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Mi or scd in patients with very abnormal cardiac test results

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Mi or scd in patients with very abnormal cardiac test results

  1. 1. MI or SCD in Patients with VeryMI or SCD in Patients with Very Abnormal Cardiac Test ResultsAbnormal Cardiac Test Results 25% 12.3% Circ 1998;97:535-43 7.1% JACC 2001;37:1551-7 17% Cancer Database 0 5 10 15 20 25 30 EBT Score >1,000 Severe SPECT Abn. MWMA Stress Echo Lung Cancer Mortality AnnualEventRate(%) * Asymptomatic Subjects, No Intervention, 36 m. f/u, n=104 * Wayhs JACC 2002;39:225-30 ** ** Known Lung Cancer
  2. 2. 25 % 50 % 75 % 90 % Patient's Score Coronary Calcium Scores in Asymptomatic Women 1 10 100 1000 10000 35 40 45 50 55 60 65 70 75 80 Age CoronaryCalciumScore Coronary Calcium Scores in Asymptomatic Men 1 10 100 1000 10000 35 40 45 50 55 60 65 70 75 80 Age Electron Beam CT – Patient Database Hoff et al, Am J Cardiol 2001;87:1335-1339 EBT Database n=32,246
  3. 3. Prediction of MI/SCD in Asymptomatic Patients:Prediction of MI/SCD in Asymptomatic Patients: EBTEBT Raggi et al AHJ 2001;141:193-199Raggi et al AHJ 2001;141:193-199 0.36 0.51 0.71 0.99 1.38 1.92 2.64 3.62 4.9 6.54 0 1 2 3 4 5 6 7 0 10 20 30 40 50 60 70 80 90 Percentile Rank for Baseline EBCT Calcium Score 676 initially asymptomatic patients676 initially asymptomatic patients 3232++7 months f/u7 months f/u AnnualAnnual AbsoluteAbsolute RiskRisk
  4. 4. 15 1.25 1.6 1.6 1.8 2.15 2.35 2.5 5 Lp(a) Homocysteine TC Fibrinogen t-PA Ag TC/HDL hs-CRP hs-CRP + TC/HDL EBT Score > 75th RR in men from the Physicians Health Study - values in the upper quartile Meta-analysis of 6 EBT Studies Risk of MI in Apparently Healthy PeopleRisk of MI in Apparently Healthy People
  5. 5. 96% 16% 25% 8% 29% 8% 39% 0% 0 20 40 60 80 100 Obst. Disease 1-Vessel 2-Vessel 3-Vessel SCD (n=28) Control (n=18) Schmermund et alSchmermund et al AtherosclerosisAtherosclerosis 2001 Apr;155(2):499-5082001 Apr;155(2):499-508 %ofIncidence Obst. Disease: >75% area stenosis SCD in Patients Under the Age of 50 MOST acute coronary syndromes occur in patients with extensive pre-existing CAD
  6. 6. EBT and Vulnerable Plaque:EBT and Vulnerable Plaque: Stary ClassificationStary Classification I Isolated macrophage foam cells II Mainly intracellular lipid accumulation, “Fatty Streak” III Extra-cellular lipid pools, intra- and extra-cellular calcium IV Core of extra-cellular lipids, “Atheroma” V Lipid core covered by fibrous cap Fibroatheroma (Va)/Mainly calcific (Vb)/Mainly fibrotic (Vc) VI Surface defect (VIa)/Hematoma-hemorrhage (VIb)/Thrombus (VIc) “regression” possible potentially “vulnerable”
  7. 7. Clinical data confirm that coronary calcium by EBT is found in 96% of those patients either presenting or, in future, developing acute coronary syndromes - AND that the amount of CAC was significantly greater at baseline in such individuals compared with asymptomatic age and gender matched persons Histologic Plaque CharacteristicsHistologic Plaque Characteristics and Coronary Artery Calciumand Coronary Artery Calcium
  8. 8. Histologic Plaque CharacteristicsHistologic Plaque Characteristics and Coronary Artery Calciumand Coronary Artery Calcium 77 43 54 0 10 20 30 40 50 60 70 80 Acute Rupture Erosion Stable Frequency(%)Frequency(%) Histologic plaque characterizationHistologic plaque characterization Stary, Circ 1995;92:1355-1374Stary, Circ 1995;92:1355-1374 Davies, NEJM 1984;310:1137-1140Davies, NEJM 1984;310:1137-1140 Corrado, Circ 1994;90:2315-2323Corrado, Circ 1994;90:2315-2323 after Schmermund et alafter Schmermund et al Circulation [10/01]Circulation [10/01] 0 % 20 % Extent (relativetototalplaquearea)
  9. 9. Histologic Plaque CharacteristicsHistologic Plaque Characteristics and Coronary Artery Calciumand Coronary Artery Calcium Thus, because there exists considerable overlap between all types of plaques, calcium is a marker for neither stable nor unstable plaque
  10. 10. Histologic Plaque CharacteristicsHistologic Plaque Characteristics and Coronary Artery Calciumand Coronary Artery Calcium Thus, because there exists considerable overlap between all types of plaques, calcium is a marker for neither stable nor unstable plaque

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