•Prevention of acute events must be the primary goal.

Treatment should be regarded as “locking the barn door after the horse is stolen”Eugene Braunwald

DES

Naghavi et al. Circulation. 2003;108:1664

Non-Stenotic Vulnerable Plaques overall are More Dangerous Since they are far More Frequent than Stenotic Ones

IntroducingThe Vulnerable Patient Consensus Statement

Published in

Circulation Journal Vol108, No14; October 7, 2003

Naghavi et al. Circulation. 2003;108:1664

The most common type

Naghavi et al. Circulation. 2003;108:1664

•Prevention of acute events must be the primary goal.

Treatment should be regarded as “locking the barn door after the horse is stolen”

DES

> 15 Million Events Each Year

CVD Genotyping?

Naghavi et al. Circulation. 2003;108:1664

<0.5%/yr

0.5-2%/yr

2-15%/yr

>15%/yr Very High Risk

High Risk

Intermediate Risk

Low Risk

Eugene Braunwald, MD The 2nd Vulnerable Patient Symposium - ACC’04

Low riskLow risk Lifestyle & Lifestyle & 0.5%/yr 0.5%/yr Follow- Follow-

upup(40%)(40%)

Framingham Risk ScoreFramingham Risk Score IntermediateIntermediate AdditionalAdditionalCRP, Cholest., GlucoseCRP, Cholest., Glucose 0.5-2%/yr0.5-2%/yr TestingTesting (50%)(50%)

High riskHigh risk IntensiveIntensive

> 2%/yr> 2%/yr global risk global risk (10%)(10%)

Eugene Braunwald, MD The 2nd Vulnerable Patient Symposium - ACC’04

Low riskLow risk Risk factor Risk factor ABIABIEBCTEBCTIMTIMT

High riskHigh risk Intensive global + non-invasiveIntensive global + non-invasiveriskrisk detection of detection of

unstable unstable placque(s) placque(s)

Eugene Braunwald, MD The 2nd Vulnerable Patient Symposium - ACC’04

Non-invasiveNon-invasive

Detection +Detection + novel anti-novel anti- ++ inflammatoriesinflammatories25%/yr25%/yr anti-thrombotic Rx;anti-thrombotic Rx;

Very high risk Invasive detection Very high risk Invasive detection CABG, multiCABG, multi15%/yr15%/yr of unstable of unstable DESDES2%2% plaques plaques

--

10%/yr10%/yr continue intensive continue intensive risk factorrisk factor

Eugene Braunwald, MD The 2nd Vulnerable Patient Symposium - ACC’04

How Good Is NCEP III At Predicting MI?How Good Is NCEP III At Predicting MI?JACC 2003:41 1475-9 JACC 2003:41 1475-9 (Slide from J. Rumberger)(Slide from J. Rumberger)

222 patients with 1222 patients with 1stst acute MI, no prior CAD acute MI, no prior CADmen <55 y/o (75%), women <65 (25%), no DMmen <55 y/o (75%), women <65 (25%), no DM

RiskRisk>20%/>20%/10 yrs.10 yrs.

RiskRisk10-20%/10-20%/10 yrs.10 yrs.

RiskRisk<10%/<10%/10 yrs.10 yrs.

NCEP GoalNCEP GoalLDL<100LDL<100

NCEP GoalNCEP GoalLDL<160LDL<160

NCEP GoalNCEP GoalLDL<130LDL<130

Qualify for RxQualify for RxNot-Qualify for RxNot-Qualify for Rx

6%6% 6%6%

TotalTotal

12%12%8%8% 10%10%

TotalTotal

18%18%

61%61%

9%9%

TotalTotal

70%70%

88% of these “young” patients who suffered a88% of these “young” patients who suffered afirst Myocardial Infarction were in thefirst Myocardial Infarction were in the

Low to Intermediate “risk” category accordingLow to Intermediate “risk” category accordingTo Framingham Risk AssessmentTo Framingham Risk Assessment and and

would have been missed as truly would have been missed as truly ““High Risk” individuals who shouldHigh Risk” individuals who should

have been treated “aggressively”have been treated “aggressively”

August 6th and 7th 2004 - Santa Monica

140 Million Americans Have Average or High Cholesterol 140 Million Americans Have Average or High Cholesterol

76.5 Million Americans Have High CRP76.5 Million Americans Have High CRP

Correlates of Elevated C-Reactive Protein Among Adults in the United States: Findings From the 1999-2000 National Health and Nutrition Examination Survey

•Screening for prevention of heart attack must be established Screening for prevention of heart attack must be established as a standard of practice in preventive cardiology. as a standard of practice in preventive cardiology.

•Comparing to most cancer with established screening Comparing to most cancer with established screening guidelines, screening for prevention of heart attack is more guidelines, screening for prevention of heart attack is more cost effective.cost effective.

•Current risk factors are not desirable for screening and Current risk factors are not desirable for screening and should NOT be used as the first stepshould NOT be used as the first step

•High Prevalence High Prevalence

•Less than Desirable Predictive ValueLess than Desirable Predictive Value

•Numerous Risk Factors, More EmergingNumerous Risk Factors, More Emerging•Risk factors are best for guiding and monitoring therapy Risk factors are best for guiding and monitoring therapy

•Noninvasive tests capable of measuring the disease Noninvasive tests capable of measuring the disease (structural and or functional) at the arterial level should be (structural and or functional) at the arterial level should be considered as the first step in screening.considered as the first step in screening.

Highlights from Santa Monica MeetingHighlights from Santa Monica Meeting

Analogy of Smoking and Lung Cancer

Of course smoking cigarette is a strong risk factor for lung cancer

Butin a town where almost everyone smokes,

smoking has no predictive value for lung cancer!

AEHA SHAPE Screening Guideline

Structure and Function Testing•EBTEBT•CIMTCIMT•Endothelial Function?Endothelial Function?

(-) Test Results

(+) TestResults

-RF’s +RF’s

•Lifestyle Modification•RF reduction (incl Rx per guidelines) •Reassess in 3 yrs

-RF’s +RF’s

•Lifestyle Modification•Aggressive RF Modification •Aggressive Lipid Lowering•Reassess in 2years (Optional)

•No Treatment•Reassess In 5 years

•Lifestyle Modification•Lipid Lowering•Reassess in 2-4 years (optional)

The 3The 3rdrd Vulnerable Patient Vulnerable Patient Satellite SymposiumSatellite Symposium

in conjunction within conjunction withAmerican Heart Association 2004American Heart Association 2004

November 6November 6thth, 2004, 2004Riverside Hilton New OrleansRiverside Hilton New Orleans

6:00-10:00 pm6:00-10:00 pm

The SHAPE Task Force Will Present the First The SHAPE Task Force Will Present the First SHAPE Guideline for Cardiovascular Screening SHAPE Guideline for Cardiovascular Screening

in Asymptomatic Populationin Asymptomatic Population