nonnon--invasive cad screening invasive cad screening · cac in 2016: who and what? who...

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NonNon--invasive CAD Screeninginvasive CAD Screening

Khurram Nasir, MD MPH

DisclosuresDisclosures

I have no relevant commercial

relationships to disclose, and my

presentation will not include off label or

unapproved usage.

HOW & WHAT WOULD YOU DECIDE?

60 white Male60 white Male60 white Male60 white MaleT T T T CholCholCholChol: 182 mg/dl: 182 mg/dl: 182 mg/dl: 182 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlHTN on ACEIHTN on ACEIHTN on ACEIHTN on ACEINon Non Non Non smokersmokersmokersmokerSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgNon diabeticNon diabeticNon diabeticNon diabeticFH of premature CVDFH of premature CVDFH of premature CVDFH of premature CVDHsHsHsHs----CRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LNon smokerNon smokerNon smokerNon smoker

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Step 1: Start with ASCVD Risk Calculation Age (years) 20-79

Gender Male

Female

Race African American

Other

Total cholesterol(mg/dL)

130-320

HDL cholesterol(mg/dL)

20-100

Systolic bloodpressure (mmHg)

90-200

Diastolic bloodpressure (mmHg)

30-140

Treated for highblood pressure

No

Yes

Diabetes No

Yes

Smoker No

Yes

Calculate

ASCVD RISK IS 12%: WHAT WOULD YOU DO NOW?

60 white Male60 white Male60 white Male60 white MaleT T T T CholCholCholChol: 182 mg/dl: 182 mg/dl: 182 mg/dl: 182 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlHTN on ACEIHTN on ACEIHTN on ACEIHTN on ACEINon Non Non Non smokersmokersmokersmokerSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgNon diabeticNon diabeticNon diabeticNon diabeticFH of premature CVDFH of premature CVDFH of premature CVDFH of premature CVDHsHsHsHs----CRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LNon smokerNon smokerNon smokerNon smokerASCVD Risk: 12%ASCVD Risk: 12%ASCVD Risk: 12%ASCVD Risk: 12%Framingham Risk: 11%Framingham Risk: 11%Framingham Risk: 11%Framingham Risk: 11%ReynoldReynoldReynoldReynold Risk: 15%Risk: 15%Risk: 15%Risk: 15%

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Out of 101 million adults free of ASCVD in US, 33 million (recommended) and

12 million (considered) for statin

Challenges with Risk Assessment & Management Challenges with Risk Assessment & Management Challenges with Risk Assessment & Management Challenges with Risk Assessment & Management Guidelines in 2015Guidelines in 2015Guidelines in 2015Guidelines in 2015

Two third patients averse to taking long term medication unless at high risk and substantial benefit. (Fontana M et al , Circulation 2015)

1 billion individuals worldwide candidates for statin

Generic cost for statins 1 trillion dollars in 2020

Systematic overestimation of risk is a significant concern if it leads to prescription of statin therapy (and its potential adverse effects) among groups in which actual risk scores are lower than predicted. (Ridker P et al Ann Intern Med 2015)

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Computed Tomography for Non-Invasive Imaging of Subclinical Coronary Atherosclerosis

Imaging Imaging Imaging Imaging ofofofof coronarycoronarycoronarycoronary arteryarteryarteryarterycalcificationcalcificationcalcificationcalcification asasasas a a a a specificspecificspecificspecific signsignsignsignofofofof atherosclerosisatherosclerosisatherosclerosisatherosclerosis Agatston AS, Janowitz WR et al.

Quantification of coronary artery calcium using ultrafast computed tomography. JACC 1990

WOULD YOU CONSIDER CAC TEST?


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Looking upside down: what is value of absence of CAC?

Study Type Population (n)

CAC=0(%)

FU(Years)

Number of events (%)

Meta-Analysis * 71,595 29,312 (41%)

4.3 154 (0.47%) CVD events

Retrospective** 44,052 19,898 (45%)

5.6 104 (0.52%) Deaths

Prospective*** 6,809 3,414(50%)

4.1 17 (0.52%) CHD events

*Sarwar A, Shaw LJ, Shapiro MD, Blankstein R, Hoffman U, Brady TJ, Cury R, Budoff MJ, Blumenthal RS, Nasir K. JACC Imaging 2009

** Blaha M, Budoff MJ, Shaw LJ, Khosa F, Rumberger JA, Berman D, Callister T, Raggi P, Blumenthal RS, Nasir K. JACC Imaging 2009

*** Budoff M, McClelland R, Nasir K, Greenland P, K ronmal RA, Kondos G, Shea S, Lima JAC, Blumenthal RS. Am Heart J 2009

WOULD YOU CONSIDER TO RULE OUT DISEASE?


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CLINICAL REASEARCHPrevention and epidemiology

Impact of coronary artery calcium on coronaryheart disease events in individuals at the extremesof t radit ional risk factor burden: the Mult i-EthnicStudy of AtherosclerosisMichael G. Silverman1,2, Michael J. Blaha1, Har lan M. Krumholz3, Mat thew J. Budoff4,Ron Blankstein2, Chr istopher T. Sibley5, Ar thur Agatston6, Roger S. Blumenthal1,and Khurram Nasir 1,6,7,8*

European Heart Journaldoi:10.1093/eurheartj/eht508

doi: 10.1161/CIRCULATIONAHA.113.0036252014;129:77-86; originally published online October 20, 2013;Circulation.

CLIN ICAL REASEARCHPrevention and epidemiology

Impact of coronary artery calcium on coronaryheart disease events in individualsat the extremesof t radit ional r isk factor burden: the Mult i-EthnicStudy of AtherosclerosisMichael G. Silverman1,2, Michael J. Blaha1, Har lan M. Krumholz3, Mat thew J. Budoff4,Ron Blankstein2, Chr istopher T. Sibley5, A r thur Agatston6, Roger S. Blumenthal1,and Khurram Nasir 1,6,7,8*

European Heart Journaldoi:10.1093/eurheart j/eht508

doi: 10.1161/CIRCULATIONAHA.113.0036252014;129:77-86; originally published online October 20, 2013;Circulation.

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Malik S, Budoff M, Katz R, Blementhal RJ, Alain Bert oni, Blumenthal RS, Nasirk K, Szklo M, Barr G, Wong ND ( Diabetes Care 2012)

Are all Diabetics Equivalent?

47%47%47%47%

25%25%25%25%

28%28%28%28%

Number needed to treatNumber needed to treatNumber needed to treatNumber needed to treat:CAC 0 549CAC 1-100 94CAC > 100 24

75% of all events occurred in 25% with CAC>10075% of all events occurred in 25% with CAC>10075% of all events occurred in 25% with CAC>10075% of all events occurred in 25% with CAC>100

�Risk Factors Does Not Equate Presence and Burden

of Atherosclerosis

�Huge Heterogeneity Exists even at spectrum of

Traditional Risk Profile

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ANY VALUE FOR CAC IN NEW GUIDELINES?

60 white Male60 white Male60 white Male60 white MaleT T T T CholCholCholChol: 182 mg/dl: 182 mg/dl: 182 mg/dl: 182 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlHTN on ACEIHTN on ACEIHTN on ACEIHTN on ACEINon Non Non Non smokersmokersmokersmokerSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgNon diabeticNon diabeticNon diabeticNon diabeticFH of premature CVDFH of premature CVDFH of premature CVDFH of premature CVDHsHsHsHs----CRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LNon smokerNon smokerNon smokerNon smoker

4 QUESTIONS

“ How Many Adult Without Established

ASCVD Will be Candidates for Statins?”

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“ What is the probability of CAC=0 across

statin recommendation groups?”

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“ Will CAC=0 lower risk below threshold

where statins are recommended?”

“ Is CAC testing useful across the

entire spectrum of risk categories?”

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Challenges with CAC Testing in

2016

http://nyti.ms/1Nh3dWF

HEALTH

Heart Scan Can Fine-Tune Risk Estimate forPatients Considering StatinsBy GINA KOLATA OCT. 5, 2015

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Does CAC Testing Has Such a Dramatic Downstream Impact?

No-CAC Testing(n = 623)

CAC Testing(n = 1,311)

P value

Downstream TestsStress Test 33.9% 34.6% 0.74Cardiac CT 7.1% 7.7% 0.62Cardiac Catherization 2.9% 3.3% 0.71Coronary Revascularization 1.8% 2.3% 0.46Downstream CostsMedian Procedure costs* $721 $904 0.56Median Medication costs $2,937 $3,149 0.09

*Include $150 for CAC testing.Rozanski et al, J Am Coll Cardiol. 2011;57:1622-1632

EISNER STUDY: 4 YEAR FOLLOW-UP

“How Can We Incorporate CAC Testing (especially CAC=0) in

Shared Decision Making”?

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PHARMA & HEALTHCARE 10/05/2015 @ 2:00PM 1,307 views

This Test Might Tell You If You Don'tNeed A Statin

Harlan Krumholz Contributor

I cover science and medicine.

Opinions expressed by Forbes Contributors are their own.

PHARMA & HEALTHCARE 10/05/2015 @ 2:00PM 1,307 views

This Test Might Tell You If You Don'tNeed A Statin

Harlan Krumholz Contributor

I cover science and medicine.

Opinions expressed by Forbes Contributors are their own.

Patient # 1: ASCVD 12%

Patient Discussion (part 2)Probability of CAC categoriesRevised Risk with CAC scoresRevised Impact with Statin Use

CostsRadiation

Patient Discussion (part 1)Risk in simple terms

Statin efficacySide-effects

Costs

CAC=0CAC=0CAC=0CAC=0

Patients decide against statinPatients decide against statinPatients decide against statinPatients decide against statin

Patient # 2: ASCVD 12%

Patient Discussion (part 2)Probability of CAC categoriesRevised Risk with CAC scoresRevised Impact with Statin Use

CostsRadiation

Patient Discussion (part 1)Risk in simple terms

Statin efficacySide-effects

Costs

Patients decide against CACPatients decide against CACPatients decide against CACPatients decide against CAC

Patients decide for moderate Patients decide for moderate Patients decide for moderate Patients decide for moderate dose statindose statindose statindose statin

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Op-Ed: Coronary Calcium forInformed Statin Choices— It 's not about screening, says Khurram Nasir,MD, MPH

Op-Ed: Coronary Calcium forInformed Statin Choices— It 's not about screening, says Khurram Nasir,MD, MPH

“ What about other tests/risk factors?”

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Circulation. 2016 Jan 22. pii: CIRCULATIONAHA.115.018524. [Epub ahead of print]

Role of Coronary Artery Calcium Score of Zero and O ther Negative RiskMarkers for Cardiovascular Disease: The Multi-Ethni c Study Of Atherosclerosis(MESA).Blaha MJ , Cainzos-Achirica M , Greenland P , McEvoy JW , Blankstein R , Budoff MJ , Dardari Z , Sibley CT ,Burke GL , Kronmal RA , Szklo M , Blumenthal RS , Nasir K .

1 2 3 4 5 6 4 7

8 9 10 4 11

BACKGROUND:Abstract

-Limited attention has been paid to negative cardiovascular disease (CVD) riskmarkers despite their potential to improve medical decision-making. We compared thirteen negativerisk markers using diagnostic likelihood ratios (DLR), which model the change in risk for an individualafter the result of an additional test.

De-risking: Comparison of CAC=0 with Other Markers

“What about Costs?

….Is the approach of not treating those with CAC=0 compared to current

guidelines cost-effective”?

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PLOS ONE PLOS ONE PLOS ONE PLOS ONE March 18 2015March 18 2015March 18 2015March 18 2015

CAC in 2016: The question to ask is“Why Not” rather than “Why”?

� Most precise measure for risk of clinical CVD event

� Widely available

� Inexpensive (75-100 $)

� Easy to perform (takes 2-3 minutes) and interpret

� Radiation equivalent to mammogram

�Advantages to stakeholders

�Health System: Appropriately allocating healthcare resources to groups likely to receive net benefit from proven Interventions.

�Clinician: personalized assessment of risk on case by case situation

�Patient: Shared decision making

CAC in 2016: Who and What?

�Who�Intermediate risk patients 5-20% undecided about statin

use

�Patient choice driven

�What�CAC=0� Focus on Lifestyle Intervention

�CAC 1-100� +Moderate/High Dose Statin

�CAC>100 � +High Dose Statin & Aspirin

�CAC>400 � Can consider functional testing (stress test)

� At no point, asymptomatic patient should be considered for invasive angiography.

nonnon--invasive cad screening invasive cad screening · cac in 2016: who and what? who...

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