Electron Beam Tomography The Most Powerful Screening Test

Electron Beam Tomography: The Most Powerful Screening Test For The Imaging Section of the VP Pyramid © John A. Rumberger, Ph. D, MD, FACC Clinical Professor of Medicine The Ohio State University Medical Director Health. WISE Wellness Diagnostic Center 2 nd VP Symposium, New Orleans, LA, 3/6/04

Risk Based Treatment Guidelines for Primary Prevention of CAD 1. 2. 3. Cannot be fully exploited without an adequate method of separating higher-risk individuals from those at lower risk. If serious misclassification is present, many higher-risk individuals would not be identified, denying them appropriate therapy, and. . . conversely, many lower-risk individuals would be subject to over-treatment with expensive drugs having an uncertain long-term safety. © JA Rumberger, MD

EBT: Imaging for the VP Pyramid Coronary Heart Disease in a given person is a consequence to a variety of factors related Such as: Genetics & Metabolism Habits Lifestyle Environment and Susceptibility to inflammation © JA Rumberger, MD

How Good Is NCEP III At Predicting MI? JACC 2003: 41 1475 -9 Not-Qualify for Rx 222 patients with 1 st acute MI, no prior CAD 88% of these “young” patients who suffered a Qualify for Rx men <55 y/o (75%), women <65 (25%), no DM first Myocardial Infarction were in the Risk NCEP Goal Low to LDL<100 Intermediate “risk” LDL<130 category according >20%/ 10 -20%/ <10%/ LDL<160 Risk Assessment 10 and 10 yrs. To Framingham 10 yrs. 70% would have been missed as truly 61% “High Risk” individuals who should have been treated “aggressively” 6% 6% 12% Total 18% 8% 10% Total 9% Total

EBT: Imaging for the VP Pyramid CVD Subclinical Atherosclerosis Intermediate Risk Low Conventional Risk & +FH © JA Rumberger, MD Low Risk Population

All Cause Mortality in Patients Without Known CAD Relative Risk All Cause Mortality [NDR] n = 10, 377 asymptomatic men and women f/u = 5. 0+3. 5 yrs. EBT found to be independent and incremental to risk factors 826 -833 DM Smoke HTN Shaw, Radiology 2003; 228: 826 -833 <10 101 -400 >1000 10 -100 401 -1000 EBT Coronary Calcium Score

EBT: Imaging for the VP Pyramid Brief Case: Two prominent men: • Both smokers - #1 stopped, #2 continued • Both with limited exercise - #1 became and avid runner, lost weight, became very fit, #2 continued to be inactive and obese • Both #1 and #2 had a family history of premature death © JA Rumberger, MD

EBT: Imaging for the VP Pyramid Who was at greater risk for the development of heart disease? Jim Fixx - marathon runner, Sir Winston Churchill – broke exercise advocate, author dead at 53 of a heart attack every tenet of “healthy life style” – dead at age 91 © JA Rumberger, MD

EBT: Imaging for the VP Pyramid 8, 500 Middle-aged patients referred for EBT Testing (single site) 1. 4 X Women Men 2. 0 x 2. 2 x No FHx of Premature CAD vs. +FHx below age 55 in a parent or sibling © JA Rumberger, MD

EBT: Imaging for the VP Pyramid Composite of 9 studies – weighted average n = 292 Range 5%-20% n = 792 Range 22%-52% © JA Rumberger, MD

Annual Absolute Risk (%) Prediction of MI/SCD in Asymptomatic Patients: EBT Adapted from data presented in Raggi et al AHJ 2001; 141: 193 -199 © JA Rumberger, MD High Risk Intermediate Risk Low Risk Percentile Rank for Baseline EBCT Calcium Score Very High Risk

EBT “Heart Age” Percentile Ranking of CAS <25 th Percentile Adjustments to Chronological Age Subtract 10 years >25 th - <75 th Percentile No adjustment >75 th - <90 th Percentile Add 10 years >90 th Percentile Add 20 years * Originally suggested by * Grundy: AJC 2001; 88: 8 E-11 E © JA Rumberger, MD ©

Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age” Conventional “Low to Intermediate” Risk Patient Age 35 to 65 years Male TC = 210 mg/dl HDL = 40 mg/dl No Diabetes No Smoking Systolic BP = 150 mm. Hg © JA Rumberger, MD Use NCEP ATP-III and Framingham point scoring system

Coronary Risk per Decade Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age” “Low to Intermediate” Conventional Risk Male High Risk © JA Rumberger, MD Intermediate Risk Low Risk Age (years)

Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age” Conventional “Intermediate to High” Risk Patient Age 35 to 65 years Male TC =240 mg/dl HDL = 35 mg/dl No Diabetes No Smoking Systolic BP = 180 mm. Hg © JA Rumberger, MD Use NCEP ATP-III and Framingham point scoring system

Coronary Risk per Decade Over and Under Estimation of Cardiac Risk: Framingham vs. EBT “Heart Age” © JA Rumberger, MD “Intermediate to High” Conventional Risk Male High Risk Intermediate Risk Low Risk Age (years)

EBT “Heart Age” and Risk Intermediate Conventional Risk High Conventional Risk © JA Rumberger, MD 1/3 or more actually LOW risk 1/3 or more actually HIGH risk 1/3 or more actually INTERMED risk 1/3 or more actually LOW risk

EBT: Imaging for the VP Pyramid Incremental Value of CAC Incidence Of CHD 35 © JA Rumberger, MD AGE 70

EBT: Imaging for the VP Pyramid “Risk” increases as an individuals CAC score and/or percentile rank increases Thus, although EBT and CAC is not able to identify the “vulnerable” plaque, it CAN identify “the vulnerable patient” © JA Rumberger, MD

EBT: Imaging for the VP Pyramid At PRESENT the following has been established: o Coronary calcium IS Atherosclerosis o The magnitude of the calcium score relates to the severity of ASO disease o The calcium score as well as the percentile rank provide information in which to view risk factors, rather than the other way around o The 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 therapy © JA Rumberger, MD

EBT: Imaging for the VP Pyramid The calcium score is a measure of overall disease extent in a given person and is a consequence of a variety of factors related to genetics, habits, environment and susceptibility to inflammation and many of These are not “measurable” by blood tests. So, it might make more sense to use EBT as an additional risk factor and incorporate its results with conventional assessments © JA Rumberger, MD

EBT: Imaging for the VP Pyramid CVD EBT (and other forms of Atherosclerosis Imaging) take “Population” Statistics to “Personal” Statistics by Measuring the extent of “Pre-Symptomatic” CHD Atherosclerosis Imaging Intermediate Risk Low Conventional Risk & +FH © JA Rumberger, MD Low Risk Population