NonNon--invasive CAD Screening invasive CAD Screening · CAC in 2016: Who and What? Who...
Transcript of NonNon--invasive CAD Screening invasive CAD Screening · CAC in 2016: Who and What? Who...
1
NonNon--invasive CAD Screeninginvasive CAD Screening
Khurram Nasir, MD MPH
DisclosuresDisclosures
I have no relevant commercial
relationships to disclose, and my
presentation will not include off label or
unapproved usage.
HOW & WHAT WOULD YOU DECIDE?
60 white Male60 white Male60 white Male60 white MaleT T T T CholCholCholChol: 182 mg/dl: 182 mg/dl: 182 mg/dl: 182 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlHTN on ACEIHTN on ACEIHTN on ACEIHTN on ACEINon Non Non Non smokersmokersmokersmokerSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgNon diabeticNon diabeticNon diabeticNon diabeticFH of premature CVDFH of premature CVDFH of premature CVDFH of premature CVDHsHsHsHs----CRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LNon smokerNon smokerNon smokerNon smoker
2
3
Step 1: Start with ASCVD Risk Calculation Age (years) 20-79
Gender Male
Female
Race African American
Other
Total cholesterol(mg/dL)
130-320
HDL cholesterol(mg/dL)
20-100
Systolic bloodpressure (mmHg)
90-200
Diastolic bloodpressure (mmHg)
30-140
Treated for highblood pressure
No
Yes
Diabetes No
Yes
Smoker No
Yes
Calculate
ASCVD RISK IS 12%: WHAT WOULD YOU DO NOW?
60 white Male60 white Male60 white Male60 white MaleT T T T CholCholCholChol: 182 mg/dl: 182 mg/dl: 182 mg/dl: 182 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlHTN on ACEIHTN on ACEIHTN on ACEIHTN on ACEINon Non Non Non smokersmokersmokersmokerSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgNon diabeticNon diabeticNon diabeticNon diabeticFH of premature CVDFH of premature CVDFH of premature CVDFH of premature CVDHsHsHsHs----CRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LNon smokerNon smokerNon smokerNon smokerASCVD Risk: 12%ASCVD Risk: 12%ASCVD Risk: 12%ASCVD Risk: 12%Framingham Risk: 11%Framingham Risk: 11%Framingham Risk: 11%Framingham Risk: 11%ReynoldReynoldReynoldReynold Risk: 15%Risk: 15%Risk: 15%Risk: 15%
4
Out of 101 million adults free of ASCVD in US, 33 million (recommended) and
12 million (considered) for statin
Challenges with Risk Assessment & Management Challenges with Risk Assessment & Management Challenges with Risk Assessment & Management Challenges with Risk Assessment & Management Guidelines in 2015Guidelines in 2015Guidelines in 2015Guidelines in 2015
Two third patients averse to taking long term medication unless at high risk and substantial benefit. (Fontana M et al , Circulation 2015)
1 billion individuals worldwide candidates for statin
Generic cost for statins 1 trillion dollars in 2020
Systematic overestimation of risk is a significant concern if it leads to prescription of statin therapy (and its potential adverse effects) among groups in which actual risk scores are lower than predicted. (Ridker P et al Ann Intern Med 2015)
5
Computed Tomography for Non-Invasive Imaging of Subclinical Coronary Atherosclerosis
Imaging Imaging Imaging Imaging ofofofof coronarycoronarycoronarycoronary arteryarteryarteryarterycalcificationcalcificationcalcificationcalcification asasasas a a a a specificspecificspecificspecific signsignsignsignofofofof atherosclerosisatherosclerosisatherosclerosisatherosclerosis Agatston AS, Janowitz WR et al.
Quantification of coronary artery calcium using ultrafast computed tomography. JACC 1990
WOULD YOU CONSIDER CAC TEST?
60 white Male60 white Male60 white Male60 white MaleT T T T CholCholCholChol: 182 mg/dl: 182 mg/dl: 182 mg/dl: 182 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlHTN on ACEIHTN on ACEIHTN on ACEIHTN on ACEINon Non Non Non smokersmokersmokersmokerSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgNon diabeticNon diabeticNon diabeticNon diabeticFH of premature CVDFH of premature CVDFH of premature CVDFH of premature CVDHsHsHsHs----CRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LNon smokerNon smokerNon smokerNon smokerASCVD Risk: 12%ASCVD Risk: 12%ASCVD Risk: 12%ASCVD Risk: 12%Framingham Risk: 11%Framingham Risk: 11%Framingham Risk: 11%Framingham Risk: 11%ReynoldReynoldReynoldReynold Risk: 15%Risk: 15%Risk: 15%Risk: 15%
6
Looking upside down: what is value of absence of CAC?
Study Type Population (n)
CAC=0(%)
FU(Years)
Number of events (%)
Meta-Analysis * 71,595 29,312 (41%)
4.3 154 (0.47%) CVD events
Retrospective** 44,052 19,898 (45%)
5.6 104 (0.52%) Deaths
Prospective*** 6,809 3,414(50%)
4.1 17 (0.52%) CHD events
*Sarwar A, Shaw LJ, Shapiro MD, Blankstein R, Hoffman U, Brady TJ, Cury R, Budoff MJ, Blumenthal RS, Nasir K. JACC Imaging 2009
** Blaha M, Budoff MJ, Shaw LJ, Khosa F, Rumberger JA, Berman D, Callister T, Raggi P, Blumenthal RS, Nasir K. JACC Imaging 2009
*** Budoff M, McClelland R, Nasir K, Greenland P, K ronmal RA, Kondos G, Shea S, Lima JAC, Blumenthal RS. Am Heart J 2009
WOULD YOU CONSIDER TO RULE OUT DISEASE?
60 white Male60 white Male60 white Male60 white MaleT T T T CholCholCholChol: 182 mg/dl: 182 mg/dl: 182 mg/dl: 182 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlHTN on ACEIHTN on ACEIHTN on ACEIHTN on ACEINon Non Non Non smokersmokersmokersmokerSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgNon diabeticNon diabeticNon diabeticNon diabeticFH of premature CVDFH of premature CVDFH of premature CVDFH of premature CVDHsHsHsHs----CRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LNon smokerNon smokerNon smokerNon smokerASCVD Risk: 12%ASCVD Risk: 12%ASCVD Risk: 12%ASCVD Risk: 12%Framingham Risk: 11%Framingham Risk: 11%Framingham Risk: 11%Framingham Risk: 11%ReynoldReynoldReynoldReynold Risk: 15%Risk: 15%Risk: 15%Risk: 15%
7
CLINICAL REASEARCHPrevention and epidemiology
Impact of coronary artery calcium on coronaryheart disease events in individuals at the extremesof t radit ional risk factor burden: the Mult i-EthnicStudy of AtherosclerosisMichael G. Silverman1,2, Michael J. Blaha1, Har lan M. Krumholz3, Mat thew J. Budoff4,Ron Blankstein2, Chr istopher T. Sibley5, Ar thur Agatston6, Roger S. Blumenthal1,and Khurram Nasir 1,6,7,8*
European Heart Journaldoi:10.1093/eurheartj/eht508
doi: 10.1161/CIRCULATIONAHA.113.0036252014;129:77-86; originally published online October 20, 2013;Circulation.
CLIN ICAL REASEARCHPrevention and epidemiology
Impact of coronary artery calcium on coronaryheart disease events in individualsat the extremesof t radit ional r isk factor burden: the Mult i-EthnicStudy of AtherosclerosisMichael G. Silverman1,2, Michael J. Blaha1, Har lan M. Krumholz3, Mat thew J. Budoff4,Ron Blankstein2, Chr istopher T. Sibley5, A r thur Agatston6, Roger S. Blumenthal1,and Khurram Nasir 1,6,7,8*
European Heart Journaldoi:10.1093/eurheart j/eht508
doi: 10.1161/CIRCULATIONAHA.113.0036252014;129:77-86; originally published online October 20, 2013;Circulation.
8
Malik S, Budoff M, Katz R, Blementhal RJ, Alain Bert oni, Blumenthal RS, Nasirk K, Szklo M, Barr G, Wong ND ( Diabetes Care 2012)
Are all Diabetics Equivalent?
47%47%47%47%
25%25%25%25%
28%28%28%28%
Number needed to treatNumber needed to treatNumber needed to treatNumber needed to treat:CAC 0 549CAC 1-100 94CAC > 100 24
75% of all events occurred in 25% with CAC>10075% of all events occurred in 25% with CAC>10075% of all events occurred in 25% with CAC>10075% of all events occurred in 25% with CAC>100
�Risk Factors Does Not Equate Presence and Burden
of Atherosclerosis
�Huge Heterogeneity Exists even at spectrum of
Traditional Risk Profile
9
ANY VALUE FOR CAC IN NEW GUIDELINES?
60 white Male60 white Male60 white Male60 white MaleT T T T CholCholCholChol: 182 mg/dl: 182 mg/dl: 182 mg/dl: 182 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlHDL: 40 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlTG: 152 mg/dlHTN on ACEIHTN on ACEIHTN on ACEIHTN on ACEINon Non Non Non smokersmokersmokersmokerSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgSBP 125 mm HgNon diabeticNon diabeticNon diabeticNon diabeticFH of premature CVDFH of premature CVDFH of premature CVDFH of premature CVDHsHsHsHs----CRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LCRP: 3.1 mg/LNon smokerNon smokerNon smokerNon smoker
4 QUESTIONS
“ How Many Adult Without Established
ASCVD Will be Candidates for Statins?”
10
“ What is the probability of CAC=0 across
statin recommendation groups?”
11
“ Will CAC=0 lower risk below threshold
where statins are recommended?”
“ Is CAC testing useful across the
entire spectrum of risk categories?”
12
Challenges with CAC Testing in
2016
http://nyti.ms/1Nh3dWF
HEALTH
Heart Scan Can Fine-Tune Risk Estimate forPatients Considering StatinsBy GINA KOLATA OCT. 5, 2015
13
Does CAC Testing Has Such a Dramatic Downstream Impact?
No-CAC Testing(n = 623)
CAC Testing(n = 1,311)
P value
Downstream TestsStress Test 33.9% 34.6% 0.74Cardiac CT 7.1% 7.7% 0.62Cardiac Catherization 2.9% 3.3% 0.71Coronary Revascularization 1.8% 2.3% 0.46Downstream CostsMedian Procedure costs* $721 $904 0.56Median Medication costs $2,937 $3,149 0.09
*Include $150 for CAC testing.Rozanski et al, J Am Coll Cardiol. 2011;57:1622-1632
EISNER STUDY: 4 YEAR FOLLOW-UP
“How Can We Incorporate CAC Testing (especially CAC=0) in
Shared Decision Making”?
14
PHARMA & HEALTHCARE 10/05/2015 @ 2:00PM 1,307 views
This Test Might Tell You If You Don'tNeed A Statin
Harlan Krumholz Contributor
I cover science and medicine.
Opinions expressed by Forbes Contributors are their own.
PHARMA & HEALTHCARE 10/05/2015 @ 2:00PM 1,307 views
This Test Might Tell You If You Don'tNeed A Statin
Harlan Krumholz Contributor
I cover science and medicine.
Opinions expressed by Forbes Contributors are their own.
Patient # 1: ASCVD 12%
Patient Discussion (part 2)Probability of CAC categoriesRevised Risk with CAC scoresRevised Impact with Statin Use
CostsRadiation
Patient Discussion (part 1)Risk in simple terms
Statin efficacySide-effects
Costs
CAC=0CAC=0CAC=0CAC=0
Patients decide against statinPatients decide against statinPatients decide against statinPatients decide against statin
Patient # 2: ASCVD 12%
Patient Discussion (part 2)Probability of CAC categoriesRevised Risk with CAC scoresRevised Impact with Statin Use
CostsRadiation
Patient Discussion (part 1)Risk in simple terms
Statin efficacySide-effects
Costs
Patients decide against CACPatients decide against CACPatients decide against CACPatients decide against CAC
Patients decide for moderate Patients decide for moderate Patients decide for moderate Patients decide for moderate dose statindose statindose statindose statin
15
Op-Ed: Coronary Calcium forInformed Statin Choices— It 's not about screening, says Khurram Nasir,MD, MPH
Op-Ed: Coronary Calcium forInformed Statin Choices— It 's not about screening, says Khurram Nasir,MD, MPH
“ What about other tests/risk factors?”
16
Circulation. 2016 Jan 22. pii: CIRCULATIONAHA.115.018524. [Epub ahead of print]
Role of Coronary Artery Calcium Score of Zero and O ther Negative RiskMarkers for Cardiovascular Disease: The Multi-Ethni c Study Of Atherosclerosis(MESA).Blaha MJ , Cainzos-Achirica M , Greenland P , McEvoy JW , Blankstein R , Budoff MJ , Dardari Z , Sibley CT ,Burke GL , Kronmal RA , Szklo M , Blumenthal RS , Nasir K .
1 2 3 4 5 6 4 7
8 9 10 4 11
BACKGROUND:Abstract
-Limited attention has been paid to negative cardiovascular disease (CVD) riskmarkers despite their potential to improve medical decision-making. We compared thirteen negativerisk markers using diagnostic likelihood ratios (DLR), which model the change in risk for an individualafter the result of an additional test.
De-risking: Comparison of CAC=0 with Other Markers
“What about Costs?
….Is the approach of not treating those with CAC=0 compared to current
guidelines cost-effective”?
17
PLOS ONE PLOS ONE PLOS ONE PLOS ONE March 18 2015March 18 2015March 18 2015March 18 2015
CAC in 2016: The question to ask is“Why Not” rather than “Why”?
� Most precise measure for risk of clinical CVD event
� Widely available
� Inexpensive (75-100 $)
� Easy to perform (takes 2-3 minutes) and interpret
� Radiation equivalent to mammogram
�Advantages to stakeholders
�Health System: Appropriately allocating healthcare resources to groups likely to receive net benefit from proven Interventions.
�Clinician: personalized assessment of risk on case by case situation
�Patient: Shared decision making
CAC in 2016: Who and What?
�Who�Intermediate risk patients 5-20% undecided about statin
use
�Patient choice driven
�What�CAC=0� Focus on Lifestyle Intervention
�CAC 1-100� +Moderate/High Dose Statin
�CAC>100 � +High Dose Statin & Aspirin
�CAC>400 � Can consider functional testing (stress test)
� At no point, asymptomatic patient should be considered for invasive angiography.
18