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Morteza Naghavi, M.D. Founder Society for Heart Attack Prevention and Eradication (SHAPE) SHAPE Guidelines Prevention of Fatal Cardiovascular Events (Heart Attack & Stroke) based on the Detection and Treatment of Subclinical Atherosclerosis (Hidden Plaque Build-up in Coronary and Carotid arteries)

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The Problem

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> 15 Million Heart Attacks Each Year Source: World Heart Federation The AEHA 2005 VP Summit

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Unpredicted

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In >50% of victims, the first symptom of asymptomatic atherosclerosis is a sudden cardiac death or acute MI.

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Men Women 010203040506070 Patients Diagnosed with CHD (%) Murabito et al Circulation 1993 Sudden Cardiac Death or Acute MI as Initial Presentation of CHD 62% 42%

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Of 136,905 patients hospitalized with CAD, 77% had normal LDL levels below 130 mg/dl Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009 Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment. Humana Press, 2009

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Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009 Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment. Humana Press, 2009 Of 136,905 patients hospitalized with CAD, 45.4% had normal HDL levels above 40 mg/dl

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Of 136,905 patients hospitalized with CAD, 61.8% had normal triglyceride levels below 150 mg/dl Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009 Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment. Humana Press, 2009

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Slide Source: Lipids Online www.lipidsonline.org 1998 2002. 222 patients with 1 st acute MI, no prior CAD, no DM. Men 20% Goal LDL

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Relying on risk factors of atherosclerosis (i.e. cholesterol & blood pressure) mislead physicians and patients. A direct assessment of atherosclerosis is needed. CONCLUSION:

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Sir Winston Churchill, 91 Sir Winston Churchill, 91 Jim Fixx, 53 Jim Fixx, 53 Who Has More Cardiovascular Risk Factors?

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Philip Alexander Poole-Wilson death with 66 years March 4, 2009 Two weeks after Update in Cardiology In Davos Helmut Drexler death with 58 years Unexpected Sudden Death of Famous Cardiologists

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Status Quo IS Unacceptable Bottom Line:

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CVD Genotyping? Naghavi et al. Circulation. 2003;108:1664 ~50% Apparently Healthy People (New) ~50% CHD Patients (Recurrent)

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CVD Genotyping? Naghavi et al. Circulation. 2003;108:1664 ~50% Apparently Healthy People (New) ~50% CHD Patients (Recurrent)

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Naghavi et. al. Circulation Journal Vol108, No14; October 7, 2003 The Vulnerable Patient Consensus Statement Preceding the SHAPE Initiative

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Naghavi et. al. Circulation Journal Vol108, No14; October 7, 2003 The Vulnerable Patient Consensus Statement Preceding the SHAPE Initiative

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First SHAPE Symposium

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SHAPE Task Force Meeting

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SHAPE Guidelines Published

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Existing Guidelines (Status Quo): Screen for Risk Factors of Atherosclerosis Treat Risk Factors of Atherosclerosis The SHAPE Guidelines: Screen for Atherosclerosis (the Disease) Regardless of Risk Factors Treat based on the Severity of the Disease and its Risk Factors SHAPE v.s. Status Quo

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Based on the paper by Pepe e. al. Am J Epidemiol 2004; 159:882-890. ROC Curve, its AUC and Corresponding Odds Ratio hs-CRP LDL HDL Smoking Hypertension Diabetes etc. Risk Factors

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Based on the paper by Pepe e. al. Am J Epidemiol 2004; 159:882-890. ROC Curve, its AUC and Corresponding Odds Ratio hs-CRP LDL HDL Smoking Hypertension Diabetes etc. CAC +FRS IMT+FRS Structural Risk Factors

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Based on the paper by Pepe e. al. Am J Epidemiol 2004; 159:882-890. ROC Curve, its AUC and Corresponding Odds Ratio hs-CRP LDL HDL Smoking Hypertension Diabetes etc. CAC +FRS IMT+FRS Structural Risk Factors Combined structural & functional?

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1: No history of angina, heart attack, stroke, or peripheral arterial disease. 2: Population over age 75y is considered high risk and must receive therapy without testing for atherosclerosis. 3: Must not have any of the following: Chol>200 mg/dl, blood pressure >120/80 mmHg, diabetes, smoking, family history, metabolic syndrome. 4: Pending the development of standard practice guidelines. 5: High cholesterol, high blood pressure, diabetes, smoking, family history, metabolic syndrome. 6: For stroke prevention, follow existing guidelines.

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Some of the Members of the SHAPE Task Force (left to right): Drs Budoff, Falk, Rumberger, Naghavi, Fayad, Hecht, and Berman

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Current National Preventive Care Reimbursement Policies Do Not Match the Burden of the Problem Inadequate & Disproportionate

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Why do we screen for asymptomatic cancers but ignore asymptomatic CVD?

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$1000 for # 2 Killer

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Number (per year) Estimated Impact of SHAPE (Sensitivity Analysis Range) Estimated Change in Cost CVD Deaths910,60010% (5%-25%) ($1.2 b) MI (prevalence)7,200,000 25% (5%-35%) ($18.0 b) Chest Pain Symptoms (ER visits)6,500,000 5% (2.5%-25%) ($4.1 b) Hospital Discharge for Primary Diagnosis of CVD6,373,000 10% (5%-25%) $3.8 b Hospital Discharge for Primary Diagnosis of CHD970,000 10% (5%-25%) ($9.9 b) Cholesterol Lowering Therapy 50 % (50%-65%) 8.00 b CV Imaging8,700,000 10% (5%-25%) $358 m Angiography6,800,000 15% - CTA (2.5%-25%) $600 m PCI (percutaneous coronary interventions per year)657,000 10% (5%-50%) ($580 m) CABS (coronary artery bypass surgeries per year)515,000 5% (2.5%-50%) ($672 m) Total in Cost ($21.5 b) Cost Effectiveness of the SHAPE Guidelines

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poly pills

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WWW.SHAPESOCIETY.ORG

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The SHAPE Textbook Released at American College of Cardiology Conference