EVALUACION DEL RIESGO

CARDIOMETABOLICO

Dr. Daniel MenesesCardiólogo Intervencionista

4

V

SINDROME

CO40%RONARIOAGUDO

Dr. DANIEL MENESES

75% DE TODAS LAS MUERTES DE LOSADULTOS SE PRODUCEN PORATEROTROMBOSIS

Gives a comprehensive 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

Gives a comprehensive 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 AmericanDiabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the AmericanDiabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.

Hay diferencias de genero en el riesgo cardiovascular ???

OBESOFUMADORSEDENTARIO

Sr. Winston Churchill

No SOBREPESONO FUMADORMUY ACTIVO

Jim Fixx,

QUIEN TIENE MAYOR RIESGO CARDIOVASCULAR BASADO EN SU SCORE ?

EL CONTINUO CARDIOVASCULAREL CONTINUO CARDIOVASCULAR

HipertensiónDiabetes

DislipidemiaObesidad Central

ArteriosclerosisRemodelado vascular

LVH> Grosor IM

Infarto lacunarMicroalbuminuria

IM, AnginaACV

Insuficiencia Cardiaca CongestivaInsuficiencia Renal

Enfermedad Arterial Periferica Eventos recurrentes

no mortales

ICCIRC

DiálisisDemencia

GenesEstilo de vida Muerte

Adaptado de Dzau et al. Circulation 2006;114:2850-2870.

EL CONTINUO URBANOEL CONTINUO URBANO

Consumo de Lácteos

Muerte

1..

Ver televisiónInternetSedentarismo

Comida Chatarra

Azúcar blancaGrasas TransJarabe de Maíz alto en FructosaHarina blancaGrasas Saturadas

PesticidasHerbicidasDesechosindustriales

StressPolución yDegradación ambientalDrogas

Sodio excesivo

Sodio excesivo

NacimientoEstilos de Vida

Meneses D. El corazón en tus manos 2010

Abnormal Lipid Metabolism

LDL ApoB HDL Trigly.

Abnormal Lipid Metabolism

LDL ApoB HDL Trigly.

Cardiometabolic Risk

Global Diabetes / CVD Risk

Overweight / ObesityOverweight / Obesity

Inflammation Hypercoagulation

Inflammation Hypercoagulation

HypertensionHypertension

SmokingPhysical InactivityUnhealthy Eating

SmokingPhysical InactivityUnhealthy Eating

Age, Race, Gender,

Age, Race, Gender,

Family HistoryFamily History

GlucoseGlucoseBPBP Lipids Lipids

AgeAge GeneticsGenetics

Insulin ResistanceInsulin Resistance

?? Insulin Resistance Syndrome

Insulin Resistance Syndrome

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.

Caso clìnico

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.

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.

Examen Fìsico

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.

Datos de Laboratorio

Examen de orina: 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

HIPERTROFIA VENTRICULAR IZQUIERDA

ECOCARDIOGRAMA. HIPERTROFIA VI

Flujo mitral.

Protocolo de Bruce suspendida en la III etapa.

Molestia precordial inespecífica Alteraciones inespecificas del segmento ST

Prueba de Esfuerzo

Diabetes Mellitus tipo 2Hipertensión Arterial ModeradaObesidad Insuficiencia Renal LeveCardiopatía HipertensivaHipercolesterolemia

Diagnosticos

 The Framingham Heart Study. Circulation. 2008;117:743-753.

Es util el score de Framingham en este paciente para predecir riesgo Cardiovascular?

a)SIb)No

This tool is only 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. 

https://www.itsmyhealthrecord.com/ACCriskform2008.lasso

https://www.itsmyhealthrecord.com/ACCriskform2008.lasso

Patients with low risk 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

2012;344:e3485 doi: 10.1136/bmj.e3485 (Published 12 June 2012)

Objectives To develop prediction models that better estimate the pretestprobability 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 previouscoronary artery disease, if they were referred for computed tomography(CT) based coronary angiography or catheter based coronaryangiography (indicated as low and high prevalence settings, respectively).

2012;344:e3485 doi: 10.1136/bmj.e3485 (Published 12 June 2012)

Results We included 5677 patients (3283 men, 2394 women), of whom1634 had obstructive coronary artery disease found on catheter basedcoronary angiography. All potential predictors were significantlyassociated with the presence of disease in univariable and multivariableanalyses. The clinical model improved the prediction, compared withthe basic model (cross validated c statistic improvement from 0.77 to0.79, net reclassification improvement 35%); the coronary calcium scorein 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 pretestprobability of coronary artery disease in low prevalence populations.Addition of coronary calcium scores to the prediction models improvesThe estimates.

http://rcc.simpal.com/RCEval.cgi

http://rcc.simpal.com/RCEval.cgi

Of 136,905 patients hospitalized with CAD, 77% had normal LDL levels below 130 mg/dl

Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology,

Detection and Treatment. Humana Press, 2009

Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009Chapter 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

Of 136,905 patients hospitalized with CAD, 61.8% had normal triglyceride levels below 150 mg/dl

Modified from Sachdeva et al. AHJ, Vol 157, 111-117 Jan 2009Chapter 1: Preventive Cardiology; the SHAPE of the Future in Naghavi et al. Asymptomatic Atherosclerosis: Pathophysiology,

Detection and Treatment. Humana Press, 2009

No SOBREPESONO FUMADORMUY ACTIVO

Jim Fixx, 53 años

QUIEN TIENE MAYOR RIESGO CARDIOVASCULAR BASADO EN SU SCORE ?

CANCER DE COLON Y ATEROSCLEROSIS. LO QUE DEBEMOS APRENDER DE LOS ONCOLOGOS

Atherosclerosis Test

Very Low Risk3

Negative Test• CACS =0• CIMT <50th percentile

LowerRisk

ModerateRisk

Positive Test• CACS ≥1• CIMT 50th percentile or Carotid Plaque

ModeratelyHigh Risk

HighRisk

VeryHigh 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 3Optional

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.

Score de calcio

Score de calcio 300

MASCULNO DE 70 AÑOS, HIPERTRIGLICERIDEMIA, HIPERTENSION, PRUEBAS DE ESFUERZO NEGATIVAS CADA AÑO POR CINCO AÑOS

Coronary Calcium Progression

Calcium Score: 56 Calcium 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

Carotid Intima Media Thickness (CIMT) 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.

NNT NNH

PREVENCIONSECUNDARIA

40 240

PREVENCION PRIMARIA

1430 2500

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

JAMA. 2012;307(21):2286-2294

De Berardis G, Lucisano G, D’Ettore A et al.  Association of Aspirin Use With Major Bleeding in Patients With and Without Diabetes. 

Estatinas para todos

Estatinas para todos

Estatinas para todos

For every 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.

Monoterapia dosis plenaTerapia dual dosis intermediaTerapia triple dosis bajasTerapia triple dosis intermedias

Terapia cuadruple

Tratamiento farmacològico inicial

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

Decidiò una combinaciòn, por què?

Por su efecto 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

Por què escogerìa candesartan?

xx/xx/xxxx Editor: Presentation name here 66

Beneficios de los ARA II sobre los inhibidores ECA

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

xx/xx/xxxx Editor: Presentation name here 67

PRINCIPIOS DE TERAPIA CON ANTAGONISTAS DE RECEPTORES DE AT II

Candesartán, losartán, telmisartán, valsartán, irbesartán

+ Bloqueador selectivo receptor AT1 + Utiles en falla cardíaca - HVI + Diabetes Mellitus + < tos y angioedema + Post-infarto del miocardio

xx/xx/xxxx Editor: Presentation name here 69

Candesartan: propiedades seleccionadas

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

xx/xx/xxxx Editor: Presentation name here 70

Candesartan: eventos adversos en los estudios en hipertensión

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

ARA-II y Cáncer

31 estudios: 84.461 pts tratados con ARA-IIOR: 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 laexpectativa de vida y, por tanto, el riesgo de cancer”