Avances en arterioesclerosis 2015
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Presentación en el curso Update 2015 Hospital Cima Sanitas Barcelona. Últimas novedades en el diagnóstico y tratamiento de la arterioesclerosis y sus factores de riesgo.
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Avances en arterioesclerosis 2015
- 1. Avances en Arterioesclerosis Dr César Morcillo Serra Medicina Interna, Hospital CIMA Sanitas 8 de mayo de 2015
- 2. Sanitas
- 3. Sanitas Iceberg de las enfermedades cardiovasculares en España Rev Esp Cardiol 2007; 60:470 Diagnóstico
- 4. Sanitas • Personas asintomáticas con: • SCORE >5% • Diabetes mellitus • Síndrome metabólico • Hipertrofia ventricular izquierda • Enfermedad renal: microalbuminuria o insuficiencia renal crónica • Personas con arteriosclerosis (con o sin síntomas): • Coronaria • Arterial periférica • Cerebrovascular Enfermos de alto riesgo cardiovascular Diagnóstico
- 8. Sanitas Diagnóstico 1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use: -High-sensitivity C-reactive protein -Albuminuria -Coronary artery calcium (CAC) score -Measurement of carotid intima-media thickness -Ankle-brachial index (ABI)
- 9. Sanitas Diagnóstico 1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use: -High-sensitivity C-reactive protein, -Albuminuria, -Coronary artery calcium (CAC) score, -Measurement of carotid intima-media thickness, -Ankle-brachial index (ABI).
- 10. Sanitas Diagnóstico 1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use: -High-sensitivity C-reactive protein -Albuminuria -Coronary artery calcium (CAC) score -Measurement of carotid intima-media thickness -Ankle-brachial index (ABI)
- 12. Sanitas Diagnóstico 1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use: -High-sensitivity C-reactive protein -Albuminuria -Coronary artery calcium (CAC) score -Measurement of carotid intima-media thickness -Ankle-brachial index (ABI)
- 13. Sanitas • Cuantificación del calcio coronario • Coronariografía por TAC Diagnóstico
- 14. Sanitas • Aporta algo hacer una Coronariografía por TAC? Diagnóstico
- 15. Sanitas • 243 patients without known atherosclerosis. 54% patients had coronary atherosclerosis. • Detection of silent coronary atherosclerosis increases the risk of having an event 7,2 times. • 76% low-intermediate SCORE risk patients should be reclassified to high risk. Diagnóstico
- 16. Sanitas Diagnóstico 1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use: -High-sensitivity C-reactive protein -Albuminuria -Coronary artery calcium (CAC) score -Measurement of carotid intima-media thickness -Ankle-brachial index (ABI)
- 17. Sanitas Eco doppler arterial: Permite: – Medir grosor de la íntima – Definir tipo de placa y grado de estenosis. – Sensibilidad: 92-100%, Especificidad: 93-100%. Diagnóstico
- 19. Sanitas Possibly beneficial: Stanol/sterol ester margarines (2 g per day) [IID] Not recommended: Vitamin C, vitamin E, and beta-carotene supplementation in patients with ischemic heart disease [IIIA] Treatment of elevated homocysteine with folate or vitamins B6 & B12 in patients with ischemic heart disease [IIIA] Garlic, coenzyme Q10, selenium and chromium [IIID] Chelating therapy [IIID] Not recommended and possibly harmful: Estrogen therapy in post-menopausal women with stable IHD and or history of stroke [IIIA] Testosterone in men with ischemic vascular disease (IVD) [IIIB] Tratamiento
- 21. Sanitas Following non-cardioembolic stroke: - Antiplatelets are recommended over anticoagulation. Acceptable options are: aspirin 50 mg to 325 mg daily, aspirin 25 mg plus dipyridamole 200mg twice daily, and clopidogrel 75 mg daily [IA]. - Not recommended for long term prevention of stroke: combination of aspirin and clopidogrel This combination increases the risk of hemorrhage [IIIA]. - If stroke occurs on an antiplatelet agent: No evidence exists for the effectiveness of changing the dose or switching to a different antiplatelet agent [IIID]. Tratamiento
- 23. Sanitas • Do not offer omega-3 fatty acid compounds for the prevention of CVD • Do not offer a bile acid sequestrant for the prevention of CVD (Resincolesteramina, Colestid) • Do not exclude from statin therapy people who have liver transaminase levels less than 3 times the upper limit of normal • Do not stop statins because of an increase in blood glucose level or HbA1c Tratamiento
- 24. Sanitas • Adults ≥21 years of age with primary LDL-C ≥190 mg/dL should be treated with statin therapy • Adults with LDL-C >70 mg/dL, with clinical ASCVD or diabetes or with an estimated 10-year risk ≥7.5% should be treated with statin. • Decreasing the statin dose may be considered when 2 consecutive values of LDL-C levels are <40 mg/dL • It may be harmful to increase the dose of simvastatin to 80 mg daily. • If unexplained muscle symptoms or fatigue develop during statin therapy: • 1º: Discontinue the statin. • 2º: If muscle symptoms resolve, give the patient the original dose of the same statin to establish a causal relationship between the muscle symptoms and statin therapy. • 3º: If a causal relationship exists, discontinue the original statin. Once muscle symptoms resolve, use a low dose of a different statin. Tratamiento
- 29. Sanitas PCSK9 inhibitors: • ODYSSEY (Alirocumab 1 iny/2 semanas) and the OSLER (Evolocumab 1 iny/2 ó 4 semanas) trials included patients with elevated LDL cholesterol values despite statin use. • As compared with placebo or standard therapy, both reduced LDL cholesterol levels by an average of 62%. • Both studies showed 50% reductions in cardiovascular events at 12 to 18 months. • Both studies showed no adverse effects overall or in those who had an LDL cholesterol level of less than 25 mg per deciliter, but more follow-up and specific assessment of neurocognitive function is needed. Tratamiento
- 30. Sanitas Conclusiones • DIAGNÓSTICO: • 1º estratificar riesgo: SCORE • 2º si riesgo intermedio o dudas hacer: PCR, albuminuria, Doppler TSA, Calcio coronario o ITB. • También tienen alto riesgo: DM, HVI, sd metabólico, esteatosis, genes. • TRATAMIENTO: • Usar fitoesteroles. • Prediabetes: metformina si IMC>35 y <60 años • Evitar AAS + sintrom • Hipercolesterolemia: • Estatinas en LDL ≥190 o alto riesgo + LDL >70 mg/dL • Si aparace DM pasar a estatina menos diabetogénica (pitavastatina) • Ezetimiba si LDL >70 • Fenofibrato si TG >150 y HDL<40