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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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slide1
Vascular Risk Prediction

Profiling tools

for subjects

at risk

for a first,

unheralded

vascular

disease

An update from

the Taskforce on Vascular Risk Prediction

slide2
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

slide3
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

slide4
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

slide5
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

slide6
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

slide7
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

slide8
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

slide9
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

slide10
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 /

slide11
Vascular Risk Prediction

Strategies to assess the value of a test

Michel Romanens, 05.05.2007 /

slide12
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 /

slide13
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

slide14
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.

slide15
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

slide16
Vascular Risk Prediction

Bayes Posttest Risk

with 95% CI

Using

Coronary calcium

percentiles

95% CI by Newcombe

Michel Romanens, 05.05.2007

slide17
Vascular Risk Prediction

Bayes Posttest Risk

with 95% CI

Michel Romanens, 05.05.2007

slide18
Vascular Risk Prediction

Bayes Posttest Risk

with 95% CI

http://scopri.ch/posttestcalculators1.html

Michel Romanens, 05.05.2007

slide19
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

slide20
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

slide21
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

slide22
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

slide23
Vascular Risk Prediction

The presentation is open for discussion

Michel Romanens, 05.05.2007

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