UltraPrevention: UltraPrevention: Living Heart Attack FreeLiving Heart Attack Free
Joel Kahn MD, FACC, FSCAIJoel Kahn MD, FACC, FSCAI
Clinical Professor of MedicineClinical Professor of Medicine
Wayne State University School of MedicineWayne State University School of Medicine
Medical Director, Preventive CardiologyMedical Director, Preventive Cardiology
Detroit Medical CenterDetroit Medical Center
Heart Attack Prevention:Heart Attack Prevention: Don’t Help Fat People? Don’t Help Fat People?
““Rosie O’Donnell Suffered a Heart Attack After Helping a Fat Lady Get Out of a Car” Rosie O’Donnell Suffered a Heart Attack After Helping a Fat Lady Get Out of a Car” Gawker.comGawker.com
21Vascular Biology in Clinical Practice, Oct. 2000; Mark C. Houston,MD
EndotheliumEndothelium
The endothelium serves a The endothelium serves a critical role as a barrier and critical role as a barrier and primary sensor of primary sensor of physiological and chemical physiological and chemical changes in the blood stream.changes in the blood stream.
Traditional Cardiovascular Risk Traditional Cardiovascular Risk FactorsFactors
HypertensionHypertension DyslipidemiaDyslipidemia Diabetes MellitusDiabetes Mellitus SmokingSmoking ObesityObesity
Figure 1 Figure 1
Atherosclerosis Pathogenesis: “Endarteritis Deformans” “Atheroma is a product of an inflammatory process within the intima” - 1845
Fig 1 Rudolph Ludwig Carl Virchow, 1821-1902. Source: Photograph reproduced from Ref. No. 2 (public
domain)
Atherosclerosis is a reaction to injury and inflammation within the arterial wall
Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Assessing CHD Risk in MenAssessing CHD Risk in MenStep 1: Age
YearsPoints
20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13
Step 2: Total CholesterolTC Points at Points at Points at Points at
Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69
Age 70-79 <160 0 0 0 0
0160-199 4 3 2 1
0200-239 7 5 3 1
0240-279 9 6 4 2
1280 11 8 5 3
1
HDL-C(mg/dL) Points
60 -1
50-59 0
40-49 1
<40 2
Step 3: HDL-Cholesterol
Systolic BP PointsPoints
(mm Hg) if Untreated if Treated
<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3
Step 4: Systolic Blood Pressure
Step 5: Smoking Status
Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0Smoker 8 5 3 1 1
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 6: Adding Up the Points
Point Total 10-Year Risk Point Total 10-Year Risk
<0 <1% 11 8%0 1% 12 10%1 1% 13 12%2 1% 14 16%3 1% 15 20%4 1% 16 25%5 2% 17 30%6 2%7 3%8 4%9 5%
10 6%
Step 7: CHD Risk
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Framingham Score approach to Framingham Score approach to CHD risk assessmentCHD risk assessment
LOW RISKLOW RISK designated as <0.6% CHD designated as <0.6% CHD risk per year (<6% in 10 years)risk per year (<6% in 10 years)
INTERMEDIATE RISKINTERMEDIATE RISK designated as a designated as a CHD risk of 0.6%-2.0% per year (6-20% CHD risk of 0.6%-2.0% per year (6-20% over 10 years)over 10 years)
HIGH RISKHIGH RISK designated as a CHD risk of designated as a CHD risk of >2% per year (20% in 10 years) (CHD >2% per year (20% in 10 years) (CHD risk equivalent), including those with risk equivalent), including those with CVD, diabetes, and PADCVD, diabetes, and PAD
Greenland P et al. Circulation 2001; 104: 1863-7Greenland P et al. Circulation 2001; 104: 1863-7
Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk FactorsFramingham Heart Study
AA B B C C D D
Blood Pressure (mm Hg)Blood Pressure (mm Hg) 120/80120/80 140/90140/90 140/90140/90 140/90140/90
Total Cholesterol (mg/dL)Total Cholesterol (mg/dL) 200 200 240 240 240 240 240 240
HDL Cholesterol (mg/dL)HDL Cholesterol (mg/dL) 50 50 50 50 40 40 40 40
DiabetesDiabetes No No No No Yes Yes Yes Yes
CigarettesCigarettes No No No No No No Yes Yes
mm Hg = millimeters of mercurymm Hg = millimeters of mercurymg/dL = milligrams per deciliter of bloodmg/dL = milligrams per deciliter of blood
Source: Circulation 1998;97:1837-1847.
Not all individuals with coronary Not all individuals with coronary heart disease have traditional risk heart disease have traditional risk
factorsfactors
Khot et al. JAMA 2003
17 daggers (or 400) of heart risk17 daggers (or 400) of heart risk
Circulation 108: 250-252
A Multimarker Approach Should Focus on Multiple Mechanisms / Pathologies
Daniels LB. Curr CV Risk Rep 2009.
Potential Components of aPotential Components of a“Multimarker” Approach“Multimarker” Approach
Multiple Biomarkers for Multiple Biomarkers for Prediction of CV Death in Older Prediction of CV Death in Older
AdultsAdults
VariablesVariables C statisticC statistic P valueP value
Established risk factorsEstablished risk factors 0.660.66 RefRef
+ cTnI+ cTnI 0.720.72 0.0020.002
+ NT-proBNP+ NT-proBNP 0.750.75 <0.001<0.001
+ cystatin C+ cystatin C 0.690.69 0.070.07
+ CRP+ CRP 0.690.69 0.070.07
+ all biomarkers+ all biomarkers 0.770.77 <0.001<0.001
Zethelius B et al. N Engl J Med 2008;358:2107-2116
Rader NEJM 2000
hs-CRP and Risk of Future MI in Apparently hs-CRP and Risk of Future MI in Apparently Healthy Men Healthy Men
PP<0.001<0.001
PP<0.001<0.001
PP=0.03=0.03
Quartile of hs-CRP (range, mg/dL)Quartile of hs-CRP (range, mg/dL)
P P Trend <0.001Trend <0.001
0.0550.055 0.056–0.1140.056–0.114 0.115–0.2100.115–0.210 0.2110.211
Re
lati
ve
Ris
k o
f M
IR
ela
tiv
e R
isk
of
MI
Ridker PM et al. N Engl J Med. 1997;336:973–979.
0
1
2
3
1 2 3 4
Inadequate Monitoring of Vascular Response to Treatments
<$100 for # 1 killer
>$1000 for # 2 Killer
The Vulnerable Patient Consensus Statement Preceding the SHAPE
Initiative
Naghavi et. al. Circulation Journal Vol108, No14; October 7, 2003
Review: Current Perspective
From Vulnerable Plaque to Vulnerable PatientA Call for New Definitions and Risk Assessment Strategies: Part I
Morteza NagilaNi. MD: Peter Libby. MD: Erling Falk. MD. PhD; S. Ward Casscells, MD: Silvio Litovsky. MD: John Rut-nix:Ter. MD: Juan Jose Badimon. PhD: Christodoulos Stelanadis, MD; Pedro Moreno, MD: Gerald Pasterkamp. MD. PhD: Zahi Fayad. PhD: Peter H. Stone. MD Sergio Waxman. MD: Paolo Raggi. MD: Mohammad Madjid. MD; Alireza Zarrabi. MD Allen Burke, Ma Chun Yuan. PhD; Peter J. Fitzgerald. MD. PhD: David S. Siscovick. MD: Chris L. de Korte. PhD: Masanori Aikawa, MD. PhD: K.E. Jukuii Nuaksinen. MD: Gerd Assmann. MD: Christoph R. Becker. MD: James H. Chesebro. MD: Andrew Farb. MD: Zorina S. Galls. PhD: Chris Jackson. PhD: lk-Kyung king. MD. PhD: Wolfgang Koenig. MD. PhD: Robert A. Lodder. PhD: Keith March. MD. PhD: Jasenka Deminwic. MD. PhD. Mohamad Navab. PhD: Silvia G. Priori. MD. PhD; Mark D. Rekhter. PhD: Raymond Bahr. MD: Scott NI. Gmndy, MD. PhD: Roman Mehran. MD: Antonio Colombo. MD: Eric Boerwinkle. PhD: Christie Ballantyne. MD: William Insult. Jr. MD: Robert S. Schwartz. MD: Robert Vogel. MD: Patrick W. Sermys. MD. PhD: Gana) K. Ruisson. MD. PhD: David P. Fawn, MD; Sanjay Kalil. MD: Fleh»ut Drexler. MD: Philip Greenland. MD: James E. Muller. MD: Renu Vinnani, Ma Paul M Ricker. MD: Douglas P. Zipes, MD; Prediman K. Shah, MD; James T. Willerson, MD
SHAPE vs. Status Quo
Existing Guidelines (Status Quo):•Screen for Risk Factors of Atherosclerosis•Treat Risk Factors of Atherosclerosis
The SHAPE Guidelines:•Screen for Atherosclerosis (the Disease) Regardless of Risk Factors•Treat based on the Severity of the Disease and its Risk Factors
Atherosclerosis Test
Negative Positive
No Risk Factors + Risk Factors
Step 1Test for Presence of the Disease
Step 2Stratify based on the Severity of the Disease and Presence of Risk Factors
Step 3Treat based on the Level of Risk
LowerRisk
ModerateRisk
ModeratelyHigh Risk
HighRisk
VeryHigh Risk
Apparently Healthy At-Risk Population
The 1st S .H .A .P .E . Guideline
Conceptual Flow Chart
<75th
Percentile75th-90th
Percentile≥90th
Percentile
Atherosclerosis Test
Very Low Risk3
Negative Test• CACS =0• CIMT <50th percentile
LowerRisk
ModerateRisk
Positive Test• CACS ≥1• CIMT 50th percentile or Carotid Plaque
ModeratelyHigh Risk
HighRisk
VeryHigh Risk
No Risk Factors5 + Risk Factors • CACS <100 & <75th%• CIMT <1mm & <75th%
& no Carotid Plaque
• Coronary Artery Calcium Score (CACS)or
• Carotid IMT (CIMT) & Carotid Plaque4
• CACS 100-399 or >75th%• CIMT 1mm or >75th%
or <50% Stenotic Plaque
• CACS >100 & >90th%or CACS 400
• 50% Stenotic Plaque6
LDL Target
<160 mg/dl <130 mg/dl <130 mg/dl<100 Optional
<100 mg/dl<70 Optional
<70 mg/dl
Re-test Interval 5-10 years 5-10 years Individualized Individualized Individualized
All >75y receive unconditional treatment2
Apparently Healthy Population Men>45y Women>55y1
ExitExit
Myocardial IschemiaTest
NoAngiography
Follow Existing Guidelines
Yes
The 1st SHAPE Guidelines
Step 1
Step 2
Step 3Optional
CRP>4mg
ABI<0.9
Carotid B-Mode Ultrasonography: Carotid B-Mode Ultrasonography: CIMTCIMT
Measurement of intimal medial thicknessMeasurement of intimal medial thickness Non-invasive, inexpensive, no radiationNon-invasive, inexpensive, no radiation Well-established as an indicator of Well-established as an indicator of
cardiovascular risk from epidemiologic cardiovascular risk from epidemiologic studiesstudies
ACCF/AHA 2010 Guideline: CIMT measurement ACCF/AHA 2010 Guideline: CIMT measurement may be reasonable for CV risk assessment in may be reasonable for CV risk assessment in asymptomatic adults at intermediate risk (Class asymptomatic adults at intermediate risk (Class IIa-B)IIa-B)
Cardiovascular Health Study: Cardiovascular Health Study: Combined intimal-medial thickness Combined intimal-medial thickness
predicts total MI and strokepredicts total MI and stroke
Cardiovascular Health Study (CHS) (aged 65+): MI or stroke rate 25% over 7 years in those at highest quintile of combined IMT (O’Leary et al. 1999)
Common carotid intima-media thickness Common carotid intima-media thickness measurements in cardiovascular risk measurements in cardiovascular risk
prediction: : A meta-analysis.prediction: : A meta-analysis.
JAMAJAMA 2012; 308:796-803. 2012; 308:796-803. Common carotid intima-media thickness (CIMT) Common carotid intima-media thickness (CIMT) measurement did not add clinically meaningful measurement did not add clinically meaningful information to the Framingham risk score for information to the Framingham risk score for predicting a person's 10-year risk of first MI or predicting a person's 10-year risk of first MI or stroke, according to a meta-analysis of relevant stroke, according to a meta-analysis of relevant studies studies
"Our results suggest that common CIMT "Our results suggest that common CIMT measurements should not routinely be performed measurements should not routinely be performed in the general population, as the overall added in the general population, as the overall added value may be too limited to result in health value may be too limited to result in health benefits," the authors say.benefits," the authors say.
Coronary Calcium as a marker for Coronary Calcium as a marker for AtherosclerosisAtherosclerosis
Coronary calcium invariably Coronary calcium invariably indicates the presence of indicates the presence of atherosclerosis, but atherosclerosis, but atherosclerotic lesions do not atherosclerotic lesions do not always contain calcium always contain calcium
Calcium deposition may occur Calcium deposition may occur early in life, as early as the early in life, as early as the second decade, and in lesions second decade, and in lesions that are not advanced that are not advanced
1) Wexler et al., Circ 1996; 94: 1175-92, 2) Blankenhorn and Stern, Am J Roentgenol 1959; 81: 772-7, 3) Blankenhorn and Stern, Am J Med Sci 1961; 42: 1-49, 4) Stary, Eur Heart J 1990; 11(suppl E): 3-19, 5) Stary, Arteriosclerosis 1989; 9 (suppl I): 19-32.
Cumulative Incidence of Any Cumulative Incidence of Any Coronary Event: MESA Study Coronary Event: MESA Study
(Detrano et al., NEJM 2008)(Detrano et al., NEJM 2008)
Comparison of novel risk markers for improvement in Comparison of novel risk markers for improvement in cardiovascular risk assessment incardiovascular risk assessment in
intermediate-risk individuals. intermediate-risk individuals. Association of risk markers with incident coronary heart disease*
Risk markerRisk marker Hazard ratio (95% CI)Hazard ratio (95% CI)
Ankle-brachial indexAnkle-brachial index 0.79 (0.66-0.96) 0.79 (0.66-0.96)
Brachial flow-mediated dilationBrachial flow-mediated dilation 0.93 (0.74-1.16) 0.93 (0.74-1.16)
Coronary artery calcium 2.60 (1.94-3.50)Coronary artery calcium 2.60 (1.94-3.50)
Carotid intima-media thicknessCarotid intima-media thickness 1.17 (0.96-1.45) 1.17 (0.96-1.45)
Family historyFamily history 2.18 (1.38-3.42) 2.18 (1.38-3.42)
High-sensitivity CRPHigh-sensitivity CRP 1.28 (1.00-1.64) 1.28 (1.00-1.64)
JAMAJAMA 2012; 308: 788-795. 2012; 308: 788-795.
Indications for CAC Assessment Indications for CAC Assessment (Greenland et al., ACCF/AHA Guideline for Assessment (Greenland et al., ACCF/AHA Guideline for Assessment
of Cardiovascular Risk in Asymptomatic Adults of Cardiovascular Risk in Asymptomatic Adults (Circulation, 2010)(Circulation, 2010)
• CV risk assessment in asymptomatic adults at CV risk assessment in asymptomatic adults at intermediate risk (10-20% 10-year risk) intermediate risk (10-20% 10-year risk) (Class (Class IIa, Level of Evidence B)IIa, Level of Evidence B)
• CV risk assessment in persons at low to CV risk assessment in persons at low to intermediate risk (6-10% 10-year risk) intermediate risk (6-10% 10-year risk) (Class IIb, (Class IIb, Level of Evidence B)Level of Evidence B)
• CV risk assessment in asymptomatic adults CV risk assessment in asymptomatic adults with diabetes (Class IIa-B)with diabetes (Class IIa-B)
• Persons at low risk (<6% 10-year risk) should Persons at low risk (<6% 10-year risk) should not undergo CAC measurement for CV risk not undergo CAC measurement for CV risk assessment assessment (Class III, Level of Evidence B)(Class III, Level of Evidence B)
In 703 men and women aged 28-84 who received scanning for In 703 men and women aged 28-84 who received scanning for coronary coronary
calcium by EBCT, calcium score remained independentlycalcium by EBCT, calcium score remained independently associated with:associated with:
new aspirin usagenew aspirin usage new cholesterol medicationnew cholesterol medication consulting with a physicianconsulting with a physician losing weightlosing weight decreasing dietary fatdecreasing dietary fat … …but also increased worry but also increased worry ……..potentially important risk-reducing behaviors may be ..potentially important risk-reducing behaviors may be
reinforced by the knowledge of a positive coronary artery reinforced by the knowledge of a positive coronary artery scan, independent of preexisting coronary risk factor scan, independent of preexisting coronary risk factor status.status.
Wong ND et al, Am J Cardiol. 1996 Dec 1;78(11):1220-3. Wong ND et al, Am J Cardiol. 1996 Dec 1;78(11):1220-3.
Does coronary artery screening by electron
beam computed tomography
motivate potentially beneficial lifestyle behaviors?
Calcium Score GuidelinesCalcium Score GuidelinesCalcium Calcium ScoreScore
PlaquePlaqueBurdenBurden
Probability of Probability of Significant CADSignificant CAD
ImplicationsImplicationsfor CV Riskfor CV Risk
RecommendationsRecommendations
00 No identifiable No identifiable PlaquePlaque
Very low, Very low, generally <5% generally <5%
Very lowVery low Reassure patient. Reassure patient. Discuss general public Discuss general public health guidelines for health guidelines for primary prevention of primary prevention of CV disease.CV disease.
1-101-10 Minimal Minimal identifiable plaque identifiable plaque burdenburden
Very unlikely Very unlikely <10% <10%
LowLow Discuss general public Discuss general public health guidelines for health guidelines for primary prevention of primary prevention of CV disease.CV disease.
11-10011-100 Definite, at least Definite, at least mild mild atherosclerotic atherosclerotic placque burdenplacque burden
Mild or minimal Mild or minimal coronary coronary stenoses likelystenoses likely
ModerateModerate Counsel about risk Counsel about risk factor modification, factor modification, strict adherence with strict adherence with primary prevention primary prevention goals. Daily ASA.goals. Daily ASA.
101-400101-400 Definite, at least Definite, at least moderate moderate atherosclerotic atherosclerotic plaque burdenplaque burden
Non-obstructive Non-obstructive CAD highly likely CAD highly likely although although obstructive obstructive disease possibledisease possible
Moderately HighModerately High Institute risk factor Institute risk factor modification and modification and secondary prevention secondary prevention goals. Consider exercise goals. Consider exercise testing for further risk testing for further risk stratification. Daily ASA.stratification. Daily ASA.
> 400> 400 Extensive Extensive atherosclerotic atherosclerotic plaque burdenplaque burden
High likelihood High likelihood >50% of at least >50% of at least one significant one significant coronary coronary stenosisstenosis
HighHigh Institute very Institute very aggressive risk factor aggressive risk factor modification. Consider modification. Consider exercise for exercise for pharmacologic nuclear pharmacologic nuclear stress testing to stress testing to evaluate for inducible evaluate for inducible ischemia. Daily ASA.ischemia. Daily ASA.
Rumberger et al. Mayo Clin Proc 1999; 74: 243-52
Newman A et al ATVB 1999
Ankle Brachial Index as a Predictor of Cardiovascular Mortality in the CHS Study
ABI and Total Mortalty ABI and Total Mortalty (ABI Collaboration, JAMA 2008)(ABI Collaboration, JAMA 2008)
LDL Particle Number (LDL-P) in the Clinical Management of Heart
Disease
• 80% of subjects with cardiac events had lipid levels similar to subjects that were event free
• 35% of CHD occurs in people with TC<200
Framingham Heart Study Indicates that Measuring Cholesterol Does Not Tell Us Enough
20/100 40/100 90/100
Evidence of Residual CVD Evidence of Residual CVD RiskRisk • 136,905 hospitalizations for
(non-CHF) CAD and lipids w/in 24 hrs of admit (at 541 hospitals)
• Over 50% of patients with LDL-C <100 mg/dL and 17.6% with LDL-C <70 mg/dL
• For patients without h/o CAD, 72.1% with LDL-C <130 mg/dL and 41.5% with LDL-C <100 mg/dL
Sachdeva A, et al. Am Heart J 2009; 157:111-7.e2.From AHA’s Get with The Guidelines (GWTG) CAD Program and database; 2000-2006.
At the same LDL cholesterol, more small LDL vs. large LDL particles present
Up to 70%More Particles
Small LDLLarge LDL
CholesterolBalance
100 mg/dL 100 mg/dL
Otvos JD et al. Am J Cardiol 2002;90(suppl):22i-29i
LDL-C can vary with particle size
Cromwell WC et al. J Clin Lipidology. 2007;1(6):583-592.
With the same-size LDL particles (at any triglyceride level),the cholesterol content per LDL particle is highly variable.
More Particles
Less Cholesterol Carried Per Particle
Normal Cholesterol Carried Per Particle
100 mg/dL 100 mg/dL
Otvos JD et al. Am J Cardiol 2002;90(suppl):22i-29iCromwell WC et al. J Clin Lipidology. 2007;1(6):583-592.
CholesterolBalance
LDL-C can vary, even in particles of the same size
Multiple Outcome Studies Demonstrate Difference Between LDL-P and LDL-C
CHD Event Associations of LDL-P versus LDL-CFramingham Offspring Study
Cromwell WC et al. J Clin Lipidology 2007;1(6):583-592.
LDL-C and LDL-P Correlations in MESA (n=5,598)LDL-C and LDL-P Correlations in MESA (n=5,598)
Otvos et al. J Clin Lipidol 2011;5:105-13
MESA: LDL-P and LDL-C Discordance MESA: LDL-P and LDL-C Discordance Relations with Incident CVD Events (n=319)
Follow-up (years)0 1 2 3 4 5
Cum
ulati
ve In
cide
nce
0.02
0.04
0.06LDL-P < LDL-CConcordantLDL-P > LDL-C
0
0.02
0.04
0.06
0.08
0 1 2 3 4 5 6
0 1 2 3 4 5
0.02
Follow-up (years)
Cum
ulat
ive
Inci
denc
e
0.04
0.06
LDL-P > LDL-C
LDL-P < LDL-C
Concordant
LDL-P > LDL-C
LDL-P < LDL-C
Concordant
16%33%54%
MetSyn
LDL-C underestimatesLDL-attributable risk
LDL-C overestimates LDL-attributable risk
LDL-C
104
117
130
mg/dL
LDL-P
1372
1249
1117
nmol/L
Otvos et al. J Clin Lipidol 2011;5:105-13
Measures reactive hyperemia and ED. FDA approved. Measures reactive hyperemia and ED. FDA approved. 5 minute occlusion of brachial artery with BP cuff5 minute occlusion of brachial artery with BP cuff
Measure pre and post occlusion ratio indexMeasure pre and post occlusion ratio index Index of 1.67 has sensitivity of 82% and specificity of Index of 1.67 has sensitivity of 82% and specificity of
77% to diagnose coronary ED and highly correlates to 77% to diagnose coronary ED and highly correlates to brachial artery FMD(r=.0.33 to 0.55)brachial artery FMD(r=.0.33 to 0.55)
ENDO-PAT: Endothelial dysfunction ENDO-PAT: Endothelial dysfunction before atherosclerosisbefore atherosclerosis
JACC 2010;55:1688JACC 2010;55:1688JACC 2004;44:2137JACC 2004;44:2137
Circulation 2008;117:2467Circulation 2008;117:2467
Control arm
Occluded armReactive hyperemia
ENDOPAT Good and poor resultsENDOPAT Good and poor results
Normal EF Poor EDF
04/19/23 (c) Itamar-Medical 49
Apr 19, 2023(c) Itamar-Medical
ENDOPAT AND FRAMINGHAM RISK SCORE AND ENDOPAT AND FRAMINGHAM RISK SCORE AND CHD RISK CHD RISK
n=270, Intermediate risk patientsMayo Clinic & Tufts Medical Center
EndoPAT vs. Framingham Risk Score Mayo Clinic, 2010
EndoPAT vs. Framingham Risk Score Mayo Clinic, 2010
Low risk & normal endothelial function
Low risk & normal endothelial function
Low risk but with endothelial dysfunction
Low risk but with endothelial dysfunction~
300%~
300%
All CV Deaths were in Patients with Endothelial DysfunctionAll CV Deaths were in Patients with Endothelial Dysfunction
ENDO-PAT AND CVD OUTCOMES ENDO-PAT AND CVD OUTCOMES Eur Heart J 2010 ;31:1142Eur Heart J 2010 ;31:1142
270 patients over 7 years : ED and Framingham risk 270 patients over 7 years : ED and Framingham risk scorescore
Abnormal Index predicted cardiac events such as Abnormal Index predicted cardiac events such as cardiac death, MI cardiac hospitalization and CABG: cardiac death, MI cardiac hospitalization and CABG: 48% vs 28% (p=0.03). This was independent of 48% vs 28% (p=0.03). This was independent of Framingham risk score.Framingham risk score.
Also correlates with risk factorsAlso correlates with risk factors The more severe the CVD the worse the indexThe more severe the CVD the worse the index
ConclusionsConclusions
Standard risk factors alone or in combination Standard risk factors alone or in combination do not predict global risk well enoughdo not predict global risk well enough
Too many events in too many lower risk Too many events in too many lower risk individualsindividuals
Modest screening performanceModest screening performance
Measurement of certain biomarkers such as Measurement of certain biomarkers such as hs-CRP and advanced lipid profiles may be hs-CRP and advanced lipid profiles may be useful in conjunction with global risk useful in conjunction with global risk assessment to improve risk classification.assessment to improve risk classification.
Screening tests for subclinical Screening tests for subclinical atherosclerosis should provide incremental atherosclerosis should provide incremental risk prediction for CHD events over global risk prediction for CHD events over global risk assessmentrisk assessment
Guidelines suggest intermediate risk Guidelines suggest intermediate risk subjects may be suitable for such screening subjects may be suitable for such screening that may help identify those needing more that may help identify those needing more aggressive risk factor intervention.aggressive risk factor intervention.
A Man Is As Old As His A Man Is As Old As His Blood VesselsBlood Vessels
Sir William OslerSir William Osler
It's not your lungs this time, it's It's not your lungs this time, it's your heart that holds your fateyour heart that holds your fate
Bruce SpringsteenBruce Springsteen