braunwald

APPROACH TO IDENTIFYING AND APPROACH TO IDENTIFYING AND MANAGING CORONARY RISKMANAGING CORONARY RISK

Eugene Braunwald, M.D.Eugene Braunwald, M.D.March 6, 2004March 6, 2004

• Prevention of acute events must be the primary goal. Treatment should be regarded as “locking the barn door after the horse is stolen”

• One third of cases of sudden death and acute MI occur in previously asymptomatic persons - - previously regarded as “acts of God”

• Most of these are now known to have pre-clinical disease, classical or novel risk factors

• Need to identify high risk asymptomatic persons prospectively to provide intensive prevention

• All patients with clinically apparent atherosclerotic disease require intensive global risk factor reduction

• Some have unstable placques (“accidents about to happen”) and these must be identified

<0.5%/yr

0.5-2%/yr

2-15%/yr

>15%/yr Very High Risk

High Risk

Intermediate Risk

Low Risk

Low riskLow risk Lifestyle & Lifestyle & 0.5%/yr0.5%/yr Follow-Follow-

upup

(40%)(40%)

Framingham Risk ScoreFramingham Risk Score IntermediateIntermediate AdditionalAdditional

CRP, Cholest., GlucoseCRP, Cholest., Glucose 0.5-2%/yr0.5-2%/yr TestingTesting

(50%)(50%)

High riskHigh risk IntensiveIntensive

> 2%/yr> 2%/yr global risk global risk (10%)(10%)

Low riskLow risk Risk factor Risk factor ABIABIEBCTEBCTIMTIMT

High riskHigh risk Intensive global + non-invasiveIntensive global + non-invasiveriskrisk detection ofdetection ofunstable unstable placque(s)placque(s)

Non-invasiveNon-invasive

Detection +Detection + novel anti-novel anti- ++ inflammatoriesinflammatories25%/yr25%/yr anti-thrombotic Rx;anti-thrombotic Rx;

Very high risk Invasive detection Very high risk Invasive detection CABG, multiCABG, multi15%/yr15%/yr of unstable of unstable DESDES2%2% placques placques

--

10%/yr10%/yr continue intensive continue intensive risk factorrisk factor