MOHAMMED R. ESSOP DIVISION OF CARDIOLOGY CH-BARAGWANATH HOSPITAL
DEFINITION OF A SCREENING TEST TESTING FOR A DISEASE OR CONDITION IN ASYMPTOMATIC PERSONS TO IDENTIFY THE CONDITION BEFORE IT MANIFESTS CLINICALLY
MOHAMMED R. ESSOP DIVISION OF CARDIOLOGY CH-BARAGWANATH HOSPITAL
REQUIREMENTS OF A GOOD SCREENING TEST The prevalence of the disease must be high enough to justify screening The test must accurately diagnose the disease and characterise low and high risk patients The test must have incremental value beyond other standard measures of risk Identification of afflicted individuals should lead to a treatment that improves outcomes The screening test should be easily available and free of risk The screening test should be cost effective
PREVALENCE OF DIABETES IN THE USA 1980 2011 (millions) CDC, National Institute for Statistics, USA.Gov
AGE SPECIFIC SURVIVAL AMONG PATIENTS WITH TYPE 1 DIABETES COMPARED WITH THE GENERAL POPULATION Livingstone et al, JAMA 2015;313(1):37-44
CAUSE SPECIFIC CONTRIBUTION TO MORTALITY BY AGE AND SEX Livingstone et al, JAMA 2015;313(1):37-44
CHANGES IN DIABETIC RELATED COMPLICATIONS, 1990-2010 Gregg et al, NEJM 2014;370:1515-23
DIABETES MELLITUS IS A CORONARY ARTERY DISEASE EQUIVALENT Haffner et al, NEJM1998;339:229-34
EVENT RATES FOR CARDIOVASCULAR MORTALITY IN MEN (A) AND WOMEN (B) STRATIFIED BY AGE AND SEX IN RELATION TO DIABETES MELLITUS AND PRIOR MI Schramm TK et al, Circulation 2008;117:1945-54
CARDIOVASCULAR RISK PREDICTION SCORES Framingham CHD score 1998 Framingham CVD score 2001 UKPDS risk engine 2001 ATP III modified Framingham score 2002 Reynolds score 2007 AHA-ACC ASCVD score 2013
CARDIOVASCULAR RISK FACTORS DIABETES OBESITY RACE SEX LDL BLOOD PRESSURE EXERCISE FAMILY HISTORY AGE HS-CRP HOMOCYSTEINE SMOKING
FRAMINGHAM RISK SCORE LOW MEDI UM HIGH 0% 100% 10 20 10 Year risk of a cardiovascular event
PERCENTAGE DISCORDANCE BETWEEN PREDICTED AND OBSERVED CARDIOVASCULAR EVENTS USING 5 RISK PREDICTION ALGORITHMS Ridker PM, Annals Int Med 2015;162:313-14
THE MAJORITY OF ADVERSE EVENTS OCCUR IN THE LOW RISK POPULATION Rose G. BMJ 1981;282:1847-51
SCREENING TESTS FOR CORONARY ATHEROSCLEROSIS ECG Stress ECG Stress echocardiography Carotid intima media thickness (IMT) Myocardial perfusion imaging CT coronary artery calcium (CAC) CT coronary angiography (CTCA)
MYOCARDIAL PERFUSION IMAGING
PREDICTION OF CARDIOVASCULER EVENTS USING MPI IN ASYMPTOMATIC PATIENTS WITH DIABETES AUTHOR YEAR N AGE RISK RATIO Torremocha 2001 72 55 2.7 Le Feuvre 2005 100 61 0.8 Sejil 2006 203 54 3.7 Sholte 2009 120 53 10 Choi 2009 116 62 1.9 Jaqueminet 2010 204 65 n/a Giovachini 2013 77 63 2.8 De Lorenzo 2002 180 61 2.4 Yamasaki 2010 485 67 1.9
ÇT CORONARY ARTERY CALCIUM
SURVIVAL STRATIFIED BY CAC SCORE Raggi P et al, JACC 2004;43:1663-9
CUMULATIVE RELATIVE RISK RATIO FOR EVENTS IN NO CAC VERSUS CAC IN ASYMPTOMATIC PATIENTS Sarwar et al, JACC Imaging 2009;2:675-88
CAC IN ASYMPTOMATIC DIABETIC PATIENTS Hecht HS et al, Journal of Diabetes 2012;4:342-50
WHY WERE THE DIAD AND FACTOR 64 TRIALS NEGATIVE? The event rate in the control arms were extremely low resulting in the trials being underpowered Mean entry LDL in control arm 2.3mmol/L Mean systolic BP 130mmHg Inability to implement a more aggressive strategy in patients with an abnormal CCTA The assumption regarding the benefits of CCTA may have been overly optimistic
WHAT IS THE TAKE HOME MESSAGE? Further RCT are needed which focus on intermediate and high risk patients Guideline based therapy for cholesterol and blood pressure should be implemented more consistently Until further data become available, widespread MPI or CCTA cannot be recommended for asymptomatic patients with diabetes. THANK YOU
Preis et al, Circulation 2009;120:212-20
EVENT RATES FOR THE COMPOSITE END POINT OF MI, STRKE AND CARDIOVASCULAR DEATH IN MEN (A) AND WOMEN (B) STRATIFIED BY AGE AND SEX IN RELATION TO DIABETES MELLITUS AND PRIOR MI Schramm TK et al, Circulation 2008;117:1945-54
TRENDS FOR MEDICAL TREATMENT DURING FOLLOW- UP IN RELATION TO DIABETES AND PRIOR MI
AHA-ACC ASCVD 7.5% LOW ME DI UM HIGH 0% 100% 5 10 Risk of a cardiovascular event
CHARACTERISTICS AND RISK RATIO FOR CAC IN ASYMPTOMATIC PATIENTS Hecht HS et al, Journal of Diabetes 2012;4:342-50
ANNUAL EVENT RATES IN PRIMARY PREVENTION PATIENTS AT VARYING CAC LEVELS
RECLASSIFICATION OF FRS WITH CAC IN PRIMARY PREVENTION STUDIES