Morteza Naghavi, M'D' Society for Heart Attack Prevention and Eradication SHAPE Houston, TX

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Screening for Early Detection and Prevention of
Heart Attack
Morteza Naghavi, M.D. Society for Heart Attack
Prevention and Eradication (SHAPE)Houston, TX
Presented at the 2008 Annual Scientific Sessions
of the American Heart Association
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Why does screening for the prevention of heart
attack needs to look beyond risk factors?
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Because Traditional Risk Factor Based Screening
Miserably Fails to Identify the Vulnerable
Patient
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Of 136,905 patients hospitalized with CAD, more
than 75 had LDL levels below 130 mg/dl
Heart attack with normal LDL
Lipid levels in patients hospitalized with
coronary artery disease An analysis of 136,905
hospitalizations in Get With The Guidelines
Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009
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Of 136,905 patients hospitalized with CAD, more
than 45 had HDL levels above 40 mg/dl
HDL levels in patients hospitalized with coronary
artery disease An analysis of 136,905
hospitalizations in Get With The Guidelines
Heart attack with normal HDL
Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009
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Triglyceride levels in patients hospitalized with
coronary artery disease An analysis of 136,905
hospitalizations in Get With The Guidelines
Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009
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How Good Is NCEP III At Predicting MI? Akosah et
al. JACC 200341 1475-9
1998 2002. 222 patients with 1st acute MI, no
prior CAD, no DM. Men lt55 y/o (75), Women lt65.
40 hypertensive
of total
would qualify for statin Rx
would not qualify for statin Rx
What was NCEP risk before the MI? Would they have
received statin therapy or more intensive statin
therapy?
10 yr risk lt10 Goal LDLlt160 mg/dL
10 yr risk gt20 Goal LDLlt100 mg/dL (optional lt 70
mg/dL)
10 yr risk 10 - 20 Goal LDLlt130 mg/dL (optional
lt 100 mg/dL)
75 would not qualify for statin Rx.
High Risk
Lower / Moderate Risk
Moderately High Risk
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Two Major Problems Exist in Cardiology Today1-
Inaccurate Individualized Risk
Assessment2- Inadequate Monitoring of
Response to Therapy
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Who Has More Cardiovascular Risk Factors?
Jim Fixx, 53 ??
Sir Winston Churchill, 91 ?
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1 No history of angina, heart attack, stroke, or
peripheral arterial disease. 2 Population over
age 75y is considered high risk and must receive
therapy without testing for atherosclerosis. 3
Must not have any of the following Cholgt200
mg/dl, blood pressure gt120/80 mmHg, diabetes,
smoking, family history, metabolic syndrome. 4
Pending the development of standard practice
guidelines. 5 High cholesterol, high blood
pressure, diabetes, smoking, family history,
metabolic syndrome. 6 For stroke prevention,
follow existing guidelines.
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ROC Curve, its AUC and Corresponding Odds Ratio
hs-CRP LDL HDL Smoking
HypertensionDiabetes etc.
Risk Factors
Based on the paper by Pepe e. al. Am J Epidemiol
2004 159882-890.
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ROC Curve, its AUC and Corresponding Odds Ratio
Structural
CAC FRS
IMTFRS
hs-CRP LDL HDL Smoking
HypertensionDiabetes etc.
Risk Factors
Based on the paper by Pepe e. al. Am J Epidemiol
2004 159882-890.
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ROC Curve, its AUC and Corresponding Odds Ratio
Structural
CAC FRS
IMTFRS
hs-CRP LDL HDL Smoking
HypertensionDiabetes etc.
Risk Factors
Based on the paper by Pepe e. al. Am J Epidemiol
2004 159882-890.
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Functional Assessment
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The Combination of Low Fingertip Temperature
Rebound and High Framingham Risk Score is
Associated with High Risk Coronary Artery Calcium
Score
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Combining Structural and Functional Assessments
with Risk Factors Provide for the Maximum
Predictive Value
Structural CAC Functional VENDYS
FRS Framingham Risk Score
Preliminary Data from VENDYS Vascular Function
Studies (Budoff et al.)
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The AEHA 2005 VP Summit
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More than 80 of CVD Death and Disability is due
to the V
Vascular Disorders
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Why do we screen for asymptomatic cancers but
ignore asymptomatic CVD?
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50 for 1 Killer
1000 for 2 Killer
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