This document discusses strategies for screening patients for cardiovascular risk. It highlights several methods for evaluating risk, including calculating risk scores based on traditional risk factors as well as screening for subclinical disease using tests such as coronary artery calcium scoring and carotid intima-media thickness measurements. Finding and treating disease early, before symptoms occur, is important as atherosclerosis often begins decades before clinical events. Screening for and treating the underlying disease, not just risk factors, may help identify vulnerable patients at highest risk.

1. Heart Institute of the Caribbean (HIC)
CARDIAC RISK EVALUATION:
Searching for the vulnerable
patient

2. Screening
for the Risk
Factors for
the disease
Screening
for the
disease
The Disease: Atheroesclerosis

3. Types of Cardiovascular Disease

4. What do you think about this
patient ?
23 points,
22 % CV Risk

5. What do you think about this patient..?
18 points,
> 30 % CV Risk

6. The risk of develop CV disease ( CHD or Stroke) in
the next 10 years in percent (%) can be calculated
with the help of the Framingham Risk Score
Gender, Age, Total-C , HDL-C, SBP, Smoking status

7. Systematic COronary Risk Evaluation (SCORE): based on gender,
age, total cholesterol, systolic blood pressure and smoking status.
Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE.
Eur Heart J. 2003 May;24(9):882-3

8. Effects of any treatment (to lower
cholesterol / lower blood pressure) that
reduced the risk of CVD in 50 %
100
ptes
With
20%
CV
Risk 20
80
Treatment
10
80
10
Will develop CHD or Stroke in the
next 10 years
Will not develop CHD or
Stroke in the next 10 years

9. 1994 4S 2002 PROSPER
1995 WOSCOPS 2002 ALLHAT-LLA
1996 CARE 2002 ASCOT-LLA
1998 AFCAPS/TEXCAPS 2004 PROVE-IT
1998 LIPID 2004 A to Z
2001 MIRACL 2005 TNT
2002 HPS 2005 IDEAL
2008 JUPITER
Study populations:
Primary prevention
Acute coronary syndromes (Secondary prevention)
Chronic Coronary heart disease (Secondary prevention)
*Trials with clinical outcomes
HMG-CoA Reductase Inhibitor:STATINSHMG-CoA Reductase Inhibitor:STATINS
Chronological Order of Event Driven TrialsChronological Order of Event Driven Trials

10. Efficacy of antihypertensive treatmentEfficacy of antihypertensive treatment: Duration and homogeneity of
the efficacy of antihypertensive drugs are currently quantified by
computation of the smoothness index (SI) from ambulatory blood
pressure monitoring (ABPM) recordings.
The smoothness index (SI) identifies
the occurrence of a balanced 24 h
blood pressure reduction with
treatment and correlates with the
favourable effects of treatment on left
ventricular hypertrophy better than
the commonly used trough : peak
ratio.
According to the standard definition,
the SI is calculated as the ratio
between the mean hourly reductions
and the standard deviation of these
reductions. (American Journal of
Hypertension 2005; 18, 24A )

11. What do you think about this
patient ?
Lifetime Risk
50 %

12. What do you think about this
patient ?
Lifetime Risk
69 %

13. Future CV Risk Prediction:
Concept of Lifetime Risk
Lloyd-Jones et al. Circulation 2006; 113: 791-798
Framingham Heart Study: Optimization of RFs in asymptomatic
50 year-olds associated with low lifetime CVD risk
Optimal
Total chol <180
BP <120/80
Nonsmoker
Non diabetic
Not optimal
Total chol 180-200
BP 120-140/80-90
Elevated RF
Total chol 200-240
SBP 140-160/90-100
Major RF
Total chol >240
BP >160/90
Smoker
Diabetic

14. Other issues:
Low
H D L
Diabetes
Metabolic
Syndrome
Inflammation
HsCRP
Triglycerides
Stress

15. The “Super-Sizing” of America
“This year, Americans will spend more money on
fast food than on higher education…”
Eric Schlosser.Eric Schlosser. Fast Food Nation: The Dark Side of the All-American MealFast Food Nation: The Dark Side of the All-American Meal..
Harper Collins. 2002.Harper Collins. 2002.

16. Haffner SM, Lehto S, Ronnemaa T, et al: N Engl J Med 339:229–234, 1998
Diabetes is a “cardiovascular disease
risk equivalent”

18. Systemic inflammation
Eur Heart J 2010 (31) 3: 290-297

19. Current Opinion 2012; 142:w13502

20. Ps: Psychosocial stress as a risk factor

21. Many times the
traditional
risk factor based
screening
fails
in identifying
the Vulnerable Patient.
-

22. Sir Winston Churchill, 91Sir Winston Churchill, 91  Jim Fixx, 53Jim Fixx, 53 ♥♥
Who Has More Cardiovascular RiskWho Has More Cardiovascular Risk
Factors?Factors?

23. Existing Guidelines (Status Quo):
• Screen for Risk Factors of Atherosclerosis
• Treat Risk Factors of Atherosclerosis
Goal of “ new” Guidelines:
• Screen for Atherosclerosis (the Disease)
regardless of, Risk Factors
• Treat based on the Severity of the Disease
and its Risk Factors
ATHEROESCLEROSIS:
Risk Factor screen Vs the
disease screen

24. Slide 24
Atherosclerosis begins early :Usefulness and
Prognostic Implications of Surrogate Markers
in Atherosclerosis
Risk
factors
Surrogate
markers
Arterial
vascular
symptoms
Clinical
events
(MI,
sudden
death)
Autopsy
LateEarly
Adapted from Crouse JR III. J Lipid Res. 2006;47:1677–1699; Nissen S. Am J Cardiol. 2001;87(suppl):15A–20A.

25. Importance of
Subclinical Disease Detection
• Atherosclerosis begins early
• can be detected prior to a cardiac event
• Most MI’s -previously <40% stenosis
• plaque rupture and thrombus (blood clot)!
• Stress tests only detects flow-limiting stenoses
(blockages)
• Subclinical disease measures
• target patients for “aggressive primary prevention”

27. Evaluating coronary vasoreactivity
Eur. Heart J 2010 (31) 7, 777-783

28. 0
1
2
3
4
5
6
7
8
<0.5 0.5-
1.0
1.0-
2.0
2.0-
3.0
3.0-
4.0
4.0-
5.0
5.0-
10.0
10.0-
20.0
>20.0
Crude RRs Risks Adjusted for FRS
RRoffutureCardio.Events
Low risk Mod. risk High risk
hsCRP
mg/L
Ridker PM, et al. Circulation 2004;109:1955-9.
Higher CRP levels predict
increased risk for heart disease

30. From: Coronary Artery Calcium Scanning Should be Used for
Primary Prevention: Title and subTitle BreakPros J Am Coll
Cardiol Img. 2012;5(1):111-118. doi:10.1016/j.jcmg.2011.11.007

31. Coronary Artery CalciumCoronary Artery Calcium
No CalcificationNo Calcification Severe CalcificationSevere Calcification
Left Main
LAD
LCX
AortaAorta
LALA
PAPA
Left Main
LAD
Measurement of CAC may be reasonable for cardiovascular risk
assessment persons at low to intermediate risk (6% to 10% 10-year
risk).

32. Direct in vivo measurement of thickness
of carotid artery wall by B-mode
ultrasound – “arterial biopsy”
Vessel wall thickness correlates with
status of atherosclerosis and
cardiovascular events
Atherosclerosis is a systemic disorder
Disease in carotid artery is predictive of
disease in other vascular beds
Measurement of CA IMT
Adapted from Crouse JR III. J Lipid Res. 2006;47:1677–1699; Espeland MA, et al. Curr Controll Trials Cardiovasc Med. 2005;6:3; Kastelein JJP,
et al. Am Heart J. 2005;149:234–239. .

33. A well-established marker of atherosclerotic disease
CA IMT Measured by B-Mode Ultrasound

34. Slide 34
Rotterdam Study
CA IMT Strongly Predictive of MI
*Adjusted for age and gender
Adapted from van der Meer I, et al. Circulation. 2004;109:1089–1094.
1
1.68
2.05
2.91
0
1
2
3
<0.88 0.88–<0.99 0.99–<1.12 ≥1.12
CA IMT, mm
HazardRatio*
(n=1277) (n=1279) (n=1287) (n=1273)

35. Current: “Sick care” to “Health care”

36. Systematic COronary Risk Evaluation (SCORE): based on gender,
age, total cholesterol, systolic blood pressure and smoking status.
Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE.
Eur Heart J. 2003 May;24(9):882-3