ACC: Early Aggressive Management Urged to Prevent Cardiovascular Risk Migration

NEW ORLEANS, March 30 -- Cardiovascular risk is not static and intermediate risk patients may be on their way toward high risk, although that migration might be avoided or slowed by aggressive management.

The appropriate strategy, according to speakers at an industry symposium on improving risk prediction and care, held in conjunction with the American College of Cardiology meeting here, is to treat intermediate risk patients as if they are already high risk.

And to do that, clinicians need to begin using available imaging and office-based tests to persuade the patients that this level of intervention is necessary.

That was the take-home message from the symposium, "Improving Risk Prediction Precision and Care: From 'Intermediate Risk' to Office-Based Therapeutic Interventions," sponsored by an educational grant from Pfizer.

"Most intermediate-risk patients will become high-risk patients as they age," said David Waters, M.D., a professor of medicine at the University of California San Francisco.

Dr. Waters said that the results of trials such as the West of Scotland Coronary Prevention Study (WOSCOPS), Air Force/Texas Coronary Atherosclerosis Trial (AFCCAPS/TexCAPS) and the Anglo/Scandinavian Cardiac Outcomes Trial (ASCOT) indicate that intermediate risk patients will benefit from statin therapy.

Diabetic patients, especially, should be targeted for aggressive lipid management with statin therapy because this strategy typically provides greater relative risk reduction than later treatment, he said..

Anthony DeFranco, M.D., director of cardiovascular quality and cardiovascular research at Aurora Health Care/St. Luke's Hospital in Milwaukee, concurred, saying, "Clinical data suggest that intermediate risk patients receive substantial benefit form pharmacologic intervention."

He added that risk factor management of patients is something that either the cardiologist or the primary care physician has to do with patients, but neither should wait for the other to initiate it.

The problem that faces all clinicians is how to identify that "high-risk individual who is masquerading as an intermediate risk," Dr DeFranco said.

One thing that clinicians can do to get the conversation in motion, suggested Allen Taylor, M.D., chief of the cardiovascular disease service at Walter Reed Army Medical Center in Washington, is to have patients undergo electron-beam computed-tomography calcium screening to determine their risk of cardiovascular disease on the basis of the calcium score.

"A person's calcium score changes management," Dr. Taylor said. He noted that his studies show that once a patient has determined his calcium score, the patient's use of statin, aspirin or both increase significantly (P=.001).

Another test that can be conducted easily in a doctor's office, the ankle brachial index (ABI), was cited by symposium chair Alan Hirsch, M.D., a professor of epidemiology and community health at the University of Minnesota School of Public Health.

He said the test can be easily and non-invasively performed in the office and has proven to be 95% sensitive and 99% specific for peripheral artery disease. He said that that the cost of identifying one patient with peripheral artery disease using ABI ranged from to .

"Individuals with asymptomatic peripheral artery disease should be identified in order to offer therapeutic interventions known to diminish their increased rate of myocardial infarction, stroke and death," Dr. Hirsch said.