Hội Tim mạch học Việt Nam novel risk factors

CCRE TherapeuticsNovel approachs to cardiovascular risk assessment - do we need them?. CCRE TherapeuticsCurrent approaches to risk assessment • Framingham Study • Original cohort ~ 5000

CCRE Therapeutics

Novel approachs to cardiovascular risk assessment

- do we need them?

Christopher Reid

Monash Centre for Cardiovascular Research

& Education in Therapeutics School of Public Health & preventive Medicine

Monash University

Vietnam 2010

CCRE Therapeutics

Current approaches to risk assessment

• Framingham Study

• Original cohort ~ 5000

• Long follow-up >30 years

• Additional subjects / off-spring added along the way

• Additional risk factors included along the way

CCRE Therapeutics

Current approaches to risk assessment

• Risk Factors include

– Age

– Sex

– SBP

– Lipid levels: TC and HDL-C

– Smoking status

– Presence or absence of DM and/or

LVH

Jackson R BMJ 2000;320:709-710

CCRE Therapeutics

Framingham Score

• Limitations?

• Population specific

• Measure not included

• Family history

• Physical activity

• Obesity

• New marker

• Age range

• 5 year / 10 year risks

• Recalibration

• Populations specific risk assessment tools

Over 1900 articles on FRS

in the last 10 years!

CCRE Therapeutics

Variety of risk scores now available

CCRE Therapeutics

Variety of risk scores now available

CCRE Therapeutics

Can we do better?

CCRE Therapeutics

Can we do better?

• Inclusion of new risk markers in risk models

• CRP

• Other biomarkers – eg BNP

• Genetic markers

• Imaging markers – eg coronary calcium scoring

traditional risk factors (?)

Potential to better classify those in the intermediate risk

categories (?)

CCRE Therapeutics

New risk markers?

Must add predictive information over and above the

method currently in use Independent odds or hazard ratios are not enough

CCRE Therapeutics

Biomarkers?

Blankenberg etal, 2006

• Incremental improvement

in risk prediction with a combination of biomarkers

• cRP

• Fibrinogen

• IL6, IL18

• TNF 1 – 2

• Troponin

• Cystatin C

CCRE Therapeutics

CRP?

Improvements in risk prediction (c-statistic) ?

Wilkins Lloyd-Jones, Preventive Cardiology 2010

CCRE Therapeutics

Can we do better?

• Majority of studies claimed to improve prediction

• Many were flawed in designed, analysis and reporting

• Casts doubt on claims of improving prediction

CCRE Therapeutics

Genetic Markers?

CCRE Therapeutics

Genetic Markers?

• No association with CVD events

• Family history probably as good?

CCRE Therapeutics

What to focus on?

age, sex, and smoking (99% CI)

PAR adjusted for all (99% CI)

ApoB/ApoA-1 (fifth

quintile compared

with first)

Vegetable and fruits

Yusuf, 2004, Lancet

CCRE Therapeutics

What to focus on?

High blood pressure

Tobacco High cholesterol

Underweight

Unsafe sex Low fruit and vegetables

High BMI Physical inactivity

Alcohol Unsafe water, S&H

Indoor smoke from solid fuels

Iron deficiency

Urban air pollution

Zinc deficiency

Vitamin A deficiency

Unsafe health care injections

Occupational particulates

Occupational injury

Lead exposure

Illicit drugs

Attributable mortality in millions (Total 55.9 million)

Developing high mortality Developing lower mortality Developed

CCRE Therapeutics

Summary

• Current conventional methods are limited

• Further research and development on new markers is

required

• For population screening the bar should be set very high before the transition into clinical practice

• Costs / benefits

• Research agenda needs to include exploration for

novel markers that will improve the identification of those

at risk

CCRE Therapeutics

Summary

Primordial prevention should remain a focus for

prevention

Value for money approach

- Lifestyle factors

- Physical activity

- Dietary intake

- Smoking

- Age / Family history

- Blood Pressure

- Blood cholesterol / Glucose