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Vascular Risk Prediction

Vascular Risk Prediction. Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction. Vascular Risk Prediction. Principle Goal of the Taskforce.

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Vascular Risk Prediction

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  1. Vascular Risk Prediction Profiling tools for subjects at risk for a first, unheralded vascular disease An update from the Taskforce on Vascular Risk Prediction

  2. Vascular Risk Prediction Principle Goal of the Taskforce Improve risk prediction in originally healthy people, in whom a high risk derived from the major independent cardiovascular risk factors is not evident Michel Romanens, 05.05.2007

  3. Vascular Risk Prediction Guidelines 2005: .... AGLA / Executive Committee SGK Secondary prevention: Intensification Primary Prevention: Discuss Guidelines of ESC and IAS Try to reach common guidelines in the next years Michel Romanens, 05.05.2007

  4. Vascular Risk Prediction 3 Questions IAS-AGLA or EAS-SCORE or FRAMINGHAM as a first measure ? PLAQUE or ISCHEMIA or hsCRP to further stratify risk ? BAYES or ROC or ODDS to estimate the value of a test ? Michel Romanens, 05.05.2007

  5. Vascular Risk Prediction 3 levels of risk PROCAM CORDICARE I Germany OLTEN COHORT Men Only Men and Women Age 35-65 Age 45+ N=5389 N=914 RISK Distribution Events Distribution Events High 8% 33% 2% ? Intermediate 15% 33% 11% ? Low 77% 33% 87% ? Michel Romanens, 05.05.2007

  6. Vascular Risk Prediction 3 possible strategies A down-calibrate definition of high risk from 20% to 15%? general practitionars might be even more confused than they are already now B treat virtually everybodies cholesterol in intermediate risk C further risk stratify with new tools in intermediate risk Michel Romanens, 05.05.2007

  7. Vascular Risk Prediction IAS-AGLA or EAS-SCORE / Strategy B CORIDCARE I Indication for LDL or total Cholesterol lowering intervention Michel Romanens, 05.05.2007

  8. Vascular Risk Prediction IAS-AGLA or EAS-SCORE Strategy B: treat them all in intermediate risk defined by IAS-AGLA IAS-AGLA Intermediate Risk CORDICARE I = 11% of 914 subjects > 45 years 10 year risk for AMI is about 15% on average Year 2005: 410251 subjects in CH > 40 years at intermediate risk Of these, 91% would be treated with statins (CORDICARE I) 61538 AMI would occur in 10 years (30769 deaths) Statins lower risk by 30% Risk would be reduced from 15% to 11% with statins Absolute Risk reduction 16800 AMI (8400 deaths) Relative Risk reduction 27% NNT 24 Michel Romanens, 05.05.2007

  9. Vascular Risk Prediction IAS-AGLA or EAS-SCORE Strategy C: further risk stratify intermediate risk defined by IAS-AGLA Ca-Scoring ? Ultrasound Plaque Imaging ? hsCRP? Michel Romanens, 05.05.2007

  10. Vascular Risk Prediction Strategies to assess the value of a test A ROC analysis B ODD ratios, relative risk, correction for co-factors C Bayes Posttest Calculator Michel Romanens, 05.05.2007 /

  11. Vascular Risk Prediction Strategies to assess the value of a test Michel Romanens, 05.05.2007 /

  12. Vascular Risk Prediction ROC, ODD, or BAYES Nancy Cook statements: „Indeed, if improvement in the ROC statistic was used as the criterion for model inclusion, then neither LDL-C, HDL-C, nor total cholesterol would have been included in risk models after accounting for age, blood pressure, and smoking.” “The Bayes information …is related to the posterior probability that the model is correct, and is a conservative criterion for model selection.” Michel Romanens, 05.05.2007 /

  13. Vascular Risk Prediction ROC, ODD, or BAYES Single Risk Factor Testing Significant overlap between diseased and non diseased Michel Romanens, 05.05.2007 / Wald NJ, Law MR. BMJ. 2003;326:1419

  14. Vascular Risk Prediction IAS-AGLA or EAS-SCORE Strategy C: further risk stratify intermediate risk defined by IAS-AGLA: relative risk for various risk factors in middle aged subjects Hypertension LDL>4.1 Men LDL>4.1 Women Nicotine Men Nicotine Women Diabetes Men Diabetes Women ARIC Study Michel Romanens, 05.05.2007 / Hypertension. 2006;48:392-396.

  15. Vascular Risk Prediction Bayes Posttest Risk as a – third – solution between ROC and ODDs ? Look for practiclesolutions on www.scopri.ch SE = Sensitivity SP = Specificity PV = prevalence or pretest probability PTP = posttest probability PTP pos PV × SE / PV × SE + (1 – PV) × (1 – SP) PTP neg PV × (1 – SE) / PV × (1 – SE) + SP × (1 – PV) Michel Romanens, 05.05.2007

  16. Vascular Risk Prediction Bayes Posttest Risk with 95% CI Using Coronary calcium percentiles 95% CI by Newcombe Michel Romanens, 05.05.2007

  17. Vascular Risk Prediction Bayes Posttest Risk with 95% CI Michel Romanens, 05.05.2007

  18. Vascular Risk Prediction Bayes Posttest Risk with 95% CI http://scopri.ch/posttestcalculators1.html Michel Romanens, 05.05.2007

  19. Vascular Risk Prediction Future themes of the taskforce www.taskforce.atherosclerosisimaging.ch Which emerging imaging test should be ideally used in Switzerland? Are sequential posttest-calculations an issue in risk prediction ? Who should do atherosclerosis imaging tests (accreditation)? Does atherosclerosis imaging convince patients more than verbal communication, that a treatment is necessary? For which test should there be reimbursement and how can that be achieved? What is the cost-efficiency issues of emerging imaging tests? What is the risk-benefit ratio of calcium scoring in intermediate risk subjects in view of the radiation burden per scan (1 mSv). ….. Michel Romanens, 05.05.2007

  20. Vascular Risk Prediction An Update of the Taskforce Taskforce Founding Members in 2005 Darioli Roger Romanens Michel Scientific Coordinator Romanens Michel Michel Romanens, 06.05.2006

  21. Vascular Risk Prediction Summary and Future Directions Proposition: in God we trust, the others must bring numbers Let us do the COCA study (5 year outcome of coronary calcifications and carotid total plaque area from a real life experience) It is designed to produce numbers on outcome, since practice based algorithms may be more useful than population wide epidemiological testing in the future Michel Romanens, 05.05.2007

  22. Vascular Risk Prediction Summary and Future Directions Goal of the taskforce: improve risk prediction in originally healthy subjects, and : several publications are underway …. IAS-AGLA or EAS-SCORE: rather IAS-AGLA Calcium scoring passes the hardliner test (ROC analysis) Bayes Posttest Risk Calculators are useful Many themes are open to debate within the Taskforce Check on www.taskforce.atherosclerosisimaging.ch Michel Romanens, 05.05.2007

  23. Vascular Risk Prediction The presentation is open for discussion Michel Romanens, 05.05.2007

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