Task Force 1: Identification of coronary heart disease risk: Is there a detection gap?
Task Force 1: Identification of coronary heart disease risk: Is there a detection gap?
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DOI：
10.1016/s0735-1097(03)00358-9
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发表时间：
2003-06-04
影响因子：
24
通讯作者：
Houston-Miller, Nancy
中科院分区：
文献类型：
--
作者：
Pasternak, Richard C.;Abrams, Jonathan;Houston-Miller, Nancy
与症状性冠心病(CHD)患者相对容易识别和明确的治疗和预防策略相比，CHD的检测、治疗和预防的主要问题存在于没有心脏病症状但发展为CHD风险增加的大量人群中。在这类无症状个体中预防冠心病事件传统上被称为“一级预防”，因为它的目的是预防首次冠心病事件。在开始降低危险因素之前等待CHD的临床诊断将错失预防大量CHD事件的机会，美国公众将继续遭受CHD的沉重负担。这对于首次出现心源性猝死或残疾的患者尤其重要。因此，有机会预防冠心病事件，而不是被迫治疗急性事件及其未来后果，具有重大吸引力。在过去的几十年里，针对患者的特定风险而量身定做的风险降低已经取得了显著的进展，并已被证明在适当应用时是有效的。同样，基于风险评估的指导方针也取得了相当大的进步。临床医生也越来越熟悉考虑绝对风险而不是相对风险的基本原理，计算“需要治疗的数量”，以及理解预测各种不同未来临床结果(不包括死亡率)的重要性。风险评估是第27届贝塞斯达会议的中心原则，题为“使风险因素管理的强度与冠状动脉疾病事件的危险相匹配”(1)。尽管如此，我们准确确定风险的能力仍然有限，特别是对于那些根据标准风险评估发现处于中等风险范围的无症状患者(图1)。后者包括许多无症状或“亚临床”动脉粥样硬化患者。这份特别工作组的报告阐述了理解第34届贝塞斯达会议压倒一切的问题的答案所需的概念框架和背景信息：动脉粥样硬化成像技术能否改善对有缺血性心脏病风险的患者的检测？动脉粥样硬化成像，包括许多不同的新兴技术，可能会加强对有冠心病风险的患者的检测和治疗。然而，首先必须解决问题的各个方面，包括其范围和历史，并了解涉及风险预测和当代非成像方法的理论问题。常见的术语存在混淆，这些术语描述了与冠状动脉粥样硬化相关的疾病的临床和实验室诊断。在本次贝塞斯达会议上，我们将使用术语“冠心病”(CHD)，定义为心脏事件或与心肌缺血和/或损伤有关的症状，在绝大多数情况下，是由于动脉粥样硬化。这些事件包括不稳定心绞痛、心肌梗死(MI)和因缺血性心脏病而导致的猝死。一些被引用的研究还包括心绞痛，或“新发”心绞痛，作为一种“事件”。重要的是要认识到，冠状动脉粥样硬化、缺血和事件是作为一个连续体存在的。前者不一定导致后者，而后者实际上总是先于前者的存在。因此，挑战不仅在于“检测”冠状动脉粥样硬化，还在于“预测”哪些被检测到冠状动脉粥样硬化的个体将进展为冠心病事件。关于“风险”的定义也存在共识。尽管对风险的全面讨论是在…
In contrast to the relative ease of recognition and clarity of treatment and prevention strategies in patients with symptomatic coronary heart disease (CHD), a major problem of detection, treatment, and prevention of CHD exists in the large population who have no symptoms of heart disease yet are at increased risk to develop CHD. Prevention of CHD events in such asymptomatic individuals has traditionally been called “primary prevention,” as it aims to prevent first CHD events. Awaiting the clinical diagnosis of CHD before beginning risk factor reduction will miss the opportunity to prevent a substantial number of CHD events, and the American public will continue to suffer from a heavy burden of CHD. This is particularly critical for people whose first presentation is sudden cardiac death or disability. Thus, the opportunity to prevent CHD events, rather than be forced to treat the acute events and their future consequences, has substantial appeal. Risk reduction tailored to a patient’s specific risk has evolved significantly over the past several decades and has been shown to be effective when appropriately applied. Similarly, guidelines based on risk assessment have advanced considerably. Clinicians have also become increasingly familiar with the rationale for considering absolute risk rather than relative risk, for calculating the “number needed to treat,” and for understanding the importance of predicting a wide range of different future clinical outcomes (beyond mortality). Risk assessment was the central principle delineated at the 27th Bethesda Conference, entitled “Matching the Intensity of Risk Factor Management With the Hazard for Coronary Disease Events”(1). Despite this, our ability to accurately determine risk remains limited, especially for those asymptomatic people found to be in intermediate risk ranges based on standard risk assessment (Fig. 1). The latter group includes many individuals with asymptomatic or “subclinical” atherosclerosis. This task force report addresses the conceptual framework and background information necessary for understanding answers to the overriding question for this 34th Bethesda Conference: Can Atherosclerosis Imaging Techniques Improve the Detection of Patients at Risk for Ischemic Heart Disease? Atherosclerosis imaging, including many different emerging technologies, may enhance the detection and treatment of patients at risk for CHD. However, it is essential first to address aspects of the problem, including its scope and history, and to understand theoretical issues involving risk prediction and contemporary nonimaging approaches. Confusion exists over the common terminologies that describe both clinical and laboratory diagnoses of conditions related to coronary atherosclerosis. For the purpose of this Bethesda Conference, we will use the term “coronary heart disease”(CHD), defined as cardiac events or symptoms related to myocardial ischemia and/or injury due, in the vast majority of cases, to atherosclerosis. Such events include unstable angina, myocardial infarction (MI), and sudden death due to ischemic heart disease. Some studies cited also include angina, or “new-onset” angina, as an “event.” It is important to recognize that coronary atherosclerosis, ischemia, and events exist as a continuum. The former need not necessarily lead to the latter, whereas the latter is virtually always preceded by the presence of the former. The challenge, then, is not only to “detect” coronary atherosclerosis, but also to “predict” which individuals, in whom coronary atherosclerosis is detected, will progress to develop CHD events.Confusion also exists regarding the definition of “risk.” Although a full discussion of risk is …