1. Electron Beam Tomography: The Most Powerful Screening Test For The Imaging Section of the VP Pyramid © John A. Rumberger, PhD, MD, FACC Clinical Professor of Medicine The Ohio State University Medical Director HealthWISE Wellness Diagnostic Center 2 nd VP Symposium, New Orleans, LA, 3/6/04

2. 1.Cannot be fully exploited without an adequate method of separating higher-risk individuals from those at of separating higher-risk individuals from those at lower risk. lower risk. 2.If serious misclassification is present, many higher-risk individuals would not be identified, denying them individuals would not be identified, denying them appropriate therapy, and... appropriate therapy, and... 3.conversely, many lower-risk individuals would be subject to over-treatment with expensive drugs having subject to over-treatment with expensive drugs having an uncertain long-term safety. an uncertain long-term safety. Risk Based Treatment Guidelines for Primary Prevention of CAD © JA Rumberger, MD

3. Coronary Heart Disease in a given person is a consequence to a variety of factors related Such as: Genetics & Metabolism HabitsLifestyle Environment and Susceptibility to inflammation © JA Rumberger, MD EBT: Imaging for the VP Pyramid

4. How Good Is NCEP III At Predicting MI? JACC 2003:41 1475-9 222 patients with 1 st acute MI, no prior CAD men <55 y/o (75%), women <65 (25%), no DM Risk>20%/ 10 yrs. Risk10-20%/ Risk<10%/ NCEP Goal LDL<100 LDL<160 LDL<130 Qualify for Rx Not-Qualify for Rx 6%6% Total12% 8% 10% Total18% 61% 9% Total70% 88% of these “young” patients who suffered a first Myocardial Infarction were in the Low to Intermediate “risk” category according To Framingham Risk Assessment and would have been missed as truly “High Risk” individuals who should have been treated “aggressively”

5. EBT: Imaging for the VP Pyramid Low Risk Population Intermediate Risk Subclinical Atherosclerosis CVD Low Conventional Risk & +FH © JA Rumberger, MD

6. Relative Risk DMSmokeHTN<10 10-100 101-400 401-1000 >1000 EBT Coronary Calcium Score All Cause Mortality [NDR] n = 10,377 asymptomatic men and women f/u = 5.0+3.5 yrs. Shaw,Radiology 2003; 228:826-833 EBT found to be independent and incremental to risk factors826-833 All Cause Mortality in Patients Without Known CAD

7. EBT: Imaging for the VP Pyramid © JA Rumberger, MD Brief Case: Two prominent men: Both smokers - #1 stopped, #2 continued Both smokers - #1 stopped, #2 continued Both with limited exercise - #1 became and avid runner, Both with limited exercise - #1 became and avid runner, lost weight, became very fit, lost weight, became very fit, #2 continued to be inactive and obese #2 continued to be inactive and obese Both #1 and #2 had a family history of premature death Both #1 and #2 had a family history of premature death

8. EBT: Imaging for the VP Pyramid © JA Rumberger, MD 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

9. EBT: Imaging for the VP Pyramid Figure 1 Women Men © JA Rumberger, MD 8,500 Middle-aged patients referred for EBT Testing (single site) No FHx of Premature CAD vs. +FHx below age 55 in a parent or sibling 1.4X 2.0x 2.0x 2.2x

10. EBT: Imaging for the VP Pyramid © JA Rumberger, MD n = 792 n = 292 Range 5%-20% Range 22%-52% Composite of 9 studies – weighted average

11. Prediction of MI/SCD in Asymptomatic Patients: EBT Percentile Rank for Baseline EBCT Calcium Score LowRisk IntermediateRisk HighRisk VeryHighRisk Annual Absolute Risk (%) Adapted from data presented in Raggi et al AHJ 2001;141:193-199 © JA Rumberger, MD

12. EBT “Heart Age” Percentile Ranking of CAS Adjustments to Chronological Age <25 th Percentile Subtract 10 years >25 th - 25 th - <75 th Percentile No adjustment >75 th - 75 th - <90 th Percentile Add 10 years * * Originally suggested by Grundy: AJC 2001;88:8E-11E >90 th Percentile Add 20 years © © JA Rumberger, MD

13. Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age” Conventional “Low to Intermediate” Risk Patient Age 35 to 65 years Male TC = 210 mg/dl HDL = 40 mg/dl No Diabetes No Smoking Systolic BP = 150 mmHg Use NCEP ATP-III and Framingham point scoring system © JA Rumberger, MD

14. Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age” Age (years) “Low to Intermediate” Conventional Risk Male Coronary Risk per Decade Low Risk Intermediate Risk High Risk © JA Rumberger, MD

15. Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age” Conventional “Intermediate to High” Risk Patient Age 35 to 65 years Male TC =240 mg/dl HDL = 35 mg/dl No Diabetes No Smoking Systolic BP = 180 mmHg Use NCEP ATP-III and Framingham point scoring system © JA Rumberger, MD

16. Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age” Age (years) “Intermediate to High” Conventional Risk Male Coronary Risk per Decade Low Risk High Risk Intermediate Risk © JA Rumberger, MD

17. EBT “Heart Age” and Risk IntermediateConventionalRisk HighConventionalRisk 1/3 or more are actually LOW risk 1/3 or more are actually HIGH risk 1/3 or more are actually INTERMED risk 1/3 or more are actually LOW risk © JA Rumberger, MD

18. EBT: Imaging for the VP Pyramid © JA Rumberger, MD AGE IncidenceOfCHD Incremental Value of CAC 3570

19. EBT: Imaging for the VP Pyramid © JA Rumberger, MD “Risk” increases as an individuals CAC score and/or percentile rank increases score and/or percentile rank increases Thus, although EBT and CAC is not able to identify the “vulnerable” plaque, it CAN identify “the vulnerable patient”

20. EBT: Imaging for the VP Pyramid © JA Rumberger, MD At PRESENT the following has been established: o Coronary calcium IS Atherosclerosis o The magnitude of the calcium score relates to the severity of ASO disease o The calcium score as well as the percentile rank provide information in which to view risk factors, rather than the other way around in which to view risk factors, rather than the other way around o The data on examining progression of CAD with CT are consistent with the potential for the calcium score/rank to be used as the “goal” of therapy the potential for the calcium score/rank to be used as the “goal” of therapy

21. EBT: Imaging for the VP Pyramid © JA Rumberger, MD The calcium score is a measure of overall disease extent in a given person and is a consequence of a variety of factors related to genetics, habits, environment and susceptibility to inflammation and many of These are not “measurable” by blood tests. So, it might make more sense to use EBT as an additional risk factor and incorporate its results with conventional assessments

22. EBT: Imaging for the VP Pyramid © JA Rumberger, MD Low Risk Population Intermediate Risk Atherosclerosis Imaging CVD Low Conventional Risk & +FH EBT (and other forms of Atherosclerosis Imaging) take “Population” Statistics to “Personal” Statistics by Measuring the extent of “Pre-Symptomatic”CHD