Sanford Heart Hospital

Project Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Comparison of Coronary Calcium Score and Framingham Score in

Determination of Cardiovascular Risk and Disease in Native American vs.

General Population.

Muhammad Khan, MD

Tom P. Stys, MD, FSCAI, FACC

Medical Director, Sanford Heart Hospital

Sanford Cardiovascular Institute

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Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Background: Scope of Cardiovascular Problem.

• 81 million have 1 or more type of CVD †• CVD # 1 cause of mortality for the last 100 yrs • Cost of CVD and stroke in 2009 $470 billion †• At 50 yrs lifetime risk of

– CVD 50% ‡– breast cancer at 50 yrs 10%

† Lloyd-Jones, D., R. Adams, et al. (2009). "Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee." Circulation 119(3): e21-181.

‡ Lloyd-Jones, D. M., E. P. Leip, et al. (2006). "Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age.“ Circulation 113(6): 791-798.

http://seer.cancer.gov

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Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Background: Cardiovascular Disease is Preventable and Treatable; Early Detection is Key.

• CVD mortality declined by 50% from 1980 to 2000 †

• Decline due to:

– Half of the decline due to primary prevention †

• 24% due to cholesterol reduction• 20% due to blood pressure control• 12% due to smoking cessation• 5% due to increase in physical activity

† Ford, E. S., U. A. Ajani, et al. (2007). "Explaining the decrease in U.S. deaths from coronary disease, 1980-2000." N Engl J Med 356(23) 2388-2398.

4

Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Background: Need to do more.

• Rate of decline of CVD mortality is slowing down †

• 50% of adults suffer acute MI each year without prior symptoms ‡

• For 25% of people the first sign of underlying CVD is sudden cardiac

death ‡

† Cooper, R., J. Cutler, et al. (2000). "Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention." Circulation 102(25): 3137-3147.

‡ Myerburg, R. J., K. M. Kessler, et al. (1993). "Sudden cardiac death: epidemiology, transient risk, and intervention assessment." Ann Intern Med 119(12): 1187-1197.

5

Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Background: Coronary Calcium Score.

• Strong correlation between coronary artery calcium score and underlying

coronary atherosclerosis †• Coronary artery calcium score predicts CVD outcomes prospectively

ॠCalcium score has incremental value over traditional risk factors ॠAdding calcium score to traditional risk factors can change

recommended therapy *

† Sangiorgi, G., J. A. Rumberger, et al. (1998). "Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque

burden in humans: a histologic study of 723 coronary artery segments using nondecalcifying methodology." J Am Coll Cardiol 31(1): 126 133.

‡ Detrano, R., A. D. Guerci, et al. (2008). "Coronary calcium as a predictor of coronary events in four racial or ethnic groups." N Engl J Med 358(13):1336-1345.

* Polonsky, T. S., R. L. McClelland, et al. (2010). "Coronary artery calcium score and risk classification for coronary heart disease prediction." JAMA 303(16): 1610-1616.

6

Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Background: Coronary Calcium Score.

Coronary artery calcification provides additional risk stratification beyond the Framingham risk estimate, especially in individuals with high calcium scores. A zero score does not exclude the risk of an event.

Greenland, P., L. LaBree, et al. (2004). "Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals." JAMA 291(2): 210-215.

7

Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Background: Why Native Americans?

• Higher cardiovascular risk patient population• 8% of all Native Americans reside in SD †

• Incidence of CVD on the rise among Native Americans Ε SD/ND has the highest rate of non fatal MI * • SD/ND has twice as high CVD mortality as general US population *

† www.census.govÎ Howard, B. V., E. T. Lee, et al. (1999). "Rising tide of cardiovascular disease in American Indians. The Strong Heart Study." Circulation 99(18): 2389-2395* Lee, E. T., L. D. Cowan, et al. (1998). "All-cause mortality and cardiovascular disease mortality in three American Indian populations aged 45-

74 years, 1984-1988. The Strong Heart Study." Am J Epidemiol 147(11): 995-1008

8

Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Purpose: Comparison of Coronary Calcium Score and Framingham Score in Determination of Cardiovascular

Risk and Disease in Native American vs General Population.

Compare the value of coronary calcium score in detection of higher cardiovascular risk profile in a higher cardiovascular risk patient population (Native Americans) vs general patient population.

9

Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Methods: Study Design.

Retrospective comparative analysis of Sanford Cardiovascular Prevention Program February 2008 – February 2010

This project was reviewed and approved by the Sanford IRB.

10

Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Methods: Sanford Cardiovascular Prevention Program.

• Program initiated February 2008• The Heart Screen is available for any person between the ages of 40-70

years old• Personal and Family History by Self Report• Height, Weight, BMI• Non-Fasting Cholesterol, HDL• Blood Pressure and EKG• CT Coronary Calcium Score• Physician Review of all test results• Case Manager follow-up with participant

* Data is recorded in Sanford Prevention Program Database.

11

Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Results: Baseline Demographics of Non-Native American vs. Native American patient population.

Non Native- American Native American

Number of patients 16453 1304

Gender Male 7546 (45.9%) 459 (35.2%) p<.0001 ChiSq

Female 8907 (54.1%) 844 (64.8%)

Age Mean (Std Dev) 56.298.55 54.309.17 p<.0001 ANOVA

Height Mean (Std Dev) 67.55(3.98) 66.48(3.84) p<.0001 ANOVA

Weight Mean (Std Dev) 193.33(44.52) 201.75(46.39) p<.0001 ANOVA

BMI Mean (Std Dev) 27.32(5.37) 29.50(6.21) p<.0001 ANOVA

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Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Results: Medication use.

General Population Native Americans

BP medication 29.3% 36.8% <.0001 ChiSq

Cholesterolmedication

20.5% 12.2% <.0001 ChiSq

ASA 11.1% 11.7% 0.5240 ChiSq

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Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Results: Risk status of General Population vs Native Americans.

General Population

Native Americans

HDL Cholesterol(Mean ±SD)

48.57(16.92) 42.40(15.67) <.0001 ANOVA

TC/HDL Ratio(Mean ±SD)

4.50(3.82) 4.57(1.64) 0.5118 ANOVA

BP: Systolic(Mean ±SD)

125.98(14.66) 127.22(16.44) 0.0040 ANOVA

BP: Diastolic(Mean ±SD)

78.78(9.19) 78.33(10.71) 0.0933 ANOVA

Diabetic (PH) 7.1% 20.3% <.0001 ChiSq

Smoking 10.3% 40.4% <.0001 ChiSq

Stroke (PH) 0.8% 2.1% <.0001 ChiSq

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Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Results: Coronary Calcium Score VS Framingham Score.

General population

Native Americans

Framingham Score

(Mean ± SD)

5.73 ± 6.30 5.77 ± 6.29 0.7960 Anova

Calcium Score(Mean ±SD)

122.87 ± 361.47 171.67 ± 465.19 p<.0001 Anova

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Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Conclusions:

• Native Americans are a higher cardiovascular risk patient population

– Higher prevalence of Smoking– Higher BMI– Less optimal lipid profile and less frequent pharmacotherapy for

dyslipidemia– Higher systolic blood pressure– Higher prevalence of Diabetes and Stroke

• Framingham score failed to identify Native Americans as a higher risk patient population

• Calcium score did differentiate between higher risk patient population (Native Americans) as compared to general population

16

Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Conclusions:

• Coronary Calcium Score is superior to Framingham Score in identification of patients with higher cardiovascular risk profile.

• Early identification of patients with higher cardiovascular risk profile through Cardiovascular Prevention Programs allows earlier initiation of aggressive preventive cardiovascular care measures.

• Coronary Calcium Score should be considered a valuable tool (superior to traditional approaches) in early detection of higher risk cardiovascular patients allowing appropriate early initiation of cardiovascular disease management and preventive care.

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Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Special Thank You To:

• Adam Stys, MD, FACC, FASA, FSCAI• Marian Petrasko, MD, PhD, FACC, FSCAI, FACP• Karen Tobin Heart and Vascular Vice President• Lynn Thomas RN, BSN

• Nichol Burton, RN, BSN• Richard Clark, MD• Christian Gaissmaier, MD• Deb Griffith RN, BSN• Orvar Jonsson, MD, FACC

• James Olson, MD, FACC• Scott Pham, MD, FACC• Lloyd Solberg, MD, PhD,

FACC, FASA, FSCAI• Maria Stys, MD, FACC• Paul Thompson, PhD

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Sanford Heart HospitalProject Summary:

•Total Estimated Square Feet 205,000

•Physician Offices 23•Cardiac, Thoracic, and Vascular Surgery•Sanford Cardiovascular Institute

•Inpatient Beds Potential for 58•Critical Care Unit•Cardiology

•Operating Rooms Potential for 5

•Cath Labs Potential for 9 including a Hybrid Cath and dedicated EP Cath Lab

•Outpatient Diagnostic Testing Nuclear Medicine, Echo, Stress, Imaging

•Project Completion Early 2012

Thank you