Transcript Our Mission Is Eradication of Heart Attack Morteza Naghavi, MD

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
Extreme Poverty Is a Shame to the World
“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
The AEHA 2005 VP Summit
After extreme poverty and
associated infectious diseases,
eradication of heart attack
can be the most rewarding
opportunity in the 21st century
for saving productive life years
worldwide.
The AEHA 2005 VP Summit
How the World Dies Today?
Atherosclerotic
Diseases
YLLs: Years of Life Lost
World Health Organization
The AEHA 2005 VP Summit
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
DEATHS FROM CARDIOVASCULAR CAUSES
WORLDWIDE
Western countries
countries.
30
Non-Western (developing)
countries
>25m tomorrow
Millions of Deaths
from Cardiovascular Causes
Over 2/3
of the
global
burden of
heart
attack
and
stroke is
on poor
25
6 million
20
15
~15m today
5 million
19 million
10
5
9 million
0
1990
KS Reddy. NEJM 2004; 350:2438
The AEHA 2005 VP Summit
2020
The AEHA 2005 VP Summit
More than
half caused
by a sudden
heart attack
in healthylooking
population
The AEHA 2005 VP Summit
Epidemic
of Heart
Failure
The AEHA 2005 VP Summit
Global Epidemic of Diabetes
The AEHA 2005 VP Summit
Epidemic of Obesity & Diabetes in the U.S.
1990/1991
2000
Obesity
No Data
< 10%
10%-14%
15%-19%
 20%
Diabetes
Mokdad et al., JAMA
286:1195–1200, 2001
No Data
< 4%
4%-6%
The AEHA 2005 VP Summit
> 6%
ejt 0901–120
Global Atherosclerosis;
A Bigger Threat than
Global Warming!
The AEHA 2005 VP Summit
Prevent Attack!
•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
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 “lowhanging” fruit of preventive
cardiology.
The 1st S.H.A.P.E. Guideline
Towards the National Screening for Heart Attack Prevention and Education (SHAPE) Program
Conceptual Flow Chart
Apparently Healthy At-Risk Population
Step 1
Atherosclerosis Test
Test for
Presence of the
Disease
Positive
Negative
No Risk Factors
+ Risk Factors
<75th
Percentile
75th-90th
Percentile
≥90th
Percentile
Moderately
High Risk
High
Risk
Very
High Risk
Step 2
Stratify based on the
Severity of the Disease and
Presence of Risk Factors
Step 3
Treat based on
the Level of
Risk
Lower
Risk
Moderate
Risk
The 1 st S.H.A.P.E. Guideline
Towards the National Screening for Heart Attack Prevention and Education (SHAPE) Program
Apparently Healthy Population Men>45y Women>55y1
Step 1
Very Low Risk
3
Exit
Exit
All >75y receive unconditional treatment2
• Coronary Calcium Score (CCS)
or
• Carotid IMT (CIMT) & Carotid Plaque4
Atherosclerosis Test
Step 2
Negative Test
Positive Test
• CCS =0
• CIMT<50th percentile
No Risk Factors5
Step 3
Lower
Risk
+ Risk Factors
Moderate
Risk
• CCS ≥1
• CIMT 50th percentile or Carotid Plaque
• CCS <100 & <75th%
• CIMT <1mm & <75th%
& No Carotid Plaque
Moderately
High Risk
• CCS 100-399 or >75th%
• CIMT 1mm or >75th%
or <50% Stenotic Plaque
ABI<0.9
CRP>4mg
Optional
High
Risk
• CCS >100 & >90th%
or CCS 400
• 50% Stenotic Plaque6
Very
High Risk
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
Follow Existing
Guidelines
Angiography
Myocardial
IschemiaTest
Yes
No
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
Get in SHAPE!