Hội Tim mạch học Việt Nam novel risk factors

12th National Congress of Cardiology Vietnam 2010 CCRE Therapeutics Novel approachs to cardiovascular risk assessment - we need them? Christopher Reid Monash Centre for Cardiovascular Research & Education in Therapeutics School of Public Health & preventive Medicine Monash University Current approaches to risk assessment CCRE Therapeutics • 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 Current approaches to risk assessment CCRE Therapeutics • 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 Framingham Score CCRE Therapeutics • Limitations? • Population specific • Measure not included • Family history • Physical activity • Obesity • New marker • Age range • year / 10 year risks Over 1900 articles on FRS in the last 10 years! • Recalibration • Populations specific risk assessment tools Variety of risk scores now available CCRE Therapeutics Variety of risk scores now available CCRE Therapeutics Can we better? CCRE Therapeutics Can we better? CCRE Therapeutics • >50% of events occur in those with non-elevated traditional risk factors (?) • Inclusion of new risk markers in risk models • CRP • Other biomarkers – eg BNP • Genetic markers • Imaging markers – eg coronary calcium scoring Potential to better classify those in the intermediate risk categories (?) New risk markers? CCRE Therapeutics • To • • • • be useful Standardised Accurate Precise Reproducable in large diverse populations Must add predictive information over and above the method currently in use Independent odds or hazard ratios are not enough Biomarkers? CCRE Therapeutics Blankenberg etal, 2006 • Incremental improvement in risk prediction with a combination of biomarkers • • • • cRP Fibrinogen IL6, IL18 TNF – • Troponin • Cystatin C CRP? CCRE Therapeutics Improvements in risk prediction (c-statistic) ? Traditional Model Rotterdam 0.746 Framingham 0.78 WHI 0.81 + CRP 0.748 0.78 0.82 Wilkins Lloyd-Jones, Preventive Cardiology 2010 Can we better? CCRE Therapeutics • Majority of studies claimed to improve prediction • Many were flawed in designed, analysis and reporting • Casts doubt on claims of improving prediction Genetic Markers? CCRE Therapeutics Genetic Markers? CCRE Therapeutics • No association with CVD events • Family history probably as good? What to focus on? CCRE Therapeutics Risk factor PAR adjusted for age, sex, and smoking (99% CI) 54.1 (49.6-58.6) PAR adjusted for all (99% CI) 36.4 (33.9-39.0) 35.7 (32.5-39.1) Diabetes 12.3 (11.2-13.5) 9.9 (8.5-11.5) Hypertension Abdominal obesity 23.4 (21.7-25.1) 33.7 (30.2-37.4) 17.9 (15.7-20.4) 20.1 (15.3-26.0) Psychosocial Vegetable and fruits daily Exercise Alcohol intake All combined 28.8 (22.6-35.8) 12.9 (10.0-16.6) 32.5 (25.1-40.8) 13.7 (9.9-18.6) 25.5 (20.1-31.8) 13.9 (9.3-20.2) 90.4 (88.1-92.4) 12.2 (5.5-25.1) 6.7 (2.0-20.2) 90.4 (88.1-92.4) ApoB/ApoA-1 (fifth quintile compared with first) Current smoking 49.2 (43.8-54.5) Yusuf, 2004, Lancet What to focus on? CCRE Therapeutics 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 Developing high mortality Developing lower mortality Developed 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) Summary CCRE Therapeutics • 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 Summary CCRE Therapeutics 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 ... year risks Over 1900 articles on FRS in the last 10 years! • Recalibration • Populations specific risk assessment tools Variety of risk scores now available CCRE Therapeutics Variety of risk. .. Therapeutics • >50% of events occur in those with non-elevated traditional risk factors (?) • Inclusion of new risk markers in risk models • CRP • Other biomarkers – eg BNP • Genetic markers • Imaging... approaches to risk assessment CCRE Therapeutics • Framingham Study • Original cohort ~ 5000 • Long follow-up >30 years • Additional subjects / off-spring added along the way • Additional risk factors