From Vulnerable Plaque to From Vulnerable Plaque to Vulnerable PatientVulnerable 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 SymposiumThe 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 SummitThe 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 SummitThe 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 SummitThe 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 SummitThe AEHA 2005 VP Summit

How the World Dies Today?

YLLs: Years of Life Lost

AtheroscleroticDiseases

The AEHA 2005 VP SummitThe AEHA 2005 VP SummitWorld Health Organization

Worldwide Causes of Death Source: WHO

The AEHA 2005 VP SummitThe AEHA 2005 VP Summit

> 15 Million Heart Attacks Each Year

Source:

World HeartFederation

The AEHA 2005 VP SummitThe AEHA 2005 VP Summit

0

5

10

15

20

25

30

1990 2020

Mill

ion

s o

f D

eath

sfr

om

Car

dio

vasc

ula

r C

ause

s

Western countries

Non-Western (developing) countries

5 million

DEATHS FROM CARDIOVASCULAR CAUSESWORLDWIDE

KS Reddy. NEJM 2004; 350:2438

9 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 SummitThe AEHA 2005 VP Summit

The AEHA 2005 VP SummitThe AEHA 2005 VP Summit

More than More than half caused half caused by a sudden by a sudden heart attack heart attack in in healthy- healthy-

looking looking populationpopulation

The AEHA 2005 VP SummitThe AEHA 2005 VP Summit

The AEHA 2005 VP SummitThe AEHA 2005 VP Summit

Epidemic of Heart Failure

Global Epidemic of Diabetes

The AEHA 2005 VP SummitThe AEHA 2005 VP Summit

Epidemic of Obesity & Diabetes in the U.S.

1990/19911990/1991 20002000

ejt 0901–120

Mokdad et al., JAMA Mokdad et al., JAMA 286:1195–1200, 2001286:1195–1200, 2001 No DataNo Data < 4%< 4% 4%-6%4%-6% > 6%> 6%

No DataNo Data < 10%< 10% 10%-14%10%-14% 15%-19%15%-19% 20%20%

ObesityObesity

DiabetesDiabetes

The AEHA 2005 VP SummitThe AEHA 2005 VP Summit

Global Atherosclerosis; A Bigger Threat than

Global Warming!

The AEHA 2005 VP SummitThe 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 SummitThe 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 PatientWhat 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.

Atherosclerosis Test

Negative Positive

No Risk Factors + Risk Factors

Step 1Test forPresence of the Disease

Step 2Stratify based on the Severity of the Disease andPresence of Risk Factors

Step 3Treat based on the Level of

Risk

LowerRisk

ModerateRisk

ModeratelyHigh Risk

HighRisk

VeryHigh Risk

Apparently Healthy At-Risk Population

The 1st S .H .A .P .E . GuidelineTowards the National Screening for Heart Attack Prevention and Education (SHAPE) Program

Conceptual Flow Chart

<75th

Percentile75th-90th

Percentile≥90th

Percentile

Atherosclerosis Test

Very Low Risk3

Negative Test• CCS =0• CIMT<50th percentile

LowerRisk

ModerateRisk

Positive Test• CCS ≥1• CIMT 50th percentile or Carotid Plaque

ModeratelyHigh Risk

HighRisk

VeryHigh Risk

No Risk Factors5 + Risk Factors • CCS <100 & <75th% • CIMT <1mm & <75th%

& No Carotid Plaque

• Coronary Calcium Score (CCS)or

• Carotid IMT (CIMT) & Carotid Plaque4

• CCS 100-399 or >75th%• CIMT 1mm or >75th%

or <50% Stenotic Plaque

• CCS >100 & >90th%or CCS 400

• 50% Stenotic Plaque6

IndividualizedIndividualizedIndividualized5-10 years5-10 yearsRe-test Interval

<70 mg/dl<100 mg/dl<70 Optional

<130 mg/dl<100 Optional

<130 mg/dl<160 mg/dlLDLTarget

All >75y receive unconditional treatment2

Apparently Healthy Population Men>45y Women>55y1

ExitExit

Myocardial IschemiaTest

NoAngiography

Follow Existing Guidelines

Yes

The 1st S .H .A .P .E . GuidelineTowards the National Screening for Heart Attack Prevention and Education (SHAPE) Program

Step 1

Step 2

Step 3Optional

CRP>4mg

ABI<0.9

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!