#1

While as preventive cardiologist we all organize information from imaging and biomarkers in a debate with my dear friend @CBallantyneMD , asked tough Q what would I choose if I had one option?

The answer is clear and maybe not debatable anymore

@ASPCardio @Heart_SCCT
# 2 What ur risk? remains the foundational strategy in preventive cardiology and in this pursuit we continue to rely on risk factors and a growing list of biomarkers

@ASPCardio @CBallantyneMD @DrMarthaGulati
# 3
And the goal is worthy as the ACCURATE identifying those at higher but also at low risk is critical for treating the right patient at the right time with the right intervention, societal resource allocation and informed patient choices
# 4

However, if we believe, atherosclerosis is the main underlying mechanism for CVD clinical complications, then why not focus where the money is only captures the impact of prior exposures as well as accounts for resilience and vulnerability.
# 5 In this SPACE, clearly CAC is the fleader
s no better marker that predicts those at the highest risk, provides clear discrimination and reclassify the most individuals in a meaningful manner to impact decisions, but also has a feature of most accurately derisking
# 6

IRRESPECTIVE OF how u slice and dice the pie of Lipids, the very basic foundational biomarker for CVD risk assessment, in what matters the most is do you have CAC and how much
# 7
While inflammation ALSO remain a “contributor” like Lipids, nearly half of those with elevated hs-CRP have no CAC, you cannot have a more favorable prognosis than what we observe, and truly most of the event happen when there is significant CAC (common sense)
# 8 we clearly showed that CAC based approach overcomes the biomarker based fallacies that can only elevate risk estimates and try to medicate more individuals, CAC actually best to clear out nearly half of individuals who are below the risk threshold for treatment selections
# 9

and not only that now there is data
that for derisking cac zero is peerless,
there is no societal dowsize in guiding statin decisions based on cac
no true benefit of statin with cac zero in 12 yrs fu
# 10
All of this eventually led the conservative guideline committee to acknowledge undeniable evidence on role of cac and importance of zeor that upgraded use of CAC testing as rec IIA, as a SDM and for the first time that even with abnormal biomarkers for flexibility.
# 11
while i am excited about lpa and growing list of ref , but again we see the same pattern of no increased risk with cac zero and mainly explained with higher cac burden, forcing many to question why bother for biomarkers based risk enhancers
# 12 also in severe hyperlipidemia no further risk stratification?

13 yr data from mesa suggest nearly 1/3rd of individuals with ldl>190 have power of zero and a 3% 13 yr event rate
another hurdle allowing for a preciosr approach overcome another biomarker based fallacy
# 13
In end choice is yours
Keep doing the same thing or move on with emerging technology
Also CAC helps precisely ensure there is no one size fit all

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More from @khurramn1

6 Aug 20
#COVID19 recovery?

My thoughts below

For most of us on the frontline including myself, the 100% focus in the last 4 months, rightly so, been on beating the initial sickness

Unaware it may be just the first of many battles

Sometimes we all need perspective (definitely I did)
#2
For me, As a physician, it was my collogues, including Dr Wu a surgeon one of the first doctors falling sick all across in US

learning from their personal experience as a patient….

getting insights on their anxieties, isolation and struggles was an eye opening experience
#3
Social media is full of stories with such struggles

As a population health scentist I always viewed these scattered reports with skepticism…

trained not to place to much emphasis on ancedotes…
Read 21 tweets
25 Jul 20
Debate CAC vs CTA in primary prevention?
I will start with a provocative statement
Screening, foundational strategy for decades in prev cardio is a seductive paradigm
Its so 1990’s
We are barking on the wrong tree
In 2020, I will explain why this strategy is a fallacy
#ASPC2020
#1 Both primary and secondary prevention lower disease burden and outcomes
#2 Marginal benefit of extensive screening
#3 Whats left to screen? Majority already treatment candidates
#4 Our stakeholders asking for "derisking" vs "screening"

#APSC2020
-Despite being being an avid advocate of CAC screening in past, it was time to move on
-Showed 1 in 2 statin candidates have #PowerOfZero
-Proposed CAC as SDM tool
-Concept confirmed in 3 other cohorts, better than any neg marker, cost-effective, and no statin treatment benefit
Read 8 tweets
17 Jul 20
Humbly honored for this recognition today

Thank you, @Heart_SCCT and especially my friends @RonBlankstein @Agatston_Center presenting it, made it more special

Truly proud to be among the pantheon of cardiology giants who were previously recognized.
In reality honor for #PowerOfZero is really a tribute to the man with Midas touch

Privilege to work & learn so closely, this relationship blossoming not only with him but entire family

@Agatston_Center is national treasure & even today remains a source of inspiration for me🙏
Early on I was lucky to run across 3 mentors @Agatston_Center @hmkyale @rblument1 who took immense interest in our mission

I then hit #jackpot with collaboration of most dynami, smartest individuals

#PowerOfFriendship of this group been the biggest gift from this journey
Read 9 tweets
28 Apr 20
#1 Many raised concerns reg racial disparities in face of recent COVID-19 pandemic
@eff_ve leading efforts @HMethodistMD to systematically examine inequalities reg susceptibility to SARS-CoV-2 infection in nation’s most diverse metropolitan area: Houston
medrxiv.org/content/10.110…
#2 @eff_ve building a novel data platform form to automatize ingestion, organization & analytics serving @HMethodistMD entire research community data needs via COVID-19 Surveillance and Outcomes Registry (CURATOR)

Operational details of this registry/platform coming soon.
#3 @eff_ve showed high probability of testing positive

-African American vs White; OR:1.84, 95% 1.49–2.27
-Hispanic vs non-Hispanic; OR, 1.70, 95% CI 1.35–2.14

explored 3 mechanism of disparities: SES, residence in higher population dense areas, & higher level of comorbidities
Read 6 tweets
29 Oct 19
Nice piece by @CoronaryDoc

It was interesting to see almost similar views for

"Is CAC Imaging Ready to be the Gatekeeper For Advanced Imaging in Low-Risk, Symptomatic Patients?"

Whats to disagree😀
@lesleejshaw @RonBlankstein @ChinnaiyanMD
@CoronaryDoc @lesleejshaw @RonBlankstein @ChinnaiyanMD @WilliamZoghbi @Heart_SCCT @FiRSTSCCT @ACCinTouch @escardio @YaleCardiology @HMethodistCV @HMethodistMD @almallahmo @MBittencourtMD Q1
"Do you think there is enough evidence to use CAC as the front-line test and the gatekeeper for coronary CT angiography (CCTA) in low-to-intermediate risk symptomatic patients?"
@RonBlankstein @lesleejshaw @CoronaryDoc @ChinnaiyanMD
Read 5 tweets
5 Nov 18
With 5 days to Chol management guidelines update @AHAMeetings..gentle reminder in @JACCJournals: It’s time to accept the #PowerOfZero.

Hope it’s not too late! @rblument1 @hmkyale @MichaelJBlaha @RonBlankstein @ErinMichos @MBittencourtMD.
Some thoughts👇
onlinejacc.org/content/early/…
#1 Going back to early 2000’s when many showed RF-based approach fell short for individual patient management decisions... aspirations for CAC ‘screening’ gained momentum, though progress stalled due to lack of RCT & waiting for prospective cohorts to confirm prognostication
#3, while hard to rationalize @NIH aversion to fund much needed RCT, sig progress with MESA & HNR confirmed CAC risk stratification capacity->In 2010 Class IIa rec for ‘screen-detect disease-treat’. At that time many hoped next guidelines update wud strengthen CAC screening recs
Read 10 tweets

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