ASSESSMENT OF CARDIOVASCULAR RISK

Transcription

1 ASSESSMENT OF CARDIOVASCULAR RISK M MOHSEN IBRAHIM, MD CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY

2 The Complications of CAD Often Emerge without Warning Adapted from Levy et al, Textbook of Cardiovascular Medicine,

3 ASSESSMENT OF CARDIOVASCULAR RISK 50 Y/O woman Non-smoking BP: 170/100 mmhg Total cholesterol : 228 mg/dl HDL-C : 46 mg/dl Non-diabetic Chance of major CV event in the next 5 years : 6 % 60 Y/O male Smoker BP: 170/100 mmhg Total cholesterol : 228 mg/dl HDL-C : 38 mg/dl Non-diabetic Chance of major CV event in the next 5 years : 30 %

4 ASSESSMENT OF CARDIOVASCULAR RISK DEFINITIONS Definition of Risk Risk Factors METHODS Risk Score Risk Charts IMPLICATIONS Initiation of Pharmacologic Therapy

5 ASSESSMENT OF CARDIOVASCULAR RISK RISK OF WHAT? ENDPOINTS

6 RISK OF WHAT? HARD END POINTS TOTAL MORTALITY TOTAL CVD MORTALITY CORONARY MORTALITY FATAL MI SUDDEN CARDIAC DEATH NONFATAL MI RESUSCITATED CARDIAC ARREST STROKE

7 DEFINITION OF CORONARY HEART DISEASE - FRAMINGHAM TOTAL CHD Angina pectoris Myocardial infarction recognized & unrecognized Unstable angina CHD death HARD CHD Myocardial infarction Unstable angina CHD death

8 RISK OF WHAT? SOFT END POINTS UNSTABLE ANGINA CABG PTCA TOTAL DAYS OF HOSPITALIZATION WORSENING ANGINA TIME TO FIRST ISCHEMIC EVENT

9 RISK OF WHAT? SURROGATE END POINTS CORONARY ART DISEASE PROGRESSION Coronary angiography IVUS MRI UFCT (quantitative assessment of coronary calcium) VASCULAR ENDOTHELIAL FUNCTION INFLAMMATORY MARKERS CAMs, hscrp

10 RISK ESTIMATES ABSOLUTE RISK Probability of developing CHD or CV death over given time period e.g. the next 10 years RELATIVE RISK The ratio of the absolute risk of a given patient (or group) to that of a lower risk group : - Average risk - Low risk

11 DEFINITION OF A LOW- RISK STATE Framingham SERUM TOTAL CHOLESTEROL 160 TO 199 mg/dl. LDL-C 100 TO 129 mg/dl HDL-C >45 mg/dl IN MEN AND >55 mg/dl IN WOMEN BLOOD PRESSURE <120 mmhg SYSYOLIC AND <80 mmhg DIASTOLIC NONSMOKER NO DIABETES MELLITUS

12 CARDIOVASCULAR RISK FACTORS

13 CATEGORIES OF CARDIOVASCULAR RISK FACTORS INDEPENDENT CAUSATIVE CONDITIONAL PREDISPOSING SUSCEPTIBILITY ESTABLISHED - EMERGING PROATHEROGENIC PROTHROMBOTIC MODIFIABLE NONMODIFIABLE

14 CARDIOVASCULAR RISK FACTORS CHARACTERISTICS OF A MAJOR-CAUSATIVE RISK FACTOR INDEPENDENCE OF CONTRIBUTION FROM OTHER RISK FACTORS QUANTITAVE CONTRIBUTION TO RISK

15 CARDIOVASCULAR RISK FACTORS Independent / Established/Major NON-MODIFIABLE Age Gender Family history Established CVD Dis MODIFIABLE Cigarette Smoking Hypertension Hypercholesterolemia Low HDL-Cholesterol Obesity Diabetes Mellitus Hypertriglyceridemia Sedentary Life-Style M M Ibrahim 2003 Dependent / Emerging/Novel Homocysteine Lp (a) Small, dense LDL-Cholest Other lipid disorders Abnormalities in blood coagulation Plasma fibrinogen Coagulation factors: V, VII, VIII Platelets abnormalities Impaired fibrinolysis: PAI-1 Inflammatory markers C-Reactive protein Interlukin Short stature Impaired glucose tolerance Increased oxidative stress Personality type Tachycardia Ethnic group S.creatinine

16 Novel Risk Factors fibrinogen sicam-1 interleukin-6 hs-crp hs-crp + TC:HDL Relative Risk of Future Myocardial Infarction Ridker et al NEJM,2000

17 Ultra-Novel Risk Factors 2003 Plasma Myeloperoxidase Red Cell Glutathione Peroxidase 1 Activity

18 Red Cell Glutathione Peroxidase 1 Activity Blankenberg et al. NEJM; October 23, 2003

19 PREVALENCE OF CONVENTIAL RISK FACTORS (%) IN CHD : MI/UA/PCI Women Men no Age (y) Current smoking Diabetes Hyperlipedemia Hypertension No risk factors Khot et al. JAMA- 2003

20 80 % 0f CAD are preventable by interfering with Cardiovascular Risk Factors AHA Meeting, New Orleans

21 METHODS OF ASSSESSMENT OF RISK o Global Risk Score o Risk Charts

22 ASSESSMENT OF ABOLUTE RISK METHODS Calculate The Number Of Points For Each Risk Factor Estimate Global Risk Score ( Sum Of Points ) Consult Coronary/CV Risk Chart Assess 10-years Asolute Risk Level For CHD or CV event

23 GLOBAL RISK ASSESSMENT SCORING SYSTEMS FRAMINGHAM Scoring System PROCAM Scoring System SCORE Project INDIANA Project

24 GLOBAL RISK ASSESSMENT SCORING FRAMINGHAM RISK FACTORS AGE,y TOTAL CHOLESTEROL ( OR LDL-C ), mg/dl HDL- C, mg/dl SYSTOLIC BLOOD PRESSURE, mmhg DIABETES SMOKER

25 FRAMINGHAM Scoring System Risk Factor Risk Points Men Women Age, y < Risk Points Risk Factor Men Women Systolic blood pressure, mm Hg < > Risk Factor Risk Points Men Women Total Cholesterol < > Risk Factor Risk Points Men Women Diabetes No 0 0 Yes 2 4 Smoker No 0 0 Yes 2 2

26 FRAMINGHAM Scoring System Global Risk Assessment Scoring Risk Factor Risk Points Men Women HDL Cholesterol, mg/dl < > Source: Framingham Heart Study

27 Global Risk Assessment Scoring Adjusted FRAMINGHAM Scoring System Plasma Glucose, mg/dl Risk Points < >126 Men Women 0 2 4

28 FRAMINGHAM Scoring System Global Risk Assessment Scoring Adding up the points Age Cholesterol HDL-C Blood pressure Diabetes Smoker Total points Source: Framingham Heart Study

29 FRAMINGHAM Scoring System Risk Corresponding to Total Points Probability Probability Probability pts. 10 yrs pts 10 yrs pts 10 yrs 1 < 2% 12 7% 23 23% 2 2% 13 8% 24 25% 3 2% 14 9% 25 27% 4 2% 15 10% 26 29% 5 3% 16 12% 27 31% 6 3% 17 13% 28 33% 7 4% 18 14% 29 34% 8 4% 19 16% 30 39% 9 5% 20 18% 31 40% 10 6% 21 19% 32 44% 11 6% 22 21%

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32 FRAMINGHAM Scoring System ASSESSMENT OF CARDIOVASCULAR RISK Interaction With Other Risk Factors Smoking increases risk x 2 3 Hypertension increases risk x 2 3 LVH increases risk x 2 LV strain pattern increases risk x 2 3 Diabetes increases risk x 1.5 2

33 INFLUENCE OF RISK FACTORS ON RISK OF CHD 59 year old man, non-smoker, BP 140/85mmHg, TC:HDL = 4 10 year risk of CHD event = 11.9% Smoking 18.3% 25.5% 41.9% 33.3% 32.5% Hyperlipidaemia (TC:HDL=8) 24.5% Hypertension (185/100mmHg) all risk factors + diabetes = 47.9% 17.7%

34 Risk Categorization Typical 10 year risk of stroke or myocardial infarction Low risk Medium risk High risk = < 15 percent = percent = percent Very high risk > 30 percent

35 INFLUENCE OF RISK FACTORS ON RISK OF STROKE 59 year old man, non-smoker, BP 140/85mmHg, TC:HDL = 4 10 year risk of stroke = 2.8% Smoking 5.0% 13.8% 14.1% 5.1% 8.0% Hyperlipidaemia (TC:HDL=8) 2.8% Hypertension (185/100mmHg) all risk factors + diabetes = 21.7% 7.8%

36 FRAMINGHAM GLOBAL RISK ASSESSMENT SCORING LIMITATIONS DOES NOT ACCOUNT FOR OTHER ESTABLISHED MAJOR RISK FACTORS e g Hypertriglyceridemia, Obesity, Physical Inactivity, Family History DOES NOT ACCOUNT FOR SEVERE ABNORMALITIES OF RISK FACTORS ABSOLUTE RISK IN TYPE 2 DIABETES EXCEEDS FRAMINGHAM SCORE?APPLICATION TO OTHER POPULATIONS

37 PROCAM Scoring System GLOBAL RISK ASSESSMENT SCORING

38 GLOBAL RISK ASSESSMENT SCORING PROCAM Scoring System Prospective Cardiovascular Munster Study men aged years -10 years follow-up -Major coronary event :. Sudden cardiac death. Definite fatal or nonfatal MI

39 Age, LDL cholesterol, mg/dl < >= Diabetes mellitus N0 0 YES 6 MI in family history No 0 Yes 4 Smoker No 0 Yes 8 PROCAM Scoring System HDL cholesterol, mg/dl < >=55 0 Triglycerides, mg/dl < >=200 4 Systolic blood pressure, mmhg < >=160 8 PROCAM Score Acute Coronary Events Mean Estimated Risk In 10 y (%) >

40 SCORE Project GLOBAL RISK ASSESSMENT SCORING

41 GLOBAL RISK ASSESSMENT SCORING SCORE Project Ten year risk of fatal cardiovascular disease persons Separate estimation equations were calculated for CHD and for non-chd and for high risk and low risk regions of Europe Two estimation models based upon: Total cholesterol and TC/HDL-C ratio High risk if 10-year risk of fatal CVD is more than 5% Conroy et al. Eu Heart J : 2003

42 Framingham vs SCORE Framingham Based on 5000 Americans Predicts coronary event Includes nonfatal events Cannot be adjusted for national variations SCORE Based on >200,000 Europeans Predicts CVD Restricted to fatal events Can be customized using national mortality statistics

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45 INDIANA Project GLOBAL RISK ASSESSMENT SCORING

46 INDIANA Project men and women from eight randomised controlled trials 5.2 years (mean) follow-up Risk score developed from 11 factors 5 years risk of death from CV disease, fatal CHD, fatal stroke and all cause mortality

47 INDIANA Projct Scoring for Predicting Risk of Death from CVD, Pococket al. 2001

48 INDIANA Project Scoring for Predicting Risk of Death from CVD,

49 INDIANA Project Scoring for Predicting Risk of Death from CVD, Pococket al. 2001

50 INDIANA Project Scoring for Predicting Risk of Death from CVD, Pococket al. 2001

51 GLOBAL RISK ASSESSMENT SCORING Age is a particularly strong risk factor Male sex carries an increased risk. Sex difference narrows with age Median age specific score for men is similar to the median score for women 10 years older Smoking contributes more in women and in younger age groups Total cholesterol is more important in men than in women Total cholesterol and SBP have similar predictive strength in men Diabetes has more effect in women than in men

52 RISK OF DEVELOPING CORONARY HEART DISEASE LIFETIME RISK Framingham % BEFORE 40 AT 40 Y AT 70 Y Lloid-Jones et al Lancet MEN WOMEN

53 HIGH RISK INDIVIDUAL Probability of Developing a Fatal or Nonfatal MI =>20% in next 10 years CHD Risk Equivalent Three or more major risk factors High risk score Established clinicalatherosclerotic disease Very high level single risk factor

54 CHD RISK EQUIVALENTS DIABETES CLINICAL ASO DISEASE Abdominal Aortic Aneurysm Peripheral Arterial Disease Carotid Arterial Disease MULTIPLE RISK FACTORS ( CHD Risk in 10-y >20%)

55 CLINICAL ASO DISEASE Risk Comparison with General Population MI: 5-7 fold of increased risk of recurrent MI Cerebrovascular disease : 2-3 fold increased risk of MI Peripheral vascular disease : 4- fold increased risk of MI

56 ASSESSMENT OF CARDIOVASCULAR RISK IMPLICATIONS

57 IMPLICATIONS IDENTIFCATION OF HIGH RISK INDIVIDUALS Intensive Life Style Modification Need To Initiate Pharmacologic Intervention Extent Of Risk Factors Correction INDICATIONS FOR NON-INVASIVE TESTING

58 HIGH RISK INDIVIDUAL Probability of Developing a Fatal or Nonfatal MI >20% in next 10 years CHD Risk Equivalent Symptomatic Established CHD Carotid art disease Peripheral art disease Abdominal aortic aneurysm Asymptomatic Diabetes mellitus Multiple major risk factors (3 or more - absolute risk > 20% in 10 ys) Very high level single risk factor

59 RISK FACTORS 0-1 MULTIPLE NO SCORING LEVEL OF RISK FACTOR CHD RISK SCORE 10-Y RISK OF CHD HIGH >20% INTERMEDIATE 10-20% LOW <10%

60 INITIATION OF DRUG THERAPY SINGLE vs MULTIPLE RISK FACTORS LDL-C SBP mg/dl mmhg >/= 190 mg/dl > 180 mmhg DBP Other Risk factors CHD 10-y risk mmhg + Severe single risk factor Multiple RFs Approaches 10 % > 110 mmhg

61 RISK CATEGORIZATION NEED FOR PHARMACOLOGIC INTERVENTION RISK HIGH MODERATE LOW CATEGORY CHD Risk in 10 years >20% 10-20% <10% CHD Multiple Risk 0-1 Risk Factor CHD Risk Factors - 2+ No need for Equivalents risk scoring DRUG THERAPY Intesity of pharmacologic intervention and risk factors reduction

62 ELEVATED LDL CHOLESTEROL Pharmacologic Therapy In Absence of Other Risk Factors LDL cholesterol >220 mg/dl Always Necessary LDL cholesterol >=190 mg/dl Should be considered Except : -Young men (<35 y} -Premenopausal women

63 RISK ASSESSMENT OFFICE CLINICAL CVDCVDCVD ASYMPTOMATIC HIGH RISK INTERMEDIATE RISK LOW RISK INITIATE DRUG THERAPY?NONINVASIVE TESTING FOLLOW UP MYOCARDIAL ISCHEMIA STRESS ECG STRESS ECHO PERFUSION IMAGING SUBCLINICAL ASO Ankle/Brachial BP Index Carotid B mode US-IMT EBCT-Coronary Ca score CRP, Endothelial function

64 ASSESSMENT OF CARDIOVASCULAR RISK In Asymptomatic Patient, To Treat Or Not To Treat That s The Question. Whether To Initiate Drug Therapy Is Cost Effective. Whether Drug Therapy Should Be Intensive Risk Assessment Can Answer Many Questions In Many Times Clinical Judgement Is the Choice, But When Symptomatic There Is No Choice but Secondary Prevention