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Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

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Page 1: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Vascular Risk Prediction

Profiling tools for subjects at risk for a first, unheralded vascular disease

An update from the Taskforce on Vascular Risk Prediction

Page 2: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk Prediction

Principle Goal of the Taskforce

Improve risk prediction in originally healthy people, in whom a high risk derived from the major independent cardiovascular risk factors is not evident

Page 3: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk Prediction

Guidelines 2005: ....

AGLA / Executive Committee SGK Secondary prevention:

IntensificationPrimary Prevention:

Discuss Guidelines of ESC and IAS Try to reach common guidelines in the next years

Page 4: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk Prediction

3 Questions

IAS-AGLA or EAS-SCORE or FRAMINGHAM as a first measure ?

PLAQUE or ISCHEMIA or hsCRP to further stratify risk ?

BAYES or ROC or ODDS to estimate the value of a test ?

Page 5: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk Prediction

3 levels of risk

PROCAM CORDICARE I Germany OLTEN COHORTMen Only Men and WomenAge 35-65 Age 45+N=5389 N=914

RISK Distribution Events Distribution Events

High 8% 33% 2% ?Intermediate 15% 33% 11% ?Low 77% 33% 87% ?

Page 6: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk Prediction

3 possible strategies

A down-calibrate definition of high risk from 20% to 15%?general practitionars might be even more confused than they are already now

B treat virtually everybodies cholesterol in intermediate risk

C further risk stratify with new tools in intermediate risk

Page 7: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk Prediction

IAS-AGLA or EAS-SCORE / Strategy B

CORIDCARE I

Indication forLDL or total Cholesterolloweringintervention

Page 8: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk PredictionIAS-AGLA or EAS-SCORE

Strategy B: treat them all in intermediate risk defined by IAS-AGLA

IAS-AGLA Intermediate Risk CORDICARE I = 11% of 914 subjects > 45 years10 year risk for AMI is about 15% on average Year 2005: 410251 subjects in CH > 40 years at intermediate riskOf these, 91% would be treated with statins (CORDICARE I)61538 AMI would occur in 10 years (30769 deaths)Statins lower risk by 30%Risk would be reduced from 15% to 11% with statinsAbsolute Risk reduction 16800 AMI (8400 deaths)Relative Risk reduction 27%NNT 24

Page 9: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk PredictionIAS-AGLA or EAS-SCORE

Strategy C: further risk stratify intermediate risk defined by IAS-AGLA

Ca-Scoring ?

Ultrasound Plaque Imaging ?

hsCRP?

Page 10: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007 /

Vascular Risk PredictionStrategies to assess the value of a test

A ROC analysisB ODD ratios, relative risk, correction for co-factorsC Bayes Posttest Calculator

Page 11: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007 /

Vascular Risk PredictionStrategies to assess the value of a test

Page 12: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007 /

Vascular Risk PredictionROC, ODD, or BAYES

Nancy Cook statements:

„Indeed, if improvement in the ROC statistic was used as the criterion for model inclusion, then neither LDL-C, HDL-C, nor total cholesterol would have been included in risk models after accounting for age, blood pressure, and smoking.”

“The Bayes information …is related to the posterior probability that the model is correct, and is a conservative criterion for model selection.”

Page 13: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007 / Wald NJ, Law MR. BMJ. 2003;326:1419

Vascular Risk PredictionROC, ODD, or BAYES

Single Risk Factor Testing

Significant overlap between diseased and non diseased

Page 14: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007 / Hypertension. 2006;48:392-396.

Vascular Risk PredictionIAS-AGLA or EAS-SCORE

Strategy C: further risk stratify intermediate risk defined by IAS-AGLA: relative risk for various risk factors in middle aged subjects

Hypertension

LDL>4.1 Men

LDL>4.1 Women

Nicotine Men

Nicotine Women

Diabetes Men

Diabetes Women

ARIC Study

Page 15: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk PredictionBayes Posttest Risk as a – third – solution between ROC and ODDs ?

Look for practicle solutions on www.scopri.ch

SE = SensitivitySP = SpecificityPV = prevalence or pretest probabilityPTP = posttest probability

PTP pos PV × SE / PV × SE + (1 – PV) × (1 – SP) PTP neg PV × (1 – SE) / PV × (1 – SE) + SP × (1 – PV)

http://www.scopri.ch/
Page 16: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk PredictionBayes Posttest Riskwith 95% CI

Using

Coronary calciumpercentiles

95% CI by Newcombe

Page 17: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk PredictionBayes Posttest Riskwith 95% CI

Page 18: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk PredictionBayes Posttest Riskwith 95% CI

http://scopri.ch/posttestcalculators1.html

Page 19: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk PredictionFuture themes of the taskforce www.taskforce.atherosclerosisimaging.ch

Which emerging imaging test should be ideally used in Switzerland?Are sequential posttest-calculations an issue in risk prediction ? Who should do atherosclerosis imaging tests (accreditation)?Does atherosclerosis imaging convince patients more than verbal communication, that a treatment is necessary?For which test should there be reimbursement and how can that be achieved?What is the cost-efficiency issues of emerging imaging tests?What is the risk-benefit ratio of calcium scoring in intermediate risk subjects in view of the radiation burden per scan (1 mSv).…..

http://www.taskforce.atherosclerosisimaging.ch/
Page 20: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 06.05.2006

Vascular Risk Prediction

An Update of the Taskforce

Taskforce

Founding Members in 2005Darioli RogerRomanens Michel

Scientific CoordinatorRomanens Michel

Page 21: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk PredictionSummary and Future Directions

Proposition: in God we trust, the others must bring numbers

Let us do the COCA study (5 year outcome of coronary calcifications and carotid total plaque area from a real life experience)

It is designed to produce numbers on outcome, since practice based algorithms may be more useful than population wide epidemiological testing in the future

Page 22: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk PredictionSummary and Future Directions

Goal of the taskforce: improve risk prediction in originally healthy subjects, and : several publications are underway ….

IAS-AGLA or EAS-SCORE: rather IAS-AGLA

Calcium scoring passes the hardliner test (ROC analysis)

Bayes Posttest Risk Calculators are useful

Many themes are open to debate within the TaskforceCheck on www.taskforce.atherosclerosisimaging.ch

http://www.taskforce.atherosclerosisimaging.ch/
Page 23: Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

Michel Romanens, 05.05.2007

Vascular Risk Prediction

The presentation is open for discussion


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