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From Vulnerable Plaque to From Vulnerable Plaque to Vulnerable PatientVulnerable Patient;
Our Mission Is Eradication of Heart Attack
Morteza Naghavi, M.D.Founder and President,
Association for Eradication of Heart Attack (AEHA)
The AEHA VP Summit – An American Heart Association 2005 Satellite SymposiumThe AEHA VP Summit – An American Heart Association 2005 Satellite Symposium
Heart attack is NOT the world’s number
one problem, extreme poverty
is.The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
“50,000 per day die of infectious diseases which
could almost all be cured or prevented at a cost which
is sometimes no more than $1 per person”
World Health Organization
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
Extreme Poverty Is a Shame to the World
Much Kudus to Bono and the One Campaign
Extreme Poverty Is a Shame to the World
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
After extreme poverty and associated infectious diseases,
eradication of heart attack can be the most rewarding
opportunity in the 21st century for saving productive life years
worldwide.
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
How the World Dies Today?
YLLs: Years of Life Lost
AtheroscleroticDiseases
The AEHA 2005 VP SummitThe AEHA 2005 VP SummitWorld Health Organization
Worldwide Causes of Death Source: WHO
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
> 15 Million Heart Attacks Each Year
Source:
World HeartFederation
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
0
5
10
15
20
25
30
1990 2020
Mill
ion
s o
f D
eath
sfr
om
Car
dio
vasc
ula
r C
ause
s
Western countries
Non-Western (developing) countries
5 million
DEATHS FROM CARDIOVASCULAR CAUSESWORLDWIDE
KS Reddy. NEJM 2004; 350:2438
9 million
19 million
6 million
Over 2/3 of the global
burden of heart attack
and stroke is on poor
countries.
~15m today
>25m tomorrow
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
More than More than half caused half caused by a sudden by a sudden heart attack heart attack in in healthy- healthy-
looking looking populationpopulation
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
Epidemic of Heart Failure
Global Epidemic of Diabetes
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
Epidemic of Obesity & Diabetes in the U.S.
1990/19911990/1991 20002000
ejt 0901–120
Mokdad et al., JAMA Mokdad et al., JAMA 286:1195–1200, 2001286:1195–1200, 2001 No DataNo Data < 4%< 4% 4%-6%4%-6% > 6%> 6%
No DataNo Data < 10%< 10% 10%-14%10%-14% 15%-19%15%-19% 20%20%
ObesityObesity
DiabetesDiabetes
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
Global Atherosclerosis; A Bigger Threat than
Global Warming!
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
•Heart attack is not equal to heart disease, and is not equal to atherosclerosis either.
It is the attack part of coronary heart disease that is most devastating, and the first focal point of the AEHA movement.
Heart attack is the tip of atherosclerosis problem.
The AEHA 2005 VP SummitThe AEHA 2005 VP Summit
Prevent Attack!
From Vulnerable Plaque to Vulnerable Patient
What have we learned in the past 5 years.• More than one vulnerable plaque exists and rupture prone plaques are
not the only type of vulnerable plaques. Besides plaque, blood and myocardial vulnerability must be considered.
• Coronary calcification is a marker subclinical disease and can identify the vulnerable patient. The level of calcification directly correlates with the level of risk.
• The need for measuring disease activity through inflammatory markers or else remains high and currently unanswered. CRP does not seem to be the one.
• Noninvasive CT imaging has taken the lead in the race among diagnostic technologies. Molecular imaging holds the future.
• The hot race among emerging intra-coronary vulnerable plaque detection technologies slowed. IVUS made a come back.
• Aggressive lipid lowering reduces adverse events, nonetheless CHD patients experience over ~10% MACE every year.
• Drug eluting stent has become the final contender in the fight against restenosis. Its role in pre-emptive therapy of non-culprit non-flow-limiting plaques remains to be defined.
From V Plaque to V PatientWhat to expect in the next 5 years.
• Noninvasive screening of the vulnerable patient with CT and IMT will be improved and widely practiced.
• Molecular imaging for the detection of vulnerable plaques with different target molecules will rise, nonetheless, its use for clinical practice remains far from 5years.
• Combined LDL-HDL therapy will be the mode of treatment. Emerging anti-inflammatory drugs may find a role but limited.
• The new coming of IVUS will expand its use in cath labs, however, the magnitude of success in systemic drug therapy will define the future of vulnerable plaque detection.
• Rapid acting systemic drugs for plaque stabilization may obviate the need for the detection of vulnerable plaques, unless they are extremely expensive.
• The outcome of pre-emptive DES clinical trials versus the outcome of emerging drug trials will define the direction of preventive cardiology to 2010 and after. The direction may go to more non-invasive or may open the floodgate to preventive interventional cardiology.
In this meeting you will learn how screening for the detection and treatment of the vulnerable patient presents as a “low-hanging” fruit of preventive cardiology.
Atherosclerosis Test
Negative Positive
No Risk Factors + Risk Factors
Step 1Test forPresence of the Disease
Step 2Stratify based on the Severity of the Disease andPresence of Risk Factors
Step 3Treat based on the Level of
Risk
LowerRisk
ModerateRisk
ModeratelyHigh Risk
HighRisk
VeryHigh Risk
Apparently Healthy At-Risk Population
The 1st S .H .A .P .E . GuidelineTowards the National Screening for Heart Attack Prevention and Education (SHAPE) Program
Conceptual Flow Chart
<75th
Percentile75th-90th
Percentile≥90th
Percentile
Atherosclerosis Test
Very Low Risk3
Negative Test• CCS =0• CIMT<50th percentile
LowerRisk
ModerateRisk
Positive Test• CCS ≥1• CIMT 50th percentile or Carotid Plaque
ModeratelyHigh Risk
HighRisk
VeryHigh Risk
No Risk Factors5 + Risk Factors • CCS <100 & <75th% • CIMT <1mm & <75th%
& No Carotid Plaque
• Coronary Calcium Score (CCS)or
• Carotid IMT (CIMT) & Carotid Plaque4
• CCS 100-399 or >75th%• CIMT 1mm or >75th%
or <50% Stenotic Plaque
• CCS >100 & >90th%or CCS 400
• 50% Stenotic Plaque6
IndividualizedIndividualizedIndividualized5-10 years5-10 yearsRe-test Interval
<70 mg/dl<100 mg/dl<70 Optional
<130 mg/dl<100 Optional
<130 mg/dl<160 mg/dlLDLTarget
All >75y receive unconditional treatment2
Apparently Healthy Population Men>45y Women>55y1
ExitExit
Myocardial IschemiaTest
NoAngiography
Follow Existing Guidelines
Yes
The 1st S .H .A .P .E . GuidelineTowards the National Screening for Heart Attack Prevention and Education (SHAPE) Program
Step 1
Step 2
Step 3Optional
CRP>4mg
ABI<0.9
Heart Attack History Makers
Faculty of the Past 9 VP Symposia and the SHAPE Task Force
Lets Hope the World Will Do First Thing First!
SHAPE
Get in SHAPE!