The screening procedures currently accepted today
are mammography and the PAP (Papanicolau) test for the prevention of cervical
cancer (carcinoma).
However atherosclerotic based cardiovascular
diseases (myocardial infarction and stroke) represent the first cause of
mortality and morbidity in the population of industrialised countries.
The mortality rate for coronary artery disease alone
is greater than that of all the types of cancer added together.
There is a growing interest concerning the
possibility of identifying and treating patients at risk and the atherosclerotic
plaques can increase progress made in fighting against atherosclerotic, coronary
and peripheral vascular diseases.
Innovations in medical therapy (statins, ACE
inhibitors, omega-3 fatty acids and new cardiological intervention therapy
treatments, such as medicated stents, have considerably reduced mortality and
morbidity caused by atherosclerotic coronary-artery diseases..
In spite of this, I am not aware that there exists
a detailed prevention program for atherosclerotic disease in preclinical phase
in Europe and in the USA.
Only in U.K., the Department of Health recognised
the importance of developing better stroke services for Older People, launched
in March 2001.
Following on from this, the U.K. Government has launched, in the
year 2007, a national stroke strategy to modernise service provision and deliver
the newest treatments for stroke. The Government's target which aims to reduce
the death rate from Stroke, CHD and related diseases in people under 75 by at
least 40% by 2010 has already been achieved.
In the USA there are approximately 930,000 deaths
per year caused by atherosclerosis.
In Europe a total of 1,2 million deaths occur
from myocardial infarction.
In Italy there are 360.000 cases of acute coronary
syndrome and 50000 cases of sudden death.
The total number of deaths per year from stroke in
Italy results as 29.500 Males and 42.850 Females.
According to ISTAT figures, in 2002, in Italy
deaths were classified as follows: in first position 237.198 deaths from
cardiovascular diseases and in second position 163.070 from
cancer, respectively equal to 42,3 and 29,1% of total deaths.
In addition, once again according to ISTAT figures, in 2004, cardiovascular
diseases were the primary cause for hospital admission, followed
by neoplastic diseases in third position.
In fact 1.413.082 patients were released with
circulatory system pathologies with an annual consumption of drugs equal
to 48,6% of the total. Patients released diagnosed with cancer
diseases numbered 761.582, with a drug consumption equal to 0,7%
of the tof the total consumption..
Cardiovascular diseases in women deserve particular attention.
Current attention paid to breast cancer in women
tends to draw attention away from the greatest life-threatening danger for
middle aged women which is cardiovascular diseases.
Women
have paid a high price as far as cardiovascular diseases are concerned in
terms of delayed diagnosis, inadequate therapy when compared to the male
population, such as failure to administer thrombolytic drugs for example.
According to certain studies this has led to higher mortality and morbidity
levels in women suffering from acute myocardial infarction.
The reasons that have focussed major attention on men, is the fact that they
generally begin to suffer at a younger age, around 50 years of age, while women
tend to be affected 10 or 20 years later.
At 60 years of age, a woman has the same probabilities of contracting a
cardiovascular disease as a 50 year old man.
In the USA 1 out of 5 women suffer from some form of cardiovascular
disease or predisposing risk factors.
At 65, 1 out of 3 women will possibly develop a cardiovascular disease.
- One third of all deaths of American women every year are attributed to
heart disease.
-
Heart disease kills more women every year, compared to all the various forms of
cancer, accidents, and diabetes combined together.
- All the forms of cardiovascular disease are responsible for the death of
480.000 women and 450.000 men every year.
- Strokes account for 97.000 deaths in women every year.
- Myocardial infarction is responsible for 244.000 deaths among women
every year.
Approximately 6.3 million American women have a clinical history of myocardial
infarction, angina or both.
In Italy,
according to ISTAT figures collected in 2002, for the age group between 55 and
75 years of age, cardiovascular diseases are responsible for the death of
approximately 29.616 men and 15.560 women, equal to 30,7 and 28,3%. Over the age
of 75, cardiovascular mortality in women increases considerably: 114.000 cases
compared to 70.800 men, equal to 53.8 and 45, 6%, respectively.
Fortunately, the medical profession is focussing far closer atten**tion on risks
of coronary artery disease in women, so that they are less inclined to attribute
chest pains to anxiety or non-cardiac problems.
For their part, women should be far better informed concerning the risks of
cardiovascular diseases and should not limit health check-ups simply to an
annual gynaecologist’s visit.
Inoltre, dopo la terapia efficace tramite
angioplastica coronarica di una lesione iniziale (PTCA) il rischio di eventi
coronarici dovuto a nuove lesioni è 10% nell'anno seguente e 5% anno per i
successivi 4 anni.
Moreover, following efficacious therapy on an
initial lesion (PTCA) with coronary angioplasty procedure, the risk of a
coronary event caused by new lesions result as 10% the following year and only
5% for the following 4 years after that.
Current attention paid to breast cancer in women
tends to discount the greatest life-threatening danger for middle aged women
which is cardiovascular diseases.
Ideal screening should be non-invasive, low cost,
easily and widely available and cost-efficient.
It should be highly specific and show results
that are statistically better compared to control group results, respecting
health cost criteria based on cost-efficient concepts.
In 1968, Wilson and Junger established the criteria
for screening:
• The gravity of the disease must be
sufficient;
• The disease must be diagnosed during the
preclinical phase;
• An efficient test must exist for disease
diagnosis;
• An efficacious treatment must exist.
The American guidelines ATPIII (National Cholesterol
Education Program Adult Treatment Panel III) recently established that over a
ten-year period, individuals with low, moderate or high coronary artery
disease(CAD) risk levels are those that have less than 6%, between 6% and 20%
and more than 20% probability, respectively.
Even though the effort stress ECG, stress
echocardiogram, and the myocardial scintigraphy with radionuclides are all valid
instruments for symptomatic patients, or those with recognised coronary artery
disease, they do not have favourable cost-efficiency ratios for asymptomatic
patients with or without risk factors.
Most acute ischemic events occur because of a
rupture of a coronary plaque, which are not significant from a hemodynamic
viewpoint, and this explains the low predictive value of these tests in
identifying asymptomatic patients at risk who may be in danger of acute
myocardial infarction or sudden death, in spite of the negative results obtained
through a stress tests.
Other screening tests, such as Coronary
Calcification measurement using cardiac CT or carotid intima media thickness and
carotid plaques with ultrasound, are available and more capable than other tests
in demonstrating direct evidence of the presence and the extension of the
Atherosclerosis.
Both these imaging methods provide information
that have proved their prognostic value in relation to future risks heart
attacks and strokes.
If the criteria of the new ATPIII guidelines are
adopted for major cardiac event prevention, the costs for years of life quality
saved vary between 25.000 and 35.000€.
In addition, it should be remembered that studies
for the prevention of Atherosclerosis have demonstrated a considerable reduction
in major cardiac events after 5 years therapy with statins, equal to 37% in the
AFCAPS/TextCAPS study using lovastatin and 38% in HPS, using simvastatin.
However, if less selective criteria are adopted, the
costs for therapy using statins only can rise to 1000 € per patient per year.
The cost for treating 26 million people has
been estimated at being 26 billion €.
However, while the ATPIII guidelines are reasonably
efficient in identifying the people at high risk, it is also true that more than
half the patients who suffer a sudden cardiac arrest or myocardial infarction
presented a low or moderate cardiovascular risk before the event occurred.
Many individuals with severe atherosclerosis are
unaware of their risk because they show no signs of symptoms.
In 30-50% of these individuals, sudden death or
myocardial infarction are the first signs of the disease.
Although efficacious therapies exist able to reduce
the risk of heart attack and sudden death, these people are not able to benefit
because their disease is not recognisable (asymptomatic) or because they were
not recognised as being in high risk categories by current guidelines.
In addition, the guidelines tend to
underestimate the risk of disease in young adults.
Limitations of the NCEP III scheme have been
described by others. Akosah et al. found that 75% of 222 asymptomatic young to
middle-aged adults (men < 55 years, women < 65 years) presenting with their
first myocardial infarction would not have been considered candidates for statin
therapy.
In fact, when the 10-year risk for major cardiac
events was calculated according to the number of risk factors and to the LDL
Cholesterol levels, only 25% of the Males and 18% of the Females presented the
correct criteria for treatment.
Those patients who showed signs of a moderate
cardiovascular risk, calculated according to the Framingham method, in other
words, between 6 and 20%, are those for whom therapeutic decisions are most
difficult.
More intensive diagnosis using
non-invasive studies is very useful for this category.
It is for this reason that the new cardiovascular
risk assessment through a search for coronary and carotid atherosclerotic
lesions can provide precious information.
Determining the entity of coronary-artery
calcification does not require a great deal of preparation, and lasts only 15
minutes.
The lack of calcification in patients
about 50 years of age can identify a group at low future event risk for the
following 2-5 years.
A 2-year predictive period
is accurate to almost 100%. Medical therapy in these patients can be avoided or
delayed, with considerable savings for the National Health System.
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