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![ Direct in vivo measurement of thickness of carotid
artery wall by B-mode ultrasound
Vessel wall thickness correlates with status of
atherosclerosis and CV events
Atherosclerosis is a systemic disorder
◦ Atherosclerosis in the carotid artery is predictive of disease in
other vascular beds
de Groot E, et al. Circulation. (2004) 109[Suppl III]:III-33-III-38.](https://image.slidesharecdn.com/riesgocardiometaboliconov2012-130806083411-phpapp02/85/RIESGO-CARDIOMETABOLICO-52-320.jpg)
Uploaded byDaniel Meneses
RIESGO CARDIOMETABOLICO
Los fármacos recomendados para iniciar el tratamiento antihipertensivo en este paciente son: - Candesartán: por su demostrada capacidad para disminuir la hipertrofia ventricular izquierda y reducir la proteinuria, lo que es importante dado que el paciente presenta diabetes e hipertrofia ventricular. - Telmisartán: al igual que el candesartán, ha demostrado reducir la proteinuria en pacientes diabéticos. Además, posee efecto antioxidante y antiaterogénico que son beneficiosos en este tipo de pacientes. - V
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RIESGO CARDIOMETABOLICO
- 1. Dr. Daniel Meneses CardiólogoIntervencionista
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- 5. 75% DE TODASLAS MUERTES DE LOS ADULTOS SE PRODUCEN POR ATEROTROMBOSIS
- 6. Gives acomprehensive picture of a patient’s health and potential risk for future disease and complications Is inclusive of all risks related to metabolic changes associated with CVD Accommodates emerging risk factors as useful predictive tools Focuses clinical attention to the value of systematic evaluation, education, disease prevention and treatment Supports an integrated approach to care Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.
- 7. Hay diferencias degenero en el riesgo cardiovascular ???
- 8. OBESO FUMADOR SEDENTARIO Sr. Winston Churchill NoSOBREPESO NO FUMADOR MUY ACTIVO Jim Fixx, QUIEN TIENE MAYOR RIESGO CARDIOVASCULAR BASADO EN SU SCORE ?
- 9. Hipertensión Diabetes Dislipidemia Obesidad Central Arteriosclerosis Remodelado vascular LVH >Grosor IM Infarto lacunar Microalbuminuria IM, Angina ACV Insuficiencia Cardiaca Congestiva Insuficiencia Renal Enfermedad Arterial Periferica Eventos recurrentes no mortales ICC IRC Diálisis Demencia Genes Estilo de vida Muerte Adaptado de Dzau et al. Circulation 2006;114:2850-2870.
- 10. Consumo de Lácteos Muerte 1.. Ver televisión Internet Sedentarismo Comida Chatarra Azúcarblanca Grasas Trans Jarabe de Maíz alto en Fructosa Harina blanca Grasas Saturadas Pesticidas Herbicidas Desechos industriales Stress Polución y Degradación ambiental Drogas Sodio excesivo NacimientoEstilos de Vida Meneses D. El corazón en tus manos 2010
- 11. Abnormal Lipid Metabolism LDL ApoB HDL Trigly. Cardiometabolic Risk Global Diabetes/ CVD Risk Overweight / Obesity Inflammation Hypercoagulation Hypertension Smoking Physical Inactivity Unhealthy Eating Age, Race, Gender, Family History GlucoseBPLipids Age Genetics Insulin Resistance ?Insulin Resistance Syndrome
- 12. Paciente masculino,45ª. Casado, comerciante. Motivo de Consulta: evaluaciòn CV anual. Hx. Actual: asintomàtico CV. Antecedentes personales: tabaquismo 20/dìa desde los 15ª. Bebe: 4-6 cervezas por semana y un promedio de ½ botella de licor semanal. No refiere alergias y hace ejercicio en gimnasio 1 hora diaria.
- 14. Antecedentes Patológicos:Enf. Péptica desde hace 2 años, en Tx.irregular. Hernia de disco por lo cual toma en forma regular AINES. Accidente de auto a los 40ª. le resecaron el riñón izquierdo. Antecedentes familiares: madre diabética tipo 2 en tratamiento, actualmente tiene 70 años. Padre sufrió IAM a los 65 años y está Asx.
- 15. Examen Fìsico:PA: 170/110, FC: 96x´, FR: 14x´ IMC: 32 . CA: 120cms. Ojos: fondo de ojo: retinopatìa G-1 Cuello: pulso carotideo: nls. No plétora yugular. Tiroides: normal. Corazón Rítmico, 1er. Y 2do. ruido normales. No hay 4to. ruido. No hay soplos. Pulmones: normales.
- 16. Hematologìa :Hb 18 gms/dl. Ht: 52%. GB: 7500. Fòrmula diferencial: normal. Glucosa: 175 mgs%. Nitrògeno de Urea: 25mgs% (10-20mgs%), creatinina: 1.5 mgs% (0.5-1.3 mgs%). TGO: 23mgs% (10-34mgs%), TGP: 20 mgs% (15-40 mgs5). Bilirrubinas y proteínas normales.
- 17. Examen deorina: densidad urinaria 1.005 (1.010-1.030). Proteinas 300mgs%. Glucosuria ++. Leucitos 1-2xcampo. Eritrocitos 1-2 campo no hay cilindros. TSH 2.2 (0.4 a 4 mU/l CT: 250 mgs%, LDLc: 170 mgs%, HDLc: 30 mgs%, TG: 150 mgs%. PSA: normal
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- 21. Protocolo deBruce suspendida en la III etapa. Molestia precordial inespecífica Alteraciones inespecificas del segmento ST
- 22. Diabetes Mellitustipo 2 Hipertensión Arterial Moderada Obesidad Insuficiencia Renal Leve Cardiopatía Hipertensiva Hipercolesterolemia
- 25. The Framingham HeartStudy. Circulation. 2008;117:743-753.
- 26. Es util elscore de Framingham en este paciente para predecir riesgo Cardiovascular? a)SI b)No
- 27. This tool isonly useful for assessing the risk of suffering a heart attack or dying due to coronary disease for people age 20 or older who do not already have heart disease and have not been diagnosed with diabetes.
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- 31. Patients with lowrisk of CHD usually do not benefit from further testing (for example by ExECG) and such tests will often show "false positive“ Results Patients with intermediate risk are most appropriate for ExECG testing, to provide a more accurate assessment of the probability of CHD (See Duke Treadmill Risk Score) Patients with high risk of CHD do not need ExECG for "diagnosis“, but ExECG is still useful in determining prognosis. Angiography will often be appropriate. Duke Risk Score
- 33. 2012;344:e3485 doi: 10.1136/bmj.e3485(Published 12 June 2012) Objectives To develop prediction models that better estimate the pretest probability of coronary artery disease in low prevalence populations. Design Retrospective pooled analysis of individual patient data. Setting 18 hospitals in Europe and the United States. Participants Patients with stable chest pain without evidence for previous coronary artery disease, if they were referred for computed tomography (CT) based coronary angiography or catheter based coronary angiography (indicated as low and high prevalence settings, respectively).
- 34. 2012;344:e3485 doi: 10.1136/bmj.e3485(Published 12 June 2012) Results We included 5677 patients (3283 men, 2394 women), of whom 1634 had obstructive coronary artery disease found on catheter based coronary angiography. All potential predictors were significantly associated with the presence of disease in univariable and multivariable analyses. The clinical model improved the prediction, compared with the basic model (cross validated c statistic improvement from 0.77 to 0.79, net reclassification improvement 35%); the coronary calcium score in the extended model was a major predictor (0.79 to 0.88, 102%). Calibration for low prevalence datasets was satisfactory. Conclusions Updated prediction models including age, sex, symptoms, and cardiovascular risk factors allow for accurate estimation of the pretest probability of coronary artery disease in low prevalence populations. Addition of coronary calcium scores to the prediction models improves The estimates.
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- 39. Of 136,905 patientshospitalized with CAD, 77% had normal LDL levels below 130 mg/dl Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009 Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment. Humana Press, 2009
- 40. Modified from Sachdevaet al. AHJ, Vol 157, 111-117 Jan 2009 Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment. Humana Press, 2009 Of 136,905 patients hospitalized with CAD, 45.4% had normal HDL levels above 40 mg/dl
- 41. Of 136,905 patientshospitalized with CAD, 61.8% had normal triglyceride levels below 150 mg/dl Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009 Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment. Humana Press, 2009
- 44. No SOBREPESO NO FUMADOR MUYACTIVO Jim Fixx, 53 años QUIEN TIENE MAYOR RIESGO CARDIOVASCULAR BASADO EN SU SCORE ?
- 45. CANCER DE COLONY ATEROSCLEROSIS. LO QUE DEBEMOS APRENDER DE LOS ONCOLOGOS
- 47. Atherosclerosis Test Very LowRisk3 Negative Test • CACS =0 • CIMT <50th percentile Lower Risk Moderate Risk Positive Test • CACS ≥1 • CIMT 50th percentile or Carotid Plaque Moderately High Risk High Risk Very High Risk No Risk Factors5 + Risk Factors • CACS <100 & <75th% • CIMT <1mm & <75th% & no Carotid Plaque • Coronary Artery Calcium Score (CACS) or • Carotid IMT (CIMT) & Carotid Plaque4 • CACS 100-399 or >75th% • CIMT 1mm or >75th% or <50% Stenotic Plaque • CACS >100 & >90th% or CACS 400 • 50% Stenotic Plaque6 LDL Target <160 mg/dl <130 mg/dl <130 mg/dl <100 Optional <100 mg/dl <70 Optional <70 mg/dl Re-test Interval 5-10 years 5-10 years Individualized Individualized Individualized All >75y receive unconditional treatment2 Apparently Healthy Population Men>45y Women>55y1 ExitExit Myocardial IschemiaTest NoAngiography Follow Existing Guidelines Yes The 1st SHAPE Guidelines Step 1 Step 2 Step 3 Optional CRP>4mg ABI<0.9 1: No history of angina, heart attack, stroke, or peripheral arterial disease. 2: Population over age 75y is considered high risk and must receive therapy without testing for atherosclerosis. 3: Must not have any of the following: Chol>200 mg/dl, blood pressure >120/80 mmHg, diabetes, smoking, family history, metabolic syndrome. 4: Pending the development of standard practice guidelines. 5: High cholesterol, high blood pressure, diabetes, smoking, family history, metabolic syndrome. 6: For stroke prevention, follow existing guidelines.
- 48. Score de calcio Scorede calcio 300
- 49. MASCULNO DE 70AÑOS, HIPERTRIGLICERIDEMIA, HIPERTENSION, PRUEBAS DE ESFUERZO NEGATIVAS CADA AÑO POR CINCO AÑOS
- 50. Calcium Score: 56Calcium Score: 90 Calcium Score: 128 Volume Score: 45 Volume Score: 78 Volume Score: 113 1993 1995 1997 Progression of Right coronary artery calcium score over 5 years
- 52. Direct invivo measurement of thickness of carotid artery wall by B-mode ultrasound Vessel wall thickness correlates with status of atherosclerosis and CV events Atherosclerosis is a systemic disorder ◦ Atherosclerosis in the carotid artery is predictive of disease in other vascular beds de Groot E, et al. Circulation. (2004) 109[Suppl III]:III-33-III-38.
- 53. NNT NNH PREVENCION SECUNDARIA 40 240 PREVENCION PRIMARIA 14302500 ASPIRINA , NNT Y NNH EN PREVENCION CARDIOVASCULAR 6:1 Siller-Matula JM. Hemorrhagic complications associated with aspirin: An underestimated hazard in clinical practice. JAMA 2012; 307:2318-2320. 2:1
- 54. JAMA. 2012;307(21):2286-2294 De BerardisG, Lucisano G, D’Ettore A et al. Association of Aspirin Use With Major Bleeding in Patients With and Without Diabetes .
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- 59. Estatinas para todos Forevery 1,000 people in the low-risk group treated with statins for five years there would be 11 fewer major heart attacks or strokes. “A benefit that greatly exceeds any known hazards of statin therapy,” the authors wrote.
- 61. Monoterapia dosisplena Terapia dual dosis intermedia Terapia triple dosis bajas Terapia triple dosis intermedias Terapia cuadruple
- 62. Paciente diabètico Hay evidencia de proteinuria Se detectò hipertrofia ventricular Es un paciente jòven El nivel de PA es muy elevado La cifra objetivo de reducciòn en este caso es mayor a 20/10 mmHg
- 65. Por suefecto prolongado. Por su alta afinidad al receptor AT1 Por su demostrada capacidad para disminuir la hipertrofia ventricular izquierda Por que disminuye la proteinuria Por que el paciente tiene disfunción endotelial Por que es muy útil en pacientes con DM2 y síndrome metabólico
- 66. xx/xx/xxxx Editor: Presentationname here 66 Los ARA II brindan un bloqueo más específico y selectivo de los efectos de la angiotensina II que los inhibidores ECA Los ARA II tienden a tener una tolerabilidad más favorable que los inhibidores ECA Contrario a los inhibidores ECA, los ARA II no interrumpen la degradación de la bradicinina, lo que lleva a una incidencia mucho menor de tos relacionada al tratamiento
- 67. xx/xx/xxxx Editor: Presentationname here 67 Candesartán, losartán, telmisartán, valsartán, irbesartán + Bloqueador selectivo receptor AT1 + Utiles en falla cardíaca - HVI + Diabetes Mellitus + < tos y angioedema + Post-infarto del miocardio
- 69. xx/xx/xxxx Editor: Presentationname here 69 Bloqueo específico de los efectos de la angiotensina II mediante el bloqueo selectivo del receptor AT1 Induce una reducción dosis-dependiente en la respuesta de la PAD a angiotensina II exógena El efecto antihipertensivo persiste por más de 24 horas; esta larga duración de la acción parece estar relacionada a una lenta tasa de disociación del receptor AT1 Tiene una tolerabilidad parecida a placebo en los estudios clínicos
- 70. xx/xx/xxxx Editor: Presentationname here 70 Candesartan (n=1388) Placebo (n=573) Dolor de cabeza Infección respiratoria Dolor de espalda Mareos Náusea Tos % de pacientes que reportan eventos adversos 114321 5 6 7 10980
- 71. 31 estudios: 84.461pts tratados con ARA-II OR: 0.99 (0.92-1.06) (1.82/100 pts.año ARA-II vs 1.84/100 pts.año otro tto) “Un fármaco que reduce la mortalidad CV aumenta la expectativa de vida y, por tanto, el riesgo de cancer”