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