Heart Institute of the Caribbean (HIC) CARDIAC RISK EVALUATION: Searching for the vulnerable patient
Heart Institute of the Caribbean (HIC)
CARDIAC RISK EVALUATION:Searching for the vulnerable
patient
Screening for the Risk Factors for the disease
Screening for the
disease
The Disease: Atheroesclerosis
Types of Cardiovascular Disease
What do you think about this patient ?
23 points, 22 % CV Risk
What do you think about this patient..?
18 points, > 30 % CV Risk
The risk of develop CV disease ( CHD or Stroke) in the next 10 years in percent (%) can be calculated
with the help of the Framingham Risk Score
Gender, Age, Total-C , HDL-C, SBP, Smoking status
Systematic COronary Risk Evaluation (SCORE): based on gender, age, total cholesterol, systolic blood pressure and smoking status.
Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE. Eur Heart J. 2003 May;24(9):882-3
Effects of any treatment (to lower cholesterol / lower blood pressure) that reduced the risk of CVD in 50 %
100ptes
With20%CV
Risk 20
80
Treatment10
80
10
Will develop CHD or Stroke in the next 10 years
Will not develop CHD or Stroke in the next 10 years
1994 4S 2002 PROSPER 1995 WOSCOPS 2002 ALLHAT-LLA 1996 CARE 2002 ASCOT-LLA 1998 AFCAPS/TEXCAPS 2004 PROVE-IT 1998 LIPID 2004 A to Z 2001 MIRACL 2005 TNT 2002 HPS 2005 IDEAL
2008 JUPITER
Study populations:Primary prevention
Acute coronary syndromes (Secondary prevention)Chronic Coronary heart disease (Secondary prevention)
*Trials with clinical outcomes
HMG-CoA Reductase Inhibitor:STATINSHMG-CoA Reductase Inhibitor:STATINSChronological Order of Event Driven Chronological Order of Event Driven
TrialsTrials
Efficacy of antihypertensive treatmentEfficacy of antihypertensive treatment: Duration and homogeneity of the efficacy of antihypertensive drugs are currently quantified by computation of the smoothness index (SI) from ambulatory blood
pressure monitoring (ABPM) recordings.
The smoothness index (SI) identifies the occurrence of a balanced 24 h
blood pressure reduction with treatment and correlates with the
favourable effects of treatment on left ventricular hypertrophy better than the commonly used trough : peak
ratio.
According to the standard definition, the SI is calculated as the ratio
between the mean hourly reductions and the standard deviation of these
reductions. (American Journal of Hypertension 2005; 18, 24A )
What do you think about this patient ?
Lifetime Risk50 %
What do you think about this patient ?
Lifetime Risk69 %
Future CV Risk Prediction: Concept of Lifetime Risk
Lloyd-Jones et al. Circulation 2006; 113: 791-798
Framingham Heart Study: Optimization of RFs in asymptomatic 50 year-olds associated with low lifetime CVD risk
OptimalTotal chol <180BP <120/80NonsmokerNon diabetic
Not optimalTotal chol 180-200BP 120-140/80-90
Elevated RFTotal chol 200-240SBP 140-160/90-100
Major RFTotal chol >240BP >160/90SmokerDiabetic
Other issues:Low
H D L
Diabetes
Metabolic Syndrome
Inflammation
HsCRP
Triglycerides
Stress
The “Super-Sizing” of America
“This year, Americans will spend more money on fast food than on higher education…”
Eric Schlosser. Eric Schlosser. Fast Food Nation: The Dark Side of the All-American MealFast Food Nation: The Dark Side of the All-American Meal..Harper Collins. 2002.Harper Collins. 2002.
Haffner SM, Lehto S, Ronnemaa T, et al: N Engl J Med 339:229–234, 1998
Diabetes is a “cardiovascular disease risk equivalent”
Systemic inflammation
Eur Heart J 2010 (31) 3: 290-297
Current Opinion 2012; 142:w13502
Ps: Psychosocial stress as a risk factor
Many times the traditional risk factor based screening fails in identifying the Vulnerable Patient.
-
Sir Winston Churchill, 91 Sir Winston Churchill, 91 Jim Fixx, 53Jim Fixx, 53 Who Has More Cardiovascular Risk Who Has More Cardiovascular Risk
Factors?Factors?
Existing Guidelines (Status Quo):• Screen for Risk Factors of Atherosclerosis• Treat Risk Factors of Atherosclerosis
Goal of “ new” Guidelines:• Screen for Atherosclerosis (the Disease)
regardless of, Risk Factors• Treat based on the Severity of the Disease
and its Risk Factors
ATHEROESCLEROSIS: Risk Factor screen Vs the disease
screen
Slide 24
Atherosclerosis begins early :Usefulness and Prognostic Implications of Surrogate Markers
in Atherosclerosis
Risk factors
Surrogatemarkers
Arterial vascular symptoms
Clinical events (MI,
suddendeath)
Autopsy
LateEarly
Adapted from Crouse JR III. J Lipid Res. 2006;47:1677–1699; Nissen S. Am J Cardiol. 2001;87(suppl):15A–20A.
Importance of Subclinical Disease Detection
• Atherosclerosis begins early• can be detected prior to a cardiac event
• Most MI’s -previously <40% stenosis • plaque rupture and thrombus (blood clot)!
• Stress tests only detects flow-limiting stenoses (blockages)
• Subclinical disease measures • target patients for “aggressive primary prevention”
Evaluating coronary vasoreactivity
Eur. Heart J 2010 (31) 7, 777-783
012345678
<0.5 0.5-1.0
1.0-2.0
2.0-3.0
3.0-4.0
4.0-5.0
5.0-10.0
10.0-20.0
>20.0
Crude RRs Risks Adjusted for FRS
RR
of f
utur
e C
ardi
o. E
vent
s
Low risk Mod. risk High risk
hsCRPmg/L
Ridker PM, et al. Circulation 2004;109:1955-9.
Higher CRP levels predict increased risk for heart disease
From: Coronary Artery Calcium Scanning Should be Used for Primary Prevention: Title and subTitle BreakPros J Am Coll Cardiol Img. 2012;5(1):111-118. doi:10.1016/j.jcmg.2011.11.007
Coronary Artery CalciumCoronary Artery Calcium
No CalcificationNo Calcification Severe Severe CalcificationCalcification
Left Main
LAD
LCX
AortaAorta
LALA
PAPA
Left Main
LAD
Measurement of CAC may be reasonable for cardiovascular risk assessment persons at low to intermediate risk (6% to 10% 10-year
risk).
Direct in vivo measurement of thickness of carotid artery wall by B-mode ultrasound – “arterial biopsy”Vessel wall thickness correlates with status of atherosclerosis and cardiovascular events
Atherosclerosis is a systemic disorderDisease in carotid artery is predictive of disease in other vascular beds
Measurement of CA IMT
Adapted from Crouse JR III. J Lipid Res. 2006;47:1677–1699; Espeland MA, et al. Curr Controll Trials Cardiovasc Med. 2005;6:3; Kastelein JJP, et al. Am Heart J. 2005;149:234–239. .
A well-established marker of atherosclerotic disease
CA IMT Measured by B-Mode Ultrasound
Slide 34
Rotterdam StudyCA IMT Strongly Predictive of MI
*Adjusted for age and genderAdapted from van der Meer I, et al. Circulation. 2004;109:1089–1094.
1
1.682.05
2.91
0
1
2
3
<0.88 0.88–<0.99 0.99–<1.12 ≥1.12
CA IMT, mm
Haz
ard
Rat
io*
(n=1277) (n=1279) (n=1287) (n=1273)
Current: “Sick care” to “Health care”
Systematic COronary Risk Evaluation (SCORE): based on gender, age, total cholesterol, systolic blood pressure and smoking status.
Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE. Eur Heart J. 2003 May;24(9):882-3