Tabaquismo como factor de riesgo endotelial y disfuncion endotelial; Dr. Ricardo Mora Moreno R2C; IMSS UMAE T1; León, Guanajuato, Mexico; 09 de Noviembre del 2017

1. INSTITUTO MEXICANO DEL SEGURO SOCIAL
CENTRO MÉDICO NACIONAL DEL BAJÍO
UNIDAD MÉDICA DE ALTA ESPECIALIDAD
>>DEPARTAMENTO DE CARDIOLOGÍA<<
TEMA:
“TABAQUISMO COMO FACTOR DE RIESGOY DISFUNCION ENDOTELIAL”
DR. RICARDO MORA MORENO
RESIDENTE 2º AÑO CARDIOLOGIA (R2C)
LEON, GUANAJUATO
09 / NOVIEMBRE / 2017

2. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries
(the INTERHEART study): case-control study. Lancet 2004: 292: 1307-16
EPIDEMIOLOGIA

3. EPIDEMIOLOGIA
Centers for Disease Contro 1 and Prevention (US), National Center for Chronic Disease Prevention and Health Promotion (US), Office on Smoking and Health (US): How
tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the Surgeon General. Atlanta, Centers for Disease Control
and Prevention, 2010.(www.cdc.gov/tobacco/ data_statistics/sgr/2010/index.htm).
Muertes relacionadas
al tabaquismo
1 de cada 5
Muertes en fumadores
pasivos al año
49,000
Muertes de
fumadores al año
443, 000

4. Ezzati M, Lopez AD. Regional, disease specific patterns of smoking-Attrbutable mortality in 2000. Tob control 2004; 13: 388-95
EPIDEMIOLOGIA

5. Ezzati M, Lopez AD. Regional, disease specific patterns of smoking-Attrbutable mortality in 2000. Tob control 2004; 13: 388-95
EPIDEMIOLOGIA

6. Ezzati M, Lopez AD. Regional, disease specific patterns of smoking-Attrbutable mortality in 2000. Tob control 2004; 13: 388-95
EPIDEMIOLOGIA

7. Value in Health, de la Sociedad Internacional de Farmacoeconomía e Investigación de Resultados. Pichon-Riviere A, et al; 2011
EPIDEMIOLOGIA

8. EPIDEMIOLOGIA
Jha P, Ramasundarahettige C, Landsman V, et al: 21st-century hazards of smoking and benefits of cessation in the United States, N Engl J Med 368:341,2013.
Thun MJ, Carter BD, Feskanich D, et al: 50-year trends in smoking-related mortality in the United States, N Engl J Med 368:351,2013.
Esperanza
de vida 10
años menos
en
fumadores
Riesgo
similar en
ambos
géneros

9. Ezzati M, Henley SJ, Lopez AD,Thun MJ. Role of smoking in global and regional cardiovascular mortality. Circulation 2005; 112: 489-97
EPIDEMIOLOGIA

10. EPIDEMIOLOGIA
Mundialmente:
1.3 billones de personas son fumadoras
>50% son hombres
Njolstad I, Arnesen E, Lund-Larsen PG. Smoking, serum lipids, blood pressure, and sex differences in myocardial infarction. A 12-year follow-up of the Finnmark Study.
Circulation 1996; 93:450
Prescott E, Hippe M, Schnohr P, et al. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ 1998; 316:1043

11. EPIDEMIOLOGIA

12. EPIDEMIOLOGIA
L. Erhardt / Atherosclerosis 205 (2009) 23–32

13. EPIDEMIOLOGIA
Riesgo cardiovascular
Enfermedad Coronaria y EVC
2-4 veces mayor
Mortalidad Cardiopatía isquémica
Fumadores 35-40%
Fumadores pasivos 8%
Centers for Disease Control and Prevention: 2011 National Health Interview Survey (NHIS) Public Use Data Release. Division of Health Interview Statistics, National
Center for Health Statistics, 2012.

14. EPIDEMIOLOGIA
Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart
disease: a systematic review. JAMA 2003; 290: 86-87

15. EPIDEMIOLOGIA
Riesgo cardiovascular
IAM yTabaquismo >20 cigarrillos al día
Njolstad I, Arnesen E, Lund-Larsen PG. Smoking, serum lipids, blood pressure, and sex differences in myocardial infarction. A 12-year follow-up of the Finnmark Study.
Circulation 1996; 93:450
Prescott E, Hippe M, Schnohr P, et al. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ 1998; 316:1043
Mujeres
6 veces
Hombres
2 veces

16. EPIDEMIOLOGIA
Riesgo Enfermedad Coronaria y tabaquismo:
>40 cigarrillos al día = Riesgo 9.0
>15 cigarrillos al día = Riesgo 2.5
< 15 cigarrillos al día = Riesgo 2.0
Tolstrup JS, Hvidfeldt UA, Flachs EM, Et al. Smoking and risk of coronary heart disease in younger, middle-aged, and older adults. Am J Public Health 2014; 104: 96
Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet 2006; 368: 647

17. EPIDEMIOLOGIA
L. Erhardt / Atherosclerosis 205 (2009) 23–32

18. EPIDEMIOLOGIA
Law MR, Wald NJ. Enviromentaltobacco smoke and ischemic heart disease. Prog Cardiovasc Dis 2003; 46: 31-8

19. EPIDEMIOLOGIA
Dislipidemia y tabaquismo:
ColesterolTotal = +3%
Triglicéridos = +9.1%
VLDL = +10.4%
LDL= +1.7%
HDL= -5.7%
Craig WY, Palomaki GF, Haddow JF. Cigarette smoking and serum lipid and lipoprotein concentrations: an analysis of published data. Br Med J 1989; 298: 784-8

20. FISIOPATOLOGIA

21. FISIOPATOLOGIA
J A C CV O L . 7 0 , N O . 2 , 2 0 1 7 Niemann et al. J U LY 1 1 , 2 0 1 7 : 2 3 0– 51 Role of Oxidative Stress and CV Risk Factors

22. FISIOPATOLOGIA
J A C CV O L . 7 0 , N O . 2 , 2 0 1 7 Niemann et al. J U LY 1 1 , 2 0 1 7 : 2 3 0– 51 Role of Oxidative Stress and CV Risk Factors

23. FISIOPATOLOGIA
http://www.who.int/topics/tobacco/es/

24. FISIOPATOLOGIA
Cardiovascular toxicity of nicotine: Implications for electronic cigarette use; Neal L. Benowitz, Andrea D. Burbank;Trens in
cardiovascular medicine 26 (2016) 515-523

25. FISIOPATOLOGIA
Disfunción Endotelial
Daño
endotelial
Disminución
actividad NO
Endotelial
Disfunción
endotelial
L. Erhardt / Atherosclerosis 205 (2009) 23–32
Disminución flujo
coronario
Disminución oxigeno del
miocardio

26. FISIOPATOLOGIA
Aterogenesis
Incremento
actividad de
Macrófagos y
Plaquetas
Actividad
Metaloproteinasas
(MMPs)
Disminución
inhibidores de MMPs
Disfunción
endotelial
Morris et al. J A C CV O L . 6 6 , N O . 1 2 , 2 0 1 5 Cardiovascular Effects ofTobacco S E PT E M B E R 2 2 , 2 0 1 5 : 1 3 7 8– 91
Neovascularización

27. FISIOPATOLOGIA
Aterogenesis
Incremento células
y actividad
inflamatoria
Reclutamiento leucocitos
Aumento adhesión celular
(leucocitos y plaquetas)
Citocinas, FNT, Interleucina -1B
Morris et al. J A C CV O L . 6 6 , N O . 1 2 , 2 0 1 5 Cardiovascular Effects ofTobacco S E PT E M B E R 2 2 , 2 0 1 5 : 1 3 7 8– 91
Disfunción
endotelial

28. FISIOPATOLOGIA
Componentes Hemostasia yTrombosis
Rinder HM, Schuster JE, Rinder CS, et al. Correlation of thrombosis with incresed platelet turnover in thrombocytosis. Blood 1998; 91: 1288-94
Varol E, IcliA, Kocygit S, et al. Effect of smoking cessation on mean platelet volume. Clin ApplThromb Hemost 2013; 19: 315-9
Plaquetas
Incremento de
actividad
Incremento
adhesión
Pseudopodos
de superficie
Incremento
recuento
Disminución tras 3
meses suspensión
tabaquismo

29. FISIOPATOLOGIA
Componentes Hemostasia yTrombosis
Dotevall A, Johansson S, Wilhelmsen L. Association between fibrinogen na other risk factors for cardiovascular disese in men and women. Results from the Goteborg MONICA survey 1985. Ann Epidemiol
1994; 4: 369-74
Barua RS, Sy F, Srikanth S, et al. Effects of cigarette smoke exposure on clot dynamics and fibrina strcure: na ex vivo investigation. Arterioscler Thromb Vasc Biol 2010: 30: 75-9
Trombo
Aumento
niveles
fibrinógeno
plasmático
Incremento
Factor XIII
Disminución
expresión
inhibidor
factor tisular
Reducción
actividad
fibrinolitica
Consistencia coagulo
Mayor densidad
Distribución uniforme
Estabiliza
fibrina del
coagulo
Principal fuente
placa de
ateroma

30. FISIOPATOLOGIA
Cardiovascular toxicity of nicotine: Implications for electronic cigarette use; Neal L. Benowitz, Andrea D. Burbank;Trens in
cardiovascular medicine 26 (2016) 515-523

31. Morris et al. J A C CV O L . 6 6 , N O . 1 2 , 2 0 1 5 Cardiovascular Effects ofTobacco S E PT E M B E R 2 2 , 2 0 1 5 : 1 3 7 8– 91

32. Efectos Clínicos
Fribrinolisis
IAM y trombolisis
Mejor resultado en fumadores en
comparación a “No fumadores”
Efecto “Paradoja del Fumador”
Barbash GI, Reiner J, White HD, et al. Evaluation of paradoxic beneficial efectos of smoking in patients reciving thrombolityc therapy for acute myocardial infraction:
mechanism of the “smoker”s paradox” from the GUSTO-I Trial, with angiographic insights. Global Utilization of Streptokinase and Tissue-Plasminogen Activator for
Occluded Coronary Arteries. J Am Coll Cardiol 1995; 26: 1222

33. Efectos Clínicos
Fribrinolisis
GUSTO-I
Fumadores 17, 507
Ex-Fumadores 11,117
No fumadores 11,975
Barbash GI, Reiner J, White HD, et al. Evaluation of paradoxic beneficial efectos of smoking in patients reciving thrombolityc therapy for acute myocardial infraction:
mechanism of the “smoker”s paradox” from the GUSTO-I Trial, with angiographic insights. Global Utilization of Streptokinase and Tissue-Plasminogen Activator for
Occluded Coronary Arteries. J Am Coll Cardiol 1995; 26: 1222
Mortalidad
Intrahospitalaria
Mortalidad
30-días
3.7% 4.0%
9.9% 10.3%

34. Efectos Clínicos
Efecto “Paradoja del Fumador”
GUSTO-I
Barbash GI, Reiner J, White HD, et al. Evaluation of paradoxic beneficial efectos of smoking in patients reciving thrombolityc therapy for acute myocardial infraction:
mechanism of the “smoker”s paradox” from the GUSTO-I Trial, with angiographic insights. Global Utilization of Streptokinase and Tissue-Plasminogen Activator for
Occluded Coronary Arteries. J Am Coll Cardiol 1995; 26: 1222
Hematocrito
Fibrinogeno
Estado
Hipercoagulable
MásTrombo
Más
susceptibilidad

35. Efectos Clínicos
Revascularización:
ICP (EPIC, EPILOG, EPISTENT)
34% Fumadores
Riesgo IAM, Muerte, revascularización a 30 días
RR 1.22% (IC 1.02-1.47)
RVM (SYNTAX)
Tabaquismo, factor independiente
Predictor de IAM, EVC, Muerte
RR 1.8% (IC 1.3-2.5%)
Zhang YJ, Iqbal J, Van Klaveren D, et al. Smoking is associated with adverse clinical outcomes in patients undergoing revascularization with PCI or CABG: the SYNTAX
trial at 5-year follow-up. J Am Coll Cardiol 2015; 65:1107

36. TRATAMIENTO
Fiore M, Jaen C, Baker T, et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, MD: U. S. Departament of Health and Human
Services. Public Health service; 2008

37. PRONOSTICO
AbandonoTabaquismo y Riesgo Cardiovascular
Enfermedad Coronaria:
50% reducción (1-2 años)
Riesgo No fumadores (3-5 años)
EventoVascular Cerebral:
Riesgo No fumadores (5-15 años)
Malarcher A Dube S, Shaw L, et al: Quitting smoking among adults—United States, 2001-2010, MMRWMorb Mortal Wkly Rep 60:1513,2011.
Wilhelmsson C, Vedin JA, Elmfeldt D, et al. Smoking and myocardial infarction. Lancet 1975; 1:415

38. PRONOSTICO

39. PRONOSTICO
S.C. Campbell et al. / Atherosclerosis 201 (2008) 225–235

40. Gracias!!!