Dr. Ehrlich's Lecture: Early Detection and Aggressive Prevention of Coronary
Disease
Within the last decade, large lipid intervention trials have convincingly
demonstrated the value of aggressive risk factor modification in reducing
clinical events among a broad range of patients (most recently including those
with relatively “normal” cholesterol in a primary setting). It is now an
undeniable fact that atherosclerosis is a highly prevalent disease whose
progression can be halted and whose potential clinical consequences largely
prevented in a suitably cost-effective way. Guidelines have been established
based upon considerable epidemiologic evidence to help in the identification and
management of patient groups at excess risk for premature symptomatic disease.
These recommendations are currently being challenged and re-evaluated in the
context of recent studies involving apparently healthy people. Today, we will
explore whether a more refined approach to the identification and treatment of
individuals is possible and necessary. In order to accomplish this, a few
questions must be addressed and their implications examined:
Why do some
individuals with “normal” cholesterol levels experience heart attacks in their
forties while others avoid acute coronary events with lifelong cholesterol
values greater than 300 mg/dl?
How does our emerging understanding of the nature
of “vulnerable” plaque account for the clear observation that individuals can
and do develop acute coronary syndromes after receiving a negative stress test?
Two important questions arise from these common situations—
Are there better
ways to detect those individuals who are at high risk for an event so that our
advances in therapy can be appropriately directed to them?
Can individuals who
are in fact at low risk be identified in order to spare them the possible
adverse effects and expense of modern therapeutic options?
Introducing a new
diagnostic procedure to a community inevitably leads to various questions about
its incremental value, necessity and role among other modalities that have
earned a more established place. It also affords an opportunity to re-examine
many of our traditionally accepted notions concerning the natural history of
coronary disease and our ability and recommended policies to detect those
individuals in our society who are truly at risk for a devastating coronary
event. Ultimately, a new clinical tool changes the way in which we look at
disease processes by compelling us to revisit long held beliefs and concepts.
The present discussion will explore the diagnostic challenges concerning
individual coronary risk assessment and introduce a rational targeted approach
to cardioprotective therapy. Several aspects of our evolving understanding about
atherosclerosis, the “vulnerable plaque”, emerging risk factors and “newer
paradigms” in preventive cardiology will be scrutinized. Prevalent fallacies
about modern diagnostic techniques and accurate risk assessment will be
challenged in the light of current studies. Coronary calcification and its
significance will be introduced and the technical aspects of its quantification
by Electron Beam (ultrafast) Tomography will be detailed.
Objectives:
Review our
current understanding of coronary risk assessment and proposed modifications in
national cholesterol guidelines
Understand the value of identifying individuals
with subclinical atherosclerosis (non-critical stenosis) so as to apply an
aggressive clinical approach to their preventive management
Explore the
contemporary role and limitations of an advanced imaging technology (EBT) for
risk stratification and diagnosis in asymptomatic and symptomatic individuals
