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Morteza Naghavi, M.D. Society for Heart Attack Prevention and Eradication (SHAPE )

Detection and Treatment of Asymptomatic Atherosclerosis for Primary Prevention of CVD. Morteza Naghavi, M.D. Society for Heart Attack Prevention and Eradication (SHAPE ). SHAPE 2012 Summit AHA 2012 Satellite Symposium November 2, 2012 Cedars Sinai Medical Center Los Angeles, California.

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Morteza Naghavi, M.D. Society for Heart Attack Prevention and Eradication (SHAPE )

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  1. Detection and Treatment of Asymptomatic Atherosclerosis for Primary Prevention of CVD Morteza Naghavi, M.D. Society for Heart Attack Prevention and Eradication (SHAPE) SHAPE 2012 Summit AHA 2012 Satellite Symposium November 2, 2012 Cedars Sinai Medical Center Los Angeles, California

  2. http://www.theheart.org/article/1459893.do

  3. The Problem

  4. > 15 Million Heart Attacks Each Year Source: World HeartFederation The AEHA 2005 VP Summit

  5. Unpredicted

  6. In >50% of victims, the first symptom of asymptomatic atherosclerosis is a sudden cardiac death or acute MI.

  7. Men Women 0 10 20 30 40 50 60 70 Patients Diagnosed with CHD (%) Murabito et al Circulation 1993 Sudden Cardiac Death or Acute MI as Initial Presentation of CHD 62% 42%

  8. Of 136,905 patients hospitalized with CAD, 77% had normal LDL levels below 130 mg/dl Modified from Sachdevaet al. AHJ, Vol 157, 111-117 Jan 2009 Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment. Humana Press, 2009

  9. Of 136,905 patients hospitalized with CAD, 45.4% had normal HDL levels above 40 mg/dl Modified from Sachdevaet al. AHJ, Vol 157, 111-117 Jan 2009 Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment. Humana Press, 2009

  10. Of 136,905 patients hospitalized with CAD, 61.8% had normal triglyceride levels below 150 mg/dl Modified from Sachdevaet al. AHJ, Vol 157, 111-117 Jan 2009 Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment. Humana Press, 2009

  11. Traditional Risk Factors Miss the Majority of High Risk Patients Akosah et al. JACC 2003:41 1475-9 70% 61% 18% 12% 9% 10% 8% 6% 6% 1998 – 2002. 222 patients with 1st acute MI, no prior CAD, no DM. Men <55 y/o (75%), Women <65. 40% hypertensive % of total would qualify for statin Rx would not qualify for statin Rx What was NCEP risk before the MI? Would they have received statin therapy or more intensive statin therapy? 10 yr risk <10% Goal LDL<160 mg/dL 10 yr risk >20% Goal LDL<100 mg/dL (optional < 70 mg/dL) 10 yr risk 10 - 20% Goal LDL<130 mg/dL (optional < 100 mg/dL) 75% would not qualify for statin Rx. High Risk Moderately High Risk Lower / Moderate Risk

  12. CONCLUSION: Relying on risk factors of atherosclerosis (i.e. cholesterol & blood pressure) mislead physicians and patients. A direct assessment of atherosclerosis is needed.

  13. Who Has More Cardiovascular Risk Factors? Jim Fixx, 53 Sir Winston Churchill, 91 

  14. Unexpected Sudden Death of Famous Cardiologists Helmut Drexler death with 58 years Philip Alexander Poole-Wilson death with 66 years March 4, 2009 Two weeks after Update in Cardiology In Davos

  15. Bottom Line: Status Quo IS Unacceptable

  16. ~50% Apparently Healthy People(New) ~50%CHD Patients (Recurrent) Naghavi et al. Circulation. 2003;108:1664 CVD Genotyping?

  17. ~50% Apparently Healthy People(New) ~50%CHD Patients(Recurrent) Naghavi et al. Circulation. 2003;108:1664 CVD Genotyping?

  18. The Vulnerable Patient Consensus Statement Preceding the SHAPE Initiative Naghavi et. al. Circulation Journal Vol108, No14; October 7, 2003

  19. The Vulnerable Patient Consensus Statement Preceding the SHAPE Initiative Naghavi et. al. Circulation Journal Vol108, No14; October 7, 2003

  20. First SHAPE Symposium

  21. SHAPE Task Force Meeting

  22. SHAPE Guidelines Published

  23. SHAPE Guidelines Published

  24. SHAPE v.s. Status Quo • Existing Guidelines (Status Quo): • Screen for Risk Factors of Atherosclerosis • Treat Risk Factors of Atherosclerosis • The SHAPE Guidelines: • Screen for Atherosclerosis (the Disease) Regardless of Risk Factors • Treat based on the Severity of the Disease and its Risk Factors

  25. ROC Curve, its AUC and Corresponding Odds Ratio hs-CRP LDL HDL Smoking HypertensionDiabetes etc. Risk Factors Based on the paper by Pepe e. al. Am J Epidemiol 2004; 159:882-890.

  26. ROC Curve, its AUC and Corresponding Odds Ratio Structural CAC +FRS IMT+FRS hs-CRP LDL HDL Smoking HypertensionDiabetes etc. Risk Factors Based on the paper by Pepe e. al. Am J Epidemiol 2004; 159:882-890.

  27. ROC Curve, its AUC and Corresponding Odds Ratio Structural Combined structural & functional? CAC +FRS IMT+FRS hs-CRP LDL HDL Smoking HypertensionDiabetes etc. Risk Factors Based on the paper by Pepe e. al. Am J Epidemiol 2004; 159:882-890.

  28. 1: No history of angina, heart attack, stroke, or peripheral arterial disease. 2: Population over age 75y is considered high risk and must receive therapy without testing for atherosclerosis. 3: Must not have any of the following: Chol>200 mg/dl, blood pressure >120/80 mmHg, diabetes, smoking, family history, metabolic syndrome. 4: Pending the development of standard practice guidelines. 5: High cholesterol, high blood pressure, diabetes, smoking, family history, metabolic syndrome. 6: For stroke prevention, follow existing guidelines.

  29. SHAPE II Guidelines– Under Discussions Step 1 Calculate 10yr Risk using Risk Calculators such as Framingham Risk Score1 10y Risk 6%-20% 10y Risk <6% 10yr Risk >20% No test: Follow Preventive Recommendations as in Low Risk Diabetics >40yr or family history of premature coronary artery disease Optional No test: Follow Preventive Recommendations as in High Risk Atherosclerosis Test Carotid IMT & Plaque CIMT >75th% and (or?) Plaque>1.5mm Step 2 CIMT <75th % or Plaque<1.5mm Coronary Artery Calcium Scan (CACS) Step 3 Very Low Risk2 CACS =0 Low Risk2 CACS <100 &<75th% Intermediate Risk2 CACS 100-399 &<75th% High Risk CACS 400 or  75th% Diet,Exercise, Smoking Cessation, BP and Diabetes Control See the SHAPE II Task Force report for further cardiac imaging tests in selected High Risk individuals. Consider LDL Target Consider HDL and TG Rx 1 http://www.framinghamheartstudy.org/risk/hrdcoronary.html 2Elevate to High Risk if 1.4<Ankel Brachail Index <0.9

  30. SHAPE II Guidelines– Under Discussions Coronary Artery Calcium Score (CACS) or Carotid Plaque Burden Carotid Plaque 0 Carotid Plaque CACS>400 or >75th% CACS 100-399 &<75th% Lowest Tertile Carotid Plaque Middle Tertile Carotid Plaque Highest Tertile Carotid Plaque Low Risk Intermediate Risk High Risk Lowest Risk

  31. Some of the Members of the SHAPE Task Force (left to right): Drs Budoff, Falk, Rumberger, Naghavi, Fayad, Hecht, and Berman

  32. Current National Preventive Care Reimbursement PoliciesDo Not Match the Burden of the ProblemInadequate & Disproportionate

  33. Why do we screen for asymptomatic cancers but ignore asymptomatic CVD?

  34. <$100 for # 1 killer >$1000 for # 2 Killer

  35. Cost Effectiveness of the SHAPE Guidelines

  36. poly pills

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