SHAPE Society

1. APPROACH TO IDENTIFYING AND
MANAGING CORONARY RISK
Eugene Braunwald, M.D.
March 6, 2004

2. • Prevention of acute events must
be the primary goal. Treatment
should be regarded as “locking the
barn door after the horse is stolen”

3. • One third of cases of sudden death and acute
MI occur in previously asymptomatic persons
- - previously regarded as “acts of God”
• Most of these are now known to have pre-
clinical disease, classical or novel risk factors
• Need to identify high risk asymptomatic
persons prospectively to provide intensive
prevention

4. • All patients with clinically apparent
atherosclerotic disease require
intensive global risk factor reduction
• Some have unstable placques
(“accidents about to happen”) and these
must be identified

5. <0.5%/yr
0.5-2%/yr
2-15%/yr
>15%/yr Very High Risk
High Risk
Intermediate Risk
Low Risk

6. Low riskLow risk Lifestyle &Lifestyle &
0.5%/yr0.5%/yr Follow-upFollow-up
(40%)(40%)
Framingham Risk ScoreFramingham Risk Score IntermediateIntermediate AdditionalAdditional
CRP, Cholest., GlucoseCRP, Cholest., Glucose 0.5-2%/yr0.5-2%/yr TestingTesting
(50%)(50%)
High riskHigh risk IntensiveIntensive
> 2%/yr> 2%/yr global riskglobal risk ↓
(10%)(10%)

7. Low riskLow risk Risk factorRisk factor
ABIABI
EBCTEBCT
IMTIMT
High riskHigh risk Intensive global + non-invasiveIntensive global + non-invasive
riskrisk detection ofdetection of
unstableunstable
placque(s)placque(s)

8. Non-invasiveNon-invasive
Detection +Detection + novel anti-novel anti-
++ inflammatoriesinflammatories
25%/yr25%/yr anti-thrombotic Rx;anti-thrombotic Rx;
Very high risk Invasive detectionVery high risk Invasive detection CABG, multiCABG, multi
15%/yr15%/yr of unstableof unstable DESDES
2%2% placquesplacques
--
10%/yr10%/yr continue intensivecontinue intensive
risk factorrisk factor ↓