the healthy who need a doctor, but the sick.” Matthew 9:12

  16. A better approach? Dr. is everything OK? DO I HAVE LATENT CVD?

  17. Focus on the early detection • Atherosclerosis • Hypertensive Cardiovascular Disease

  18. Vascular elasticity • Endothelial function • Digital retinal scan • CIMT • Microalbumin • Cardiac stress markers (eg. BNP) • Vascular calcium • Others

  19. Early detection approach PROS CONS Does not avoid problem of prediction Must distinguish disease patterns from age-related changes in the vasculature More expensive Not “validated” • Focused on the individual • Not a statistical assessment • Can be monitored in response to intervention • May identify patients without risk factors who have CVD • Facilitates dialogue regarding future risk

  20. The conundrum for early detection technologies A role for the private sector?

  21. The good news for the people

  22. Thank you

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