Paul M Ridker, MD, MPH Paul M Ridker, MD, MPH Eugene Braunwald Professor of Medicine Eugene Braunwald Professor of Medicine Director, Center for Cardiovascular Disease Prevention Director, Center for Cardiovascular Disease Prevention Brigham and Women Brigham and Women’s Hospital s Hospital Harvard Medical School, Boston, MA USA Harvard Medical School, Boston, MA USA Dr Ridker is listed as a co-inventor on patents held by the Brigham and Women’s Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease and diabetes. Annual Intensive Review of Internal Medicine Annual Intensive Review of Internal Medicine CVD Prevention for the Boards CVD Prevention for the Boards Dr Ridker has received investigator Dr Ridker has received investigator-initiated research support from the initiated research support from the NHLBI, NCI, American Heart Association, Donald W Reynolds NHLBI, NCI, American Heart Association, Donald W Reynolds Foundation, Leduc Foundation, Doris Duke Charitable Foundation, Foundation, Leduc Foundation, Doris Duke Charitable Foundation, AstraZeneca, Novartis, and SanofiAventis. AstraZeneca, Novartis, and SanofiAventis. Dr Ridker has served as a consultant to Seimens, AstraZeneca, Dr Ridker has served as a consultant to Seimens, AstraZeneca, Vascular Biogenics, Merck Schering Plough, and Novartis. Vascular Biogenics, Merck Schering Plough, and Novartis. Dr Ridker is listed as a co Dr Ridker is listed as a co-inventor on patents held by the Brigham and inventor on patents held by the Brigham and Women Women’s Hospital that relate to the use of inflammatory biomarkers in s Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease and diabetes that have been licensed to cardiovascular disease and diabetes that have been licensed to Seimens and AstraZeneca. Seimens and AstraZeneca. 3 Evidence Based Prevention of CV Disease Evidence Based Prevention of CV Disease • Evidence based guidelines are based on rigorous and expert analysis of available data, documenting relative benefits and risks of procedures and therapies • ACC/AHA practice guidelines reflect a consensus of expert opinion and are intended to assist healthcare providers in decision making by describing a range of approaches for the diagnosis, management, and prevention of CVD • Intended to help improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies ACC=American College of Cardiology, AHA=American Heart Association, CV=Cardiovascular, CVD=Cardiovascular disease 4 Evidence Based Prevention of CV Disease Evidence Based Prevention of CV Disease • Implications for taking the boards: The most conservative answer is almost always the correct answer, even if that is not what you would actually do in practice. ACC=American College of Cardiology, AHA=American Heart Association, CV=Cardiovascular, CVD=Cardiovascular disease 5 Class I Benefit >>> Risk Procedure or Rx SHOULD be performed or administered Class IIa Benefit >> Risk Additional studies needed REASONABLE to perform procedure or administer Rx Class IIb Benefit ≥ Risk Additional studies/registry data would be helpful Procedure or Rx MAY BE CONSIDERED Class III Risk ≥ Benefit No additional studies needed Procedure or Rx should NOT be performed or administered Applying Classification of Applying Classification of Recommendations and Level of Evidence Recommendations and Level of Evidence Rx=Treatment 6 Level A Multiple (3-5) population risk strata evaluated General consistency of direction and magnitude of effect Class I Procedure or Rx useful or effective Sufficient evidence from multiple trials or meta- analyses Class IIa In favor of being useful or effective Some conflicting evidence Class IIb Less well established whether useful or effective Greater conflicting evidence Class III Not useful or effective and may be harmful Sufficient evidence Applying Classification of Applying Classification of Recommendations and Level of Evidence Recommendations and Level of Evidence Rx=Treatment
15
Embed
CVD Prevention for the Boards Foundation, Leduc Foundation ...statelinegraphics.com/dev/content/day3/02CVPreventionfortheBoards-DrPaulRidker.pdfThe most conservative answer is almost
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Paul M Ridker, MD, MPHPaul M Ridker, MD, MPHEugene Braunwald Professor of MedicineEugene Braunwald Professor of Medicine
Director, Center for Cardiovascular Disease PreventionDirector, Center for Cardiovascular Disease PreventionBrigham and WomenBrigham and Women’’s Hospitals Hospital
Harvard Medical School, Boston, MA USAHarvard Medical School, Boston, MA USA
Dr Ridker is listed as a co-inventor on patents held by the Brigham and Women’s Hospital
that relate to the use of inflammatory biomarkers in cardiovascular disease and diabetes.
Annual Intensive Review of Internal MedicineAnnual Intensive Review of Internal Medicine
CVD Prevention for the BoardsCVD Prevention for the BoardsDr Ridker has received investigatorDr Ridker has received investigator--initiated research support from the initiated research support from the NHLBI, NCI, American Heart Association, Donald W Reynolds NHLBI, NCI, American Heart Association, Donald W Reynolds Foundation, Leduc Foundation, Doris Duke Charitable Foundation, Foundation, Leduc Foundation, Doris Duke Charitable Foundation, AstraZeneca, Novartis, and SanofiAventis.AstraZeneca, Novartis, and SanofiAventis.
Dr Ridker has served as a consultant to Seimens, AstraZeneca, Dr Ridker has served as a consultant to Seimens, AstraZeneca, Vascular Biogenics, Merck Schering Plough, and Novartis.Vascular Biogenics, Merck Schering Plough, and Novartis.
Dr Ridker is listed as a coDr Ridker is listed as a co--inventor on patents held by the Brigham and inventor on patents held by the Brigham and WomenWomen’’s Hospital that relate to the use of inflammatory biomarkers in s Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease and diabetes that have been licensed to cardiovascular disease and diabetes that have been licensed to Seimens and AstraZeneca. Seimens and AstraZeneca.
3
Evidence Based Prevention of CV DiseaseEvidence Based Prevention of CV Disease
• Evidence based guidelines are based on rigorous and expert analysis of available data, documenting relative benefits and risks of procedures and therapies
• ACC/AHA practice guidelines reflect a consensus of expert opinion and are intended to assist healthcare providers in decision making by describing a range of approaches for the diagnosis, management, and prevention of CVD
• Intended to help improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies
ACC=American College of Cardiology, AHA=American Heart Association, CV=Cardiovascular, CVD=Cardiovascular disease
4
Evidence Based Prevention of CV DiseaseEvidence Based Prevention of CV Disease
• Implications for taking the boards: The most conservative answer is almost always the correct answer, even if that is not what you would actually do in practice.
ACC=American College of Cardiology, AHA=American Heart Association, CV=Cardiovascular, CVD=Cardiovascular disease
5
Class I
Benefit >>> Risk
Procedure or Rx SHOULD be performed or administered
Class IIa
Benefit >> RiskAdditional studies
needed
REASONABLE to perform procedure or administer Rx
Class IIb
Benefit ≥ RiskAdditional
studies/registry data would be
helpful
Procedure or RxMAY BE
CONSIDERED
Class III
Risk ≥ BenefitNo additional
studies needed
Procedure or Rx should NOT be performed or administered
Applying Classification of Applying Classification of Recommendations and Level of EvidenceRecommendations and Level of Evidence
Rx=Treatment6
Level A
Multiple (3-5) population risk
strata evaluated
General consistency of direction and magnitude of
effect
Class I
Procedure or Rx useful or
effective
Sufficient evidence
from multiple trials or meta-
analyses
Class IIa
In favor of being useful or effective
Some conflicting evidence
Class IIb
Less well established
whether useful or effective
Greater conflicting evidence
Class III
Not useful or effective and
may be harmful
Sufficient evidence
Applying Classification of Applying Classification of Recommendations and Level of EvidenceRecommendations and Level of Evidence
Rx=Treatment
7
Level B
Limited (2-3) population risk
strata evaluated
Class I
Procedure or Rx useful or
effective
Limited evidence
from single trial or non-randomized
studies
Class IIa
In favor of being useful or effective
Some conflicting evidence
Class IIb
Less well established
whether useful or effective
Greater conflicting evidence
Class III
Not useful or effective and
may be harmful
Sufficient evidence
Applying Classification of Applying Classification of Recommendations and Level of Evidence Recommendations and Level of Evidence
Rx=Treatment8
DefinitionDefinition
Primordial Prevention: Prevention of CHD risk factors
Primary Prevention: Modification of risk factors in order to prevent or delay the onset of CHD
Secondary Prevention: Initiation of therapy to reduce recurrent CHD events and decrease cardiac mortality in patients with established CHD
CHD=Coronary heart disease
9
Aspirin Evidence: Primary Prevention in MenAspirin Evidence: Primary Prevention in Men
Physicians’ Health Study (PHS)22,071 men randomized to aspirin (325mg every other day) followed for an
average of 5 years
Aspirin significantly reduces the risk of MI in men
End point Relative Risk (95% CI) P value Myocardial infarction Fatal 0.34 (0.15-0.75) 0.007 Nonfatal 0.59 (0.47-0.74) <0.00001 Total 0.56 (0.45-0.70) <0.00001 Stroke Fatal 1.51 (0.54-4.28) 0.43 Nonfatal 1.20 (0.91-1.59) 0.20 Total 1.22 (0.93-1.60) 0.15
Physicians’ Health Study Research Group. NEJM1989;321:129-35
CI=Confidence interval, MI=Myocardial infarction
10
Aspirin Evidence: Primary Prevention in WomenAspirin Evidence: Primary Prevention in Women
Womens’ Health Study (WHS)
Placebo
Aspirin
Ridker P et al. NEJM 2005;352:1293-304
MI=Myocardial infarction
39,876 women randomized to aspirin (100 mg every other day) or placebo for an average of 10 years
Aspirin did not reduce the risk of MI, CVA & CV death
*Specific guideline recommendations for men do not exist, but these guidelines are based on previous general (not gender specific) primary prevention guidelines
13
Aspirin (81 mg daily or 100 mg every other day) in at risk women >65 years of age
Aspirin in at risk women <65 years of age for ischemic stroke prevention
*Treatment determined by highest blood pressure category†Initial combined therapy should be used cautiously in those
at risk for orthostatic hypotension‡Treat patients with chronic kidney disease or diabetes
mellitus to blood pressure goal of <130/80 mmHg
17
Ask and document tobacco use status
Advise: Provide a strong, personalizedmessage
Assess* readiness to quit in next 30 days
Prevent Relapse• Congratulate successes• Encourage • Discuss benefits experienced by patient• Address weight gain, negative mood, and lack of support
Increase Motivation• Relevance to personal situation• Risks: short and long-term, environmental• Rewards: potential benefits of quitting• Roadblocks: identify barriers and solutions• Repetition: repeat motivational intervention• Reassess readiness to quit
Assist• Negotiate plan • STAR**• Discuss pharmacotherapy• Social support• Provide educational materials
Arrange follow-up to check plan or adjust meds• Call right before and after quit date• Weekly follow-up x 2 weeks, then monthly x 6 months• Ask about difficulties (withdrawal, depressed mood)• Build upon successes• Seek commitment to stay tobacco-free
**STARSet quit dateTell family, friends, and coworkersAnticipate challenges: withdrawal, breaksRemove tobacco from the house, car etc.
– Minimizing intake of partially hydrogenated fats
• Minimize intake of beverages and foods with added sugar
• Choose and prepare foods with little or no salt
• If alcohol is consumed, do so in moderation
Recommendations for Cardiovascular Disease Risk Reduction
AHA Nutrition Committee. Circulation 2006;114:82-96
AHA=American Heart Association
24
Primary Prevention
Dietary Guidelines Dietary Guidelines
Consume a diet rich in fruits and vegetables; choose whole-grain, high-fiber foods; consume fish, especially oily fish,* at least twice a week; limit intake of saturated fat to <10% of energy, and if possible to <7%, cholesterol to <300 mg/d, alcohol intake to no more than 1 drink per day, and sodium intake to <2.3 g/d(approximately 1 tsp salt). Consumption of trans-fatty acids should be as low as possible (eg, <1% of energy)
*Pregnant and lactating women should avoid eating fish potentially high in methylmercury
Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and
cholesterol (to <200 mg/d).
Encouraging consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g per d) for risk reduction may be reasonable for patients with known CAD.
Effect of cardiac rehabilitation in randomized controlled trials following a MI
Oldridge NB et al. JAMA 1988;260:945-950
*p<0.0125
CV=Cardiovascular, MI=Myocardial infarction,
29
Assess risk, preferably with an exercise test, to guide prescription (Class I, Level B)
Encourage aerobic activity (e.g., walking, jogging, cycling) supplemented by an increase in daily activities (e.g., walking breaks at work, gardening, household work) (Class I, Level B)
Encourage resistance training (e.g., weight machines, free weights) 2 days a week (Class IIb, Level C)
Encourage cardiac rehabilitation for patients with stable angina, recent MI, LV systolic dysfunction, or recent CABG (Class I, Level B)
MI=Myocardial infarction, RRR=Relative risk reduction, SCD=Sudden cardiac death
Downs JR et al. JAMA 1998;279:1615–1622
6,605 patients with average LDL-C levels randomized to lovastatin (20-40 mg) or placebo for 5 years
Statins provide benefit in those with average LDL-C levels
34
HMGHMG--CoACoA ReductaseReductase Inhibitor: Primary PreventionInhibitor: Primary PreventionJustification for Use of statins in Prevention: an Intervention
Trial Evaluating Rosuvastatin (JUPITER)
Ridker et al, NEJM 2008
17,802 men and women with mean LDL of 100 mg/dL but
elevated levels of hsCRP > 2 mg/L randomized to rosuvastatin 20 mg or placebo for 5 years
Statins provide benefit in those with low LDL-C but high hsCRP
55 percent reduction in MI48 percent reduction in stroke47 percent reduction in need for CABG/PTCA43 percent reduction in DVT/PE20 percent reduction in all cause mortality
Greatest absolute benefit with the highest CRP levelsNo relationship of benefit to baseline LDLC levels
Sachdeva et al, Am Heart J 2009;157:111-7.e2.
LDLC Levels in 136,905 Patients Hospitalized With CAD: 2000- 2006
LDLC (mg/dL) 130-160 > 160< 130
hsCRP and Risk of Future MI and CVA in Apparently Healthy Men
Quartile of Quartile of hshs--CRPCRP
Ridker et al, N Engl J Med 1997;336:973–979.
P P Trend <0.001Trend <0.001
Rel
ativ
e R
isk
of
MI
Rel
ativ
e R
isk
of
MI
0
1
2
3
1 2 3 4
Re
lati
ve R
isk
of
Str
oke
Re
lati
ve R
isk
of
Str
oke
P P Trend <0.01Trend <0.01
0
1
2
1 2 3 4
Quartile of hsQuartile of hs--CRPCRP
37
Coronary Heart Disease
3.0
2.5
2.0
1.5
1.0
hsCRP concentration (mg/L)
Ris
k r
ati
o (
95
% C
I)
All Vascular Deaths
3.0
2.5
2.0
1.5
1.0
0.5 1.0 2.0 4.0 8.0
Meta-analysis of 54 Prospective Cohort StudieshsCRP concentration and risk of cardiovascular events : 2010
Emerging Risk Factor Collaborators, Lancet January 2010
0.5 1.0 2.0 4.0 8.0
38
CR-39Emerging Risk Factor Collaborators, Lancet January 2010
0.5 1.0 1.2 1.4 1.8
hsCRP
Systolic BP
Total cholesterol
Non-HDLC
1.37 (1.27-1.48)
1.35 (1.25-1.45)
1.16 (1.06-1.28)
1.28 (1.16-1.40)
Risk Ratio (95%CI)
Meta-analysis of 54 Prospective Cohort Studies:The magnitude of independent risk associated with inflammation is
at least as large, if not larger, than that of BP and cholesterol
Risk Ratio (95%CI) per 1-SD higher usual values
Adjusted for age, gender, smoking, diabetes, BMI, triglycerides, alcohol, lipid levels, and hsCRP
1.00
0.99
0.98
0.97
0.96
0.000 2 4 6 8
Years of Follow-up
Primary Prevention : Whom Should We Treat ?Primary Prevention : Whom Should We Treat ?
JUPITERJUPITERMultiMulti--National Randomized Double Blind Placebo Controlled Trial of National Randomized Double Blind Placebo Controlled Trial of
RosuvastatinRosuvastatin in the Prevention of Cardiovascular Eventsin the Prevention of Cardiovascular EventsAmong Individuals With Low LDL and Elevated Among Individuals With Low LDL and Elevated hsCRPhsCRP
44--week week runrun--inin
No Prior CVD or DMNo Prior CVD or DMMen Men >>50, Women 50, Women >>6060
LDL <130 mg/dLhsCRP >2 mg/L
JUPITERTrial Design
Placebo (N=8901)Placebo (N=8901)
Argentina, Belgium, Brazil, Bulgaria, Canada, Chile, Colombia, Costa Rica, Denmark, El Salvador, Estonia, Germany, Israel, Mexico, Netherlands, Norway, Panama, Poland, Romania, Russia, South Africa, Switzerland,
United Kingdom, Uruguay, United States, Venezuela
JUPITERWhy Consider Statins for Low LDL, high hsCRP Patients?
While intriguing and of potential public health importance, the observation in AFCAPS/TexCAPS that statin therapy might be effective among those with elevated hsCRP but low cholesterol was made on a post hoc basis. Thus, a large-scale randomized trial of statin therapy was needed to directly test this hypotheses.
New Engl J Med 2001;344:1959-65
Low LDL, Low hsCRP
Low LDL, High hsCRP
Statin Effective Statin Not Effective
1.0 2.00.5
[A]
[B]
Low LDL, Low hsCRP
Low LDL, High hsCRP
Statin Effective Statin Not Effective
1.0 2.00.5
AFCAPS/TexCAPS Low LDL Subgroups
RR
JUPITERBaseline Clinical Characteristics
Rosuvastatin Placebo(N = 8901) (n = 8901)
Age, years (IQR) 66.0 (60.0-71.0) 66.0 (60.0-71.0)Female, N (%) 3,426 (38.5) 3,375 (37.9)Ethnicity, N (%)
JUPITERIncident Diabetes Limited to Those With Impaired Fasting Glucose
(51) (62) (18)
(43)
(39) (38)
(34)
(53)
(34) (29)
(39)
(45)
Fasting Glucose Level (mg/dL)
0
2
4
6
8
10
12
14
<100 100-104 105-109 110-114 115-119 120-125
Inci
den
ce R
ate
(per
10
0 p
erso
n y
ears
)
Placebo
Rosuvastatin
JUPITERStatin Highly Effective in All Patients – Primary Endpoint
HR 0.51, 95% CI 0.40-0.67
Normal Fasting Glucose
HR 0.69, 95% CI 0.49-0.98
Impaired Fasting Glucose
0 1 2 3 4
Follow-up Years
0.0
00
.02
0.0
40
.06
0.0
80
.10
Cu
mu
lati
ve In
cid
ence
0 1 2 3 4
Follow-up Years
RosuvastatinRosuvastatin
PlaceboPlacebo
JUPITERCardiovascular Benefits of Statin Therapy In All High Risk Groups for Diabetes
0.20 0.5 1.0 2.0
Nonfatal MI+ Stroke
RosuvastatinSuperior Inferior
MetabolicSyndrome
Y
N
FG >100 mg/dL_ Y
N
BMI > 30 kg/m2_ Y
N
HbA1c >6 % Y
N
Any Risk Factor Y
N
N
7,316
10,278
5,504
12,170
6,637
11,042
3,008
14,615
11,508
6,095
0.20 0.5 1.0 2.0
Revascularization +Unstable Angina
RosuvastatinSuperior Inferior
0.20 0.5 1.0 2.0
VTE
RosuvastatinSuperior Inferior
0.20 0.5 1.0 2.0
Mortality
RosuvastatinSuperior Inferior
0.20 0.5 1.0 2.0
Diabetes
RosuvastatinSuperior Inferior
Cardiovascular Benefits and Diabetes Risks of Statin Therapy in Primary Prevention: The JUPITER Trial
• In absolute terms for those without a major diabetes risk factor, 65 vascular events or death were avoided by statin therapy with no excess cases of diabetes diagnosed.
• In absolute terms for those with a major diabetes risk factor, 93 vascular events or deaths were avoided by statin therapy for every 54 new cases of diabetes diagnosed.
• Conclusion: In primary prevention, the cardiovascular and mortality benefits of statin therapy exceed the diabetes hazard, including among individuals at high risk for developing diabetes. Long-term microvascular effects unknown.
65 year old non65 year old non--smoking man with systolic BP 130 mm smoking man with systolic BP 130 mm Hg, TC 205 mg/dL, HDLC 45 mg/dL, hsCRP 4.0 mg/L, Hg, TC 205 mg/dL, HDLC 45 mg/dL, hsCRP 4.0 mg/L, and a positive family history for MI.and a positive family history for MI.
“The Reynolds Risk Score was better calibrated than the Framingham model in this large external validation cohort. The Reynolds score also showed improved discrimination overall in black and white women. Large differences in risk estimates exist between models, with clinical implications for statin therapy.”
CR-68
Primary Goal : LDLC
High CAD, CVA, PVD <2mmol/L or 50% reduction Class IMost pts with Diabetes Level AFRS > 20 %RRS > 20 %
Moderate FRS 10- 19 % <2mmol/L or 50 % reduction Class IIARRS 10-19 % Level ALDL > 3.5 mmol/LTC/HDLC > 5.0hsCRP > 2 in
2009 Canadian Cardiovascular Society (CCS)Guidelines for the Diagnosis and Treatment of Dyslipidemia
and Prevention of Cardiovascular Disease in the Adult
567 References - No mention of the JUPITER trial, No Change in Practice at all
Impression: As far as Europe is concerned, the trial did not happen!
CR-70
2010 ACC/AHA Guidelines for Assessment of Cardiovascular Risk in Asymptomatic Adults
JACC November 16, 2010
“The initial step in risk assessment in individual patients involves the ascertainment of a global risk score (Framingham, Reynolds, etc) and the elucidation of a family history of atherosclerotic CVD. These Class I recommendations which are simple and inexpensivedetermine subsequent strategies to be undertaken”
Reynolds = Framingham + hsCRP + HbA1c + family history
CR-71
2010 ACC/AHA Guidelines for Assessment of Cardiovascular Risk in Asymptomatic Adults
Class I Class II Class IIIBenefit >>>Risk Benefit >> Risk No Benefit
Global Screening hsCRP Apo A, apo BFramingham HbA1c Lp(a)Reynolds ABI Advance Lipid Testing
“The estimated lifetime cancer risk is 42 cases per 100,000 men and 62 per 100,000 women… These radiation risks can be compared withpotential benefits from screening when such estimates are available”.
Arch Int Med 2009;169:1188-1194
What about radiation exposure?
“ > 50% of participants may have at least one non-calcified nodule”“Current limitations thus include the cost and morbidity of follow-up and further testing, the small but difficult to quantify potential risk of cancer associated with multiple follow-up CT scans, and the potential for increased anxiety of both the
patient and the physician about non-significant pathology”
What about incidentalomas?
Be Wary of Expert Opinion
“I know there is no outcome data, but when I tell my patient their CAC score, they improve
their risk factor profiles and have better medication compliance”
Imaging Advocate, ACC 2011
Hackam DG, et al; Arch Intern Med 2011; epublished
“There is little evidence suggesting that non-invasive cardiovascular imagingalters primary prevention efforts”
What About Surrogate Endpoints? Doesn’t CAC at least improve those?
“Compared with no scanning, randomization to CAC was associated with superior coronary artery disease risk factor control”
What About EISNER ? Wasn’t that a positive study” ?No-Scan Scan P
Quit smoking, % 44 49 NSRegular exercise, % 36 37 NSChange in DBP, mm Hg -4 -5 NSChange in TC, mg/dL -16 -21 NSChange in HDLC, mg/dL -1 -1 NSChange in TG, mg/dL -9 -10 NSChange in glucose, mg/dL -2 -0 NSChange in weight, lbs 1 0 NSNew lipid meds,% 25 29 NSNew DM meds, % 3 3 NSNew ASA use, % 7 8 NSAdherence to lipid meds,% 86 86 NSAdherence to BP meds, % 90 94 NSAdherence to DM meds, % 93 88 NSAdherence to ASA, % 31 27 NS
EISNER Trial Results - Rozanski et al, JACC March 28,2100
Death or MI was HIGHER in the scan group than in the no-scan group (2.1 vs 1.0 %, P=0.08)
LDL, HDL,hsCRP
Yes Yes
Yes No
Predict risk ?
Randomized trial evidence ?
Cost-effective or cost-saving ? Yes No
CACLDL, HDL,
hsCRP
No Yes
Yes Yes
Yes No
Predict risk ?
Randomized trial evidence ?
Cost-effective or cost-saving ?
Irradiate my patient ?
Unnecessary downstream testing ?
Major infrastructure investment ?
Anxiety producing incidentalomas ?
Divert time, energy, and resources away from quality patient care ?
Yes No
No Yes
No Yes
No Yes
No Yes
CAC
Two World Views Regarding Screening in Primary Prevention
If you want to practice evidence-free medicine, increase expenses to our health care system, irradiate your patients, and take the medical-legal risk of performing un-indicated down-stream procedures, order imaging tests in the asymptomatic patient.
If you want to practice evidence-based medicine, improve outcomes, and use medical resources wisely, order a simple panel of inexpensive biomarkers in the asymptomatic patient.
Advertisement Campaigns•$635 million (McDonald’s)•$298 million (Burger King)•$224 million (Coca Cola)