1. Only You Can Prevent CVD Matthew Johnson, MD

2. What can we do to prevent CVD?

3. What can WE do to save the most lives?

4. What risk factors are important in the development of heart disease?

5. Who is at risk and how can we calculate risk?

6. Background: Clinical guidelines for primary prevention of CAD recommend a risk management based on the Framingham score.

7. Screening for early detection of high risk patients with asymptomatic atherosclerosis and monitoring their response to treatments in order to reduce sudden cardiovascular events remain as major challenges in preventive cardiology.

8. Background: Cont. Traditional tools used to assign risk of future cardiovascular events, at times fail to accurately identify individuals with severe coronary artery disease. Despite major advances in the treatment of coronary artery disease (CAD), a large number of apparently healthy people die suddenly of a heart attack without prior symptoms and do not benefit from existing preventive therapies.

9. Background: Cont. The Framingham score as applied in these guidelines is a tool to predict the absolute risk of coronary events in populations free of cardiovascular disease. Reynolds risk score is also a tool to predict the risk of coronary events. www.reynoldsriskscore.org

11. Framingham risk score (FRS) Framingham Risk Score (FRS) is calculated based on NCEP ATP III ( age, gender, total cholesterol, HDL-C, Smoking status, Systolic blood Pressure and Anti- hypertensive medication)

12. Results: Cont.

13. Role of Vascular and Neurovascular Function in Cardiovascular Disease Vascular dysfunction is generally considered a key initial event in the atherosclerotic process which is a local manifestation of systemic disorder. Numerous studies have shown that functional changes in arteries precede the development of structural changes and also reverse more quickly in response to therapies

15. http://www.endothelix.com/vendysmovie.html

17. What is a calcium score? A calcium score refers to a screening test that is used to calculate the amount of calcium in the heart. A calcium score looks specifically at calcium in the coronary arteries, where increased calcium leads to narrowing of the artery.

18. How is a CCS calculated? The calcium score is calculated from Computed Tomography (CT) scan images. The two main types of CT scanners are "Electron Beam" (EBCT) and "Multi- Detector" (MDCT). Both types of scanners are generally effective in calculating a calcium score.

19. What is the purpose of a Calcium Score? The purpose of a calcium score is to determine if a patient is at high risk for coronary artery disease, which may lead to a heart attack. In general, a high calcium score is associated with a higher risk of cardiovascular events, while a calcium score of zero is associated with a very low risk of coronary artery disease or heart attack.

25. Public Enemy #1

26. Diabetes Prevalence, 1990-1998

28. Risk of Cardiovascular Events in Diabetics Framingham Study Age-adjusted Biennial Rate Age-adjusted Per 1000 Risk Ratio Cardiovascular Event Men Women Men Women Coronary Disease 39 21 1.5** 2.2*** Stroke15 6 2.9*** 2.6*** Peripheral Artery Dis. 18 18 3.4*** 6.4*** Cardiac Failure 23 21 4.4*** 7.8*** All CVD Events 76 65 2.2*** 3.7*** Subjects 35-64 36-year Follow-up **P<.001,***P<.0001 _________________________________________________________________

29. Insulin Resistance

30. Natural History of Type 2 Diabetes

31. Relationship Between Obesity and Insulin Resistance and Dyslipidemia

32. Insulin Resistance: Associated Conditions

33. Cardiovascular Disease and Diabetes

34. Probability of Death From CHD in Patients With Type 2 Diabetes With or Without Previous MI

35. The Metabolic Syndrome Insulin Resistance Hypertension Type 2 Diabetes Disordered Fibrinolysis Complex Dyslipidemia TG, LDL HDL Endothelial Dysfunction Systemic Inflammation Athero- sclerosis Visceral Obesity Adapted from the ADA. Diabetes Care. 1998;21:310-314; Pradhan AD et al. JAMA. 2001;286:327-334.

36. Revised ATP III Metabolic Syndrome Oct 2005 *Diagnosis is established when  3 of these risk factors are present. † Abdominal obesity is more highly correlated with metabolic risk factors than is  BMI. ‡ Some men develop metabolic risk factors when circumference is only marginally increased. <40 mg/dL <50 mg/dL or Rx for ↓ HDL Men Women >102 cm (>40 in) >88 cm (>35 in) Men Women  100 mg/dL or Rx for ↑ glucose Fasting glucose  130/  85 mm Hg or on HTN Rx Blood pressure HDL-C  150 mg/dL or Rx for ↑ TG TG Abdominal obesity † (Waist circumference ‡ ) Defining LevelRisk Factor

37. International Diabetes Federation Definition: Abdominal obesity plus two other components: elevated BP, low HDL, elevated TG, or impaired fasting glucose

43. Prevalence of the Metabolic Syndrome Among US Adults NHANES 1988-1994 Prevalence (%) 0 5 10 15 20 25 30 35 40 45 20-2930-3940-4950-5960-69> 70 Men Women Age (years) Ford E et al. JAMA. 2002(287):356. 1999-2002 Prevalence by IDF vs. NCEP Definitions (Ford ES, Diabetes Care 2005; 28: 2745-9) (unadjusted, age 20+) NCEP : 33.7% in men and 35.4% in women IDF: 39.9% in men and 38.1% in women

44. http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm