PowerPoint-pr

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96 of deaths from CHD or stroke occur in people
aged 55 and over
Wald NJ, Law MR. A strategy to reduce
cardiovascular disease by more than 80. BMJ.
20033261419-
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Circulation 2004110227-39
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Almost all people with zero or 1 risk factor
have a 10-year risk lt10, and 10-year risk
assessment in people with zero or 1 risk
factor is thus not necessary.
Circulation 2004110227-39
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• Low risk
• S-chol lt200 mg/dl
• BP ?120/80
• No smoking
• No diabetes

JAMA 19992822012-8
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• Low risk
• S-chol lt200 mg/dl
• BP ?120/80
• No smoking
• No diabetes
• lt10 of population

JAMA 19992822012-8
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• Low risk
• S-chol lt200 mg/dl
• BP ?120/80
• No smoking
• No diabetes
• lt10 of population
• High negative
• predictive value!

JAMA 19992822012-8
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(Optimal)
(no prehypertension)
Circulation 19991001481-1492
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Circulation 19991001481-1492
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96 of deaths from CHD or stroke occur in people
aged 55 and over
Trajectory How early?
Wald NJ, Law MR. A strategy to reduce
cardiovascular disease by more than 80. BMJ.
20033261419-
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Susceptibility
Vulnerable Patient 10 risk/y
Risk factors Categorical levels
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Susceptibility
Vulnerable Patient 10 risk/y

• Vulnerability
• Relative
• Absolute (VP)

Risk factors Categorical levels
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Susceptibility
Tool- dependent
Vulnerable Patient 10 risk/y

• Vulnerability
• Relative
• Absolute (VP)

Risk factors Categorical levels
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Susceptibility
Vulnerable Patient 10 risk/y
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Susceptibility
Vulnerable Patient 10 risk/y
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Vulnerability
Vulnerable Patient 10 risk/y
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Madjid et al. ATVB 2004241775-82
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Vulnerable Plaque Thrombosis ? ?
smc
Thrombus
Fibrous cap
Inflammation (macr, MMP)
Lipid-rich core
Expansive growth (remodeling)
Angiogenesis
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Figure 1. Occurrence of a first coronary event
within 10 years, estimated by Cox proportional
hazards models in percentages. Left, Percentage
estimated by a model with FRS (5 categories)
adjusted for survey. Right, Percentage estimated
for each of 5 FRS categories by a model with CRP
(3 categories) adjusted for FRS (continuous) and
survey. Probability values indicate significance
status of CRP in the Cox model.
Wolfgang Koenig, SHAPE Report 2005
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Clinical utility of very high (gt10 mg/L) as well
as very low (lt0.5 mg/L) levels of hsCRP among
those with 10-year Framingham estimated risks
lt10 (left) and between 10 and 20 (right).
Circulation 20041092818-25
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Pepe et al. Am J Epidemiol 2004159882-90
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CRP MPO
!
Pepe et al. Am J Epidemiol 2004159882-90
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Pepe et al. Am J Epidemiol 2004159882-90
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Circulation 2004 Dec 14110e532
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Targeted therapy, proportionate to the
severity of the disease
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Causal factors
Targeted therapy, proportionate to the
severity of the disease
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Mosca L. N Engl J Med 20023471615-7. Editorial
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Physical inactivity
Circulation 2000101111-6
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SHAPE Cost-Effectiveness
Leslee Shaw, SHAPE Report 2005
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Screen Testing Evaluating the Cost and
Effectiveness of Strategies for Atherosclerotic
Detection and Prevention
The SHAPE Equation  N n0 ? fc ? fs ? fd ? ft ?
fe   N Number of prevented atherosclerotic
events n0 Number of atherosclerotic events in
the baseline population fc Fraction of
candidates in the baseline population fs
Fraction of candidates who are screened fd
Fraction of screened candidates who are
detected for treatment ft Fraction of detected
subjects who are effectively treated fe Fraction
of effectively treated subjects in whom events
are prevented
George A. Diamond, SHAPE Writing Group
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Early Heart Attack Care (EHAC) and Chest Pain
Centers ED
Raymond Bahr, SHAPE Report 2005
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Raggi et al. AHJ 2001141375-82
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Fatal and nonfatal MI risk and OR for each decile
of calcium score (CS)
n676, age 52y
Raggi et al. AHJ 2001141375-82
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Predictive studies Characteristics and Risk
Ratio for Follow-Up Studi
es Using EBCT in Asymptomatic Persons
Harvey Hecht, SHAPE Report 2005
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NEJM 2003 349465-73
Office-based risk assessment
RRgt10
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NEJM 199934014-22
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OLeary et al. NEJM 199934014-22
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OLeary et al. NEJM 199934014-22
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Figure 2 B-mode imaging of right carotid artery,
bifurcation and internal and external carotid
arteries. Images are obtained with ultrasound
beam perpendicular to the vessel wall showing
near wall, lumen and far wall. Distal 1 cm of
common carotid, 1 cm of carotid bulb and 1 cm of
proximal internal carotid artery are imaged for
IMT measurement and detection of plaque.
Naqvi and Douglas, SHAPE Report 2005
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Best Marker of Susceptibility to CHD prevalent
arterial disease
CHD risk equivalents
NCEP ATP III
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96 of deaths from CHD or stroke occur in people
aged 55 and over

• Future research
• Outcome studies
• Disease activity
• Search for the VP

Wald NJ, Law MR. A strategy to reduce
cardiovascular disease by more than 80. BMJ.
20033261419-
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From Vulnerable Plaque to Vulnerable Patient
Part III   Introducing a New Paradigm for the
Prevention of Heart Attack Identification and
Treatment of the Asymptomatic Vulnerable
Patient     Screening for Heart Attack Prevention
and Education (SHAPE) Task Force
Report   Chairman Editorial Committee
Writing Group Advisors Morteza Naghavi,
Harvey S. Hecht, Jay Cohn, Michael Jamieson,
Daniel Berman, Ole Faergeman, Matthew J. Budoff,
Zahi Fayad, John Rumberger, George A. Diamond,
Leslee Shaw, Tasneem Z. Naqvi, Pamela Douglas,
Raymond Bahr, Wolfgang Koenig, Jasenka Demirovic,
Dan Arking, Victoria L.M. Herrera, Juan Badimon,
Sanjay Kaul, Juhani Airaksinen, Yoram Rudy,
Arturo G. Touchard, Robert S. Schwartz, Daniel
Lane, Henrik Sillesen, Roger Blumenthal, Roxana
Mehran, Stephane Carlier, Allen J. Taylor,
Prediman K. Shah.
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From Morteza Naghavi, M.D. mailtomn2_at_vp.orgS
ent Thu 3/3/2005 129 AMTo Erling
FalkSubject Erling, please note the yellow
box is Lower Risk not Low Risk, . Mort
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Risk assessment and stratification

• Risk factor/office-basedNCEP, 10-year risk

Intermediate Risk 10-20
High Risk gt20
Low(er) Risk lt10
RR 2
Pletcher et al. Arch Intern Med 20041641285-92