From Vulnerable Plaque to Vulnerable Patient—Part III: Executive Summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force Report
Section snippets
Burden of Atherosclerotic Cardiovascular Disease
Atherosclerosis is responsible for nearly all cases of coronary heart disease (CHD), intermittent claudication and critical limb ischemia, and many cases of stroke. CHD alone is the single greatest killer of men and women in the United States (479,300 CHD deaths in 2003), causing >1 of every 5 deaths.3 In 2006, an estimated 875,000 individuals in the United States will have a first heart attack, and 500,000 will have a recurrent attack.3 Because the risk of CHD increases markedly with age, and
Risk Factors, Susceptibility, and Vulnerability
Atherosclerosis begins to develop early in life and progresses with time, but the speed of progression is, to a large extent, unpredictable and differs markedly among seemingly comparable individuals. At every level of risk factor exposure, the amount of established atherosclerosis and the vulnerability to acute events varies greatly, probably because of genetic variability in an individual’s susceptibility to atherosclerosis and propensity to arterial thrombosis (“vulnerable blood”) and
Current Guidelines in Primary Prevention
The current guidelines in primary prevention recommend initial assessment and risk stratification based on traditional risk factors (eg, the Framingham Risk Score in the United States and the Systemic Coronary Risk Evaluation [SCORE] in Europe), followed by goal-directed therapy when necessary.19, 34, 35, 36 Although this approach may identify persons at very low or very high risk of a heart attack or stroke within the next 10 years, the majority of the population belongs to an
In search of the vulnerable patient
Parts I and II of this consensus statement elaborated on new discoveries in the field of atherosclerosis that led to the concept of the vulnerable patient.39, 40 This focus on the identification and aggressive treatment of the previously unrecognized very-high-risk population neglected the majority of the population who are not in the very-high-risk category. To rectify this major omission, the SHAPE report introduces a new paradigm to stratify the entire US population at risk and to tailor
The First SHAPE Guideline
A conceptual flow chart illustrating the principles of the new paradigm is shown in Figure 3.
In contrast to the existing traditional risk factor–based guidelines, this new strategy is primarily based on noninvasive screening for subclinical atherosclerosis using 2 well-established noninvasive imaging modalities: CT for measurement of CACS and B-mode ultrasound for measurement of CIMT and carotid plaque.41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64
Genetic, structural, and functional assessment
Serum markers that can accurately identify the vulnerable individual with both high sensitivity and specificity might be derived from a thorough proteomic survey of blood samples collected from heart attack victims within a few months before the event.110 The incremental predictive value of genes over existing and emerging nongene predictors will need careful scientific and economic evaluation.111, 112 Noninvasive screening tests for subclinical atherosclerosis are rapidly advancing, and
Conclusion
The SHAPE Task Force strongly recommends screening of the at-risk asymptomatic population (men 45–75 years of age and women 55–75 years of age) for subclinical atherosclerosis to more accurately identify and treat patients at high risk for acute ischemic events, as well as to identify those at lower risk who may be treated more conservatively. The Task Force reinforces the existing guidelines for screening and treatment of atherosclerosis risk factors in the younger, very-low-risk population.
Acknowledgment
The Association for the Eradication of Heart Attack (AEHA) thanks the following individuals for their administrative support of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force: Asif Ali, MD, Lori Cantu, Suzanne Ekblad, MPH, Uzma Gul, and Daniel Jamieson. Special thanks to Khawar Gul, MD, Lisa Brown, Craig Jamieson, Brian Jenkins, Mark Johnson, Daniel Keeney, and Kelly Papinchak.
References (125)
- et al.
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study
Lancet
(2004) The global epidemiology of heart failure
Med Clin North Am
(2004)- et al.
A comparison of the PROCAM and Framingham point-scoring systems for estimation of individual risk of coronary heart disease in the Second Northwick Park Heart Study
Atherosclerosis
(2005) - et al.
Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study
J Am Coll Cardiol
(2005) The changing face of cardiovascular risk [editorial]
J Am Coll Cardiol
(2005)- et al.
Preventing myocardial infarction in the young adult in the first place: how do the National Cholesterol Education Panel III guidelines perform?
J Am Coll Cardiol
(2003) - et al.
Apolipoproteins and ischaemic heart disease: implications for screening
Lancet
(1994) - et al.
Age and gender distributions of coronary artery calcium detected by electron beam tomography in 35,246 adults
Am J Cardiol
(2001) - et al.
Prediction of coronary events with electron beam computed tomography
J Am Coll Cardiol
(2000) - et al.
Coronary artery calcium evaluation by electron beam computed tomography and its relation to new cardiovascular events
Am J Cardiol
(2000)
Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) Project
J Am Coll Cardiol
Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography
J Am Coll Cardiol
Non-invasive definition of anatomic coronary artery disease by ultrafast CT: a quantitative pathologic study
J Am Coll Cardiol
Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: a histologic study of 723 coronary artery segments using non-decalcifying methodology
J Am Coll Cardiol
Predicting risk and treatment benefit in atherosclerosis: the role of C-reactive protein
Int J Cardiol
Prognostic value of coronary artery calcium screening in subjects with and without diabetes
J Am Coll Cardiol
Cardiovascular complications in diabetes mellitus
Curr Opin Pharmacol
Atherothrombosis and high-risk plaque. Part IIapproaches by non-invasive computed tomographic/magnetic resonance imaging
J Am Coll Cardiol
The clinical implications of endothelial dysfunction [review]
J Am Coll Cardiol
Intravascular optical coherence tomography: cellular imaging
J Nucl Cardiol
Association of plaque characterization by intravascular ultrasound virtual histology and arterial remodeling
Am J Cardiol
Vulnerable plaque imaging
Neuroimaging Clin North Am
The Atlas of Heart Disease and StrokeWorld Health Organization and US Centers for Disease Control and Prevention, 2004
A Race Against Time: The Challenge of Cardiovascular Disease in Developing EconomiesReport of the Center for Global Health and Economic Development. New York: Columbia University, 2004
Heart Disease and Stroke Statistics – 2006 Update. Dallas, TX: American Heart Association, 2006
Sudden cardiac death
Circulation
State-specific mortality from sudden cardiac death—United States, 1999
MMWR Morb Mortal Wkly Rep
Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women
JAMA
Heart Disease and Stroke Statistics – 2005 Update
Centers for Disease Control and Prevention, US Dept of Health and Human Services
Screening for Coronary Heart Disease, 2004 [Agency for Healthcare Research and QualityWeb site]
for the Framingham Heart Study. Lifetime risk for developing congestive heart failure: the Framingham Heart Study
Circulation
for the CHD Risk Prediction Group. Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation
JAMA
C-reactive protein and other circulating markers of inflammation in the prediction of coronary heart disease
N Engl J Med
Predictive value for the Chinese population of the Framingham CHD risk assessment tool compared with the Chinese Multi-Provincial Cohort Study
JAMA
European guidelines on cardiovascular disease prevention in clinical practice
Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study
BMJ
for the PRIME Study Group. Are the Framingham and PROCAM coronary heart disease risk functions applicable to different European populations? The PRIME Study
Eur Heart J
A comparison of Framingham and SCORE-based cardiovascular risk estimates in participants of the German National Health Interview and Examination Survey 1998
Eur J Cardiovasc Prev Rehabil
for the Intervention as a Goal in Hypertension Treatment Study Group. The Framingham prediction rule is not valid in a European population of treated hypertensive patients
J Hypertens
Predicted and observed cardiovascular disease in South Asians: application of FINRISK, Framingham and SCORE models to Newcastle Heart Project data
J Public Health (Oxf)
Prevention of coronary heart disease and the National Cholesterol Education Program
Circulation
Major risk factors as antecedents of fatal and nonfatal coronary heart disease events
JAMA
When can a risk factor be used as a worthwhile screening test?
BMJ
Risk factor thresholds: their existence under scrutiny
BMJ
The performance of blood pressure and other cardiovascular risk factors as screening tests for ischaemic heart disease and stroke
J Med Screen
Traditional risk factors for coronary heart disease [letter]
JAMA
A strategy to reduce cardiovascular disease by more than 80% [published correction appears in BMJ 2003;327:586]
BMJ
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report
Circulation
Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines
Circulation
Cited by (539)
Noninvasive Imaging for the Asymptomatic Patient: How to Use Imaging to Guide Treatment Goals?
2022, Medical Clinics of North AmericaOn the association between circulating biomarkers and atherosclerotic calcification in a cohort of arterial disease participants
2021, Nutrition, Metabolism and Cardiovascular DiseasesCardiovascular risk assessment models: Have we found the perfect solution yet?
2020, Journal of Nuclear CardiologyThe Pathophysiology of Myocardial Ischemia and Perioperative Myocardial Infarction
2020, Journal of Cardiothoracic and Vascular AnesthesiaIgG N-Glycosylation Is Altered in Coronary Artery Disease
2023, BiomoleculesSensors-based monitoring and treatment approaches for in-stent restenosis
2023, Journal of Biomedical Materials Research - Part B Applied Biomaterials