Heat Attack Prevention - Avera HealthHeat Attack Prevention CAD kills more than 450,000 Americans...

9/9/2015

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& A Collaboration Between & A Collaboration Between

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& A Collaboration Between

Heat Attack Prevention

CAD kills more than 450,000 Americans annually (20% of all deaths)

1,260,000 Americans will have MI this year- Nearly 40% will not survive

CAD is Number 1 killer of women; more than next 7 causes combined!

Primary care setting is ideal for identifying patients before symptom onset or acute event

CAC scoring/CIMT testing ideal screening tests for CAD

Non-invasive, patient friendly, low cost


Percentage of Americans

whose First Symptom of

CAD is Myocardial

Infarction:

50%


Coronary Atherosclerosis

Long-standing association between arterial disease and calcification.

Calcification ≈ atherosclerosis

20% of plaque volume is calcium


Multi- Slice CT Technology

6 second heart scan

.5mm slice thickness

Rotation speeds of .33

seconds

Up to 1500 slices per study

Excellent 3-D image quality

Reduced radiation

exposure


Calcium Scoring

Becomes the

Prevention

Paradigm:

The Heart

Mammogram or

Colonoscopy

Goal:

Leading Causes of

Death (United States) 1.Heart Disease

2.All Cancers

3.Stroke

4.Respiratory

5.Accidents

6.Diabetes

7.Alzheimer’s 8.Influenza & Pnuemonia

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CCTA vs. Calcium Artery Calcium

CAC

CCTA: Symptomatic

CAC: Asymptomatic


Calcium Artery Calcium Score

Coronary calcium has been shown to independently

predict cardiovascular risk and…

New research indicates that calcified plaques are

intimately related to the unstable lesions

responsible for myocardial infarction

Carr JJ. Applied Radiology. December, 2005


Calcium Score Value

Current methods of identifying asymptomatic CAD

patients ineffective

Traditional risk assessment models identify only

60-65% of early CAD patients

Ca+ score plus Framingham adds incremental risk

prediction value

Ca+ linked to CAD, acute events, and mortality

5 minute test, no contrast, 1-2 mSv radiation


Radiation Exposure

Activity Radiation (mSV)__

CCTA 7-11

Nuclear Stress Test 15-20

Chest X-Ray .5

Catheter Angiography 5-8

PET CT 7-10

Mammography 1-2

Coronary Ca+ Score <1-2


Of 136,905 patients hospitalized with CAD, 77% had LDL levels below 130 mg/dl

Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009


NOT Enough!

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© 2007, CVI3 LLC & A Collaboration Between

Why Screen Asymptomatic

Individuals?

CAD may be silent

Current Framingham CV risk scoring fails many groups

Proven CV therapy is available to alter

natural history of an indolent disease


SHAPE Task Force. Am J Cardiol. 2006;98:2-15


Brief Case:

Two prominent men:

Both smokers - #1 stopped, #2 continued

Both with limited exercise - #1 became an

avid runner, lost weight, became very fit,

#2 continued to be inactive and obese

Both #1 and #2 had family history of

premature death…

Assessing the VP Pyramid


Assessing the VP Pyramid Who was at greater risk for the development

of heart disease?

Jim Fixx marathon runner,

exercise advocate, author

-dead at 53 of a heart attack

Sir Winston Churchill broke

every tenet of “healthy life style”

- dead at age 91 & A Collaboration Between

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“The best test for prediction of the risk of

atherosclerosis is the demonstration of

atherosclerosis”

Dr. Ernest Schaeffer, Editor-in-Chief of

Atherosclerosis

Common

Sense


ACCF/AHA CLINICAL EXPERT

CONSENSUS DOCUMENT

Consensus Document on Coronary Calcium Scoring

J Am Coll Card. 2007;49:378-402


Statement

Ca+ scoring has quality evidence supporting

its role in risk stratifying asymptomatic persons

Recent data supports coronary calcium is

predictive of CHD death or MI at 10-15 years

Ca+ is independently predictive of outcomes

over and above traditional risk measurements

Testing most beneficial in patients at

intermediate Framingham risk- least valuable

in low risk patients & A Collaboration Between

SHAPE TASK FORCE

GUIDELINES

National Screening for Heart Attack Prevention and Eradication (SHAPE)

Am J Cardiol. 2006;98:2-15


SHAPE Recommendations

All asymptomatic males without known CAD

and between 45-75 should be screened for

CAD (Ca+ Score or IMT)

All asymptomatic females without known CAD

and between 55-75 should be screened for

CAD (Ca+ Score or IMT)

Younger adults having >2 CAD risk factors

Limited value for subjects having no risk factors


Atherosclerosis Test

Very Low Risk

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 Factors + Risk Factors • CCS <100 & <75th%

• CIMT <1mm & <75th%

& No Carotid Plaque

• Coronary Calcium Score (CCS)

or• Carotid IMT (CIMT) & Carotid Plaque

• CCS 100-399 or >75th%

• CIMT 1mm or >75th%

or <50% Stenotic Plaque

• CCS >100 & >90th%

or CCS 400

• 50% Stenotic Plaque

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

All >75y receive unconditional treatment

Apparently Healthy Population Men>45y Women>55y

ExitExit

Myocardial

IschemiaTest

NoAngiography

Follow Existing

Guidelines

Yes

The 1st

S.H.A.P.E. Guideline

Towards the National Screening for Heart Attack Prevention and Eradication (SHAPE) Program

Step 1

Step 2

Step 3Optional

CRP>4mg

ABI<0.9

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Patient Management Strategies Following

Heart Attack Prevention Sceening


CAC Score 0/CIMT <50th

“Lower Risk”

Retest Interval

5-10 years

LDL Target

<160 mg/dl

Risk factor reduction

“Moderate Risk”

Retest Interval

5-10 years

LDL Target

<130 mg/dl


With No CAD Risk Factors Having CAD Risk Factors


CAC Score 1-99

“Moderately High

Risk”

Retest Interval

Individualized

Consider 12 month

retest

LDL Target

<130 mg/dl

<100 mg/dl (optional)


Behavioral

modification

Medically manage

Consider Statin

therapy


CAC Score 100-399

“High Risk”

Retest Interval

Individualized

Consider 12 month

retest

LDL Target

<100 mg/dl

<70 mg/dl (optional)

Consider additional

diagnostic testing


Behavioral

modification

Medically manage

Consider Statin

therapy


CAC Score >400

“Very High Risk”

Retest Interval

Individualized

Consider 12 month

retest

LDL Target

<70 mg/dl

Cardiology Consult

recommended

Consider additional

diagnostic testing


Behavioral

modification

Consider Statin

therapy


The Search for New Risk Factors to Improve Risk

Assessment: Imaging

Detrano, et al. NEJM 2008;358:1336

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CORONARY CALCIFICATION, RISK FACTORS

AND EVENTS : ST. FRANCIS HEART STUDY

Prospective, population-based primary prevention

study 5585 men and women aged 50 to 70

4.3 years follow-up

122 (0.6%/year) with ASCVD event:

Nonfatal MI/coronary death 43

CABG/PTCA 62

Non-hemorrhagic stroke 5

Peripheral vascular surgery 12


St. Francis Heart Study

Coronary outcomes* by calcium score

Calcium

Score

Event

Rate

Relative

Risk

95% CI

0 0.54 1 -

1-99 1.00 1.9 0.8-4.2

100-399 5.5 10.2 4.8-21.6

>400 14.0 26.2 12.6-53.7

*coronary death, nonfatal MI, CABG, and coronary angioplasty

Arad Y, Goodman KJ, Roth M et al. Coronary calcification, coronary disease risk factors, c-reactive protein, and

atherosclerotic cardiovascular disease events. The St Francis Heart Study. J Am Coll Cardiol 2005; 46: 158-165.


CAC Scores and CV Risk in “Low Risk” Women by FRS:

The Multi-Ethnic Study of Atherosclerosis (MESA)

Lagoski et al. 2007;167:2437-42

CAC scores

0 >0 1-99 100-299 >300

68% 32% 22% 6% 4%

2684 asymptomatic women 45-79

3.75 yr f/u

NIH sponsored prospective study;6,814 Asymptomatic pts: 3.75 year follow-up


Framingham Offspring Study

3529 subjects

All Intermediate risk

Ca+ score test

What percentage of

intermediate

Framingham subjects

would be reclassified as

high risk with “high” CAC

High CAC defined as 90th

or >100 Agatston

Results:

>90th percentile 22%

>100 score 39%

High-risk Reclassification:

61%

25% reclassified to low

risk with 0 CAC

Preis, et al. Am J Cardiol 2009;103:1710-1715.


% Maintaining Statin Therapy at 3.6 Years by CAC Level

No CAC CAC 1-99 CAC 100-399 CAC>400

0

10

20

30

40

50

60

70

80

90

100

44

63

75

90

Visualizing Coronary Calcium is Associated with

Improvements in Adherence to Statin Therapy

Kalia et al. Atherosclerosis 2005

505 pts on statins


Case Study

Introduction:

47 year old female, in the primary care office with concerns about family history for MI.

Clinical Background:

Medical History: Total cholesterol 230 with HDL 40

Family History: Both parents had MI

Physical Exam: Normal

Symptoms:

Asymptomatic

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=19539080&itool=iconabstr






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Patient is concerned about significance of

family history of premature CAD

Don’t worry her; provide reassurance?

0-1 risk factors is low risk: <1%


Outcome

Diagnostic Path:

Coronary Calcium Score Test: 106 (90th

percentile)

Outcome:

Aggressive risk and medical management


47 y/o asymptomatic female

Calcium Score:

106

(>90% percentile)

CHD Risk Equivalent: CV Risk >20%

Advanced CAD Risk

Coronary Artery Scanning

u SEVERECALCIFICATION


When To Order

All males without known CAD and between 45-

75 should be screened for CAD (Ca+ or IMT)

All females without known Cad and between

55-75 should be screened for CAD (Ca+ or IMT)

Younger adults having >2 CAD Risk factors

Asymptomatic, apparently healthy population

Limited value for subjects having no risk factors

SHAPE Task Force. Am J Cardiol. 2006;98:2-15


CAC Scoring or CIMT

Into Prevention

Paradigm;

Mammography

PSA

Goal:

Leading Causes of

Death (United States) 1.Heart Disease

2.All Cancers

3.Stroke

4.Respiratory

5.Accidents

6.Diabetes

7.Alzheimer’s 8.Influenza & Pnuemonia


Therapy of Abnormal CACS

© 2007, CVI3 LLC

9/9/2015

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Int. J. Mol. Sci. 2015, 16, 8861-8883


Changes in plaque burden over 1 y.

Matthew Budoff J. Nutr. 2006;136:741S-744S

©2006 by American Society for Nutrition


Coronary Artery Calcium Therapy


The Potential Role of Vitamin K2

© 2007, CVI3 LLC


Omega 3 PUFA: A Possible Benefit

© 2007, CVI3 LLC

Randomized Comparison of High-Dose Oral Vitamins versus Placebo

in the Trial to Assess Chelation Therapy (TACT)

Gervasio A. Lamas, MD, FACC

Professor of Clinical Medicine

Columbia University Division of Cardiology

Mount Sinai Medical Center

Miami Beach, FL

For the TACT Investigators

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0

0.1

0.2

0.3

0.4

0.5

0 6 12 18 24 30 36 42 48 54 60

Ev

en

t R

ate

Months since randomization

Placebo Infusions/Placebo Vitamins

Placebo Infusions/High-Dose Vitamins

EDTA Chelation/Placebo Vitamins

EDTA Chelation/High-Dose Vitamins

TACT Primary Endpoint: Factorial

Groups EDTA Chelation/High-dose Vitamins

vs. Placebo/Placebo

HR (95% CI): 0.74 (0.57, 0.95)

P = 0.016 Δ=8.3%

Subgroup Results for Vitamin Analyses

Participant Group N

Interaction

P-value HR 95% CI

All participants 1708 0.89 0.75, 1.07

Infusions 0.94

EDTA 839 0.89 0.68, 1.15

Placebo 869 0.90 0.7, 1.15

Gender 0.17

Male 1409 0.84 0.69, 1.03

Female 299 1.17 0.75, 1.83

Anterior MI 0.79

Yes 674 0.93 0.69, 1.26

No 1034 0.88 0.7, 1.09

Diabetes 0.72

Yes 538 0.84 0.62, 1.14

No 1170 0.90 0.72, 1.12

Statins at baseline 0.01

Yes 1248 1.03 0.84, 1.27

No 460 0.62 0.44, 0.87

CAM site 0.39

Yes 1089 0.84 0.67, 1.05

No 619 0.99 0.74, 1.33

4.0 1.0 0.25

High-Dose

Vitamins Better

Placebo

Better

2.0 0.5


Questions

Heat Attack Prevention - Avera HealthHeat Attack Prevention CAD kills more than 450,000 Americans...

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