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Can you please explain the new SHAPE guidelines? Which of our patients should have cardiovascular imaging tests, according to the guidelines?

APOLLO User

The Screening for Heart Attack Prevention and Education (SHAPE) task force has published a new report recommending screening for subclinical atherosclerosis, using computed tomography (CT), carotid artery ultrasonography, or both, for all asymptomatic "at-risk" men aged 45 to 75 years and women aged 55 to 75 years.¹ Their stated rationale is that while screening for early-stage, asymptomatic cancers, such as breast and colon cancer, is widely accepted, and although atherosclerotic cardiovascular disease is responsible for more death and disability than all cancers combined, there are no national guidelines—and no public or private funding—for screening to identify people with asymptomatic atherosclerosis. This report is the third in a 3-part series ^{2, 3} from Dr. Morteza Naghavi, chairman, and his colleagues on the SHAPE task force. Parts I and II of this consensus statement elaborated on new discoveries in the field of atherosclerotic vascular disease that led to the concept of the "vulnerable patient." The SHAPE document outlines the appropriate use of imaging technology: particularly, CT to measure coronary artery calcium and ultrasonography to measure carotid intima-media thickness.

The document calls attention to a recent scientific statement issued by the American Cancer Society, American Heart Association, and American Diabetes Association, which initiated their new collaborative effort dedicated to the prevention and early detection of cancer, cardiovascular disease (CVD), and diabetes.⁴ There are screening recommendations for breast cancer, cervical cancer, colorectal cancer and prostate cancer. The task force points out that "in contrast to cancer, early detection of CVD by screening with the best available technology is not mentioned, despite the >500,000 deaths per year from atherosclerosis, compared with ~57,000 from colorectoanal cancer, ~42,000 from breast cancer, and ~31,000 from prostate cancer."¹ The report goes on to discuss the limitations of the current guidelines for primary prevention of CVD,^5-8 which all recognize groups of asymptomatic patients who are at high risk. Furthermore, as the task force points out, the current guidelines ⁶ allow the use of noninvasive screening tests for additional risk assessment of "appropriately selected" individuals "at the physician's discretion."

The SHAPE task force, therefore, proposes that all apparently healthy men aged 45 to 75 years and women aged 55 to 75 years, with no known history of coronary heart disease (CHD) and not considered to be at very low risk, undergo screening for atherosclerosis (Figure).

Very low risk is defined by the absence of any of the following: total cholesterol level >200 mg/dL, blood pressure >120/80 mm Hg, diabetes mellitus, smoking, family history of CHD, and the metabolic syndrome. The SHAPE writing group estimates that of the more than 61 million Americans within this age range, almost 4 million have established CHD, and that the proportion at very low risk is only 5% to 10%,⁹ leaving 50 million people who should be screened, according to the SHAPE guidelines.

It is important to note that although the report announces itself as a "new practice guideline for cardiovascular screening," some voices have been raised to say quite clearly that these guidelines are just "an opinion." The lead author, Dr. Naghavi, is also the founder and president of Association for Eradication of Heart Attack (AEHA), (http://www.aeha.org/), a not-for-profit organization dedicated to ending myocardial infarction (MI) by advancing the science and the practice of MI prevention, detection, and treatment. The AEHA created the SHAPE task force and is thus the sponsor of its reports and guidelines.

MacRae F. Linton, MD

References

1. Naghavi M, Falk E, Hecht HS, et al. From vulnerable plaque to vulnerable patient—Part III: Executive summary of the Screening for Heart Attack Prevention and Education (SHAPE) task force report. Am J Cardiol. 2006;98:2H-15H.

2. Naghavi M, Libby P, Falk E, et al. From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part I. Circulation. 2003;108:1664-1672.

3. Naghavi M, Libby P, Falk E, et al. From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part II. Circulation. 2003;108:1772-1778.

4. Eyre H, Kahn R, Robertson RM, et al. Preventing cancer, cardiovascular disease, and diabetes: a common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109:3244-3255.

5. De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J. 2003;24:1601-1610.

6. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285:2486-2497.

7. Smith SC, Jr, Greenland P, Grundy SM. AHA Conference Proceedings. Prevention conference V: Beyond secondary prevention: Identifying the high-risk patient for primary prevention: executive summary. American Heart Association. Circulation. 2000;101:111-116.

8. Grundy SM, Cleeman JI, Merz CNB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227-239.

9. Stamler J, Stamler R, Neaton JD, et al. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women. JAMA. 1999;282:2012-2018.