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Global Cardiovascular Risk Assessment

Global Cardiovascular Risk Assessment. Mieczysław Pasowicz. SHAPE Poland. 130.000 First Heart Attacks Every Year. Very High Risk. High Risk. Moderately High Risk. Moderate Risk. Lower Risk. Polish population at Risk of Heart Attack – 1 mln.

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Global Cardiovascular Risk Assessment

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  1. Global Cardiovascular Risk Assessment Mieczysław Pasowicz

  2. SHAPE Poland 130.000 First Heart Attacks Every Year Very High Risk High Risk Moderately High Risk Moderate Risk Lower Risk Polish population at Risk of Heart Attack – 1 mln

  3. DEATHS FROM CARDIOVASCULARCAUSES,WORLDWIDE,IN 1990 ANDESTIMATED FOR 2020 Western countries Non-Western (developing) countries 30 25 6 20 19 Millions of Deaths from Cardiovascular Causes 15 5 10 9 5 0 1990 2020 KS Reddy. NEJM 2004; 350:2438

  4. Lancet 2004 364:937-52

  5. Major risk factors account for MI! but they are ”useless” for prediction! Why? Individual vulnerability varies greatly! Protective factors? Lancet 2004 364:937-52

  6. Major risk factors account for MI! but they are ”useless” for prediction! Why? Individual vulnerability varies greatly! Protective factors? Lancet 2004 364:937-52

  7. Major risk factors account for MI! but they are ”useless” for prediction! Why? Individual susceptibility varies greatly! Protective factors? Lancet 2004 364:937-52

  8. The Challenge in Diagnosis of CORONARY HEART DISEASE • Over 50% of cardiac events occur in ‘intermediate risk’ patients, as classified by NCEP or Framingham risk analysis • 70% of all events occur at mild stenosis (<50%) • Compliance with anti-atherosclerotic therapy is less than 50% at one year

  9. Nearly all adult Americans have 1 risk factor, regardless of CHD JAMA 2003;290:891-7

  10. Predictive power of 1 risk factor for CHD PLR <2.0: Low positive predictive power AM Weissler. JAMA 2004;291:299-300

  11. Comparing FraminghamRisk Factor Score andCoronary Artery Disease (CAD) p = 0.447 FRS BAD (Fayad ZA, Mani V, Fuster V et al.) 2005 CAD

  12. CAD and Calcium Score no CAD CAD no CAD CAD Pasowicz et al. Original study

  13. Prediction of MI/SCD in Asymptomatic Patients: EBT Annual Absolute Risk 676 initially asymptomatic patients 32+7 months f/u Percentile Rank for Baseline EBCT Calcium Score Raggi et al AHJ 2001;141:193-199

  14. Event Rates Based upon Scores Raggi, AHJ 2001

  15. PREDICTED7-YEAR EVENT RATES FORCHDDEATH ORNONFATAL MI FORCATEGORIES OFFRSORCS 20 CACS 0 1-100 101-300  301 16 12 Coronary Death or Nonfatal MI, % 8 4 0  21 0-9 10-15 16-20 Framingham Risk Score, % P Greenland et al., JAMA 2004; 291:210

  16. NCEP ATP-III : Noninvasive Testing “the finding of advanced subclinical atherosclerosis by noninvasive testing can be helpful for confirming the presence of high risk persons... and have utility in selected persons to guide intensity of risk-reduction therapy” We need more imaging guided prevention study

  17. SHAPE Poland Imaging of atherosclerotic plaques in coronary arteries by MSCT was initiated in the John Paul II Hospital October 2000 • 2500 Calcium Scoring studies • 2300 contrast enhancedcoronary angiography studies We performed:

  18. Correlation between CS and traditional atherosclerotic risk factors (hypertension, hypercholesterolemia, smoking, diabetes mellitus) 300 R=0,35; p<0.001 250 200 150 100 CS 50 0 0 1 2 3 4 Number of traditional atherosclerotic risk factors N=4 N=46 N=115 N=59 N=9 Pasowicz et al. Original study

  19. Apparently Healthy Population, M>45y & F>55y Very Low Risk Step 1 Atherosclerosis Test for subclinical atherosclerosis Positive Negative Step 2 No Risk Factors + Risk Factors + ++ +++ • Categorize based on • severity of atherosclerosis • presence of risk factors Myocardial Ischemia No Yes Step 3 Moderately High Risk Very High Risk Lower Risk Moderate Risk High Risk Treat risk factors & the disease Results 516 0 258 (50%) 101 (20%) 118 (23%) 39 (7%)

  20. Number of patients in groups identified by FRS (516) Mean Calcium Scores in groups identified by FRS p=0,0000 – Kruskal – Wallis test

  21. FRS vs. SHAPE SHAPE % Framingham

  22. Patient Z. N. age 55, hypertension, prediabetes, lipid disorders, FRS > 20

  23. Patient A. H. age 62, hypertension, FRS – 12 Calcium Score 0.7

  24. MSCT vs CCA in the detection of significant stenosis (>50%) Sens 83 Spec 99 PPV 95 NPV 96

  25. Infarction risk assessment – which subjects should undergo Calcium Scoring? Stage 1 (probability of MI < 0,2): No risk factors C, P, M, SWCS>1, only C, only M, only P, only SWCS>1, C+M Stage 2 (0,2-0,3): C+P, P+M, C+SWCS>1, SWCS>1+M Stage 3 (0,3-0,55): P+SWCS>1, C+SWCS>1+M, C+P+M Stage 4 (0,5-0,8): P+SWCS>1+M, C+P+SWCS>1, C+P+SWCS>1+M Linkage distance C – diabetes mellitus, P – smoking, M – male gender Pasowicz et al. Original study

  26. Recommendations • Each man or smoker – irrespective of gender, or diabetic – irrespective of gender and smoking status, should undergo Calcium Scoring, because its result can modify the probability of myocardial infarction in such a patient. • In smokers, diabetics, patients with atypical chest pain and ambiguous exercise stress test, irrespective of gender and age, angioCT with contrast enhancement should be considered apart from Calcium Scoring.

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