Front Page
Dr. Valentin Fuster's Editorial Note
THE SHAPE Introduction Letter
Executive Summary of the SHAPE Task Force Report
Financial Disclosure of the SHAPE Task Force The Screening for Heart Attack Prevention and Education Task Force -An International and Diverse Group of Pioneering Cardiologists Find Common Ground in Push for New Heart Attack Screening Paradigm | A group representing some of the top minds in cardiology from around the world is encouraging colleagues to rethink the standard approach to heart attack prevention. The group, brought together by the Association for Eradication of Heart Attack (AEHA) to develop the SHAPE (Screening for Heart Attack Prevention and Education) agreed that reliance solely upon traditional risk factors as a method of identifying patients in need of intervention is outdated and has proven to be unsuccessful. | | Instead, they agreed to encourage the adoption of a new approach to heart attack screening. The new approach would rely upon traditional risk factors to identify potential at-risk individuals only until age 45 in men and 55 in women. After that age, the group recommends everyone undergo a comprehensive vascular health assessment. | | Modeled after successful screening efforts in the cancer care arena, the group suggests assessing the structure and function of the patient's arteries in order to identify those who are susceptible to vulnerable plaque. "This is a new approach, a new way to look at how we can assess heart attack risk in individual patients," said Dr. Erling Falk of the Department of Clinical Research with Aarhus University in Denmark. "For some time, we have known that relying on traditional risk factors to identify at risk individuals is flawed and now science is guiding us toward a solution." | | While the group did not recommend a specific method of assessing the structure and function of the arterial vessel, it did point to two options that are being used without the benefit of accepted guidelines today. These include electron beam computed tomography (EBCT), which is used to determine coronary calcium, and evaluation of the carotid intima-media thickness (CIMT), which quantifies an individual's current atherosclerotic burden. Both EBCT and CIMT are non-invasive. "The science is telling us that we should do all we can to assess plaque buildup in the walls of the arteries because the body's reaction to these plaques cause ruptures that can lead to a heart attack," said Dr. John Rumberger of the Mayo Graduate School of Medicine. "After 20 years of refining electron beam CT, we are now at a point where the procedure can be incredibly valuable for everyone. |  | | In addition to helping identify those at high risk of heart attack, the group agreed that an assessment of vascular structure and function could ensure those not susceptible to coronary disease avoid unnecessary treatment. | | Today, physicians intervene and treat patients based on traditional risk factors that assess their statistical likelihood of suffering a heart attack. As a result, a sizeable number of people who would appear on the surface to be at risk - perhaps overweight, diabetic or sedentary - receive treatment even though their vascular structure and function has not been assessed "The powerful message is that the absence of a marker of disease in the vessel wall puts an individual in an extremely low risk category in which the annual event rate is 0.1 or 0.2 percent, said Dr. P.K Shah of Cedars-Sinai Medical Center."It is unfortunate that we are unnecessarily prescribing medications for a portion of the population simply because we don't know enough about their individual risk and have to rely on statistical probability instead." | | On the flip side, many people who otherwise appear to be the picture of health are highly susceptible to vulnerable plaque. Without an assessment of their vascular structure and function, these individuals typically would not receive treatment. With an assessment of their vascular structure and function, physicians will have the patient-specific information needed to intervene and treat the patient as necessary. As described in Illustration A, the group determined that traditional risk factors can be central elements in helping physicians determine a course of action to stop or slow the progression of the disease. | | "Instead of using traditional risk factors to assess risk among men age 45 and older and women age 55 and old, we suggest using risk factors as a means through which we reduce risk," said Dr. Daniel Berman of Cedars-Sinai Medical Center. "Once we identify a vulnerable patient based on an assessment of their vascular structure and function, we can look at the patient's risk factors to know what to treat maximally." |  | | The advisory meeting participants agreed that traditional risk factors should continue to play a central role in assessing risk among men under age 45 and women under age 55. They recommend that younger men and women with multiple risk factors and thereby identified as being at high risk of heart disease should undergo a vascular structure and function assessment to check the status of the vessel wall. | | Dr. Jay Cohn of the University of Minnesota Medical School encouraged his colleagues to keep an open mind in terms of assessing vascular structure and function earlier. "Those of us who believe in earlier intervention expect that we can prevent 80 percent to 90 percent of heart attacks," said Cohn. "As simple and inexpensive methods emerge that allow us to assess a patient's vulnerability earlier, yet with the necessary sensitivity and specificity, we should be ready to rapidly adopt them." | | The group encourages repeating vascular structure and function screening every two to three years for those found through previous screening to be at high risk and every three to five years for those found to be at low risk. As is the case with cancer screening, coronary heart disease develops over time, so repeated screenings give us important information about a patient's trajectory toward a possible event," said Dr. Morteza Naghavi, president and founder of AEHA. "We want to make heart attack screening a routine part of getting older, just like having a mammogram or colonoscopy." |  | | Currently, patients fund procedures such as EBCT and CIMT out-of-pocket. Typical costs are $300 to $450, which makes it unaffordable to the vast majority of Americans. Pushing aggressively for reimbursement from private payors and Medicare will be an important next step toward getting heart attack screening procedures widely adopted. | | "Coronary heart disease will kill half of the population," said Dr. Falk. "If screening for breast cancer and colon cancer are covered, I don't know how you could justify failing to cover screening that would reveal a patient's vascular structure and function." |
Download the SHAPE Executive Summary |
