Short and Long Term Prognosis after Coronary Artery Calcium Scoring

Transcription

1 Short and Long Term Prognosis after Coronary Artery Calcium Scoring In Pre-Elderly and Elderly Patients Michael J. Blaha MD MPH Presented by: Michael J. Blaha July 24,

2 Talk Outline 1. Coronary artery calcium (CAC), disease scores, and risk integration 2. CAC in pre-elderly patients 3. The MESA CHD Risk Score 4. CAC in elderly patients several caveats July 24,

3 Coronary Artery Calcium and Risk Integration Part I July 24,

4 ~1 msv

5 Relationship of Calcification to Coronary Atherosclerosis 20% Rumberger, Circulation 1995 July 24,

6 Continuum of Atherosclerosis Propagation Prior to a CHD Event Genetics Environment Funnel Risk Factors Biomarkers Subclinical Atherosclerosis Overt CAD

7 RISK Subclinical Disease Detection Model Integrates Risk Exposure!! AGE

8 Coronary Artery Calcium in Pre-Elderly Patients Part II July 24,

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16 CAC and Age Biologic Age > Chronologic Age Tota-Maharaj, et al. Mayo Clinic Proceedings

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18 CAC = 0

19 Comparing Negative Risk Markers in the Multi-Ethnic Study of Atherosclerosis A CAC score of zero is the strongest negative risk factor for the development of ASCVD. Imaging Hypothesis due to superior sensitivity, imaging tests for subclinical atherosclerosis are excellent at ruling out or downgrading risk estimates. Blaha MJ, et al. Circulation. 2016

20 Important Covariates Influencing Likelihood Ratio for CAC= Likelihood Ratio for Zero CAC Age in years 0% 5% 10% 15% 20% 25% 30% Pre-Test Risk Estimate (10-year CHD Risk) Age MESA FRS July 24,

21 Percent of U.S. Adults Who Would Be Eligible for Statin Therapy for Primary Prevention, According to Set of Guidelines and Age Group. Pencina MJ et al. N Engl J Med DOI: /NEJMoa

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23 Nasir K et et al, JACC 2015

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25 The MESA CHD Risk Score Part III July 24,

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27 MESA CHD Risk Score

28 The MESA CHD Risk Score

29 The MESA CHD Risk Score

30 The MESA CHD Risk Score

31 Please download the MESA Risk Score app! Search MESA CHD Risk in the app store Currently only available for Android Coming soon for iphone!

32 Coronary Artery Calcium in Pre-Elderly Patients Several Caveats! Part IV July 24,

33 Challenges in Risk Stratification in the Elderly All-cause mortality stratified by age and CAC Those with 75 years old have highest rate of long term (>10 years) all-cause mortality regardless of CAC group 1 Nakanishi, et al. EHJ IMG, 2015.

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35 Cause specific mortality by CAC group <75 Years (2,436 deaths) 75 Years (722 deaths) CVD CHD Cancer CVD CHD Cancer CAC= CAC CAC CAC

36 Cause specific mortality by CAC group <75 Years (2,436 deaths) 75 Years (722 deaths) CVD CHD Cancer CVD CHD Cancer CAC= CAC CAC CAC

37 Cause specific mortality by CAC group <75 Years (2,436 deaths) 75 Years (722 deaths) CVD CHD Cancer CVD CHD Cancer CAC= CAC CAC CAC

38 Cause specific mortality by CAC group <75 Years (2,436 deaths) 75 Years (722 deaths) CVD CHD Cancer CVD CHD Cancer CAC= CAC CAC CAC

39 Cause-specific mortality by CAC category 50% <75 Years 40% 30% 20% 10% 0% 50% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD 75 Years 40% 30% 20% 10% 0% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD

40 Cause-specific mortality by CAC category 50% <75 Years 40% 30% 20% 10% 0% 50% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD 75 Years 40% 30% 20% 10% 0% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD

41 Cause-specific mortality by CAC category 50% <75 Years 40% 30% 20% 10% 0% 50% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD 75 Years 40% 30% 20% 10% 0% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD

42 Cause-specific mortality by CAC category 50% <75 Years 40% 30% 20% 10% 0% 50% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD 75 Years 40% 30% 20% 10% 0% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD

43 Cause-specific mortality by CAC category 50% <75 Years 40% 30% 20% 10% 0% 50% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD 75 Years 40% 30% 20% 10% 0% CAC 0 CAC 1-99 CAC CAC 300 Cancer CVD CHD Non-CHD CVD

44 Hazard of cause-specific mortality CAC=0 CAC 1-99 Model <75 Years 75 years CVD CHD Cancer CVD CHD Cancer Reference Reference Reference Reference Reference Reference ( ) CAC Model ( ) CAC 300 Model ( ) 2.27 ( ) 6.10 ( ) ( ) 1.61 ( ) 2.43 ( ) 3.61 ( ) 0.91 ( ) 1.24 ( ) 2.15 ( ) 0.77 ( ) 1.05 ( ) 2.18 ( ) Model 2 race, gender, hypertension, hyperlipidemia, smoking, diabetes, family history CHD 0.74 ( ) 1.15 ( ) 1.18 ( )

45 Hazard of cause-specific mortality CAC=0 CAC 1-99 Model <75 Years 75 years CVD CHD Cancer CVD CHD Cancer Reference Reference Reference Reference Reference Reference ( ) CAC Model ( ) CAC 300 Model ( ) 2.27 ( ) 6.10 ( ) ( ) 1.61 ( ) 2.43 ( ) 3.61 ( ) 0.91 ( ) 1.24 ( ) 2.15 ( ) 0.77 ( ) 1.05 ( ) 2.18 ( ) Model 2 race, gender, hypertension, hyperlipidemia, smoking, diabetes, family history CHD 0.74 ( ) 1.15 ( ) 1.18 ( )

46 Hazard of cause-specific mortality CAC=0 CAC 1-99 Model <75 Years 75 years CVD CHD Cancer CVD CHD Cancer Reference Reference Reference Reference Reference Reference ( ) CAC Model ( ) CAC 300 Model ( ) 2.27 ( ) 6.10 ( ) ( ) 1.61 ( ) 2.43 ( ) 3.61 ( ) 0.91 ( ) 1.24 ( ) 2.15 ( ) 0.77 ( ) 1.05 ( ) 2.18 ( ) Model 2 race, gender, hypertension, hyperlipidemia, smoking, diabetes, family history CHD 0.74 ( ) 1.15 ( ) 1.18 ( )

47 SUMMARY AND TAKE HOME: CAC for Older Patients When Individualization of Prevention Is Required!! 1. When Risk/Decision to Treat is Uncertain Family History, Borderline lipids, Metabolic Syndrome 2. Statin Reluctant Patient 3. Statin Intolerant Patient 4. MESA CHD Risk Score very helpful! 5. Limited use in those >75 years old right now July 24,

48 THANK YOU!

49 July 24,