From Vulnerable Plaque to Vulnerable Patient From Vulnerable Plaque to Vulnerable 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 Symposium

Heart attack is NOT the world’s number one problem, extreme poverty is. The 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 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 Summit

After extreme poverty and associated infectious diseases, eradication of heart attack can be the most rewarding opportunity in the 21 st century for saving productive life years worldwide. The AEHA 2005 VP Summit

How the World Dies Today? YLLs: Years of Life Lost Atherosclerotic Diseases The AEHA 2005 VP Summit World Health Organization

Worldwide Causes of Death Source: WHO The AEHA 2005 VP Summit

> 15 Million Heart Attacks Each Year Source: World Heart Federation The AEHA 2005 VP Summit

Millions of Deaths from Cardiovascular Causes Western countries Non-Western (developing) countries 5 million DEATHS FROM CARDIOVASCULAR CAUSES WORLDWIDE KS Reddy. NEJM 2004; 350: 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 Summit

More than half caused by a sudden heart attack in healthy- looking population The AEHA 2005 VP Summit

Epidemic of Heart Failure

Global Epidemic of Diabetes The AEHA 2005 VP Summit

Epidemic of Obesity & Diabetes in the U.S. 1990/ ejt 0901–120 Mokdad et al., JAMA 286:1195–1200, 2001 No Data < 4% 4%-6% > 6% No Data < 10% 10%-14%15%-19%  20% Obesity Diabetes The AEHA 2005 VP Summit

Global Atherosclerosis; A Bigger Threat than Global Warming! The 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 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 Patient What 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.

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

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