This document discusses approaches to identifying and managing coronary risk. It states that the primary goal should be preventing acute cardiac events through intensive risk factor reduction for all patients with clinically apparent heart disease. Additionally, it notes that one third of sudden cardiac deaths and heart attacks occur in previously asymptomatic individuals with undiagnosed risk factors or pre-clinical disease. The document proposes identifying high-risk asymptomatic individuals through testing to provide prevention. It presents a risk stratification approach using testing like CRP, cholesterol, glucose and imaging to guide different levels of risk factor reduction and management.

1. APPROACH TO IDENTIFYING AND
MANAGING CORONARY RISK
Eugene Braunwald, M.D.
March 6, 2004

2. • Prevention of acute events must
be the primary goal. Treatment
should be regarded as “locking the
barn door after the horse is stolen”

3. • One third of cases of sudden death and acute
MI occur in previously asymptomatic persons
- - previously regarded as “acts of God”
• Most of these are now known to have pre-
clinical disease, classical or novel risk factors
• Need to identify high risk asymptomatic
persons prospectively to provide intensive
prevention

4. • All patients with clinically apparent
atherosclerotic disease require
intensive global risk factor reduction
• Some have unstable placques
(“accidents about to happen”) and these
must be identified

5. <0.5%/yr
0.5-2%/yr
2-15%/yr
>15%/yr Very High Risk
High Risk
Intermediate Risk
Low Risk

6. 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%)

7. 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)

8. 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% placquesplacques
--
10%/yr10%/yr continue intensivecontinue intensive
risk factorrisk factor ↓