PATRICIO LÓPEZ-JARAMILLO MD PhD FACP DIRECTOR DE INVESTIGACION Y DE LA CLINICA DE...
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Transcript of PATRICIO LÓPEZ-JARAMILLO MD PhD FACP DIRECTOR DE INVESTIGACION Y DE LA CLINICA DE...
PATRICIO LÓPEZ-JARAMILLO MD PhD FACP
DIRECTOR DE INVESTIGACION Y DE LA CLINICA DE SINDROMEMETABOLICO, PREDIABETES Y DIABETES. FOSCAL
DIRECTOR DE INVESTIGACIONES DE LA FACULTAD DE MEDICINA DE LA
UNIVERSIDAD DE SANTANDER UDES
BUCARAMANGA-COLOMBIA
LECCIONES APRENDIDAS DE LOS LECCIONES APRENDIDAS DE LOS ESTUDIOS INTERHEART, ESTUDIOS INTERHEART, INTERSTROKE Y PUREINTERSTROKE Y PURE
DEATHS FROM CVD WORLDWIDE
Over 70% of the global
burden of heart
attack and stroke is in developing countries
0
5
10
15
20
25
30
Establishedeconomiesand formersocialistcountries
Developingcountries
1990 2020
9
5
6
19
CV
D D
eath
s (m
illi
on
s)
KS Reddy. NEJM 2004; 350:2438
Epidemiological data indicates a continuous relationship between blood pressure level and CAD related mortality
COMPARISON OF THE LA INTERHEART STUDY RISK FACTOR PROFILES WITH THE
OVERALL INTERHEART STUDY
Lanas, et al. Circulation. 2007;115:1067-1074
ODDS RATIOS OF ACUTE MYOCARDIAL INFARCTION AND CORRESPONDING
POPULATION-ATTRIBUTABLE RISKS BY GENDER
Lanas, et al. Circulation. 2007;115:1067-1074
Rueda-Clausen et al. International Journal of Cardiolology. 2008;125:111-112.Rueda-Clausen et al. International Journal of Cardiolology. 2008;125:111-112.
EPIDEMIC OF OVERWEIGHT AND OBESITY IN EPIDEMIC OF OVERWEIGHT AND OBESITY IN LATIN AMERICA AND THE CARIBBEANLATIN AMERICA AND THE CARIBBEAN
LA TRIADA CARDIOMETABOLICA
DIABETES / ENFERMEDAD CARDIO-CEREBRO VASCULAR
HIPERINSULINISMO/ RESISTENCIA A LA
INSULINA
INFLAMACION DE BAJO GRADO
OBESIDAD ABDOMINAL
.
RAS EXPRESSION IN HUMAN ADIPOSE TISSUE
Karlsson C, et al. J Clin Endocrinol Metab. 1998; 83: 3925-3929
ANGIOTENSIN II ENHANCES ENDOTHELIAL TNF ΑLPHA PROTEIN PRODUCTION
Arenas et al, Am J Physiol. Cell Physiol. 2004 ; 286 : C779-C784
Risk factor Overall Hypertensive Nonhypertensives P value mean% mean% mean%
(n=300) (n=138) (n=162)____________________________________________________________________________________
Age (years) 59.8 65.2 55.2 <0.001 BMI (kg/m2) 28.6 29.6 27.8 0.002 Waist circunf 103.2 104.8 101.9 0.008 Fasting glicemia (mg/dL, mean) 100.2 107.0 94.3 <0.001 ____________________________________________________________________________________BMI, body mass index
MEAN VALUES OF CONTINUOUS RISK FACTORS FOR HIGH BLOOD PRESSURE
BY HYPERTENSION STATUS
Bautista et al. J Hypertens 2001;19:857-861
CRUDE AND SEX AND AGE ADJUSTED CRUDE AND SEX AND AGE ADJUSTED PREVALENCE FOR HYPERTENSION BY PREVALENCE FOR HYPERTENSION BY
C-REACTIVE PROTEIN QUARTILESC-REACTIVE PROTEIN QUARTILES
Bautista et al. J Hypertens Bautista et al. J Hypertens 2001;19:857-8612001;19:857-861
TUMOR NECROSIS FACTOR ALPHA TUMOR NECROSIS FACTOR ALPHA AND FLOW MEDIATED AND FLOW MEDIATED
VASODILATATIONVASODILATATION
López-Jaramillo et al. Rev Esp Cardiol. 2007;60:168-178
BLOOD PRESSURE AND C REACTIVE BLOOD PRESSURE AND C REACTIVE PROTEIN IN A HISPANIC PEDIATRIC PROTEIN IN A HISPANIC PEDIATRIC
POPULATIONPOPULATION
López-Jaramillo et al. Am J Hypertens 2008; 21: 527-532
PLASMA ASYMMETRIC DIMETHYLARGININE AND C-REACTIVE PROTEIN
CONCENTRATIONS
Garcia et al. Int J Cardiol 2007;127:176-178Garcia et al. Int J Cardiol 2007;127:176-178
INSULIN RESISTANCE: FOCUS ON INSULIN RESISTANCE: FOCUS ON SIGNALING PATHWAYSSIGNALING PATHWAYS
Adapted from Henriksen EJ, Jacob S. J Cell Physiol. 2003;196:171-9.
BK2 receptor
BKNO
NO Glucose transport
GLUT-4 trans-location
GLUT-4 biosynthesis
GLUT-4
Akt1
PI3-KIRS-1
AT1 receptor
Insulin receptor
Insulin
+ +
+
+
+
+
-
-
Ang II
GLYCEMIA & CV EVENTS: META-GLYCEMIA & CV EVENTS: META-REGRESSIONREGRESSION
@ 2 hr G = 7.8 mM (140 mg%)… @ Fasting G = 6.1 mM (110 mg%)… RR=1.58 (1.19-2.10) RR=1.33 (1.06-1.67)
After removal of any DM: p=0.0006 for 2 h G p=0.06 for FPG
Coutinho M, Gerstein HC, et al. Diabetes Care. 1999;22:233-240.
Rel
ativ
e R
isk
4 6 8 10 11
2-hour glucose
72 108 144 180 198R
elat
ive
Ris
k
4 7 8 9
Fasting glucose
5 6
72 90 108 126 144 162
3
2.5
2
1.5
1
3
2.5
2
1.5
1
DYSGLYCEMIA >> NORMOGLYCEMIA IN DYSGLYCEMIA >> NORMOGLYCEMIA IN ACUTE AND STABLE CV DISEASEACUTE AND STABLE CV DISEASE
• Consecutive pts: 2107 in-pts; 2854 out-pt elective CV consults in Europe (71% men; mean age 66)
• OGTT/old DM in 1587 (75%) acute & 1857 (66%) elective pts before discharge or within 2 mo.
Euro Heart SurveyEuro Heart SurveyBartnik et al; Eur Ht J 2004;1880Bartnik et al; Eur Ht J 2004;1880
NGT
IFG
IGT
Known DM
New DM
29%35%
22%22%
31% 30%
15%10%
3%3%
0
20
40
60
80
100%
Acute Elective
DISGLICEMIA >> A NORMOGLICEMIA DISGLICEMIA >> A NORMOGLICEMIA EN PACIENTES CON PRIMER INFARTOEN PACIENTES CON PRIMER INFARTO
• Grupo de estudio: 458 pacientes
admitidos con un primer infarto agudo de miocardio en diferentes centros nacionales y 1 centro internacional (27.2 % mujeres, 72.8 hombres)
30,4 %
15.1 %
15,8%
17.7 %
9.49 %
0
20
40
60
80
100%
Pacientes IAM
Glicemia Normal
Glicemia alterada en ayunas
Intolerancia OG
Antedecente DM
DM de novo
Leyendas
11.3 % Glicemia Alterada en ayunas e intolerancia OG
Lopez-Jaramillo et al. Journal of Diabetes 2011; 3 (Suppl 1): 73
HYPERINSULINEMIA IS A PREDICTOR OF NEW
CARDIOVASCULAR EVENTS
Garcia et al. Int J Cardiol. 2011; 145:85-90
HYPERINSULINEMIA IS A PREDICTOR OF NEW
CARDIOVASCULAR EVENTS
Garcia et al. Int J Cardiol. 2011;145:85-90
HYPERINSULINEMIA IS A PREDICTOR OF NEW
CARDIOVASCULAR EVENTS
Garcia et al. Int J Cardiol. 2011; 145: 85-90
HYPERINSULINEMIA IS A PREDICTOR OF NEW
CARDIOVASCULAR EVENTS
Garcia et al. Int J Cardiol. 2011: 145: 85-90
REACTIVIDAD VASCULARREACTIVIDAD VASCULAR
Anillos de Arteria mamaria interna (2 a 3 mm)
Curvas Dosis – Respuesta:
•Cloruro Potásico (KCl)
•Acetilcolina (ACh)
•Fenilefrina (PE)
•Nitropusiato Sódico (SNP)
•Angiotensina II (AII)Rueda-Clausen et al. Int J Cardiol 2010,139: 32-41
REACTIVIDAD VASCULARREACTIVIDAD VASCULAR
Rueda-Clausen et al. Int J Cardiol 2010,139: 32-41
PLASMA LEVELS OF LEPTIN AND PLASMA LEVELS OF LEPTIN AND ADIPONECTIN IN RELATION TO WAIST ADIPONECTIN IN RELATION TO WAIST
CIRCUNFERENCECIRCUNFERENCE
Rueda-Clausen et al. Int J Cardiol 2010,139: 32-41
Epigenetic and Epigenomic
http://www.springerlink.com/content/j3tj16543664/
Published online: 17 May 2006
OBESITY AND OBESITY AND METABOLIC SYNDROME METABOLIC SYNDROME
ARE A NORMAL ARE A NORMAL BIOLOGICAL RESPONSE BIOLOGICAL RESPONSE
TO AN ABNORMAL TO AN ABNORMAL DEVELOPMENT OF DEVELOPMENT OF
SOCIETYSOCIETY
MECHANISMS POSSIBLY PARTICIPATING IN THE GENESIS OF METABOLIC
SYNDROME AND CARDIOVASCULAR MORTALITY IN DEVELOPING COUNTRIES
López-Jaramillo et al. Rev Esp Cardiol. 2007;60:168-178
MATERNAL MALNUTRITION AND FETAL MATERNAL MALNUTRITION AND FETAL PROGRAMMING ASSOCIATED WITH PROGRAMMING ASSOCIATED WITH GREATER CV RISK IN ADULT LIFEGREATER CV RISK IN ADULT LIFE
López-Jaramillo P. Rev Esp Cardiol. 2009; 62: 670-676
POPULATION URBAN AND RURAL EPIDEMIOLOGY (PURE
STUDY)
Country Urban Rural Overall
All HIC 21.9 19.8 20.8
All UMIC 17.8 15.4 16.5
All LMIC 16.3 8.7 12.0
All LIC 22.4 18.8 20.5
ALL countries 19.4 15.0 17.1
The Polypill Concept – A Strategy to Reduce CV Risk by More than 80%
• For all people with established CVD
• For people > 55 years independent of cholesterol and BP levels
Wald NJ, Law MR. BMJ 2003;326:1419
Statin
Thiazide
BB
ACEI/ARA II
Metformin ?