Atherosclerosis

Very Low Risk

Negative

Lower Risk Moderate Risk

Positive

ModeratelyHigh Risk High Risk

VeryHigh Risk

No Risk Factors + Risk Factors + ++ +++

MyocardialIschemia

No Yes

Step 1Test for subclinical atherosclerosis

Step 2Categorize based on• severity of atherosclerosis• presence of risk factors

Step 3Treat risk factors & the disease

Optional: Additional Risk Stratification Based on Emerging Risk Factors, Biomarkers, and Functional Tests

Apparently Healthy Population, M>45y & F>55y

The 1st National SHAPE Guideline

• Coronary Calcium Score. Ultrasound Mean Carotid IMT+Optional: MRI Carotid IMT+

• Coronary Calcium Score. Ultrasound Mean Carotid IMT+Optional: MRI Carotid IMT+

(-) Test(-) Test (+) Test(+) Test

•LifestyleModifications

•RF Reduction •EHAC Education•Reassess in 5 years

•LifestyleModifications

•RF Reduction •EHAC Education•Reassess in 5 years

•Aggressive Lifestyle Modifications•Target LDL <100mg/dl

•Intensive EHAC Education •Reassess in5 years

•Aggressive Lifestyle Modifications•Target LDL <100mg/dl

•Intensive EHAC Education •Reassess in5 years

•No Treatment unless Pre-hypertensive•EHAC Education

•Reassess in 5 years

•No Treatment unless Pre-hypertensive•EHAC Education

•Reassess in 5 years

•Aggressive Lifestyle Modifications•Target LDL<130 mg/dl•Intensive EHAC Education•Reassess in 5 years

•Aggressive Lifestyle Modifications•Target LDL<130 mg/dl•Intensive EHAC Education•Reassess in 5 years

All Asymptomatic Males ≥45y and Females ≥55y with no History of CVDAll Asymptomatic Males ≥45y and Females ≥55y with no History of CVD

CCS >400 or CCS ≥ 100 & >90th%

CCS >400 or CCS ≥ 100 & >90th%

(–)(–) (+)(+) Very High Risk

Very High Risk

•Target LDL<70 mg/dl•Intensive EHACEducation•Follow Existing Guidelines

•Target LDL<70 mg/dl•Intensive EHACEducation•Follow Existing Guidelines + Pending standard practice guidelines.+ Pending standard practice guidelines.

- RF- RF +RF+RFCCS <75th% & <100CIMT <75th% & <1mm and No Plaque

CCS <75th% & <100CIMT <75th% & <1mm and No Plaque

CCS >75th % or >100CIMT>75th% or >1mm or

Plaque<50% stenoticLVH - Diabetes

CCS >75th % or >100CIMT>75th% or >1mm or

Plaque<50% stenoticLVH - Diabetes

CRP>4mg/lCRP>4mg/l

EHAC: Early Heart Attack CareEHAC: Early Heart Attack Care

(Screening for Heart Attack Prevention and Education -SHAPE)(Screening for Heart Attack Prevention and Education -SHAPE)

•Target LDL<70 mg/dl•Rest Follows High RiskGroup

•Target LDL<70 mg/dl•Rest Follows High RiskGroup

CRP: C Reactive ProteinCRP: C Reactive ProteinCIMT: Carotid Intima-Media ThicknessCIMT: Carotid Intima-Media ThicknessCCS: Coronary Calcium ScoreCCS: Coronary Calcium Score

*Exclude Very-Low-Risk Group*Exclude Very-Low-Risk Group

•Known cases of Chol<200 mg/dl + blood pressure ≤120/80 mmHg + no diabetes + no smoking + no family history + no metabolic syndrome.•Known cases of Chol<200 mg/dl + blood pressure ≤120/80 mmHg + no diabetes + no smoking + no family history + no metabolic syndrome.

Moderately High Risk

Moderately High Risk Myocardial

Ischemia TestMyocardial

Ischemia Test

Test for AtherosclerosisTest for Atherosclerosis

RF: Established risk factors (high cholesterol, high blood pressure, diabetes, smoking, family history, metabolic synd.) RF: Established risk factors (high cholesterol, high blood pressure, diabetes, smoking, family history, metabolic synd.)

CVD: angina, heart attack, stroke, peripheral arterial diseaseCVD: angina, heart attack, stroke, peripheral arterial disease

High RiskHigh Risk

Lower RiskLower Risk Moderate RiskModerate Risk

CCS>0CIMT >50th percentileCCS>0CIMT >50th percentile

CCS=0CIMT <50thPercentile

CCS=0CIMT <50thPercentile

ABI<0.9ABI<0.9

>50% Stenotic Plaque++>50% Stenotic Plaque++

++ For stroke prevention, follow existing guidelines.++ For stroke prevention, follow existing guidelines.

AngiographyAngiography

OptionalOptional

Optional: ABI<0.6Optional: ABI<0.6