Falk, shape aha 05, final
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Falk, shape aha 05, final
- 2. Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72
- 3. Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72 Available screening and diagnostic methods areAvailable screening and diagnostic methods are insufficient to identify the victims before the eventinsufficient to identify the victims before the event occurs.occurs.
- 4. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality?
- 5. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are known heart attacks are preventable ins killer #1, + severe disability onal approach has failed!
- 6. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are known heart attacks are preventable ins killer #1, + severe disability onal approach has failed!
- 7. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are known heart attacks are preventable ins killer #1, + severe disability onal approach has failed!
- 8. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are known heart attacks are preventable ins killer #1, + severe disability onal approach has failed!
- 9. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are knownl risk factors are known heart attacks are preventable ins killer #1, + severe disability onal approach has failed!
- 10. http://www.aeha.org/ http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html 2004
- 20. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are knownl risk factors are known heart attacks are preventable ins killer #1, + severe disability onal approach has failed!
- 21. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are knownl risk factors are known heart attacks are preventableheart attacks are preventable ins killer #1, + severe disability onal approach has failed!
- 23. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are knownl risk factors are known heart attacks are preventableheart attacks are preventable ins killer #1, + severe disability onal approach has failed!
- 24. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are knownl risk factors are known heart attacks are preventableheart attacks are preventable ins killer #1,ins killer #1, + severe disability+ severe disability onal approach has failed!
- 28. AHA Statistics – 2005 Update. http://www.americanheart.org/downloadable/heart/1105390918119HDSStats2005Update.pdf 38% of all deaths in the US caused by CVD
- 29. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality? l risk factors are knownl risk factors are known heart attacks are preventableheart attacks are preventable ins killer #1,ins killer #1, + severe disability+ severe disability onal approach has failed! Why?
- 30. Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72 Available screening and diagnostic methods areAvailable screening and diagnostic methods are insufficient to identify the victims before the eventinsufficient to identify the victims before the event occurs.occurs.
- 31. Milestone Framingham’s risk factor conceptFramingham’s risk factor concept
- 32. Milestone Framingham’s risk factor conceptFramingham’s risk factor concept
- 33. Milestone Framingham’s risk factor conceptFramingham’s risk factor concept Causal factors versus predictors
- 35. Wald et al. Lancet 1994;343:75-9 ~80% overlap … considerable overlap …
- 36. Relative odds individual at the 90individual at the 90thth centilecentile vsvs individual at the 10individual at the 10thth (RO(RO10-9010-90)) High risk Low risk ~80% overlap Wald et al. Lancet 1994;343:75-9
- 37. Relative odds individual at the 90individual at the 90thth centilecentile vsvs individual at the 10individual at the 10thth (RO(RO10-9010-90)) RO10-90 = 13 poor screening testpoor screening test High risk Low risk ~80% overlap Wald et al. Lancet 1994;343:75-9
- 40. Relative distributions of risk factors in men who subsequently died of IHD and in men who did not. Gaussian distribution fitted to data from a cohort of 22 000 men22 000 men followedfollowed prospectively for 10 yearsprospectively for 10 years (the BUPA study) Wald, Law. BMJ 2003;326:1419-23
- 41. Men CHD risk prediction (& treatment) Framingham risk factor scoringFramingham risk factor scoring
- 43. Predictive accuracyPredictive accuracy •.90-1 = excellent.90-1 = excellent •.80-.90 = good.80-.90 = good •.70-.80 = fair.70-.80 = fair •.60-.70 = poor.60-.70 = poor •.50-.60 = fail.50-.60 = fail http://gim.unmc.edu/dxtests/ROC3.htm 1 D’Agostino et al. JAMA 2001 AHA Statistical Fact Sheet 2005. Framingham1 M: 0.79; W: 0.83M: 0.79; W: 0.83 Framingham Risk Factor Scoring discrimination between +/- CHD events: AUROC curvediscrimination between +/- CHD events: AUROC curve
- 44. Honolulu1 0.720.72 New York2 0.680.68 1 D’Agostino et al. JAMA 2001; 2 Arad et al. JACC 2005 AHA Statistical Fact Sheet 2005. Physicians' Health Study1 0.630.63 Cardiovascular Health Study1 (NC, CA, MD, PA) M: 0.63; W: 0.66M: 0.63; W: 0.66 Framingham1 M: 0.79; W: 0.83M: 0.79; W: 0.83 Framingham Risk Factor Scoring discrimination between +/- CHD events: AUROC curvediscrimination between +/- CHD events: AUROC curve Predictive accuracyPredictive accuracy •.90-1 = excellent.90-1 = excellent •.80-.90 = good.80-.90 = good •.70-.80 = fair.70-.80 = fair •.60-.70 = poor.60-.70 = poor •.50-.60 = fail.50-.60 = fail http://gim.unmc.edu/dxtests/ROC3.htm
- 45. AHA Statistical Fact Sheet 2005. http://www.americanheart.org/downloadable/heart/1104962839076FS21DR5NEW.pdf Death Rates CHDCHD
- 46. AHA Statistical Fact Sheet 2005. http://www.americanheart.org/downloadable/heart/1104962839076FS21DR5NEW.pdf Death Rates StrokeStroke
- 47. Framingham Risk Factor Scoring discrimination between +/- CHD events: AUROC curvediscrimination between +/- CHD events: AUROC curve Predictive accuracyPredictive accuracy • .90-1 = excellent.90-1 = excellent • .80-.90 = good.80-.90 = good • .70-.80 = fair.70-.80 = fair • .60-.70 = poor.60-.70 = poor • .50-.60 = fail.50-.60 = fail http://gim.unmc.edu/dxtests/ROC3.htm
- 48. UK1 0.620.62 1 Cooper et al, Ath 2005 2 Danesh et al. NEJM 2004 3 Ferrario et al. IJE 2005 4 Thomsen et al. IJE 2002 5 Hense et al. EHJ 2003 Iceland2 0.640.64 Denmark4 0.750.75 GermanyMünster5 M: 0.73; W: 0.77M: 0.73; W: 0.77 Framingham Risk Factor Scoring discrimination between +/- CHD events: AUROC curvediscrimination between +/- CHD events: AUROC curve Predictive accuracyPredictive accuracy • .90-1 = excellent.90-1 = excellent • .80-.90 = good.80-.90 = good • .70-.80 = fair.70-.80 = fair • .60-.70 = poor.60-.70 = poor • .50-.60 = fail.50-.60 = fail http://gim.unmc.edu/dxtests/ROC3.htm Belfast1 0.660.66 France1 0.680.68 Italy3 0.720.72
- 49. UK1 0.620.62 PROCAM in UK1 0.630.63 1 Cooper et al, Ath 2005 2 Danesh et al. NEJM 2004 3 Ferrario et al. IJE 2005 4 Thomsen et al. IJE 2002 5 Hense et al. EHJ 2003 UK in UK1 0.640.64 Iceland2 0.640.64 Italy3 0.720.72 Denmark4 0.750.75 GermanyMünster5 M: 0.73; W: 0.77M: 0.73; W: 0.77 Framingham Risk Factor Scoring discrimination between +/- CHD events: AUROC curvediscrimination between +/- CHD events: AUROC curve Predictive accuracyPredictive accuracy • .90-1 = excellent.90-1 = excellent • .80-.90 = good.80-.90 = good • .70-.80 = fair.70-.80 = fair • .60-.70 = poor.60-.70 = poor • .50-.60 = fail.50-.60 = fail http://gim.unmc.edu/dxtests/ROC3.htm Belfast1 0.660.66 France1 0.680.68 PROCAM in It3 : 0.740.74 CUORE in It3 : 0.740.74
- 51. Atherosclerosis 2005;181:93-100 Predictive accuracy of risk factor scoring PROCAM: 0.63; Framigham = 0.62PROCAM: 0.63; Framigham = 0.62 Predictive accuracyPredictive accuracy • .90-1 = excellent.90-1 = excellent • .80-.90 = good.80-.90 = good • .70-.80 = fair.70-.80 = fair • .60-.70 = poor.60-.70 = poor • .50-.60 = fail.50-.60 = fail http://gim.unmc.edu/dxtests/ROC3.htm
- 52. Hard to improve the predictive accuracy by adding novel factors Atherosclerosis 2005;181:93-100
- 53. Risk prediction by risk factor scoring considerable overlap, not useful for screeningconsiderable overlap, not useful for screening Atherosclerosis 2005;181:93-100
- 54. Framingham Risk Factor Scoring discrimination between +/- CHD events: AUROC curvediscrimination between +/- CHD events: AUROC curve China M: 0.74; W: 0.76M: 0.74; W: 0.76 Liu et al. JAMA 2004;291:2591-9 Predictive accuracyPredictive accuracy • .90-1 = excellent.90-1 = excellent • .80-.90 = good.80-.90 = good • .70-.80 = fair.70-.80 = fair • .60-.70 = poor.60-.70 = poor • .50-.60 = fail.50-.60 = fail http://gim.unmc.edu/dxtests/ROC3.htm
- 55. Framingham Risk Factor Scoring hard endpoints: predicted vs observedhard endpoints: predicted vs observed Liu et al. JAMA 2004;291:2591-9 Hard endpoints/10-yHard endpoints/10-y 20% 3% China
- 56. China Liu et al. JAMA 2004;291:2591-9 Framingham Risk Factor Scoring hard endpoints: predicted vs observedhard endpoints: predicted vs observed
- 57. Risk in Europe based on European populations susceptibility to causal risk factors: north vs southsusceptibility to causal risk factors: north vs south
- 58. Susceptibility to disease similar risk factor exposuresimilar risk factor exposure →→ different risk of IHDdifferent risk of IHD NY < MA South < North China <<< Framingham
- 59. Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72 Available screening and diagnostic methods areAvailable screening and diagnostic methods are insufficient to identify the victims before the eventinsufficient to identify the victims before the event occurs.occurs.
- 60. Best Marker of Susceptibility to CHD prevalent arterial diseaseprevalent arterial disease CHD risk equivalentsCHD risk equivalents NCEP ATP III 2002
- 61. AEHAAEHA
- 62. Atherosclerosis Test Negative Positive No Risk Factors + Risk Factors Step 1 Test for Presence of the Disease Step 2 Stratify based on the Severity of the Disease and Presence of Risk Factors Step 3 Treat based on the Level of Risk Lower Risk Moderate Risk Moderately High Risk High Risk Very High Risk Apparently Healthy At-Risk Population The 1st S.H.A.P.E. Guideline Towards the National Screening for Heart Attack Prevention and Education (SHAPE) Program Conceptual Flow Chart <75th Percentile 75th-90th Percentile ≥90th Percentile + ++ +++
- 63. JACC 2005;46:173-5 The St. Francis Heart Study
- 64. The St. Francis Heart Study fewer hard endpoints than predictedfewer hard endpoints than predicted (Framingham)(Framingham) Grundy SM. JACC 2005;46:173-5
- 65. Grundy SM. JACC 2005;46:173-5 The St. Francis Heart Study more soft than hard endpointsmore soft than hard endpoints
- 66. Grundy SM. JACC 2005;46:173-5 Risk prediction in clinical practice ? current risk categories retained, all events included ?? current risk categories retained, all events included ?
- 67. Grundy SM. JACC 2005;46:173-5 Risk prediction in clinical practice ? current risk categories retained, all events included ?? current risk categories retained, all events included ?
- 68. Grundy SM. JACC 2005;46:173-5 Risk prediction in clinical practice ? current risk categories retained, all events included ?? current risk categories retained, all events included ?
- 69. Atherosclerosis Test Negative Positive No Risk Factors + Risk Factors Step 1 Test for Presence of the Disease Step 2 Stratify based on the Severity of the Disease and Presence of Risk Factors Step 3 Treat based on the Level of Risk Lower Risk Moderate Risk Moderately High Risk High Risk Very High Risk Apparently Healthy At-Risk Population The 1st S.H.A.P.E. Guideline Towards the National Screening for Heart Attack Prevention and Education (SHAPE) Program Conceptual Flow Chart <75th Percentile 75th-90th Percentile ≥90th Percentile + ++ +++