Maladies coronaires : Évaluation du Risque Cardiovasculaire Résiduel

Evaluation of Global Residual Cardiovascular Risk in Secondary Prevention

• Presenter: Pr Gilles Lemesle
• Affiliation: USIC et Centre Hémodynamique, CHRU de Lille, Institut Pasteur de Lille, UMR 1011, Faculté de Médecine de l'Université de Lille.
• Disclosures: Honoraria and fees from Amgen, Astra Zeneca, Bayer, Bristol Myers Squibb, Boehringer Ingelheim, Daiichi Sankyo, Lilly, MSD, Novartis, Pfizer, Sanofi Aventis, Servier, and the medicine company.

Why Evaluate Residual Cardiovascular Risk?

• Close follow-up of high-risk patients.
• Optimize treatment, especially antithrombotics and LDL-lowering drugs.

To Evaluate the Risk...

• Evaluate risk of myocardial infarction (MI) or need for revascularization, associated with complications of previous revascularization procedures (e.g., stent placement), underlying atherosclerotic disease, and new plaque rupture.
• Evaluate risk of complications from atherosclerosis progression in other arterial territories.
• Evaluate risk of progression to heart failure.

Concept of Stable CAD and Residual Risk

• Stable CAD is characterized by a linear curve of risk over time.
• However, the slope of the curve may still be high, representing residual risk.

Stent, Atherosclerotic Disease, or Both?

• Data from the CORONOR Registry shows that both the stent and underlying atherosclerotic disease contribute to risk.

Factors Associated with Disease Progression

• The presentation identifies factors associated with disease progression but doesn't list them.

The Residual Ischemic Risk

• Risk of the composite events (e.g., cardiovascular (CV) death, MI, stroke)
• Factors like current smoker, LDL-cholesterol levels, prior coronary bypass, multi-vessel CAD, diabetes mellitus, and persistent angina at baseline are predictors of risk.

History of Non-Coronary Vascular Intervention

• A history of non-coronary interventions is a predictor of increased all-cause mortality, cardiovascular mortality, and non-cardiovascular mortality.

The Residual Ischemic Risk - REACH Registry

• Evaluation of CV death/MI/stroke risk in patients with known cardiovascular disease.
• Factors like age, gender, BMI, hypertension, diabetes, renal impairment, vascular disease, congestive heart failure, atrial fibrillation, statins use, etc, affect risk.

Multivessel CAD and Impact on Prognosis

• Impact of multivessel CAD on prognosis within REACH Registry
• Obstructive CAD (3-vessel, 2-vessel, 1-vessel) and non-obstructive CAD (3-vessel, 2-vessel, 1-vessel) are evaluated.
• No apparent CAD group is also studied.

Evaluation of Coronary Anatomy - SYNTAX Score

• Categorizes different coronary lesions for evaluation.
• This includes diameter reductions, total occlusion, age, blunt stump, bridging, major side branch, bifurcations, angulation, aorto ostial stenosis, heavy calcification and thrombus.

Evaluation of Coronary Anatomy - Calcium Score on CT

• Univariate and multivariate analyses of variables like gender, age, coronary risk factors, calcium score and their impact on severe cardiac events.
• The presentation shows a survival analysis for patients with calcium score ≥ 400.

The CLARIFY Risk Model for CV death and MI

• 12 variables are associated with the risk of cardiovascular (CV) death and myocardial infarction.
• Variables include age, diabetes, smoking, current angina, atrial fibrillation, myocardial infarction, peripheral arterial disease, prior PCI/CABG, prior stroke, hospitalization for CHF, eGFR and LVEF

Incidence of Composite Criteria

• Incidence of combined cardiovascular mortality and myocardial infarction (MI), stratified by quintile
• The graph shows the cumulative incidence of patients with these events over time, with higher risk scores being associated to a higher incidence at all time points.

Le score TRS 2°P [TIMI Risk Score for Secondary Prevention]

• Risk stratification tool for patients with known atherosclerotic vascular disease.
• Indicates 3.5% risk for CV death, MI or Ischemic stroke.
• Risk factors used include age, history of diabetes, prior stroke, prior CABG, PAD, prior eGFR, and current smoking.

To Evaluate Coronary Anatomy - Plaque Vulnerability and Endovascular Imaging

• Independent predictors identified regarding lesion level events using Cox Proportional Hazards
• Variables included are Plaque Burden, Vessel Health, and Stenosis Type.

To Evaluate Stent Thrombosis Risk - Multifactorial Approach

• Identify risk factors for stent thrombosis.
• Variables including patient factors (e.g., diabetes, renal failure, low ejection fraction, antiplatelet therapy discontinuation), lesion characteristics (e.g., lesion length, diameter, pre-/post-procedural stenosis), and procedure details (e.g., stent type, stent placement) are assessed.

Stent Thrombosis Risk - High Frequency and Powerful Predictors

• High-frequency predictors for stent thrombosis include:
• ATD < 30 days
• Extent of CAD
• Stent length & number
• Acute coronary syndrome (ACS), including ST-elevation myocardial infarction (STEMI).
• Diabetes
• Smoking status
• Bifurcation lesions.
• Other more powerful predictors are listed as well.

Conclusion

• Perfect control of cardiovascular risk factors is ideal.
• Aggressive multivessel CAD and peripheral disease treatment requires aggressive antithrombotic and LDL-lowering strategies.