Rumberger 2nd vp symposium 3 6 04

Electron Beam Tomography: The Most Powerful Screening Test

For The Imaging Section of the VP Pyramid

© John A. Rumberger, PhD, MD, FACCClinical Professor of Medicine

The Ohio State UniversityMedical Director HealthWISE

Wellness Diagnostic Center

22ndnd VP Symposium, New Orleans, LA, 3/6/04 VP Symposium, New Orleans, LA, 3/6/04

1.1. Cannot be fully exploited without an adequate methodCannot be fully exploited without an adequate method of separating higher-risk individuals from those atof separating higher-risk individuals from those at lower risk.lower risk.2.2. If serious misclassification is present, many higher-riskIf serious misclassification is present, many higher-risk individuals would not be identified, denying themindividuals would not be identified, denying them appropriate therapy, and...appropriate therapy, and...3.3. conversely, many lower-risk individuals would beconversely, many lower-risk individuals would be subject to over-treatment with expensive drugs havingsubject to over-treatment with expensive drugs having an uncertain long-term safety.an uncertain long-term safety.

Risk Based Treatment Guidelines for Risk Based Treatment Guidelines for Primary Prevention of CADPrimary Prevention of CAD

© JA Rumberger, MD

Coronary Heart Disease in a given person is a consequence to a variety of factors related Such as:

Genetics & MetabolismGenetics & MetabolismHabitsHabitsLifestyleLifestyleEnvironment andEnvironment andSusceptibility to inflammationSusceptibility to inflammation

© JA Rumberger, MD

EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid

How Good Is NCEP III At Predicting MI?How Good Is NCEP III At Predicting MI?JACC 2003:41 1475-9JACC 2003:41 1475-9

222 patients with 1222 patients with 1stst acute MI, no prior CAD acute MI, no prior CADmen <55 y/o (75%), women <65 (25%), no DMmen <55 y/o (75%), women <65 (25%), no DM

RiskRisk>20%/>20%/10 yrs.10 yrs.

RiskRisk10-20%/10-20%/10 yrs.10 yrs.

RiskRisk<10%/<10%/10 yrs.10 yrs.

NCEP GoalNCEP GoalLDL<100LDL<100



Qualify for RxNot-Qualify for Rx

6%6% 6%6%

TotalTotal

12%12%8%8% 10%10%

TotalTotal

18%18%

61%61%

9%9%

TotalTotal

70%70%

88% of these “young” patients who suffered afirst Myocardial Infarction were in the

Low to Intermediate “risk” category accordingTo Framingham Risk Assessment and

would have been missed as truly “High Risk” individuals who should

have been treated “aggressively”


Low Risk Population

Intermediate Risk

SubclinicalAtherosclerosis

CVD

Low Conventional Risk & +FH

© JA Rumberger, MD

2.72 2

12.47

3.55

6.15

12.29

0

2

4

6

8

10

12

14

Rel

ativ

e R

isk

DM Smoke HTN <1010-100

101-400401-1000

>1000

EBT Coronary Calcium ScoreEBT Coronary Calcium Score

All Cause Mortality [NDR]All Cause Mortality [NDR]n = 10,377n = 10,377asymptomatic men and womenasymptomatic men and womenf/u = 5.0f/u = 5.0++3.5 yrs.3.5 yrs.

Shaw,Radiology 2003;228:826-833

EBT found to be independentand incremental to risk factors826-833

All Cause Mortality in PatientsAll Cause Mortality in PatientsWithout Known CADWithout Known CAD


© JA Rumberger, MD

Brief Case:Brief Case:

Two prominent men:Two prominent men:• Both smokers - #1 stopped, #2 continuedBoth smokers - #1 stopped, #2 continued• Both with limited exercise - #1 became and avid runner,Both with limited exercise - #1 became and avid runner,

lost weight, became very fit, lost weight, became very fit,

#2 continued to be inactive and obese#2 continued to be inactive and obese• Both #1 and #2 had a family history of premature deathBoth #1 and #2 had a family history of premature death


© JA Rumberger, MD

Who was at greater risk for the development of heart disease?Who was at greater risk for the development of heart disease?

Jim Fixx - marathon runner,exercise advocate, author -dead at 53 of a heart attack

Sir Winston Churchill – brokeevery tenet of “healthy life style” –dead at age 91


CAC>0 CAC>75th percentile0

10

20

30

40

50

60

70

80

90

100

7978

64

55

4141

29

20

BothSibling FHParental FHNo FH

CAC>0 CAC>75th percentile0

10

20

30

40

50

60

70

80

90

100

5456

36

273334

24

15

BothSibling FHParental FHNo FH

WomenMen

© JA Rumberger, MD

8,500 Middle-aged patients referred for EBT Testing (single site)8,500 Middle-aged patients referred for EBT Testing (single site)

No FHx of Premature CAD vs. +FHx below age 55 in a parent or siblingNo FHx of Premature CAD vs. +FHx below age 55 in a parent or sibling

1.4X1.4X

2.0x2.0x2.0x2.0x

2.2x2.2x

30.2%/year

12%/year

0 10 20 30 40 50 60

Untreated

Treated


© JA Rumberger, MD

n = 792

n = 292

Range 5%-20%

Range 22%-52%

Composite of 9 studies – weighted averageComposite of 9 studies – weighted average

Prediction of MI/SCD in Asymptomatic Patients:Prediction of MI/SCD in Asymptomatic Patients:EBTEBT

0

1

2

3

4

5

6

7

0 10 20 30 40 50 60 70 80 90

Percentile Rank for Baseline EBCT Calcium ScorePercentile Rank for Baseline EBCT Calcium Score

LowLowRiskRisk

IntermediateIntermediateRiskRisk

HighHighRiskRisk

VeryVeryHighHighRiskRisk

Ann

ual A

bsol

ute

Ris

k (%

)A

nnua

l Abs

olut

e R

isk

(%) Adapted from data presented inAdapted from data presented in

Raggi et al AHJ 2001;141:193-199Raggi et al AHJ 2001;141:193-199

© JA Rumberger, MD

EBT “Heart Age”EBT “Heart Age”

Percentile Ranking of CASPercentile Ranking of CAS Adjustments to Chronological AgeAdjustments to Chronological Age

<25<25thth Percentile Subtract 10 years Percentile Subtract 10 years

>>2525thth - <75 - <75thth Percentile No adjustment Percentile No adjustment

>>7575thth - <90 - <90thth Percentile Add 10 years Percentile Add 10 years

*

* Originally suggested byOriginally suggested byGrundy: AJC 2001;88:8E-11EGrundy: AJC 2001;88:8E-11E

>>9090thth Percentile Add 20 years Percentile Add 20 years

©

© JA Rumberger, MD

Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk:Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age”

Conventional “Low to Intermediate” Risk PatientConventional “Low to Intermediate” Risk Patient

Age 35 to 65 yearsAge 35 to 65 yearsMaleMaleTC = 210 mg/dlTC = 210 mg/dlHDL = 40 mg/dlHDL = 40 mg/dlNo DiabetesNo DiabetesNo SmokingNo SmokingSystolic BP = 150 mmHgSystolic BP = 150 mmHg

Use NCEPUse NCEPATP-IIIATP-IIIand Framinghamand Framinghampoint scoring systempoint scoring system

© JA Rumberger, MD


0

5

10

15

20

25

30

35 40 45 50 55 60 65

Framingham Risk<25th Percentile CAS>75th Percentile CAS>90th Percentile CAS

Age (years)

““Low to Intermediate”Low to Intermediate”ConventionalConventional

Risk MaleRisk Male

Cor

onar

y R

isk

per

Dec

ade

Low Risk

Intermediate Risk

High Risk

© JA Rumberger, MD


Conventional “Intermediate to High” Risk PatientConventional “Intermediate to High” Risk Patient

Age 35 to 65 yearsAge 35 to 65 yearsMaleMaleTC =240 mg/dlTC =240 mg/dlHDL = 35 mg/dlHDL = 35 mg/dlNo DiabetesNo DiabetesNo SmokingNo SmokingSystolic BP = 180 mmHgSystolic BP = 180 mmHg

Use NCEPUse NCEPATP-IIIATP-IIIand Framinghamand Framinghampoint scoring systempoint scoring system

© JA Rumberger, MD

0

5

10

15

20

25

30

35 40 45 50 55 60 65

Framingham Risk<25th Percentile CAS>75th Percentile CAS>90th Percentile CAS


Age (years)

““Intermediate to High”Intermediate to High”ConventionalConventional

Risk MaleRisk Male

Cor

onar

y R

isk

per

Dec

ade

Low Risk

High Risk

Intermediate Risk

© JA Rumberger, MD

EBT “Heart Age” and RiskEBT “Heart Age” and Risk

IntermediateIntermediateConventionalConventional

RiskRisk

HighHighConventionalConventional

RiskRisk

1/3 or more are actually 1/3 or more are actually LOWLOW risk risk

1/3 or more are actually 1/3 or more are actually HIGHHIGH risk risk

1/3 or more are actually 1/3 or more are actually INTERMEDINTERMED risk risk

1/3 or more are actually 1/3 or more are actually LOWLOW risk risk

© JA Rumberger, MD


© JA Rumberger, MDAGE

IncidenceIncidenceOfOf

CHDCHD

IncrementalValue of

CAC

3535 7070


© JA Rumberger, MD

““Risk” increases as an individuals CAC Risk” increases as an individuals CAC score and/or percentile rank increasesscore and/or percentile rank increases

Thus, although EBT and CAC is not ableThus, although EBT and CAC is not ableto identify the “vulnerable” plaque, it CANto identify the “vulnerable” plaque, it CAN

identify identify “the “the vulnerable patient”vulnerable patient”


© JA Rumberger, MD

At At PRESENTPRESENT the following has been established: the following has been established:

o Coronary calcium IS AtherosclerosisCoronary calcium IS Atherosclerosis

o The magnitude of the calcium score relates to the severity of ASO diseaseThe magnitude of the calcium score relates to the severity of ASO disease

o The calcium score as well as the percentile rank provide informationThe calcium score as well as the percentile rank provide information

in which to view risk factors, rather than the other way aroundin which to view risk factors, rather than the other way around

o The data on examining progression of CAD with CT are consistent withThe data on examining progression of CAD with CT are consistent with

the potential for the calcium score/rank to be used as the “goal” of therapythe potential for the calcium score/rank to be used as the “goal” of therapy


© JA Rumberger, MD

The calcium score is a measure of overall disease extent in a given person and is aconsequence of a variety of factors related to genetics, habits, environment andsusceptibility to inflammation and many ofThese are not “measurable” by blood tests.

So, it might make more sense to use EBT as anadditional risk factor and incorporate its results with conventional assessments


© JA Rumberger, MDLow Risk Population

Intermediate Risk

AtherosclerosisImaging

CVD

Low Conventional Risk & +FH

EBT (and other formsEBT (and other formsof Atherosclerosis Imaging)of Atherosclerosis Imaging)take “Population”take “Population”Statistics toStatistics to““Personal” StatisticsPersonal” Statisticsby Measuring theby Measuring theextent ofextent of““Pre-Symptomatic”Pre-Symptomatic”CHDCHD

Health & Medicine

Rumberger 2nd vp symposium 3 6 04