Braunwald
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Transcript of Braunwald
APPROACH TO IDENTIFYING AND APPROACH TO IDENTIFYING AND MANAGING CORONARY RISKMANAGING CORONARY RISK
Eugene Braunwald, M.D.Eugene Braunwald, M.D.March 6, 2004March 6, 2004
• Prevention of acute events must be the primary goal. Treatment should be regarded as “locking the barn door after the horse is stolen”
• 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
• 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
<0.5%/yr
0.5-2%/yr
2-15%/yr
>15%/yr Very High Risk
High Risk
Intermediate Risk
Low Risk
Low riskLow risk Lifestyle & Lifestyle & 0.5%/yr0.5%/yr Follow-Follow-
upup
(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 risk global risk (10%)(10%)
Low riskLow risk Risk factor Risk factor ABIABIEBCTEBCTIMTIMT
High riskHigh risk Intensive global + non-invasiveIntensive global + non-invasiveriskrisk detection ofdetection ofunstable unstable placque(s)placque(s)
Non-invasiveNon-invasive
Detection +Detection + novel anti-novel anti- ++ inflammatoriesinflammatories25%/yr25%/yr anti-thrombotic Rx;anti-thrombotic Rx;
Very high risk Invasive detection Very high risk Invasive detection CABG, multiCABG, multi15%/yr15%/yr of unstable of unstable DESDES2%2% placques placques
--
10%/yr10%/yr continue intensive continue intensive risk factorrisk factor