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Rumberger vp discussion 11 03

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Rumberger vp discussion 11 03

  1. 1. 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: EBCT vs. Conventional Risk FactorsEBCT vs. Conventional Risk Factors for Coronary Related Eventsfor Coronary Related Events Genetics & MetabolismGenetics & Metabolism HabitsHabits LifestyleLifestyle Environment andEnvironment and Susceptibility to inflammationSusceptibility to inflammation ©John A. Rumberger, MD - 2003
  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 ©John A. Rumberger, MD - 2003
  3. 3. 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(%) ©John A. Rumberger, MD - 2003 Adapted from data presented inAdapted from data presented in Raggi et al AHJ 2001;141:193-199Raggi et al AHJ 2001;141:193-199
  4. 4. 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 © 2003 John A Rumberger, MD * * Originally suggested byOriginally suggested by Grundy: AJC 2001;88:8E-11EGrundy: AJC 2001;88:8E-11E >>9090thth Percentile Add 20 yearsPercentile Add 20 years ©
  5. 5. 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 ©John A. Rumberger, MD - 2003
  6. 6. 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 © 2003 John A Rumberger, MD
  7. 7. 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 ©John A. Rumberger, MD - 2003
  8. 8. 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 © 2003 John A Rumberger, MD
  9. 9. 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 ©John A. Rumberger, MD - 2003
  10. 10. 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 ©John A. Rumberger, MD - 2003

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