Slide 1

Slide 2 Coronary Artery Disease (CAD): The Diagnosis Often Comes Too Late (Adapted from Levy et al.) Levy D et al in Textbook of Cardiovascular Medicine, 1998. Slide 3 American Heart Association , 2000 Heart and Stroke Statistical Update, 1999; Braunwald E, N Engl J Med, 1997; Kannel WB in Atherosclerosis and Coronary Artery Disease, 1996. Vascular Disease: Scope of the Problem Vascular diseaseand CAD in particular is the leading cause of death in the US and other Western nations Vascular diseaseand CAD in particular is the leading cause of death in the US and other Western nations By 2020, cardiovascular disease will become the most common cause of death worldwide By 2020, cardiovascular disease will become the most common cause of death worldwide Due to the high initial mortality of vascular disease, the target of clinical practice must be aggressive risk factor management Due to the high initial mortality of vascular disease, the target of clinical practice must be aggressive risk factor management Vascular diseaseand CAD in particular is the leading cause of death in the US and other Western nations Vascular diseaseand CAD in particular is the leading cause of death in the US and other Western nations By 2020, cardiovascular disease will become the most common cause of death worldwide By 2020, cardiovascular disease will become the most common cause of death worldwide Due to the high initial mortality of vascular disease, the target of clinical practice must be aggressive risk factor management Due to the high initial mortality of vascular disease, the target of clinical practice must be aggressive risk factor management Slide 4 Atherosclerosis: A Systemic Disease Aronow WS et al, Am J Cardiol, 1994. From a prospective analysis of 1886 patients aged 62 years, 810 patients were diagnosed with CAD as defined by a documented clinical history of MI, ECG evidence of Q-wave MI, or typical angina without previous MI. (Adapted from Aronow et al.) Slide 5 (Adapted from Salonen.) Salonen R in Risk Factors for Ultrasonographically Assessed Common Carotid Atherosclerosis, 1991. Carotid IMT Predicts Coronary Events Slide 6 Major Risk Factors for CAD Grundy SM et al, Circulation, 1998; Grundy SM, Circulation, 1999. Slide 7 CAD Risk Is Incremental (Adapted from Neaton et al.) Neaton JD et al, Arch Intern Med, 1992. Slide 8 Slide 9 Slide 10 Most Myocardial Infarctions Are Caused by Low-Grade Stenoses Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.) Falk E et al, Circulation, 1995. Slide 11 Lesion Severity: A Poor Predictor of Survival From the Coronary Artery Surgery Study (CASS) as reported by Little et al. Little WC et al, Clin Cardiol, 1991. Slide 12 Slide 13 Slide 14 Slide 15 Slide 16 Angiography: Significant Limitations in Atheroma Assessment Angiography reflects a planar, 2-dimensional silhouette of the lumen Angiography reflects a planar, 2-dimensional silhouette of the lumen Remodeling Remodeling Because angiography does not visualize the vessel wall, it cannot account for positive or negative remodeling Composition Composition Because angiography does not assess plaque composition, it cannot differentiate lipid-rich, more vulnerable plaques Postprocedure Postprocedure Due to plaque fissuring, angiography overestimates the degree of postintervention lumen expansion Angiography reflects a planar, 2-dimensional silhouette of the lumen Angiography reflects a planar, 2-dimensional silhouette of the lumen Remodeling Remodeling Because angiography does not visualize the vessel wall, it cannot account for positive or negative remodeling Composition Composition Because angiography does not assess plaque composition, it cannot differentiate lipid-rich, more vulnerable plaques Postprocedure Postprocedure Due to plaque fissuring, angiography overestimates the degree of postintervention lumen expansion Nissen SE et al in Restenosis After Intervention With New Mechanical Devices, 1992; Yamashita T et al, Progress in Cardiovascular Diseases, 1999; Topol EJ et al, Circulation, 1995. Slide 17 (Adapted from Glagov et al.) Coronary Remodeling NormalvesselMinimalCAD Progression Compensatory expansion maintains constant lumen Expansion overcome: lumen narrows SevereCADModerateCAD Glagov et al, N Engl J Med, 1987. Slide 18 3.1 mm Angiography Cannot Account for Coronary Remodeling Slide 19 Atheroma Morphology by Ultrasound Soft Lipid-Laden Plaque Hard Fibrous Plaque Slide 20 LAORAO Angiography Masks Complicated Lesions Slide 21 Angiography Underestimates Diffuse Disease Slide 22 What Is the Culprit Lesion? 58-year-old male with chronic stable angina Positive stress test with small reversible ischemic defect on nuclear scintigraphy Medical Rx, but 6 weeks later 3-day history of unstable angina, including 30 minutes of rest pain Medically cooled off followed by angiography 58-year-old male with chronic stable angina Positive stress test with small reversible ischemic defect on nuclear scintigraphy Medical Rx, but 6 weeks later 3-day history of unstable angina, including 30 minutes of rest pain Medically cooled off followed by angiography Case provided by the McLaren Heart and Vascular Center, Flint, Michigan; used with permission. Slide 23 Slide 24 Absence of Correlation Between Angiographic Results and Clinical Outcomes (Adapted from Brown et al.) (Adapted from Brown et al.) Brown BG et al, Circulation, 1993. Slide 25 Slide 26 Slide 27 Thin Cap With Lipid Core Thick Stable Fibrotic Cap Same Lumen Size: Different Atheromas Slide 28 Slide 29 Assessing Volumetric Atheroma Changes Trial performed at Kobe General Hospital (Kobe, Japan) Trial performed at Kobe General Hospital (Kobe, Japan) Hypothesis: patients with angiographically normal arteries receiving statin therapy will show reduced progression of coronary plaque as measured by IVUS Hypothesis: patients with angiographically normal arteries receiving statin therapy will show reduced progression of coronary plaque as measured by IVUS Trial performed at Kobe General Hospital (Kobe, Japan) Trial performed at Kobe General Hospital (Kobe, Japan) Hypothesis: patients with angiographically normal arteries receiving statin therapy will show reduced progression of coronary plaque as measured by IVUS Hypothesis: patients with angiographically normal arteries receiving statin therapy will show reduced progression of coronary plaque as measured by IVUS Takagi T et al, Am J Cardiol, 1997. Slide 30 IVUS: Changes in Atheroma Volume Results for 25 patients (13 in the pravastatin group, 12 in the control group) who completed the study. These patients were similar at baseline with regard to dyslipidemia (LDL-C 200-260 mg/dL) and IVUS. Mean plaque index at baseline was 41.2%. Qualifying arteries had not undergone a procedure and were angiographically normal (