Transcript Blackberries

Presenter Disclosure Information
Diane Bild, MD, MPH
Screening for Subclinical Atherosclerosis as a Strategy
for CVD Prevention
FINANCIAL DISCLOSURE:
None
UNLABELED/UNAPPROVED USES DISCLOSURE:
None
Diane Bild, MD, MPH
Associate Director, Prevention and Population Sciences Program
Division of Cardiovascular Sciences
The views expressed are not necessarily those of NHLBI.
 Prevent
morbidity and
mortality due to CVD
◦ Identify disease before it
becomes symptomatic.
◦ Prevent disease progression.
Footnote: “Screening” is a standardized population or
case-finding approach, not an individualized strategy.
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It may be costly.
It may cause undue psychological stress.
Coronary artery calcium detection
requires CT scanning and radiation,
which may induce cancer.
CT scans may uncover other subclinical
disease (such as pulmonary nodules) that
requires further work-up.
Hundreds of risk factors
 Countless analyses from observational
studies
 Recent progress in modeling risk
prediction, particularly with clinical
relevance
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◦ Discrimination
◦ Calibration
◦ Reclassification
http://lifebeat.pt/en2.php
Identify high risk
Further
diagnosis
Treatment Rx
? statins
? aspirin
? antihypertensives
Risk lowered
Long-term
adherence
The 1st S.H.A.P.E. Guideline
Towards the National Screening for Heart Attack Prevention and Education (SHAPE) Program
Apparently Healthy Population Men>45y Women>55y1
Step 1
Very Low Risk
3
Exit
Exit
All >75y receive unconditional treatment2
• Coronary Artery Calcium Score (CACS)
or
• Carotid IMT (CIMT) & Carotid Plaque4
Atherosclerosis Test
Step 2
Negative Test
Positive Test
• CACS =0
• CIMT <50th percentile
No Risk Factors5
Step 3
Lower
Risk
+ Risk Factors
Moderate
Risk
• CACS ≥1
• CIMT 50th percentile or Carotid Plaque
• CACS <100 & <75th%
• CIMT <1mm & <75 th%
& no Carotid Plaque
Moderately
High Risk
• CACS 100-399 or >75th%
• CIMT 1mm or >75th%
or <50% Stenotic Plaque
ABI<0.9
CRP>4 mg
Optional
High
Risk
• CACS >100 & >90th%
or CACS 400
• 50% Stenotic Plaque6
Very
High Risk
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
1: No history of angina, heart attack, stroke, or peripheral arterial disease.
2: Population over age 75y is considered high risk and must receive therapy without testing for
atherosclerosis.
3: Must not have any of the following: Chol>200 mg/dl, blood pressure >120/80 mmHg, diabetes,
smoking, family history, metabolic syndrome.
4: Pending the development of standard practice guidelines.
5: High cholesterol, high blood pressure, diabetes, smoking, family history, metabolic syndrome.
6: For stroke prevention, follow existing guidelines.
Follow Existing
Guidelines
Angiography
Myocardial
IschemiaTest
Yes
No
Wilson JM. J R Coll Gen Pract 1968;16 Suppl 2:48 –57.
Wilson JM. J R Coll Gen Pract 1968;16 Suppl 2:48 –57.
CAC?
?
?
Hlatky, et al. Circulation 2009; 119:2408-2416.
Suggestions for
Practice
Grade
Definition
A
The USPSTF recommends the service.
There is high certainty that the net
benefit is substantial.
Offer or provide this
service.
B
The USPSTF recommends the service.
There is high certainty that the net
benefit is moderate or there is
moderate certainty that the net benefit
is moderate to substantial.
Offer or provide this
service.
C
The USPSTF recommends against
routinely providing the service. There
may be considerations that support
providing the service in an individual
patient. There is at least moderate
certainty that the net benefit is small.
Offer or provide this
service only if other
considerations
support the offering or
providing the service
in an individual
patient.
Suggestions for
Practice
Grade
Definition
D
The USPSTF recommends against the
service. There is moderate or high
certainty that the service has no net
benefit or that the harms outweigh the
benefits.
Discourage the use of
this service
I
The USPSTF concludes that the current
evidence is insufficient to assess the
balance of benefits and harms of the
service. Evidence is lacking, of poor
quality, or conflicting, and the balance
of benefits and harms cannot be
determined.
Read the clinical
considerations section
of USPSTF
Recommendation
Statement. If the
service is offered,
patients should
understand the
uncertainty about the
balance of benefits
and harms.
State
ment
Condition
Explanation
Grade
Abdominal aortic
aneurysm (2005)
One-time screening for AAA by
ultrasonography in men aged 65 to 75
who have ever smoked.
B
No recommendation for or against
screening for AAA in men aged 65 to
75 who have never smoked.
C
The USPSTF recommends against
routine screening for AAA in women.
D
Condition
Explanation
Grade
Carotid artery stenosis Recommends against screening for
(2007)
asymptomatic carotid artery stenosis
in the general adult population.
D
Peripheral artery
disease (2005)
D
The USPSTF recommends against
routine screening for peripheral
arterial disease.
Condition
Explanation
Grade
Coronary heart
disease (2004)
Recommends against routine screening with
resting electrocardiography (ECG), exercise
treadmill test (ETT), or electron-beam
computerized tomography (EBCT) scanning
for coronary calcium for either the presence
of severe coronary artery stenosis (CAS) or
the prediction of coronary heart disease
(CHD) events in adults at low risk for CHD
events.
D
Insufficient evidence to recommend for or
against routine screening with ECG, ETT, or
EBCT scanning for coronary calcium for
either the presence of severe CAS or the
prediction of CHD events in adults at
increased risk for CHD events.
I
Condition
Explanation
Grade
Risk
assessment,
nontraditional
risk factors
(2009)
Evidence is insufficient to assess the balance
of benefits and harms of using the
nontraditional risk factors discussed in this
statement to screen asymptomatic men and
women with no history of CHD to prevent
CHD events
I
The nontraditional risk factors included in this recommendation are
high-sensitivity C-reactive protein (hs-CRP), ankle-brachial index (ABI),
leukocyte count, fasting blood glucose level, periodontal disease,
carotid intima-media thickness (carotid IMT), coronary artery
calcification (CAC) score on electron-beam computed tomography
(EBCT), homocysteine level, and lipoprotein(a) level.
Condition
Explanation
Grade
Lipid disorders
in adults (2008)
- Men
The U.S. Preventive Services Task Force
(USPSTF) strongly recommends screening
men aged 35 and older for lipid disorders.
A
The USPSTF recommends screening men
aged 20 to 35 for lipid disorders if they are
at increased risk for coronary heart disease.
B
The USPSTF strongly recommends screening
women aged 45 and older for lipid disorders
if they are at increased risk for coronary
heart disease.
A
The USPSTF recommends screening women
aged 20 to 45 for lipid disorders if they are
at increased risk for coronary heart disease.
B
Lipid disorders
in adults (2008)
– Women at
increased risk
Condition
Explanation
Grade
Lipid disorders
in Adults -Young Men and
All Women Not
at Increased
Risk
The USPSTF makes no recommendation for
or against routine screening for lipid
disorders in men aged 20 to 35, or in
women aged 20 and older who are not at
increased risk for coronary heart disease.
C
Blood pressure
The U.S. Preventive Services Task Force
(USPSTF) recommends screening for high
blood pressure in adults aged 18 and older.
A
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Level of evidence A: recommendation based
on evidence from multiple randomized
trials or meta-analyses
Level of evidence B: recommendation based
on evidence from a single randomized trial
or nonrandomized studies
Level of evidence C: recommendation based
on expert opinion, case studies, or
standards of care
Tricoci, et al. JAMA 2009;301:831-841.
Polonsky, et al. JAMA 2010;303:1610-16.
Source: Cholesterol
Treatment Trials
Collaborators. Lancet
2005:366:1267–78
“Treatment better”
~25% risk reduction
Lipid Research Clinics Program. JAMA 1984;251:351-64.
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Published in 1967
N=143
VA Cooperative Study Group on Antihypertensive Agents. JAMA 1967;202:116-21.
Douglas, et al. Outcomes Research in Cardiovascular Imaging: Report of a
Workshop Sponsored by the National Heart, Lung, and Blood Institute. JACC
Cardiovasc Imaging 2009;2:897-907.
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Guidelines may need to be changed
due to:
◦ Emergence of new evidence
◦ Changes in disease prevalence
◦ Consideration of new risk groups
◦ Development of new therapies
◦ Changes in the cost of treatment
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Goals are laudable; some candidate screening
markers have promising characteristics.
Harms of screening need to be carefully considered,
especially for coronary artery calcium detection.
Few screening targets in cardiovascular disease
prevention are deemed beneficial -- most notably,
BP and lipids.
Much work has been performed in estimating
prediction; little in estimating outcomes.
Any screening guidelines need periodic reevaluation.