Recent exchanges in cardiology media about vulnerable plaque indicate that some pundits may need to be reminded about their past remarks, and that the field of cardiology urgently needs to move from “Vulnerable Plaque” to “Vulnerable Patient”. Since the SHAPE movement roots in the early days of “Vulnerable Plaque” era, on behalf of the SHAPE Task Force, I would like to bring the following to your attention.
First, please take a moment and turn your clock back 12 years and 8 months to see this just published Circulation article:
From Vulnerable Plaque to Vulnerable Patient: A Call for New Definitions and Risk Assessment Strategies: Part I and II
Naghavi M, Libby P, Falk E, Casscells SW, Litovsky S, Rumberger J, Badimon JJ, Stefanadis C, Moreno P, Pasterkamp G, Fayad Z, Stone PH, Waxman S, Raggi P, Madjid M, Zarrabi A, Burke A, Yuan C, Fitzgerald PJ, Siscovick DS, de Korte CL, Aikawa M, Airaksinen KE, Assmann G, Becker CR, Chesebro JH, Farb A, Galis ZS, Jackson C, Jang IK, Koenig W, Lodder RA, March K, Demirovic J, Navab M, Priori SG, Rekhter MD, Bahr R, Grundy SM, Mehran R, Colombo A, Boerwinkle E, Ballantyne C, Insull W Jr, Schwartz RS, Vogel R, Serruys PW, Hansson GK, Faxon DP, Kaul S, Drexler H, Greenland P, Muller JE, Virmani R, Ridker PM, Zipes DP, Shah PK, Willerson JT.
Circulation. 2003 Oct 14;108(15):1772-8.
Then fast forward three years and five SHAPE symposia to see Part III:
From Vulnerable Plaque to Vulnerable Patient—Part III: Executive Summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force Report
Naghavi M, Falk E, Hecht HS, Jamieson MJ, Kaul S, Berman D, Fayad Z, Budoff MJ, Rumberger J, Naqvi TZ, Shaw LJ, Faergeman O, Cohn J, Bahr R, Koenig W, Demirovic J, Arking D, Herrera VL, Badimon J, Goldstein JA, Rudy Y, Airaksinen J, Schwartz RS, Riley WA, Mendes RA, Douglas P, Shah PK; SHAPE Task Force.
Am J Cardiol. 2006 Jul 17;98(2A):2H-15H.
Although these articles have been cited and downloaded over 50,000 times, early detection of the vulnerable patient is yet to be viewed a top priority and adopted by our healthcare policymakers and payers. Of course, we do not yet have an accurate method of identifying the vulnerable patient (asymptomatic high risk individuals who will have an event in the next 12 months). However, out of existing modalities it is now abundantly clear that detection of coronary calcification and carotid or femoral plaque can bring us as close to the detection of the vulnerable patient as we possibly can in today’s clinical medicine. Nonetheless, our payers continue to pay for vulnerable plaque detection (IVUS, OCT, NIRS, etc) to (possibly) prevent a second or third heart attacks (too little too late) but do not pay for vulnerable patient detection to prevent the first heart attack, perhaps because compared to coronary intervention, primary prevention is not “sexy” enough! Despite so much talk about “an ounce of prevention” being better than a pound of cure, it receives pennies versus tens of pounds spent on secondary prevention. And perhaps because our healthcare system is wrongly named healthcare. It does not pay for health care, only for sick care. What a misnomer!
In short, and in a Monday night quarterbacking remark, the answer to your question is yes, the money spent on identifying “the vulnerable plaque” could have given us more return had we broadened our view and spent it on identifying “the vulnerable patient”.
However, we should not disregard the hard work of so many outstanding pathologists, cardiologists and other cardiovascular researchers on whose shoulders we are now standing tall to see the emergence of Machine Learning algorithms for identification of the Vulnerable Patient. This is indeed the subject of a fascinating “Brave Idea” from SHAPE supported by the following investigators submitted to Google-AHA-AstraZeneca’s 1 Team 1 Vision initiative for the eradication of heart attacks:
Juan Badimon (Mount Sinai), Daniel Berman (Cedars-Sinai), Michael Blaha (Johns Hopkins), Mathew Budoff (Habor UCLA), Axel C. P. Diederichsen (Odense University Hospital), Raimund Erbel (University Hospital Essen), Erling Falk (Aarhus University), Sergio Fazio (Oregon University), Harvey Hecht (Mount Sinai), Karl-Heinz Jöckel (University Hospital Essen), Ioannis Kakadiaris (University of Houston), Stanley Kleis (University of Houston), Robert Kloner (HMRI), Harry de Koning (ROBINSCA), Tatiana Kuznetsova (University of Leuven), Daniel Levy (Framingham Heart Study), Jes Lindholt (Odense University), Amir-Abbas Mahabadi (University Hospital Essen), David Maron (Stanford University), Ralph Metcalfe (University of Houston), Susanne Moebus (University Hospital Essen), Martin Mortensen (Aarhus University), Tasneem Z. Naqvi (Mayo Clinic), Khurram Nasir (Baptist Health), Christopher O’Donnell (NIH), Ulla Roggenbuck (University Essen), Paolo Raggi (University of Alberta), James Rudd (University of Cambridge), PK Shah (Cedars-Sinai), Henrik Sillesen (University of Copenhagen), Robert Superko (Institute of Lipids & Genetics), Hiro Tanaka (University of Texas), Herman Taylor (MSM), Nathan Wong (UC Irvine). And Dr. Valentin Fuster who has strongly supported the move from Vulnerable Plaque to Vulnerable Patient.
I will be happy to share with your readers our Brave Idea in details as soon as we hear from the administrators of One Brave Idea.
Thank you for promoting discussions on primary prevention.
Cheers to the eradication of heart attacks!
On behalf of SHAPE
Morteza Naghavi, M.D.