Imaging-Guided Statin Allocation: Seeing Is Believing

Transcription

1 Imaging-Guided Statin Allocation: Seeing Is Believing The New Paradigm in Personalized Risk Assessment & Medication Prescribing Presented by: Michael J. Blaha May 15, General Principles of Talk Preventive therapies are lifelong therapies All medication have some cost and side effects Patients in general do not want to take medicines Patient receive absolute benefit in direct proportion to absolute risk Patients who are not destined to have an event receive no benefit from treatment Risk factor-based approach fails to identify many high risk, and most truly LOW RISK patients May 15,

2 STATINS I 100% agree with early intervention, but who to treat? Everybody? May 15, Critically Important Question 2 Paradigms in Primary Prevention 1) Whydoweprescribestatins? statins? Traditional View (lipid lowering drugs) Statins work by lowering circulating cholesterol Prescribe to patients with high cholesterol Paradigm Shift (risk reducing drugs) Statins also work by reducing plaque-level level inflammation, by delipidating plaque Prescribe statins to patients at high risk of developing increased atherosclerosis burden May 15,

3 Critically Important Question 2 Paradigms in Primary Prevention 2) How do we prescribe traditional risk factors vs. atherosclerosis burden Traditional View (Framingham/CVD Score) Chronologic age Risk Factors, including adult hypercholesterolemia Paradigm Shift (Imaging) Biologic Age / Arterial Age Disease Scores (Atherosclerosis burden) May 15, A Year Of Controversy: Statins for All, None, or Some? June 2012: JAMA Blaha MJ, Nasir K, Blumenthal RS. JAMA 2012;307(14): Redberg RF, Katz MH. JAMA 2012;307(14):

4 How to balance statin benefit data with cost data (muscle, diabetes, overmedicalization)? Number Needed to Treat (NNT) Number Needed to Harm (NNH) In absence of effect modification, Absolute Risk not Relative Risk! May 15, Statins Across LDL Levels, 2012 CTT Data No evidence of effect modification! CTT Lancet 2010;376:

5 How to balance statin benefit data with cost data (muscle, diabetes, overmedicalization)? Number Needed to Treat (NNT) Number Needed to Harm (NNH) In absence of effect modification, Absolute Risk, not Relative Risk! Fundamental Concept You can t prevent events if they don t occur! May 15, ~1 msv 5

6 CAC = 0 May 15,

7 CAC and Traditional Risk Factors % of individ duals in each CAC gr roup P < May 15, 2014 Silverman MG, et al. EHJ. In press CHD Event Rates (per 1,000 person-years) With Increasing CAC scores, by RF Burden May 15, 2014 Silverman MG, et al. EHJ. In press

8 Tota-Maharaj, et al. AHA Biologic Age > Chronologic Age Tota-Maharaj, et al. AHA May 15,

9 CAC and LDL Cholesterol rson-years Rate of CVD per 1,000 per < to to to99 CAC Martin SS, et al. Circulation Oct 20. [Epub ahead of print] CAC and non-hdl Cholesterol te of CVD per 1,000 pe erson-years Rat < to to to 99 CAC Martin SS, et al. Circulation Oct 20. [Epub ahead of print] 9

10 MESA JUPITER Population 25.16% 25% 47% 46.74% 28% 28.11% CAC=0 CAC CAC > MESA JUPITER: Estimated 5-year NNT JUPITER pop. 5-year NNT CHD 5-year NNT CVD Zero CAC CAC present CAC= NNH: CAC Statins/Diabetes: 255 CAC > ** Trial follow-up ~2 years, extrapolated to 5 years 10

11 21 Meeting Eligibility Criteria for Statins by NCEP: Does it Make Complete Sense? Evidence from MESA N=468 34% NCEP Eligibility Criteria (+) N=1,367 N=431 32% N=468 34% Nasir K, Budoff MJ, Blaha MJ, Blankstein R, Blumenthal RS, Agatston A, Shaw LJ, Krumholz H (AHA 2012) 11

12 Estimated 5 year NNT by NCEP Criteria & CAC NCEP Eligibility Criteria (+) NCEP Eligibility Criteria (-) CHD CVD CHD CVD CAC = CAC CAC > Nasir K, et al. AHA

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14 JAMA Case: Coronary Artery Calcium Guided Statin Use % of population CHD event rate (per 1000 patientyears) 5-year NNT with 35% event reduction CAC=0 50% CAC % CAC >100 13% JAMA Case: Coronary Artery Calcium Guided Statin Use % of population CHD event rate (per 1000 patientyears) 5-year NNT with 35% event reduction CAC=0 50% CAC % CAC >100 13% Statistics for a man in his 6 th decade of life with elevated cholesterol, normal blood pressure, and Framingham risk score placing him at intermediate risk for a hard CHD event within 10 years. A highly conservative 35% CHD event reduction with statins is assumed. Data source: Multi Ethnic Study of Atherosclerosis (MESA), mean 7.1 year follow up. 14

15 NOT JUST STATINS Aspirin too. More side effects More possibility for harm May 15, Risk/Benefits of ASA According to CAC 2500 Num mber Needed to Treat to Prev vent a CHD event * CHD Risk <10% CHD Risk >10% 0 CAC=0 CAC1 99 CAC>100 * Represents number needed to harm for a major bleeding event Miedema et al. ASA and CAC Circ Quality

16 SUMMARY: SEEING IS BELIEVING? Statins For Everyone Issue: Lifelong exposure to risk, atherogenic lipoprotein Statins work in everybody Statins are cheap Statins are in general very well tolerated Above a certain age, nearly everyone is at CVD risk Selective Therapy Treat early & aggressively those people who are at risk (those with atherosclerosis!) NNT>NNH relies on absolute risk reduction, not relative risk reduction Many older adults probably do not accrue net 5+ year benefit from statins (CAC=0) May 15, THANK YOU!!! May 15,

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