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 Heart Federation 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, Jan 2009 Chapter 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, Jan 2009 Chapter 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, Jan 2009 Chapter 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 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 Sir Winston Churchill, 91  Jim Fixx, 53  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

SHAPE Task Force Meeting

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

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 Policies Do Not Match the Burden of the Problem Inadequate & Disproportionate

Magnitude of the Burden: Causes of Death in the United States Deaths (thousands) CHDCancerAccidentsHIV/AIDS 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.A AAMINIMUM COVERAGE REQUIRED. (a) A health benefit plan that provides coverage for screening medical procedures must provide the minimum coverage required by this section to each covered individual: (1)who is: (A)a male older than 45 years of age and younger than 76 years of age; or (B)a female older than 55 years of age and younger 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 LAW noninvasive 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 measuring coronary artery calcification; Or (2) ultrasonography measuring carotid intima-media thickness and plaque.

Number (per year) Estimated Impact of SHAPE (Sensitivity Analysis Range) Estimated Change in Cost CVD Deaths910,600↓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 CVD6,373,000↑ 10% (5%-25%) $3.8 b Hospital Discharge for Primary Diagnosis of CHD970,000↓ 10% (5%-25%) ($9.9 b) Cholesterol Lowering Therapy↑ 50 % (50%-65%) 8.00 b CV Imaging8,700,000↑ 10% (5%-25%) $358 m Angiography6,800,000↑ 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.

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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 1 st SHAPE guideline is directed at the early detection and treatment of subclinical atherosclerosis and fills the gap in the existing guidelines.

The 1 st SHAPE Textbook Released at the ACC 2010

The 1 st 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