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Rumberger 2nd vp symposium 3 6 04

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Rumberger 2nd vp symposium 3 6 04

  1. 1. Electron Beam Tomography: The Most Powerful Screening Test For The Imaging Section of the VP Pyramid © John A. Rumberger, PhD, MD, FACC Clinical Professor of Medicine The Ohio State University Medical Director HealthWISE Wellness Diagnostic Center 22ndnd VP Symposium, New Orleans, LA, 3/6/04VP Symposium, New Orleans, LA, 3/6/04
  2. 2. 1.1. Cannot be fully exploited without an adequate methodCannot be fully exploited without an adequate method of separating higher-risk individuals from those atof separating higher-risk individuals from those at lower risk.lower risk. 2.2. If serious misclassification is present, many higher-riskIf serious misclassification is present, many higher-risk individuals would not be identified, denying themindividuals would not be identified, denying them appropriate therapy, and...appropriate therapy, and... 3.3. conversely, many lower-risk individuals would beconversely, many lower-risk individuals would be subject to over-treatment with expensive drugs havingsubject to over-treatment with expensive drugs having an uncertain long-term safety.an uncertain long-term safety. Risk Based Treatment Guidelines forRisk Based Treatment Guidelines for Primary Prevention of CADPrimary Prevention of CAD © JA Rumberger, MD
  3. 3. Coronary Heart Disease in a given person is a consequence to a variety of factors related Such as: Genetics & MetabolismGenetics & Metabolism HabitsHabits LifestyleLifestyle Environment andEnvironment and Susceptibility to inflammationSusceptibility to inflammation © JA Rumberger, MD EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
  4. 4. How Good Is NCEP III At Predicting MI?How Good Is NCEP III At Predicting MI? JACC 2003:41 1475-9JACC 2003:41 1475-9 222 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 Rx Not-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 a first Myocardial Infarction were in the Low to Intermediate “risk” category according To Framingham Risk Assessment and would have been missed as truly “High Risk” individuals who should have been treated “aggressively”
  5. 5. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid Low Risk Population Intermediate Risk Subclinical Atherosclerosis CVD Low Conventional Risk & +FH © JA Rumberger, MD
  6. 6. 2.7 2 2 1 2.47 3.55 6.15 12.29 0 2 4 6 8 10 12 14 RelativeRisk DM Smoke HTN <10 10-100 101-400 401-1000 >1000 EBT Coronary Calcium ScoreEBT Coronary Calcium Score All Cause Mortality [NDR]All Cause Mortality [NDR] n = 10,377n = 10,377 asymptomatic men and womenasymptomatic men and women f/u = 5.0f/u = 5.0++3.5 yrs.3.5 yrs. Shaw,Radiology 2003; 228:826-833 EBT found to be independent and incremental to risk factors826-833 All Cause Mortality in PatientsAll Cause Mortality in Patients Without Known CADWithout Known CAD
  7. 7. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid © JA Rumberger, MD Brief Case:Brief Case: Two prominent men:Two prominent men: • Both smokers - #1 stopped, #2 continuedBoth smokers - #1 stopped, #2 continued • Both with limited exercise - #1 became and avid runner,Both with limited exercise - #1 became and avid runner, lost weight, became very fit,lost weight, became very fit, #2 continued to be inactive and obese#2 continued to be inactive and obese • Both #1 and #2 had a family history of premature deathBoth #1 and #2 had a family history of premature death
  8. 8. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid © JA Rumberger, MD Who was at greater risk for the development of heart disease?Who was at greater risk for the development of heart disease? Jim Fixx - marathon runner, exercise advocate, author - dead at 53 of a heart attack Sir Winston Churchill – broke every tenet of “healthy life style” – dead at age 91
  9. 9. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid CAC>0 CAC>75th percentile 0 10 20 30 40 50 60 70 80 90 100 7978 64 55 4141 29 20 BothSibling FHParental FHNo FH CAC>0 CAC>75th percentile 0 10 20 30 40 50 60 70 80 90 100 5456 36 27 3334 24 15 BothSibling FHParental FHNo FH WomenMen © JA Rumberger, MD 8,500 Middle-aged patients referred for EBT Testing (single site)8,500 Middle-aged patients referred for EBT Testing (single site) No FHx of Premature CAD vs. +FHx below age 55 in a parent or siblingNo FHx of Premature CAD vs. +FHx below age 55 in a parent or sibling 1.4X1.4X 2.0x2.0x 2.0x2.0x 2.2x2.2x
  10. 10. 30.2%/year 12%/year 0 10 20 30 40 50 60 Untreated Treated EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid © JA Rumberger, MD n = 792 n = 292 Range 5%-20% Range 22%-52% Composite of 9 studies – weighted averageComposite of 9 studies – weighted average
  11. 11. Prediction of MI/SCD in Asymptomatic Patients:Prediction of MI/SCD in Asymptomatic Patients: EBTEBT 0 1 2 3 4 5 6 7 0 10 20 30 40 50 60 70 80 90 Percentile Rank for Baseline EBCT Calcium ScorePercentile Rank for Baseline EBCT Calcium Score LowLow RiskRisk IntermediateIntermediate RiskRisk HighHigh RiskRisk VeryVery HighHigh RiskRisk AnnualAbsoluteRisk(%)AnnualAbsoluteRisk(%) Adapted from data presented inAdapted from data presented in Raggi et al AHJ 2001;141:193-199Raggi et al AHJ 2001;141:193-199 © JA Rumberger, MD
  12. 12. EBT “Heart Age”EBT “Heart Age” Percentile Ranking of CASPercentile Ranking of CAS Adjustments to Chronological AgeAdjustments to Chronological Age <25<25thth Percentile Subtract 10 yearsPercentile Subtract 10 years >>2525thth - <75- <75thth Percentile No adjustmentPercentile No adjustment >>7575thth - <90- <90thth Percentile Add 10 yearsPercentile Add 10 years * * Originally suggested byOriginally suggested by Grundy: AJC 2001;88:8E-11EGrundy: AJC 2001;88:8E-11E >>9090thth Percentile Add 20 yearsPercentile Add 20 years © © JA Rumberger, MD
  13. 13. Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age” Conventional “Low to Intermediate” Risk PatientConventional “Low to Intermediate” Risk Patient Age 35 to 65 yearsAge 35 to 65 years MaleMale TC = 210 mg/dlTC = 210 mg/dl HDL = 40 mg/dlHDL = 40 mg/dl No DiabetesNo Diabetes No SmokingNo Smoking Systolic BP = 150 mmHgSystolic BP = 150 mmHg Use NCEPUse NCEP ATP-IIIATP-III and Framinghamand Framingham point scoring systempoint scoring system © JA Rumberger, MD
  14. 14. Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age” 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Framingham Risk <25th Percentile CAS >75th Percentile CAS >90th Percentile CAS Age (years) ““Low to Intermediate”Low to Intermediate” ConventionalConventional Risk MaleRisk Male CoronaryRiskperDecade Low Risk Intermediate Risk High Risk © JA Rumberger, MD
  15. 15. Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age” Conventional “Intermediate to High” Risk PatientConventional “Intermediate to High” Risk Patient Age 35 to 65 yearsAge 35 to 65 years MaleMale TC =240 mg/dlTC =240 mg/dl HDL = 35 mg/dlHDL = 35 mg/dl No DiabetesNo Diabetes No SmokingNo Smoking Systolic BP = 180 mmHgSystolic BP = 180 mmHg Use NCEPUse NCEP ATP-IIIATP-III and Framinghamand Framingham point scoring systempoint scoring system © JA Rumberger, MD
  16. 16. 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Framingham Risk <25th Percentile CAS >75th Percentile CAS >90th Percentile CAS Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age” Age (years) ““Intermediate to High”Intermediate to High” ConventionalConventional Risk MaleRisk Male CoronaryRiskperDecade Low Risk High Risk Intermediate Risk © JA Rumberger, MD
  17. 17. EBT “Heart Age” and RiskEBT “Heart Age” and Risk IntermediateIntermediate ConventionalConventional RiskRisk HighHigh ConventionalConventional RiskRisk 1/3 or more are actually1/3 or more are actually LOWLOW riskrisk 1/3 or more are actually1/3 or more are actually HIGHHIGH riskrisk 1/3 or more are actually1/3 or more are actually INTERMEDINTERMED riskrisk 1/3 or more are actually1/3 or more are actually LOWLOW riskrisk © JA Rumberger, MD
  18. 18. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid © JA Rumberger, MD AGE IncidenceIncidence OfOf CHDCHD Incremental Value of CAC 3535 7070
  19. 19. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid © JA Rumberger, MD ““Risk” increases as an individuals CACRisk” increases as an individuals CAC score and/or percentile rank increasesscore and/or percentile rank increases Thus, although EBT and CAC is not ableThus, although EBT and CAC is not able to identify the “vulnerable” plaque, it CANto identify the “vulnerable” plaque, it CAN identifyidentify “the“the vulnerable patient”vulnerable patient”
  20. 20. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid © JA Rumberger, MD AtAt PRESENTPRESENT the following has been established:the following has been established: o Coronary calcium IS AtherosclerosisCoronary calcium IS Atherosclerosis o The magnitude of the calcium score relates to the severity of ASO diseaseThe magnitude of the calcium score relates to the severity of ASO disease o The calcium score as well as the percentile rank provide informationThe calcium score as well as the percentile rank provide information in which to view risk factors, rather than the other way aroundin which to view risk factors, rather than the other way around o The data on examining progression of CAD with CT are consistent withThe data on examining progression of CAD with CT are consistent with the potential for the calcium score/rank to be used as the “goal” of therapythe potential for the calcium score/rank to be used as the “goal” of therapy
  21. 21. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid © JA Rumberger, MD The calcium score is a measure of overall disease extent in a given person and is a consequence of a variety of factors related to genetics, habits, environment and susceptibility to inflammation and many of These are not “measurable” by blood tests. So, it might make more sense to use EBT as an additional risk factor and incorporate its results with conventional assessments
  22. 22. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid © JA Rumberger, MD Low Risk Population Intermediate Risk Atherosclerosis Imaging CVD Low Conventional Risk & +FH EBT (and other formsEBT (and other forms of Atherosclerosis Imaging)of Atherosclerosis Imaging) take “Population”take “Population” Statistics toStatistics to ““Personal” StatisticsPersonal” Statistics by Measuring theby Measuring the extent ofextent of ““Pre-Symptomatic”Pre-Symptomatic” CHDCHD

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