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•Prevention of
acute events must
be the primary
goal.
Treatment should
be regarded as
“locking the barn
door after the
hor...
Naghavi et al. Circulation. 2003;108:1664
Non-Stenotic Vulnerable Plaques overall are More Dangerous
Since they are far Mo...
Introducing
The Vulnerable Patient Consensus Statement
Published in
Circulation Journal Vol108, No14; October 7, 2003
Naghavi et al. Circulation. 2003;108:1664
The most common type
Naghavi et al. Circulation. 2003;108:1664
•Prevention of
acute events must
be the primary
goal.
Treatment should
be regarded as
“locking the barn
door after the
hor...
> 15 Million Events Each Year
CVD Genotyping?
Naghavi et al. Circulation. 2003;108:1664
<0.5%/yr
0.5-2%/yr
2-15%/yr
>15%/yr Very High Risk
High Risk
Intermediate Risk
Low Risk
Eugene Braunwald, MD
The 2nd
Vulne...
Low riskLow risk Lifestyle &Lifestyle &
0.5%/yr0.5%/yr Follow-upFollow-up
(40%)(40%)
Framingham Risk ScoreFramingham Risk ...
Low riskLow risk Risk factorRisk factor
ABIABI
EBCTEBCT
IMTIMT
High riskHigh risk Intensive global + non-invasiveIntensive...
Non-invasiveNon-invasive
Detection +Detection + novel anti-novel anti-
++ inflammatoriesinflammatories
25%/yr25%/yr anti-t...
How Good Is NCEP III At Predicting MI?How Good Is NCEP III At Predicting MI?
JACC 2003:41 1475-9JACC 2003:41 1475-9 (Slide...
August 6th
and 7th
2004 - Santa Monica
140 Million Americans Have Average or High Cholesterol140 Million Americans Have Average or High Cholesterol
76.5 Million Americans Have High CRP76.5 Million Americans Have High CRP
Correlates of Elevated C-Reactive Protein Among A...
•Screening for prevention of heart attack must be establishedScreening for prevention of heart attack must be established
...
Analogy of Smoking and Lung
Cancer
Of course smoking cigarette is a strong risk
factor for lung cancer
But
in a town where...
AEHA SHAPE Screening Guideline
Structure and Function TestingStructure and Function Testing
•EBTEBT
•CIMTCIMT
•Endothelial...
The 3The 3rdrd
Vulnerable PatientVulnerable Patient
Satellite SymposiumSatellite Symposium
in conjunction within conjuncti...
My talk at tct04
My talk at tct04
My talk at tct04
My talk at tct04
My talk at tct04
My talk at tct04
My talk at tct04
My talk at tct04
My talk at tct04
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My talk at tct04

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My talk at tct04

  1. 1. •Prevention of acute events must be the primary goal. Treatment should be regarded as “locking the barn door after the horse is stolen” Eugene Braunwald D E S
  2. 2. Naghavi et al. Circulation. 2003;108:1664 Non-Stenotic Vulnerable Plaques overall are More Dangerous Since they are far More Frequent than Stenotic Ones
  3. 3. Introducing The Vulnerable Patient Consensus Statement Published in
  4. 4. Circulation Journal Vol108, No14; October 7, 2003
  5. 5. Naghavi et al. Circulation. 2003;108:1664 The most common type
  6. 6. Naghavi et al. Circulation. 2003;108:1664
  7. 7. •Prevention of acute events must be the primary goal. Treatment should be regarded as “locking the barn door after the horse is stolen” D E S
  8. 8. > 15 Million Events Each Year
  9. 9. CVD Genotyping? Naghavi et al. Circulation. 2003;108:1664
  10. 10. <0.5%/yr 0.5-2%/yr 2-15%/yr >15%/yr Very High Risk High Risk Intermediate Risk Low Risk Eugene Braunwald, MD The 2nd Vulnerable Patient Symposium - ACC’04
  11. 11. Low riskLow risk Lifestyle &Lifestyle & 0.5%/yr0.5%/yr Follow-upFollow-up (40%)(40%) Framingham Risk ScoreFramingham Risk Score IntermediateIntermediate AdditionalAdditional CRP, Cholest., GlucoseCRP, Cholest., Glucose 0.5-2%/yr0.5-2%/yr TestingTesting (50%)(50%) High riskHigh risk IntensiveIntensive > 2%/yr> 2%/yr global riskglobal risk ↓↓ (10%)(10%) Eugene Braunwald, MD The 2nd Vulnerable Patient Symposium - ACC’04
  12. 12. Low riskLow risk Risk factorRisk factor ABIABI EBCTEBCT IMTIMT High riskHigh risk Intensive global + non-invasiveIntensive global + non-invasive riskrisk detection ofdetection of unstableunstable placque(s)placque(s) Eugene Braunwald, MD The 2nd Vulnerable Patient Symposium - ACC’04
  13. 13. Non-invasiveNon-invasive Detection +Detection + novel anti-novel anti- ++ inflammatoriesinflammatories 25%/yr25%/yr anti-thrombotic Rx;anti-thrombotic Rx; Very high risk Invasive detectionVery high risk Invasive detection CABG, multiCABG, multi 15%/yr15%/yr of unstableof unstable DESDES 2%2% plaquesplaques -- 10%/yr10%/yr continue intensivecontinue intensive risk factorrisk factor ↓↓ Eugene Braunwald, MD The 2nd Vulnerable Patient Symposium - ACC’04
  14. 14. How Good Is NCEP III At Predicting MI?How Good Is NCEP III At Predicting MI? JACC 2003:41 1475-9JACC 2003:41 1475-9 (Slide from J. Rumberger)(Slide from J. Rumberger) 222 patients with 1222 patients with 1stst acute MI, no prior CADacute MI, no prior CAD men <55 y/o (75%), women <65 (25%), no DMmen <55 y/o (75%), women <65 (25%), no DM RiskRisk >20%/>20%/ 10 yrs.10 yrs. RiskRisk 10-20%/10-20%/ 10 yrs.10 yrs. RiskRisk <10%/<10%/ 10 yrs.10 yrs. NCEP GoalNCEP Goal LDL<100LDL<100 NCEP GoalNCEP Goal LDL<160LDL<160 NCEP GoalNCEP Goal LDL<130LDL<130 Qualify for RxQualify for Rx Not-Qualify for RxNot-Qualify for Rx 6%6% 6%6% TotalTotal 12%12% 8%8% 10%10% TotalTotal 18%18% 61%61% 9%9% TotalTotal 70%70% 88% of these “young” patients who suffered a88% of these “young” patients who suffered a first Myocardial Infarction were in thefirst Myocardial Infarction were in the Low to Intermediate “risk” category accordingLow to Intermediate “risk” category according To Framingham Risk AssessmentTo Framingham Risk Assessment andand would have been missed as trulywould have been missed as truly ““High Risk” individuals who shouldHigh Risk” individuals who should have been treated “aggressively”have been treated “aggressively”
  15. 15. August 6th and 7th 2004 - Santa Monica
  16. 16. 140 Million Americans Have Average or High Cholesterol140 Million Americans Have Average or High Cholesterol
  17. 17. 76.5 Million Americans Have High CRP76.5 Million Americans Have High CRP Correlates of Elevated C-Reactive Protein Among Adults in the United States: Findings From the 1999-2000 National Health and Nutrition Examination Survey
  18. 18. •Screening for prevention of heart attack must be establishedScreening for prevention of heart attack must be established as a standard of practice in preventive cardiology.as a standard of practice in preventive cardiology. •Comparing to most cancer with established screeningComparing to most cancer with established screening guidelines, screening for prevention of heart attack is moreguidelines, screening for prevention of heart attack is more cost effective.cost effective. •Current risk factors are not desirable for screening andCurrent risk factors are not desirable for screening and should NOT be used as the first stepshould NOT be used as the first step •High PrevalenceHigh Prevalence •Less than Desirable Predictive ValueLess than Desirable Predictive Value •Numerous Risk Factors, More EmergingNumerous Risk Factors, More Emerging •Risk factors are best for guiding and monitoring therapyRisk factors are best for guiding and monitoring therapy •Noninvasive tests capable of measuring the diseaseNoninvasive tests capable of measuring the disease (structural and or functional) at the arterial level should be(structural and or functional) at the arterial level should be considered as the first step in screening.considered as the first step in screening. Highlights from Santa Monica MeetingHighlights from Santa Monica Meeting
  19. 19. Analogy of Smoking and Lung Cancer Of course smoking cigarette is a strong risk factor for lung cancer But in a town where almost everyone smokes, smoking has no predictive value for lung cancer!
  20. 20. AEHA SHAPE Screening Guideline Structure and Function TestingStructure and Function Testing •EBTEBT •CIMTCIMT •Endothelial Function?Endothelial Function? •EBTEBT •CIMTCIMT •Endothelial Function?Endothelial Function? (-) Test Results (-) Test Results (+) Test Results (+) Test Results -RF’s-RF’s +RF’s+RF’s •Lifestyle Modification •RF reduction (incl Rx per guidelines) •Reassess in 3 yrs -RF’s-RF’s +RF’s+RF’s •Lifestyle Modification •Aggressive RF Modification •Aggressive Lipid Lowering •Reassess in 2years (Optional) •No Treatment •Reassess In 5 years •Lifestyle Modification •Lipid Lowering •Reassess in 2- 4 years (optional)
  21. 21. The 3The 3rdrd Vulnerable PatientVulnerable Patient Satellite SymposiumSatellite Symposium in conjunction within conjunction with American Heart Association 2004American Heart Association 2004 November 6November 6thth , 2004, 2004 Riverside Hilton New OrleansRiverside Hilton New Orleans 6:00-10:00 pm6:00-10:00 pm The SHAPE Task Force Will Present the FirstThe SHAPE Task Force Will Present the First SHAPE Guideline for Cardiovascular ScreeningSHAPE Guideline for Cardiovascular Screening in Asymptomatic Populationin Asymptomatic Population

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