Putting It All Together:

1
Putting It All Together How to Run a Modern
CV Primary Prevention Program
John A. Rumberger, PhD, MD, FACC Director of
Cardiac Imaging Princeton Longevity
Center Princeton, New Jersey
SHAPE Symposium ACC 3/29/08
2
Modern CV Prevention Program
Sir William Osler (circa 1900) emphasized the
power of physical examination for disease by
following a specific algorithmic approach to
diagnosis -
This has remained for the most part, the basis of
most current CV disease assessments Of course
over the years we have added blood testing,
imaging, stress testing, etc. BUT the goals
are the same to find manifest DISEASE

• Inspection
• Palpation
• Percussion
• Auscultation
• Contemplation

3
Modern CV Prevention Program
The current prevention program for the busy
physician goes something like this Fred, your
cholesterol is a bit higher than I would like and
your blood pressure is creeping up from the prior
exams. I am going to start you on cholesterol
medication and a blood pressure pill. My nurse
will have the prescriptions for you when you
check out. We might think about getting a stress
test, just to be sure you dont have any heart
disease and also, you need to lose some weight,
get a better diet, and step up your
exercise. Have a nice day!
4
Percent of Patients Maintaining Statin Rx
Percent of Patients Remaining on Rx
n 37,000 patients
Months Following Initial Prescription of Statin
5
Modern CV Prevention Program
80 (or more) of the chronic diseases that
kill individuals in industrialized nations
are preventable (or at least delay-able) by a
diagnosis in the earliest and most modifiable
stages.
But to be truly effective, early diagnosis is
of limited value unless accompanied and coupled
with a valid and specified action plan
including focused follow up within the warranty
period so that suitable adjustments in the plan
can be made
6
Modern CV Prevention Program
Thus the algorithmic approach for CVD
prevention requires some modifications/additions
to the traditional diagnosis method requires a
thematic or team program which includes the
following

• Anatomic site and severity of pre-clinical
  markers
• Functional capacity sub-clinical
  manifestations
• Inflamm. markers and modifiable blood
  chemistries
• Focused education and instruction
• Contemplation/Assimilation/Integration of data
• An executable (and realistic) Action Plan

7
Modern CV Prevention Program
Exercise Physiologists
Integrated team approach
Schedulers
Physicians
Psychological Counseling?
Dieticians
8
Modern CV Prevention Program
Step I
A physical examination and a thorough/ comprehensi
ve social and family history -
Historical Risk Factors order of importance 1
CVD in brother or sister 2 CVD in mother or
father 3 CVD in grandpa/uncles and
grandma/aunts 4 Lifestyle (smoking/diet/exercis
e/alcohol)
9
Modern CV Prevention Program
Step II
Assessment of baseline CV anatomy site/severity
of pre-clinical markers (i.e. Imaging)
Central Peripheral
Cerebro- Vascular

• Non-contrast CT
• CAC (HeartScan)
• central/abdominal aorta
• Visceral Adiposity (VAF)
• Contrast CT (optional)
• MRI (in place of CT of aorta)
• Carotid U/S (optional vs.
• optimal)

Cardiac
VAF Inflammation
10
CAC vs. FRS (USA) vs. Procam (Germany) In
Patients with Subsequent MI or Cardiac Death
After the fact what was there original risk?
83
1726 initially asymptomatic patients referred
to cardiology, ALL had normal TMET and normal echo
Becker et al, AHJ 2008155154-60 40 7 m f/u
58
54
Myocardial Infarction or CD ()
36
34
15
10
8
2
lt25th, gt25thlt75th, lt75th
11
Non-Invasive Clinical ImagingSurrogates to
Cardiac Risk Assessment
We are all familiar with a variety of methods,
other than conventional risk factors that have
been used for surrogates to defining
cardiovascular risk some include the following

• Carotid ultrasound and IMT
• MRI of the aorta and carotids
• ABI
• Stress testing
• Vascular calcification by CT

12
Twenty-Two Year f/u in Middle Aged Men and
Women As A Function of Aortic Calcification on
X-Ray
Wilson et al, Circ 20011031529-1534
n 1049
CVD
CVD Mortality
n 1466
Independent of conventional risk factors
13
Whole Vascular Screening Using CT
Coronary Artery Scoring
Aorta and Major Branches Scoring
14
Whole Vascular Screening Using CT
15
CASE 44 year old male with family history of CAD
in father (age 58), On Atorvastatin HDL 57 LDL
69 TG 165 TC 158 non-HDL 101
HTN (beta-blocker) thinking of stopping
Atorvastatin FRS 0 (lt1/yr)
Conclude high risk Recommendations Stay on
statin at current dose Monitor HTN Omega-3
FA Begin aspirin each day f/u scanning in 1-2
years
16
CASE 45 year old woman non smoker HTN treated
(now normal) MI in grandfather (age 45)
parents fine TC 256, HDL 58, LDL 171 non HDL
198 FRS 11 points (1/year low risk)
Conclusion moderately high risk Recommendations
Statin non HDL goal lt130 Aspirin Mediterranean
Diet Weight loss f/u 1-2 years
17
Visceral Abdominal Fat(full vascular scanning)

• A standardized analysis of visceral fat
• A measure of inflammation and FFA content
• A factor in the Metabolic Syndrome
• Common in patients with low HDL
• Common in patients with high TG
• Common in patients with hypertension
• Common in patients with insulin resistance
• Treated with low carbohydrate/low saturated fat
  diet
• Suggests anti-inflammatory therapy with fibrates
• insulin sensitizers (PPAR a and ?)

18
Visceral Abdominal Fat
19
CASE 44 y/o man FH of MI in parent (age 65) TC
238 HDL 53 LDL 135 TG 246 non HDL 185
fasting blood sugar 118 (no diabetes in family)
20
CASE 44 y/o man FH of MI in parent (age 65) TC
238 HDL 53 LDL 135 TG 246 non HDL 185
fasting blood sugar 118 (no diabetes in family)
Conclusions Very low CAC score low current
risk Insulin resistance and Metabolic Syndrome
increases to mod risk Recommendations South
Beach Diet/Mediterranean Diet Aspirin
daily Omega-3 FA Weight loss Re check lipids in
2-3 months if TG still elevated consider
fibrate (PPAR a agonist) and/or low dose
statin Re check FBS in 2-3 months if still gt100
mg/dl Consider insulin sensitizer (PPAR ?
agonist)
21
Modern CV Prevention Program
CTA Heart and Vascular optional vs.
optimal (prospective gating and reduced kV can
get radiation down to reasonable levels even
for combined protocols)
all images courtesy of Dr. Allessandro
Napoli, Rome, Italy
22
Modern CV Prevention Program
Step III
Functional capacity - gross and
micro-vascular
Formal Exercise Testing
Fitness Assessment
Endothelial Testing
Gross Physical Conditioning Focused Counseling
Micro vascular Function (optional vs. optimal)
23
Modern CV Prevention Program
Step IV
Serum Markers and Modifiable Blood Chemistries
Lipid Parameters
Inflammatory Markers
Broad-based Lipid Parameters With Advanced Lipid
Testing
Cytokines, CRP, etc., Erythrocyte Inflamm.
Markers
24
Modern CV Prevention Program
Step V
Focused Education and Instruction
Dietician
Exercise Physiologist
Lean sources of protein, low saturated fat,
lowered carb modified for insulin resistance
Fitness Counseling/Goals Exercise Prescription
25
Modern CV Prevention Program
Step VI
Contemplation Interpretation of Data and
Assimilation of Educational Material
Physician Contemplation
Inputs of Imaging Data, Team Consultations,
and Physical/Blood Measurements
26
Modern CV Prevention Program
Old Chinese Proverb Tell them and they will
see Show them and they will know Involve them
and they will understand
27
Modern CV Prevention Program
Reductions in Incidence of Heart Attacks/Strokes
cholesterol reduction by statins
30 Mediterranean (anti-inflammatory) diet up
to 50 a regular exercise program up to
40 education and involvement of the patient
priceless!
28
Modern CV Prevention Program
Step VII
Presentation to Individual on Executable/Realistic
Action Plan
Physician/ Patient Debrief

• Present each individual test and
• its implications
• Provide an individual summary of
• findings supplemental educational
• material
• Set up a specific and integrated
• action/treatment plans as well as
• time lines for goals and follow up

One on one presentation discussion
29
(No Transcript)
30
Patient Adherence With Statin Therapy After
Seeing Their CT Calcium Scans
Budoff et al, Circ 2004
3.6 yr f/u in 1,215 patients
Patients Remaining on Statin Therapy ()
Similar trends as a function of CAC score were
seen in adherence to dietary advice and
smoking cessation
Baseline Coronary Calcium Score