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Falk, shape aha 05, final

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Falk, shape aha 05, final

  1. 1. Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72Circulation. VP Consensus Document. 2003 Oct 7;108:1664-72
  2. 2. 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.
  3. 3. Heart attack caused by atherosclerosis Eradication: dream or reality?Eradication: dream or reality?
  4. 4. 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!
  5. 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. 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. 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. 8. 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!
  9. 9. http://www.aeha.org/ http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html 2004
  10. 10. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html
  11. 11. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html ↑↑BPBP ½½
  12. 12. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html
  13. 13. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html ↑↑CholChol 1/31/3
  14. 14. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html
  15. 15. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html SmokeSmoke 1/51/5
  16. 16. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html
  17. 17. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html ConventionalConventional risk factorsrisk factors 75%75%
  18. 18. Lancet 2004 364:937-52
  19. 19. 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!
  20. 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 preventableheart attacks are preventable ins killer #1, + severe disability onal approach has failed!
  21. 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!
  22. 22. 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!
  23. 23. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html
  24. 24. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html
  25. 25. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html Women ~ MenWomen ~ Men
  26. 26. AHA Statistics – 2005 Update. http://www.americanheart.org/downloadable/heart/1105390918119HDSStats2005Update.pdf 38% of all deaths in the US caused by CVD
  27. 27. 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?
  28. 28. 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.
  29. 29. Milestone Framingham’s risk factor conceptFramingham’s risk factor concept
  30. 30. Milestone Framingham’s risk factor conceptFramingham’s risk factor concept
  31. 31. Milestone Framingham’s risk factor conceptFramingham’s risk factor concept Causal factors versus predictors
  32. 32. Wald et al. Lancet 1994;343:75-9 ~80% overlap … considerable overlap …
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. Men CHD risk prediction (& treatment) Framingham risk factor scoringFramingham risk factor scoring
  37. 37. 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
  38. 38. 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
  39. 39. AHA Statistical Fact Sheet 2005. http://www.americanheart.org/downloadable/heart/1104962839076FS21DR5NEW.pdf Death Rates CHDCHD
  40. 40. AHA Statistical Fact Sheet 2005. http://www.americanheart.org/downloadable/heart/1104962839076FS21DR5NEW.pdf Death Rates StrokeStroke
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. Atherosclerosis 2005;181:93-100
  45. 45. 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
  46. 46. Hard to improve the predictive accuracy by adding novel factors Atherosclerosis 2005;181:93-100
  47. 47. Risk prediction by risk factor scoring considerable overlap, not useful for screeningconsiderable overlap, not useful for screening Atherosclerosis 2005;181:93-100
  48. 48. 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
  49. 49. 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
  50. 50. China Liu et al. JAMA 2004;291:2591-9 Framingham Risk Factor Scoring hard endpoints: predicted vs observedhard endpoints: predicted vs observed
  51. 51. Risk in Europe based on European populations susceptibility to causal risk factors: north vs southsusceptibility to causal risk factors: north vs south          
  52. 52. Susceptibility to disease similar risk factor exposuresimilar risk factor exposure →→ different risk of IHDdifferent risk of IHD NY < MA South < North China <<< Framingham
  53. 53. 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.
  54. 54. Best Marker of Susceptibility to CHD prevalent arterial diseaseprevalent arterial disease CHD risk equivalentsCHD risk equivalents NCEP ATP III 2002
  55. 55. AEHAAEHA
  56. 56. 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 + ++ +++
  57. 57. JACC 2005;46:173-5 The St. Francis Heart Study
  58. 58. The St. Francis Heart Study fewer hard endpoints than predictedfewer hard endpoints than predicted (Framingham)(Framingham) Grundy SM. JACC 2005;46:173-5
  59. 59. Grundy SM. JACC 2005;46:173-5 The St. Francis Heart Study more soft than hard endpointsmore soft than hard endpoints
  60. 60. 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 ?
  61. 61. 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 ?
  62. 62. 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 ?
  63. 63. 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 + ++ +++
  64. 64. http://www.aeha.org

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