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Shape symposium slide presentation

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SHAPE Society

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Shape symposium slide presentation

  1. 1. Saving the Vulnerable PatientSaving the Vulnerable Patient
  2. 2. > 15 Million Fatal Heart Attacks Each Year
  3. 3. •Prevention of heart attacks must be the primary goal. Treatment should be regarded as “locking the barn door after the horse is stolen” Eugene Braunwald Drug Eluting Stent Lock!
  4. 4. What is new? Shift in Paradigm: - Atherosclerosis; an inflammatory disease - Non-flow limiting plaque; the culprit in most heart attacks
  5. 5. What is new? Shift in Paradigm: - Atherosclerosis; an inflammatory disease - Non-flow limiting plaque; the culprit in most heart attacks
  6. 6. Introducing The Vulnerable Patient Consensus Statement Published in
  7. 7. Circulation Journal Vol108, No14; October 7, 2003
  8. 8. Naghavi et al. Circulation. 2003;108:1664
  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, M.D. –The 2nd Vulnerable Patient Symposium ACC 2004
  11. 11. Eugene Braunwald, M.D. –The 2nd Vulnerable Patient Symposium ACC 2004
  12. 12. Eugene Braunwald, M.D. –The 2nd Vulnerable Patient Symposium ACC 2004
  13. 13. Eugene Braunwald, M.D. –The 2nd Vulnerable Patient Symposium ACC 2004
  14. 14. Welcome to Santa Monica!
  15. 15. Get in SHAPE with SHAPE-A-THON!
  16. 16. We’ve got aWe’ve got a Problem!Problem!
  17. 17. Screening basedScreening based on risk factorson risk factors aint gonna work!!aint gonna work!!
  18. 18. 70.6% of American adults have one or more risk factor for heart attack!
  19. 19. 140 Million140 Million Americans HaveAmericans Have Average or HighAverage or High CholesterolCholesterol
  20. 20. 76.5 Million76.5 Million AmericansAmericans Have High CRPHave 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
  21. 21. Greenland et al JAMA August 2003, Vol 291 No7 P891-897 Major Risk Factors as Antecedents of Fatal and Nonfatal Coronary Heart Disease Events
  22. 22. Analogy of Smoking and Lung Cancer Of course smoking is a strong risk factor for lung cancer but in a town where almost everyone smokes, smoking has no predictive value for lung cancer. Too many people have risk factors specially when average cholesterol or high CRP is considered as risk factors.
  23. 23. 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”
  24. 24. August 6th and 7th 2004 - Santa Monica
  25. 25. •Screening for prevention of heart attack must be established as a standard of practice in preventive cardiology. •Comparing to most cancer with established screening guidelines, screening for prevention of heart attack is more cost effective. •Current risk factors are not desirable for screening and should NOT be used as the first step •High Prevalence •Less than Desirable Predictive Value •Numerous Risk Factors, More Emerging •Risk factors are best for guiding and monitoring therapy •Noninvasive tests capable of measuring the disease (structural and or functional) at the arterial level should be considered as the first step in screening. Highlights from Santa Monica Meeting
  26. 26. This guideline has been recently released by the three major organizations. Unlike for colon and breast cancers in which screening tests for hidden (subclinical) disease are recommended, for prevention of heart attack, the number one killer, there is no such recommendation for screening and the guideline is still limited to the assessment of traditional risk factors.
  27. 27. ???! Number 1 Killer Number ? Killer!
  28. 28. The Future Directions in SHAPE (Screening for Heart Attack Prevention and Education -SHAPE) Trajectory TestTrajectory Test • Coronary Calcium • Carotid IMT • Coronary Calcium • Carotid IMT (-)(-) (+)(+) Moderately High Risk Moderately High Risk High RiskHigh Risk •Lifestyle Modification •Aggressive RF Modification •LDL<70 5 yrs •Lifestyle Modification •Aggressive RF Modification •LDL<70 5 yrs •Lifestyle Modification •LDL<100 •Reassess in 5 yrs •Lifestyle Modification •LDL<100 •Reassess in 5 yrs Asymptomatic Males ≥45y? and Females ≥55y? with no History of CVDAsymptomatic Males ≥45y? and Females ≥55y? with no History of CVD •Follow “Very High Risk” in the 1st SHAPE Guidelines •Follow “Very High Risk” in the 1st SHAPE Guidelines Functional TestFunctional Test • Noninvasive Molecular Imaging of Plaque inflammation? •Noninvasive Coronary Endothelial Function? • Noninvasive Molecular Imaging of Plaque inflammation? •Noninvasive Coronary Endothelial Function? ≥?percentile?≥?percentile? <?%?<?%? ≥?percentile?≥?percentile? • Intravascular VP Detection for Safe and Effective Local Therapy • Expensive New Systemic Therapies (Apo A Injections...) • Intravascular VP Detection for Safe and Effective Local Therapy • Expensive New Systemic Therapies (Apo A Injections...) +?+?+?+? Structural TestStructural Test • Endothelial Dysfunction •Carotid IMT • Endothelial Dysfunction •Carotid IMT
  29. 29. The Future Directions in SHAPE (Screening for Heart Attack Prevention and Education -SHAPE) Repeated Trajectory Tests Repeated Trajectory Tests • Endothelial Dysfunction? •Carotid IMT? • Endothelial Dysfunction? •Carotid IMT? (-)(-) (+)(+) -RF’s-RF’s +RF’s+RF’s •Lifestyle Modification •Aggressive RF Modification •Reassess in 5 yrs •Lifestyle Modification •Aggressive RF Modification •Reassess in 5 yrs •Lifestyle Modification •Reassess in 5 yrs •Lifestyle Modification •Reassess in 5 yrs Asymptomatic Males 20-45y? and Females ≥20-55y? with no History of CVDAsymptomatic Males 20-45y? and Females ≥20-55y? with no History of CVD Genetic Tests for Strong Genes Genetic Tests for Strong Genes ?? • Aggressive Therapy and Close Monitoring • Aggressive Therapy and Close Monitoring +?+?+?+? -RF’s-RF’s +RF’s+RF’s •Lifestyle Modification •Reassess in 5 yrs •Lifestyle Modification •Reassess in 5 yrs Genetic Tests Highly Predictive Genetic Tests Highly Predictive ??
  30. 30. Cheers to SHAPE “Hornblower”s!
  31. 31. International Heart Doctors and Researchers Invite Former President Clinton to Join Campaign for Eradication for Heart Attack

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