SHAPE Society

1. Electron Beam Tomography:
The Most Powerful Screening Test
For The Imaging Section
of the VP Pyramid
© John A. Rumberger, PhD, MD, FACC
Clinical Professor of Medicine
The Ohio State University
Medical Director
HealthWISE
Wellness Diagnostic Center
22ndnd
VP Symposium, New Orleans, LA, 3/6/04VP Symposium, New Orleans, LA, 3/6/04

2. 1.1. Cannot be fully exploited without an adequate methodCannot be fully exploited without an adequate method
of separating higher-risk individuals from those atof separating higher-risk individuals from those at
lower risk.lower risk.
2.2. If serious misclassification is present, many higher-riskIf serious misclassification is present, many higher-risk
individuals would not be identified, denying themindividuals would not be identified, denying them
appropriate therapy, and...appropriate therapy, and...
3.3. conversely, many lower-risk individuals would beconversely, many lower-risk individuals would be
subject to over-treatment with expensive drugs havingsubject to over-treatment with expensive drugs having
an uncertain long-term safety.an uncertain long-term safety.
Risk Based Treatment Guidelines forRisk Based Treatment Guidelines for
Primary Prevention of CADPrimary Prevention of CAD
© JA Rumberger, MD

3. Coronary Heart Disease in a given person
is a consequence to a variety of factors related
Such as:
Genetics & MetabolismGenetics & Metabolism
HabitsHabits
LifestyleLifestyle
Environment andEnvironment and
Susceptibility to inflammationSusceptibility to inflammation
© JA Rumberger, MD
EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid

4. How Good Is NCEP III At Predicting MI?How Good Is NCEP III At Predicting MI?
JACC 2003:41 1475-9JACC 2003:41 1475-9
222 patients with 1222 patients with 1stst
acute MI, no prior CADacute MI, no prior CAD
men <55 y/o (75%), women <65 (25%), no DMmen <55 y/o (75%), women <65 (25%), no DM
RiskRisk
>20%/>20%/
10 yrs.10 yrs.
RiskRisk
10-20%/10-20%/
10 yrs.10 yrs.
RiskRisk
<10%/<10%/
10 yrs.10 yrs.
NCEP GoalNCEP Goal
LDL<100LDL<100
NCEP GoalNCEP Goal
LDL<160LDL<160
NCEP GoalNCEP Goal
LDL<130LDL<130
Qualify for Rx
Not-Qualify for Rx
6%6% 6%6%
TotalTotal
12%12%
8%8% 10%10%
TotalTotal
18%18%
61%61%
9%9%
TotalTotal
70%70%
88% of these “young” patients who suffered a
first Myocardial Infarction were in the
Low to Intermediate “risk” category according
To Framingham Risk Assessment and
would have been missed as truly
“High Risk” individuals who should
have been treated “aggressively”

5. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
Low Risk Population
Intermediate Risk
Subclinical
Atherosclerosis
CVD
Low Conventional Risk & +FH
© JA Rumberger, MD

6. 2.7
2 2
1
2.47
3.55
6.15
12.29
0
2
4
6
8
10
12
14
RelativeRisk
DM Smoke HTN <10
10-100
101-400
401-1000
>1000
EBT Coronary Calcium ScoreEBT Coronary Calcium Score
All Cause Mortality [NDR]All Cause Mortality [NDR]
n = 10,377n = 10,377
asymptomatic men and womenasymptomatic men and women
f/u = 5.0f/u = 5.0++3.5 yrs.3.5 yrs.
Shaw,Radiology 2003;
228:826-833
EBT found to be independent
and incremental to risk factors826-833
All Cause Mortality in PatientsAll Cause Mortality in Patients
Without Known CADWithout Known CAD

7. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
© JA Rumberger, MD
Brief Case:Brief Case:
Two prominent men:Two prominent men:
• Both smokers - #1 stopped, #2 continuedBoth smokers - #1 stopped, #2 continued
• Both with limited exercise - #1 became and avid runner,Both with limited exercise - #1 became and avid runner,
lost weight, became very fit,lost weight, became very fit,
#2 continued to be inactive and obese#2 continued to be inactive and obese
• Both #1 and #2 had a family history of premature deathBoth #1 and #2 had a family history of premature death

8. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
© JA Rumberger, MD
Who was at greater risk for the development of heart disease?Who was at greater risk for the development of heart disease?
Jim Fixx - marathon runner,
exercise advocate, author -
dead at 53 of a heart attack
Sir Winston Churchill – broke
every tenet of “healthy life style” –
dead at age 91

9. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
CAC>0 CAC>75th percentile
0
10
20
30
40
50
60
70
80
90
100
7978
64
55
4141
29
20
BothSibling FHParental FHNo FH
CAC>0 CAC>75th percentile
0
10
20
30
40
50
60
70
80
90
100
5456
36
27
3334
24
15
BothSibling FHParental FHNo FH
WomenMen
© JA Rumberger, MD
8,500 Middle-aged patients referred for EBT Testing (single site)8,500 Middle-aged patients referred for EBT Testing (single site)
No FHx of Premature CAD vs. +FHx below age 55 in a parent or siblingNo FHx of Premature CAD vs. +FHx below age 55 in a parent or sibling
1.4X1.4X
2.0x2.0x
2.0x2.0x
2.2x2.2x

10. 30.2%/year
12%/year
0 10 20 30 40 50 60
Untreated
Treated
EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
© JA Rumberger, MD
n = 792
n = 292
Range 5%-20%
Range 22%-52%
Composite of 9 studies – weighted averageComposite of 9 studies – weighted average

11. Prediction of MI/SCD in Asymptomatic Patients:Prediction of MI/SCD in Asymptomatic Patients:
EBTEBT
0
1
2
3
4
5
6
7
0 10 20 30 40 50 60 70 80 90
Percentile Rank for Baseline EBCT Calcium ScorePercentile Rank for Baseline EBCT Calcium Score
LowLow
RiskRisk
IntermediateIntermediate
RiskRisk
HighHigh
RiskRisk
VeryVery
HighHigh
RiskRisk
AnnualAbsoluteRisk(%)AnnualAbsoluteRisk(%)
Adapted from data presented inAdapted from data presented in
Raggi et al AHJ 2001;141:193-199Raggi et al AHJ 2001;141:193-199
© JA Rumberger, MD

12. EBT “Heart Age”EBT “Heart Age”
Percentile Ranking of CASPercentile Ranking of CAS Adjustments to Chronological AgeAdjustments to Chronological Age
<25<25thth
Percentile Subtract 10 yearsPercentile Subtract 10 years
>>2525thth
- <75- <75thth
Percentile No adjustmentPercentile No adjustment
>>7575thth
- <90- <90thth
Percentile Add 10 yearsPercentile Add 10 years
*
* Originally suggested byOriginally suggested by
Grundy: AJC 2001;88:8E-11EGrundy: AJC 2001;88:8E-11E
>>9090thth
Percentile Add 20 yearsPercentile Add 20 years
©
© JA Rumberger, MD

13. Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk:
Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age”
Conventional “Low to Intermediate” Risk PatientConventional “Low to Intermediate” Risk Patient
Age 35 to 65 yearsAge 35 to 65 years
MaleMale
TC = 210 mg/dlTC = 210 mg/dl
HDL = 40 mg/dlHDL = 40 mg/dl
No DiabetesNo Diabetes
No SmokingNo Smoking
Systolic BP = 150 mmHgSystolic BP = 150 mmHg
Use NCEPUse NCEP
ATP-IIIATP-III
and Framinghamand Framingham
point scoring systempoint scoring system
© JA Rumberger, MD

14. Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk:
Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age”
0
5
10
15
20
25
30
35 40 45 50 55 60 65
Framingham Risk
<25th Percentile CAS
>75th Percentile CAS
>90th Percentile CAS
Age (years)
““Low to Intermediate”Low to Intermediate”
ConventionalConventional
Risk MaleRisk Male
CoronaryRiskperDecade
Low Risk
Intermediate Risk
High Risk
© JA Rumberger, MD

15. Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk:
Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age”
Conventional “Intermediate to High” Risk PatientConventional “Intermediate to High” Risk Patient
Age 35 to 65 yearsAge 35 to 65 years
MaleMale
TC =240 mg/dlTC =240 mg/dl
HDL = 35 mg/dlHDL = 35 mg/dl
No DiabetesNo Diabetes
No SmokingNo Smoking
Systolic BP = 180 mmHgSystolic BP = 180 mmHg
Use NCEPUse NCEP
ATP-IIIATP-III
and Framinghamand Framingham
point scoring systempoint scoring system
© JA Rumberger, MD

16. 0
5
10
15
20
25
30
35 40 45 50 55 60 65
Framingham Risk
<25th Percentile CAS
>75th Percentile CAS
>90th Percentile CAS
Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk:
Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age”
Age (years)
““Intermediate to High”Intermediate to High”
ConventionalConventional
Risk MaleRisk Male
CoronaryRiskperDecade
Low Risk
High Risk
Intermediate Risk
© JA Rumberger, MD

17. EBT “Heart Age” and RiskEBT “Heart Age” and Risk
IntermediateIntermediate
ConventionalConventional
RiskRisk
HighHigh
ConventionalConventional
RiskRisk
1/3 or more are actually1/3 or more are actually LOWLOW riskrisk
1/3 or more are actually1/3 or more are actually HIGHHIGH riskrisk
1/3 or more are actually1/3 or more are actually INTERMEDINTERMED riskrisk
1/3 or more are actually1/3 or more are actually LOWLOW riskrisk
© JA Rumberger, MD

18. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
© JA Rumberger, MD
AGE
IncidenceIncidence
OfOf
CHDCHD
Incremental
Value of
CAC
3535 7070

19. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
© JA Rumberger, MD
““Risk” increases as an individuals CACRisk” increases as an individuals CAC
score and/or percentile rank increasesscore and/or percentile rank increases
Thus, although EBT and CAC is not ableThus, although EBT and CAC is not able
to identify the “vulnerable” plaque, it CANto identify the “vulnerable” plaque, it CAN
identifyidentify “the“the vulnerable patient”vulnerable patient”

20. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
© JA Rumberger, MD
AtAt PRESENTPRESENT the following has been established:the following has been established:
o Coronary calcium IS AtherosclerosisCoronary calcium IS Atherosclerosis
o The magnitude of the calcium score relates to the severity of ASO diseaseThe magnitude of the calcium score relates to the severity of ASO disease
o The calcium score as well as the percentile rank provide informationThe calcium score as well as the percentile rank provide information
in which to view risk factors, rather than the other way aroundin which to view risk factors, rather than the other way around
o The data on examining progression of CAD with CT are consistent withThe data on examining progression of CAD with CT are consistent with
the potential for the calcium score/rank to be used as the “goal” of therapythe potential for the calcium score/rank to be used as the “goal” of therapy

21. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
© JA Rumberger, MD
The calcium score is a measure of overall
disease extent in a given person and is a
consequence of a variety of factors related
to genetics, habits, environment and
susceptibility to inflammation and many of
These are not “measurable” by blood tests.
So, it might make more sense to use EBT as an
additional risk factor and incorporate its results
with conventional assessments

22. EBT: Imaging for the VP PyramidEBT: Imaging for the VP Pyramid
© JA Rumberger, MD
Low Risk Population
Intermediate Risk
Atherosclerosis
Imaging
CVD
Low Conventional Risk & +FH
EBT (and other formsEBT (and other forms
of Atherosclerosis Imaging)of Atherosclerosis Imaging)
take “Population”take “Population”
Statistics toStatistics to
““Personal” StatisticsPersonal” Statistics
by Measuring theby Measuring the
extent ofextent of
““Pre-Symptomatic”Pre-Symptomatic”
CHDCHD