Prevención primaria cardiovascular diabetes, rol de la Aspirina

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Ppt Prevención Primaria CV en diabéticos, Rol de AAS

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  • • Atherothrombosis is a vascular disease which can affect the coronary, cerebral and peripheral circulation. • It is a progressive, generalized disorder with many clinical manifestations – either acute or chronic and often multiple in any single patient. • Simple stenosis in an atherosclerotic artery may give rise to angina, a transient ischemic attack or intermittent claudication. • Atherothrombosis in the coronary arteries is the major cause of acute coronary syndrome, defined as unstable angina and non-Q-wave myocardial infarction. • Atherothrombosis of the cerebral arteries can result in TIA or ischemic stroke. • In the peripheral arteries, athero thrombosis can contribute to the progression of peripheral arterial disease, producing intermittent claudication (leg pain on walking that is relieved by rest) as well as ischemic necrosis and, potentially, loss of the limb. References 1. Drouet L. Cereobrovasc Dis 2002; 13 (suppl 1): 1–6
  • References: 1. Lichtman JH et al. Circulation 2002; 105: 1082–7. 2. CAPRIE Steering Committee. Lancet 1996; 348: 1329–39. 3. Coccheri S. Eur Heart J 1998; 19(suppl): P1268. A person suffering from any one manifestation of atherothrombosis is at risk of future disabling or life-threatening events caused by the same underlying disease process. 1 The CAPRIE trial enrolled 19,185 patients with either established peripheral arterial disease (PAD), 2,3 a recent myocardial infarction or recent ischemic stroke in approximately equal distribution. However, based on the baseline characteristics of these patients, many of them already had a prior history of ischemic events. Thus, at study entry ~26% of the patients had ischemic vascular disease in at least two vascular beds, demonstrating the generalized nature of atherothrombosis. 3 For example, 11.8% of patients had both coronary disease and PAD, 7.4% had both coronary and cerebrovascular disease, 3.8% had a combination of cerebrovascular disease and PAD, and 3.3% had disease of all three arterial beds. 3 Over time this overlap will most probably increase (in the CAPRIE trial more than 2,000 patients experienced a major ischemic event over the mean 1.9 year follow-up, and many others developed other ischemic events such as transient ischemic attack and angina). 3
  • In the UKPDS, each 1% decrease in annual mean A1C level reduced the risk of microvascular complications by 37%, peripheral vascular disease (PVD) by 43%, myocardial infarction (MI) by 14%, stroke by 12%, heart failure by 16%, and cataract extraction by 19%. These data indicate that over time there is a quantifiable relationship between the risk of complications of diabetes and glycemia. Reference Stratton IM, Adler, AI, Neil HA, et al. Association of glycemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000; 321:405-412.
  • Skyler JS. Endocrinol Metab Clin 1996
  • The chart on the right side of Figure 8 reflects the effect of A1C levels on event rates and covers a large range from 5.5% to 11%. It demonstrates that the risk of MI doubles from one extreme to another, showing that A1C is related to CHD. However, if we calculate the size of the effect, each 1% change in A1C is equivalent to about a 15% rise in risk of MI. Therefore, even if you bring someone's A1C level down from 10% to 6%, it is unlikely you will fully eliminate the 2- to 4-fold excess of cardiovascular disease in people with diabetes. On the other hand, a 15% change per 1% A1C is not trivial. A 2% change in A1C would reduce risk 30%, an effect similar to that seen in statin trials.[41] Therefore, it makes sense to use both approaches -- glucose and lipid control -- in at-risk people. Another reason to further examine the chart on the right side of Figure 8 is to understand why the slope is relatively gentle, reflecting modest impact of A1C on event risk. A possible explanation is that there is already increased risk of cardiovascular disease prior to the onset of type 2 diabetes. The increased triglycerides, decreased HDL, increased systolic blood pressure, and increased glucose and insulin levels that these patients have are all components seen in the various definitions of the metabolic syndrome, thus combining their effects to increase macrovascular risk beyond that which relates to A1C alone.
  • The hazard ratio was 0.67 (95 percent confidence interval, 0.46 to 0.97; P<0.04) for the comparison with nondiabetic subjects who had prior coronary heart disease and 1.43 (95 percent confidence interval, 1.00 to 2.03; P<0.05) for the comparison with nondiabetic subjects who did not have prior coronary heart disease.
  • CHD coronary heart disease; CVD cardiovascular disease; KQ key question. KQ 1: Does aspirin chemoprevention in patients without known cardiovascular disease reduce the risk for myocardial infarction, stroke, and death? KQ 2: Does aspirin chemoprevention increase major gastrointestinal bleeding, hemorrhagic strokes, or both? KQ 3: What is the balance of benefits and harms for aspirin therapy in patients with different levels of cardiovascular risk?
  • Summary of Primary Prevention Trials
  • Meta-analysis of total coronary heart disease events.P
  • Estimated MIs prevented and estimated harms of using aspirin for 10 years in a hypothetical cohort of 1000 men.Estimates are based on age and 10-year CHD risk. CHD = coronary heart disease; GI = gastrointestinal; MI = myocardial infarction.
  • 10-year CHD risk levels at which the number of cardiovascular disease events prevented is closely balanced to the number of serious bleeding events.CHD = coronary heart disease.
  • Hayden et al. Ann Intern Med 2002
  • Prevención primaria cardiovascular diabetes, rol de la Aspirina

    1. 1. REUNION DE PAPER SECCIÓN ENDOCRINOLOGIA Julián Vega Adauy Residente Medicina Interna UdeC
    2. 3. índice <ul><li>Introducción </li></ul><ul><li>FRCV, complicaciones macrovasculares e intervenciones </li></ul><ul><li>Riesgo Cardiovascular y Diabetes </li></ul><ul><li>Aspirina en prevención CV primaria, evidencias </li></ul><ul><li>Documentos de consenso y Conclusiones </li></ul>
    3. 5. Sir John Vane PREMIO NOBEL MEDICINA 1982 ASPIRINA INHIBE LA SÍNTESIS DE PROSTAGLANDINAS Samuelsson Bergström
    4. 6. Food and Drug Administration E.E.U.U (FDA) En enero 2004 rechazó la Aspirina para prevención primaria de cardiopatía coronaria
    5. 7. índice <ul><li>Introducción </li></ul><ul><li>FRCV, COMPLICACIONES MACROVASCULARES E INTERVENCIONES </li></ul><ul><li>Riesgo Cardiovascular y Diabetes </li></ul><ul><li>Aspirina en prevención CV primaria, evidencias </li></ul><ul><li>Documentos de consenso y Conclusiones </li></ul>
    6. 8. I, González-Maqueda. Rev Esp Cardiol Supl. 2007 LA ENFERMEDAD CORONARIA DEL DIABÉTICO. DIAGNÓSTICO, PRONÓSTICO Y TRATAMIENTO
    7. 9. ATEROTROMBOSIS TIENE MULTIPLES MANIFESTACIONES Drouet L. Cerebrovasc Dis 2002 TIA: Transient ischemic attack <ul><li>Angina </li></ul><ul><li>Estable </li></ul><ul><li>Inestable </li></ul>AVE IAM <ul><li>Enfermedad arterial periférica: </li></ul><ul><li>Clauidación </li></ul><ul><li>Insuficiencia arterial </li></ul>
    8. 10. <ul><li>MACRO X 2-4 RR </li></ul><ul><li>Cerebrovascular, carotídeo, Coronario (CHD), PAD, ICC </li></ul><ul><ul><li>>65ª, 68% CHD y 16% por causas Cerebrovasculares </li></ul></ul>US Centers for Disease Control and Prevention National Diabetes, 2007
    9. 12. R. Baechler y cols. Rev. méd. Chile  2002 FRCV ASOCIADOS A DIABETES MELLITUS
    10. 13. EL CUARTETO DE LA MUERTE IR DM2 HTA OBSD DZP Disfunción endotelial, complicaciones macro-micro
    11. 14. MANIFESTATIONS OF ATHEROTHROMBOSIS ARE COMMONLY FOUND IN MORE THAN ONE ARTERIAL BED IN AN INDIVIDUAL PATIENT *1 1. Coccheri S. Eur Heart J 1998; 19(suppl): P1268. *Data from CAPRIE study (n=19,185) Coronary disease Cerebrovascular disease Peripheral arterial disease 24.7% 3.8% 11.8% 29.9% 3.3% 7.4% 19.2%
    12. 15. PREVALENCIA DE COMPLICACIONES EN DIABETES
    13. 17. Resultados UKPDS Stratton IM, et al. BMJ . 2000 P <.0001 P = .035 P = .021 P = .0001 Reducción de riesgo con 1% de declinación annual de A1C 0% 15% 30% 45% MICRO VASCULAR 37% PAD 43% AVE IAM 14% 12% ICC Cx Catarata 16% 19%
    14. 19. Skyler JS. Endocrinol Metab Clin 1996 A1C Y COMPLICACIONES MICROVASCULARES
    15. 20. FRCV FRCV GBA FRCV IG FRCV DM ALTERACION METABOLISMO HdC CARDIOPATIA CORONARIA EFECTO SUMATIVO A FRCV
    16. 24. índice <ul><li>Introducción </li></ul><ul><li>FRCV, complicaciones macrovasculares e intervenciones </li></ul><ul><li>RIESGO CARDIOVASCULAR Y DIABETES </li></ul><ul><li>Aspirina en prevención CV primaria, evidencias </li></ul><ul><li>Documentos de consenso y Conclusiones </li></ul>
    17. 25. NEJM 1998
    18. 26. S, Haffner. NEJM 1998
    19. 27. NO DM DM S, Haffner. NEJM 1998
    20. 28. Riesgo de CV de Diabético se equipara a riesgo de no DM con IAM previo
    21. 29. Haffner SM, NEJM 1998 RIESGO SIMILAR
    22. 32. Mukamal KJ. Diabetes Care 2001 Haffner SM, NEJM 1998
    23. 34. DM sin IAM No DM DM 1.43 [1.0-2.03]* 0.67 [0.46-0.97]* No DM sin IAM No DM + IAM
    24. 36. 2005
    25. 37. RIESGO CARDIOPATIA CORONARIA EN DIABETICOS HAFFNER EVANS y otros 1.2 [0.6 - 2.4]a 1.33 [1.14-1.55]
    26. 39. índice <ul><li>Introducción </li></ul><ul><li>FRCV, complicaciones macrovasculares e intervenciones </li></ul><ul><li>Riesgo cardiovascular y diabetes </li></ul><ul><li>ASPIRINA EN PREVENCIÓN CV PRIMARIA, EVIDENCIAS </li></ul><ul><li>Documentos de consenso y Conclusiones </li></ul>
    27. 41. A. Lama, J. Vega. Rev. Chil Cardiología 2004 EVIDENCIA DE AAS EN PREVENCION PRIMARIA CV
    28. 43. SUMMARY OF PRIMARY PREVENTION TRIALS. Hayden M et al. Ann Intern Med 2002;136:161-172
    29. 44. CARDIOPATIA CORONARIA: META-ANALISIS Hayden M et al. Ann Intern Med 2002
    30. 45. Diabetes Care 26:3264-3272, 2003
    31. 46. Aspirina no reduce eventos CV ni mortalidad en diabéticos DM
    32. 47. -CONCLUSIÓN- En pacientes diabéticos, Aspirina no demostró ser efectiva en la prevención primaria de eventos cardiovasculares
    33. 48. ¿En que momento se produce un OFFSET del beneficio de AAS?
    34. 53. Booth GL et al. Lancet 2006 Moderate risk defined as a 10-year risk of 10%–19%. High risk defined as a 10-year risk of 20% or greater.
    35. 54. Booth GL, The Lancet 2006
    36. 56. Ann Intern Med 2009
    37. 57. 10-year CHD risk levels at which the number of cardiovascular disease events prevented is closely balanced to the number of serious bleeding events.CHD = coronary heart disease. Ann Intern Med 2009;150:396-404
    38. 58. NUEVAS EVIDENCIAS
    39. 63. índice <ul><li>Introducción </li></ul><ul><li>FRCV, complicaciones macrovasculares e intervenciones </li></ul><ul><li>Riesgo cardiovascular y diabetes </li></ul><ul><li>Aspirina En Prevención Cv Primaria, Evidencias </li></ul><ul><li>DOCUMENTOS DE CONSENSO Y CONCLUSIONES </li></ul>
    40. 67. MORTALI DAD
    41. 68. INFARTO AGUDO AL MIOCARDIO
    42. 69. INFARTO CEREBROVASCULAR
    43. 72. índice EVALUACION DEL RIESGO CARDIOVASCULAR
    44. 76. índice <ul><li>Introducción </li></ul><ul><li>FRCV, complicaciones macrovasculares e intervenciones </li></ul><ul><li>Riesgo cardiovascular y diabetes </li></ul><ul><li>Aspirina En Prevención Cv Primaria, Evidencias </li></ul><ul><li>CONCLUSIONES </li></ul>
    45. 78. RECOMENDACIONES Y CONCLUSIONES ONE <ul><li>AAS efecto modesto en al reducción de riesgo CV en pacientes DM (RR 10%) </li></ul><ul><ul><li>Dependiendo del riesgo basal de cada paciente </li></ul></ul><ul><li>Antes AAS a todo Diabético >40a &quot;o&quot; con FRCV mayores </li></ul><ul><li>En pacientes con RCV >1% x año </li></ul><ul><ul><li>Los efectos adversos (sangrado GI, Cerebral) son superados o igualados por la prevención de eventos CV (no fatales). </li></ul></ul><ul><ul><li>Considerar que un IAM no fatal no tiene la misma implicancia que una HDA </li></ul></ul><ul><li>HASTA LA EXISTENCIA DE NUEVA EVIDENCIA se recomienda: </li></ul><ul><li>AAS 75-162mg/dia, con RCV >10% a 10a que no tienen riesgo aumentado de sangrado </li></ul><ul><li>DM de alto riesgo CV generalmente incluyen: </li></ul><ul><ul><li>Hombres>50a y Mujeres>60a con uno o màs de: </li></ul></ul><ul><ul><ul><li>Tabaquismo, HTA, DZP, Historia familiar de CVD prematura, ProteU </li></ul></ul></ul>
    46. 79. RECOMENDACIONES Y CONCLUSIONES DOS <ul><li>AAS NO SE RECOMIENDA EN: </li></ul><ul><li>Los pacientes hombres <50a y mujeres<60 sin FRCV adicionales </li></ul><ul><li>En los pacientes con RCV 5-10% a 10a se debe considerar el caso puntual </li></ul><ul><li>CONCEPTO: </li></ul><ul><li>All patients with diabetes do not have high cardiovascular risk! </li></ul>
    47. 84. REUNION DE PAPER SECCIÓN ENDOCRINOLOGIA Julián Vega Adauy Residente Medicina Interna UdeC

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