Challenges and Models in CV Risk Management: Start Early, Invest In Your Arteries Professor John Deanfield - University College London, UK Tuesday 28 August 2018 ESC Munich 2018
Professor John Deanfield: Disclosures ▪ Received CME honoraria and/or consulting fees from Amgen, Boehringer Ingelheim, Merck, Pfizer, Aegerion, Novartis, Sanofi, Takeda, Novo Nordisk, Bayer ▪ Member of Study Steering Committees for Novo Nordisk ▪ Research grants from British Heart Foundation, MRC(UK), NIHR, PHE, MSD, Pfizer, Aegerion, Colgate, Roche ▪ No conflicts of interest for this presentation ESC Munich 2018
CVD: It’s Not All Over! Source: CVD Statistics – BHF UK Factsheet – February 2018 ESC Munich 2018
CVD Prevention: Challenge! “The human race has had long experience and a fine tradition in surviving adversity; we now face a task for which we have little experience, the task of surviving prosperity” Source: Alan Gregg (1890-1957), Rockefeller Foundation ESC Munich 2018
Investing In Your Arteries! Genetic Environmental Lots of risk in front : lots of lost opportunities behind! 9 RFs accounted for 90% of MI in men and 94% in women Clinical Events Foetus 0 20 40 60 September Age (yrs) 18 Source: INTERHEART Lancet 2004 ESC Munich 2018
Adolescent Smoking and Drinking and CV Health p=0.002 Low drinking * Low smoking Int. drinking Low smoking High drinking Low smoking Low drinking Int. smoking Int. drinking Int. smoking High drinking Int. smoking Low drinking High smoking Int. drinking High smoking High drinking * High smoking ▪ 1,266 participants (425 males and 841 females) at age 13, 15 & 17 yrs 5.0 5.5 6.0 6.5 ▪ Ao PWV at 17 yrs PWV (m/s) Adjusted for gender, SBP, BMI, LDL, SES, CRP Source: Charakida et al, EHJ 2018, in press ESC Munich 2018
Most Of Us Have Arterial Disease! Incidence of Atherosclerosis (%) 100 90 85 80 71 70 60 60 50 37 40 30 17 20 10 0 <20 20-29 30-39 40-49 >50 Age (years) 32 Year Old Female Source: Tuzcu, Circ 2001 103:2075-10 ESC Munich 2018
Combined Effect of LDL-C and SBP on CV Events N = 14,368 Major Vascular Events Arterial disease causing heart attacks and strokes may be largely preventable! Never too Late; Never too Early!! Source: B. Ference (Plymouth, US), FP 3163 ESC Munich 2018
How Early Should Prevention Start? “Poor Start in Life” ESC Munich 2018
Obesity at 2 yrs Predicts Status at 35 yrs... Source: Ward et al, N Engl J Med 2017;377:2145-53 ESC Munich 2018
CV RFs Drive Multiple Diseases Stress BP Obesity Cholesterol Smoking Systemic Inflammation Oxidative Stress Ageing Dementia A Fib. Cancer Diabetes CVD Stroke Source: Twig G et al, NEJM 2016;374:2430-40 ESC Munich 2018
Impact of Periodontitis Treatment on Glucose Control, Vascular and Renal Function in T2DM In UK population ▪ Severe in 5-10% ▪ Mild/mod. in 40% Source: D’Aiuto Lancet Diabetes 2018 ESC Munich 2018
A Periodic Diet that Mimics Fasting Promotes Multi-System Regeneration, Cognitive Performance, and Healthspan Upstream biology that underlies NCDs can be targeted resulting in leveraged gains Source: Brandhorst Cell Metab 2015; 22: 86 – 99 ESC Munich 2018
Fasting-mimicking diet and markers/risk factors for aging, T2DM, cancer, and CVD Source: Wei et al., Sci. Transl. Med. 9, eaai8700 (2017)
CANTOS: Additional Non-CV Clinical Benefits Incident Lung Cancer Source: Ridker PM et al. Lancet 2017, 390:1833-1842 ESC Munich 2018
CV RF lowering and Dementia Risk? What’s Good for the Heart is Good for the Brain! ESC Munich 2018
CV Risk Factors from Childhood and Later Cognitive Function (Young Finns Study) Source: Rovio JACC 2017; 69: 2279-2289 ESC Munich 2018
Multi-domain Treatment and Cognitive Decline: FINGER Trial Source: Ngandu Lancet 2015; 385: 2255-2263 ESC Munich 2018
CVD Prediction and Prevention Knowledge Communication Empowerment ESC Munich 2018
JBS3 Lifetime Risk Calculator Source: Heart March 2014 and www.jbs3risk.com ESC Munich 2018
PHE National Heart Age Launch 04/09/18 ESC Munich 2018
CVD Prevention: One Size Does Not Fit All! Can’t give novel, expensive drugs, with uncertain long term safety, to everyone! ESC Munich 2018
Precision Medicine Approaches Genetics Imaging Biomarkers ESC Munich 2018
Genome-wide polygenic scores for common diseases UK Biobank Genome-wide polygenic scores for risk (>3x) for: ▪ Coronary artery disease (8.0%) ▪ Atrial fibrillation (6.1%) ▪ T2DM (3.5%) ▪ IBD (3.2%) ▪ Breast Cancer (1.5%) For coronary artery disease, prevalence is 20x higher than the carrier frequency of rare monogenic mutations conferring comparable risks. Source: Khera et al, Nature Genetics online (Aug 2018) ESC Munich 2018
CT Inflammation Imaging: Fat Attenuation Index (FAI) Sources: Mancio et al, Heart 2018; 0:1-9 Sources: Mancio et al, Heart 2018; 0:1-9 Antonopoulos et al, JACC 2018; 71;23:2706-12 (Top R) Antonopoulos et al, JACC 2018; 71;23:2706-12 (Top R) ESC Munich 2018
The Digital Health Opportunities Title of Paper Assessing CV risk factors with Computer Vision Google Research Source: Poplin et al, Nature Bio Eng; Vol 2, Mar 2018: 158-64
Revolution in the Delivery of Medicine Early Management / Digital Systems Wellness Illness Ageing ESC Munich 2018
New Models of CV Risk Management ▪ Lifetime management of CV risk ▪ Engage the medical community, healthcare providers, politicians and public to promote societal change ▪ Better communication, especially with the young - use new risk tools to communicate ‘investment benefits’ ( eg JBS3) ▪ New technology and testing to deliver personalised medicine ESC Munich 2018
Final Thought… “It should be the function of medicine to have people die young as late as possible” - Ernest L. Wynder M.D ESC Munich 2018
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