Morteza Naghavi, M.D. Society for Heart Attack Prevention and Eradication

(SHAPE)Houston, TX

Screening for Early Detection and Prevention

of Heart Attack

March 2010 American College of Cardiology

> 15 Million Heart Attacks Each Year

Source:

World HeartFederation

The AEHA 2005 VP Summit

Why does screening for the prevention of heart attacks need

to look beyond cholesterol and traditional risk

factors?

Because traditional risk factor based screening

fails miserably in identifying

the Vulnerable Patient.

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

Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology,

Detection and Treatment. Humana Press, 2009

Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology,

Detection and Treatment. Humana Press, 2009

Of 136,905 patients hospitalized with CAD, 45.4% had normal HDL levels above 40 mg/dl

Of 136,905 patients hospitalized with CAD, 61.8% had normal triglyceride levels below 150 mg/dl

Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology,

Detection and Treatment. Humana Press, 2009

In >50% of victims, the first symptom of

asymptomatic atherosclerosis is

sudden cardiac death or acute MI.

Men

Women

0 10 20 30 40 50 60 70

Patients Diagnosed with CHD (%)Murabito et al Circulation 1993

Sudden Cardiac Death or Acute MI as Initial Presentation of CHD

62%

42%

Status Quo Unacceptable

CONCLUSION:

Two Major Problems Exist in Cardiology Today:

1- Inaccurate Individualized Risk Assessment

2- Inadequate Monitoring of Response to Therapy

In summary:

Sir Winston Churchill, 91 Jim Fixx, 53 Who Has More Cardiovascular Risk Factors?

CVD Genotyping?

Naghavi et al. Circulation. 2003;108:1664

~50% Apparently Healthy People(New)

~50%CHD Patients

(Recurrent)

CVD Genotyping?

Naghavi et al. Circulation. 2003;108:1664

~50% Apparently Healthy People(New)

~50%CHD Patients(Recurrent)

Naghavi et. al. Circulation Journal Vol108, No14; October 7, 2003

The Vulnerable Patient Consensus Statement Preceding the SHAPE Initiative

Naghavi et. al. Circulation Journal Vol108, No14; October 7, 2003

The Vulnerable Patient Consensus Statement Preceding the SHAPE Initiative

First SHAPE Symposium - 2004

SHAPE Task Force Meeting - 2004

SHAPE Guidelines Published

SHAPE Guidelines Published

Existing Guidelines (Status Quo):• Screen for Risk Factors of Atherosclerosis• Treat Risk Factors of Atherosclerosis

The SHAPE Guidelines:• Screen for Atherosclerosis (the Disease)

Regardless of Risk Factors• Treat based on the Severity of the Disease

and its Risk Factors

SHAPE v.s. Status Quo

Atherosclerosis Test

Negative Positive

No Risk Factors + Risk Factors

Step 1Test for Presence of the Disease

Step 2Stratify based on the Severity of the Disease and Presence 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 . Guideline

Conceptual Flow Chart

<75th

Percentile75th-90th

Percentile≥90th

Percentile

Atherosclerosis Test

Very Low Risk3

Negative Test• CACS =0• CIMT <50th percentile

LowerRisk

ModerateRisk

Positive Test• CACS ≥1• CIMT 50th percentile or Carotid Plaque

ModeratelyHigh Risk

HighRisk

VeryHigh Risk

No Risk Factors5 + Risk Factors • CACS <100 & <75th%• CIMT <1mm & <75th%

& no Carotid Plaque

• Coronary Artery Calcium Score (CACS)or

• Carotid IMT (CIMT) & Carotid Plaque4

• CACS 100-399 or >75th%• CIMT 1mm or >75th%

or <50% Stenotic Plaque

• CACS >100 & >90th%or CACS 400

• 50% Stenotic Plaque6

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 treatment2

Apparently Healthy Population Men>45y Women>55y1

ExitExit

Myocardial IschemiaTest

NoAngiography

Follow Existing Guidelines

Yes

The 1st SHAPE Guidelines

Step 1

Step 2

Step 3Optional

CRP>4mg

ABI<0.9

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.

Some of the Members of the SHAPE Task Force (left to right): Drs Budoff, Falk, Rumberger, Naghavi, Fayad, Hecht, and Berman

Current National Preventive Care Reimbursement PoliciesDo Not Match the Burden of

the ProblemInadequate & Disproportionate

Magnitude of the Burden:Causes of Death in the United States

0

100

200

300

400

500

600

700

800

900

1,000

Deat

hs (t

hous

ands

)

CHD Cancer Accidents HIV/AIDS

959.2

544.7

93.832.7

American Heart Association. Heart and Stroke Statistical Update.

Why do we screen for asymptomatic cancers but ignore asymptomatic CVD?

<$100 for # 1 killer

>$1000 for # 2 Killer

TEXAS HEART ATTACK PREVENTIVE SCREENING LAW

Sec.A1376.003.AAMINIMUM COVERAGE REQUIRED. (a) A health benefit plan that provides coverage for screening medicalprocedures must provide the minimum coverage required by thissection to each covered individual:(1)who is:(A)a male older than 45 years of age and youngerthan 76 years of age; or(B)a female older than 55 years of age andyounger than 76 years of age; and(2)who:

(A)is diabetic; or(B)has a risk of developing coronary heart disease, based on a

score derived using the Framingham Heart Study coronary prediction algorithm, that is intermediate or higher.

(b)the minimum coverage required to be provided under this

section is coverage of up to $200 for one of the following:

TEXAS HEART ATTACK PREVENTIVE SCREENING LAWnoninvasive screening tests for atherosclerosis and abnormal artery structure and function every five years, performed by a laboratory that is certified by a national organization recognized by the commissioner by rule for the purposes of this section:(1) computed tomography (CT) scanning measuringcoronary artery calcification; Or(2) ultrasonography measuring carotid intima-mediathickness and plaque.

Number(per year)

Estimated Impact of SHAPE

(Sensitivity Analysis Range)

EstimatedChange in

Cost

CVD Deaths 910,600 ↓10%(5%-25%)

($1.2 b)

MI (prevalence) 7,200,000 ↓ 25%(5%-35%)

($18.0 b)

Chest Pain Symptoms (ER visits) 6,500,000 ↓ 5%(2.5%-25%)

($4.1 b)

Hospital Discharge for Primary Diagnosis of CVD 6,373,000 ↑ 10%(5%-25%)

$3.8 b

Hospital Discharge for Primary Diagnosis of CHD 970,000 ↓ 10%(5%-25%)

($9.9 b)

Cholesterol Lowering Therapy ↑ 50 %(50%-65%)

8.00 b

CV Imaging 8,700,000 ↑ 10%(5%-25%)

$358 m

Angiography 6,800,000 ↑ 15% - CTA(2.5%-25%)

$600 m

PCI (percutaneous coronary interventions per year) 657,000 ↓ 10%(5%-50%)

($580 m)

CABS (coronary artery bypass surgeries per year) 515,000 ↓ 5%(2.5%-50%)

($672 m)

Total Δ in Cost ($21.5 b)

Cost Effectiveness of the SHAPE Guidelines

Comparing to the treatment of a heart attack, its prevention is woefully under-invested.

poly pills

The ultimate preventive strategies must be directed towards the different levels of primary prevention (i.e. prevention of atherosclerosis risk factors in the entire population, mass treatment of atherosclerosis in a smaller at-risk population, and preemptive prevention of events in further smaller pre-symptomatic population. The 1st SHAPE guideline is directed at the early detection and treatment of subclinical atherosclerosis and fills the gap in the existing guidelines.

WWW.SHAPESOCIETY.ORG

The 1st SHAPE Textbook Released at the ACC 2010

The 1st SHAPE –a-thon with onsite cardiovascular screen held in conjunction with annual scientific conference of American College of Cardiology 2005

The 1st Golf Fore Heart championed by a SHAPE volunteer in Baltimore - 2007