Archive for September, 2006
September 28th, 2006 11:39:13
CME Article: From Vulnerable Plaque to Vulnerable Patient - Part III
Journal CME Article
Title: From vulnerable plaque to vulnerable patient–Part III: Executive summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force report.
Authors: Naghavi M, Falk E, Hecht HS et al.
Reference: Am J Cardiol. 2006 Jul 17;98(2A):2H-15H. Epub 2006 Jun 12.
Summary:
- Background: This article is an executive summary of the “Screening for Heart Attack Prevention and Education” (the SHAPE) Task Force. SHAPE is looking at screening for cardiovascular disease in a manner similar to that currently being performed for early-stage, asymptomatic cancers.Although cardiovascular disease is the #1 killer worldwide, there are currently no established guildelines for the direct screening for atherosclerosis. The routine checking of a person’s blood pressure and cholesterol level is common, however, screening directly for atherosclerosis is uncommon. Furthermore, in the United States, there is no government or healthcare-sponsored reimbursement for atherosclerosis screening.These guidelines put forth by the SHAPE taskforce attempt to clarify the value of noninvasive screening tests for atherosclerosis. Based on the results of the noninvasive screening test, medical treatment would be customized.
- Commonly Available Noninvasive Screening Tests for Atherosclerosis:
- Ultrasonography - can be used to measure carotid intimal media thickness and plaque; also can be used to measure brachial vasoreactivity
- MRI - used to measure aortic and carotid plaque
- CT - used to measure the coronary calcium score
- Tonometry - used to measure vascular compliance (radial tonometry) and microvascular reactivity (fingertip tonometry).
- Sphygmomanometry - measurement of the ankle-brachial indexNote: these tests are direct measurements of atherosclerosis, and differ from the commonly performed tests that look for risk factors, e.g. family history, cholesterol levels, smoking status, daily activity levels, etc.
- SHAPE Recommended Population Categories:
- Nearly all men 45 to 75 years old should undergo a noninvasive screening test for atherosclerosis.
- Nearly all women 55 to 75 years old should undergo a noninvasive screening test for atherosclerosis.
- Those at a “Very Low Risk” do not need screening. People in this category must not have any of the following:
- total cholesterol level of >= 200 mg/dL (5.18 mmol/L)
- blood pressure > 120/80 mm Hg
- diabetes mellitus
- smoking
- positive family history
- metabolic syndrome
- SHAPE Treatment Recommendations: after undergoing a noninvasive screening test, patients are stratified into tertiles: lower risk, moderate risk, moderately high risk, high risk, and very high risk.
- Lower Risk: LDL target is < 160 mg/dL; retest in 5 to 10 years
- Moderate Risk: LDL target of < 130 mg/dL; retest in 5 to 10 years
- Moderately High Risk: LDL target of < 130 mg/dL; retesting individualized. Optionally, have an LDL target of < 100 mg/dL.
- High Risk: LDL target of < 100 mg/dL; retesting individualized. Optionally, have an LDL target of < 70 mg/dL.
- Very High Risk:
- Target LDL of < 70 mg/dL
- Retesting individualized
- Undergo testing for myocardial ischemia (e.g. nuclear stress test)
Reviewer’s Comments:
The SHAPE authors use CT coronary calcium scoring and the ultrasound measurement of carotid intimal media thickness & plaque as their primary examples of noninvasive screening tests for atherosclerosis. However, they also mention the other tests, some of which may prove useful in screening programs. In particular, measurement of the ankle-brachial index is simple and readily available in primary care settings. It does not involve any radiation, and furthermore, does not require specially trained technicians to administer the test. (- Thomas F. Heston, MD, FAAFP, FASNC)
View the entire report: Shape Guidelines - Executive Summary
Earn Category I CME credits: CLICK HERE (up to 1.0 hours available)
Links:
The Association for the Eradication of Heart Attacks
Editorial (Academic Radiology 2006)
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