Syndrome metabolique et maladies vasculaires s novo
-
Upload
sfaangeiologie -
Category
Documents
-
view
221 -
download
2
Transcript of Syndrome metabolique et maladies vasculaires s novo
Session 10 – Detection of Preclinical Atherosclerosis and Evaluation of
Cardiovascular Risk
Presidents: P.J. Touboul (France) – S. Novo (Italy)
Chirman: A. Kane (Sénégal)
Friday February 1st, 2013 - Hall Longchamp 1 – 16.30 – 17.15
METABOLIC SYNDROME, PRECLINICAL METABOLIC SYNDROME, PRECLINICAL ATHEROSCLEROSIS AND FUTURE ATHEROSCLEROSIS AND FUTURE
CARDIOVASCULAR EVENTSCARDIOVASCULAR EVENTS
Salvatore NovoSalvatore Novo2
University of Palermo - Faculty of Medicine University of Palermo - Faculty of Medicine Department of Internal Medicine and Department of Internal Medicine and
Cardiovascular Diseases Cardiovascular Diseases Section of CardioAngiology Section of CardioAngiology
Chair of Cardiovascular Diseases Chair of Cardiovascular Diseases Master of Echocardiography – Master of Vascular DiseaseMaster of Echocardiography – Master of Vascular Disease
Center for the Early Diagnosis of Preclinical and Center for the Early Diagnosis of Preclinical and Multifocal Atherosclerosis and for Secondary Prevention Multifocal Atherosclerosis and for Secondary Prevention
Division of Cardiology – University Hospital “P. Giaccone” - ItalyDivision of Cardiology – University Hospital “P. Giaccone” - ItalyDirector: Prof. Salvatore NovoDirector: Prof. Salvatore Novo
The metabolic syndrome (MetS) is a cluster of cardiovascular (CV) risk factors which includes abdominal obesity, abnormal glycemia, hypertension, low HDL-cholesterol (HDL-C), high triglycerides, insulin resistance, and proinflammatory and prothrombotic states.
The pathogenesis of the syndrome has multiple origins, but obesity and sedentary lifestyle coupled with diet and still largely unknown genetic factors clearly interact and may determine the syndrome.
3
METABOLIC SYNDROME
Criteri WHO 1999 EGIR 1999 ATP III 2001 AACE 2003
IDF 2005
A)Alterations of glucose metabolism
Diabetes Mellitus 2 o IFG o IGT
FPG 110-125 mg/dl
FPG ≥ 110 mg/dl IFG o IGT FPG ≥100 o Diabetes Mellitus 2
B) Hypertension
>140/90 ≥140/90 mmHg And/or pharmacological treatment
≥130/85 And/or pharmacological treatment
≥130/85 mmHg
≥130/85 and/or pharmacological treatment
C)Hypertriglyceridemia
≥150 ≥177 mg/dl ≥150 mg/dl and/or pharmacological treatment
≥150 mg/dland/or pharmacological treatment
≥150 mg/dl and/or pharmacological treatment
D) Low HDLc
<35 (M) mg/dl o <39 mg/dl (F)
<39 mg/dl <40 mg/dl (M) o <50 mg/dl(F)and/or pharmacological treatment
<40 mg/dl (M) o <50 (F)and/or pharmacological treatment
<40 mg/dl (M) o <50 (F) and/or pharmacological treatment
F)Obesity BMI >30 Kg/m o WHR >0,90 (M) O >0,85 (F)
Waist circunference ≥94 cm (M) o > 80 cm (F)
Weist circunference >102 cm (M) o >88 cm (F)
Weist circunference >94 cm (M)o >80 (F)
G)Mycroalbuminuria
AER >20 μg/min o Alb(u):Creat(u) ≥30 mg/gr
4
Alberti KG et al. Harmonizing the metabolic syndrome. A joint interim statement of the IDF Task Force on Epidemiology and Prevention; NHLBI; AHA; WHF; IAS; and International Association for the Study of Obesity. Circulation 2009; 120: 1640-5
The Italian Heart Project-Longitudinal Studies. Italian Heart J 2003; 4 (Suppl. 7): S13-S21 6
7
Decode Study,
PAMELA Study,
Galassi Meta-analysis,
Gami Meta-analysis,
Kuopio Ischemic Heart disease Risk factor
Study, Rotterdam Study, Cardiovascular
Health Study, Malmo Diet and Cancer
Study, Longitudinal Investigation for The
Longevity and Ageing in Hokkaido Country,
Carotid Atherosclerosis Progression Study e
Kitamura Study, …
Metabolic Syndrome and Risk of Cardiovascular Events and Death. A Systematic Review and Meta-Analysis of Longitudinal Studies
Impact of BMI and the Metabolic Syndrome on the risk of
cardiovascular rvents and death in Middle-Aged Men.
Circulation 2010; 121: 230-6
Impact of the Metabolic Syndrome on mortality from coronary heart disease, cardiovascular
disease and all causes of United States Adults.Circulation 2004; 110: 1245-50
Metabolic Syndrome and CV Risk
8
Results—Non modifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented
and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed.
Goldstein LB et al. Stroke 2011; 42: 517-84
Guidelines for the Primary Prevention of StrokeA Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.
Matthias W et al. Circulation 2007:115: 459-67
A metanalysis of 8 popolation studies (Kuopio IHD-RF Study, A metanalysis of 8 popolation studies (Kuopio IHD-RF Study, ARIC Study, Rotterdam Study, CVH Study, Malmo Diet and ARIC Study, Rotterdam Study, CVH Study, Malmo Diet and Cancer Study, Longitudinal Investigation for the Longevity Cancer Study, Longitudinal Investigation for the Longevity and Aging in Hokkaido Country, CAPS and Kitamura Study) and Aging in Hokkaido Country, CAPS and Kitamura Study) analysing the analysing the association between carotid IMT and cerebro association between carotid IMT and cerebro and CV events in a total of 37197 subjects with a mean follow-and CV events in a total of 37197 subjects with a mean follow-up of 5,5 years. up of 5,5 years.
Matthias W et al. - Circulation 2007:115:459-467Circulation 2007:115:459-467
AN IMT INCREASE OF 0.1 MM WAS ASSOCIATED AN IMT INCREASE OF 0.1 MM WAS ASSOCIATED WITH AN ENHANCED RISK OF 15% FOR AMI AND WITH AN ENHANCED RISK OF 15% FOR AMI AND
OF 18% FOR STROKE, SHOWING THAT OF 18% FOR STROKE, SHOWING THAT PRECOCIOUS ATS LESIONS OF CAROTID PRECOCIOUS ATS LESIONS OF CAROTID
ARTERIES ARE AN INDEPENDENT MARKER OF ARTERIES ARE AN INDEPENDENT MARKER OF CEREBRO- AND CV EVENTSCEREBRO- AND CV EVENTS
Nambi V et al. JACC 2010; 55 : 1660-7
Methods: Evaluate whether subclinical vascular damage adds significantly to Systemic Coronary Risk Evaluation (SCORE) risk stratification in 1968 subjects without CVD; follow-up of 12.8 years. Results: Risk of CV death was (independently of SCORE) associated with LV hypertrophy, plaques, PWV > 12 m/s for SCORE ≥ 5% and 7.3 for SCORE < 5%. Broaden primary prevention from subjects with SCORE ≥ 5% to include subjects with 1% ≤ SCORE < 5% together with subclinical organ damage increased sensitivity from 72 to 89% (P = 0.006), but reduced specificity from 75 to 57% (P < 0.002) and positive predictive value from 11 to 8% (P = 0.07). Conclusions: Subclinical organ damage predicted CV death independently of SCORE and the combination may improve risk prediction.
RISK PREDICTION IS IMPROVED BY ADDING MARKERS OF SUBCLINICAL DAMAGE TO SCORE
Sehestedt T et al. - Eur Heart J. 2010; 31: 883-91
8%
13%
15%
0%
2%
4%
6%
8%
10%
12%
14%
16%
Normal IMT ACP
Incid
en
ce o
f to
tal
Incid
en
ce o
f to
tal
eve
nts
%
eve
nts
%
p < 0.01p < 0.01
No fatal events in subjects No fatal events in subjects with normal carotid. 2 with normal carotid. 2 deaths for cardiac or deaths for cardiac or cerebrovascular cause in cerebrovascular cause in subjects with IMT or ACP subjects with IMT or ACP
INFLUENCE OF PRECLINICAL CAROTID ATHEROSCLEROSIS ON CEREBRO –
AND CV EVENTS IN 5-YEARS FOLLOW-UPNovo S, Carità P, Corrado E, Amorososo G, Muratori I, Pernice C, Tantillo R, Novo G.
Atherosclerosis 2010; 211: 287-90.
4%
14%20%
35%
43%+3%
56%+7%
0
10
20
30
40
50
60
70 43 e 56% Non fatal events
3% e 7% Fatal events
PRECLINICAL ATHEROSCLEROSIS ADD TO PREDICTION OF CARDIOVASCULAR RISK: A TEN
YEARS FOLLOW-UP STUDY IN 558 PATIENTSNovo S, Visconti C, Amoroso GR, Corrado E, Muratori I, Fazio
G, Novo G Eur J Cardiovasc Prev & Rehabiltation 2010; 17: 514-8
Patient at very very high Risk
Metabolic syndrome (MetS) predicts cardio and cerebrovascular events in a twenty years follow-up. A prospective study.
Novo S, Peritore A, Guarneri FP, Corrado E, Macaione F, Evola S, Novo G. - Atherosclerosis 2012; 223: 468-72
From our registry of more than 9000 patients referred from 1985 to 1991 and in follow-up, we identified 529 asymptomatic subjects with Metabolic
Syndrome at baseline, 257 male and 272 female, aged between 25 and 85 years.
2007 Guidelines for the management of arterial hypertension. The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and
of the European Society of Cardiology (ESC). Task Force Members Eur Heart J 2007; 28: 1462–536
2007 Guidelines for the management of arterial hypertension. The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and
of the European Society of Cardiology (ESC). Task Force Members Eur Heart J 2007; 28: 1462–536
Cardiovascular endpoints were investigated in a 20 years follow up: CV death, myocardial infarction (MI),
angina pectoris, transient ischemic attack (TIA), ischemic stroke, admissions for
abdominal aortic aneurysm (AAA), coronary intervention (PCI), and carotid
thromboendarterectomy (TEA). Non fatal events were investigated in new controls
during the follow-up in hospital. Fatal events were ascertained through the interrogation
of family members or death certificates.
20 years follow-up20 years follow-up
529 patients
20
251 patients suffering
from MetS
278 healthy patients
199 CV adverse events
120 CV adverse
events
79 CV adverse
events
OR 2.3P < 0,0003
Free-events survival Free-events survival in patients suffering in patients suffering from MetS and not.from MetS and not.
Novo S, Peritore A, Guarneri FP, Evola S, Novo G, Atherosclerosis 2012; 223: 468-72
Metabolic syndrome
Control subjects
P value
Subclinical atherosclerosis OUI
68,12% 57,5% < 0,01
Subclinical atherosclerosis NON
31,87% 42,5% < 0,01
21
Metabolic
Syndrome
(n=251)
Control Subjects
(n=278)
p-value
All CV events 144 98 < 0.0001
Fatal CV
events
24 19 (ns)
Not fatal CV
events
120 79 < 0.0001
Metabolic Syndrome
(n=251)
Control Subjects
(n=278)
p-value
ALL NOT FATAL CV EVENTS 120 79 < 0.0001
TIA 25 23 NS
Not fatal AMI 36 24 0.04
Angina pectoris 19 14 NS
Not fatal Ischemic Stroke 32 15 0.0049
Not fatal AAA 5 1 (ns)
TEA 3 2 (ns)
Metabolic Syndrome
(n=251)
Control Subjects
(n=278)
p-value
Total cerebrovascular events (TIA, not
fatal and fatal Stroke)
67 47 0.0086
Total AMI (fatal and not fatal) 47 33 0.0379
Variabile Regression Coefficient
standarderror
P value Relative Risk
CI (95%)
BMI -0,07659 0,02878 0,00778 0,9263 0,8757-0,9797
Fibrinogen 0,0001898 0,001097 0,8626 1,0002 0,9981-1,0023
CRP -0,4573 0,2367 0,05332 0,6330 0,3990-1,0042
MS -2,9124 0,5745 0,0000003992 0,0543 0,0177-0,1666
Weist circunference
-0,1486 0,2796 0,5951 0,8619 0,4997-1,4868
Preclinical atherosclerosis
-2,6772 0,4743 0,04343 0,0700 0,0373-0,1777
24
In addition, the Multivariate Cox proportional-hazards analysis showed as independent predictors of cardiovascular events, in the whole population, subclinical Atherosclerosis (p < 0.04), MetS (p = 0.0000003992), BMI (p = 0.007), high C-reactive protein serum concentration (p < 0.005).
In addition, the Multivariate Cox proportional-hazards analysis showed as independent predictors of cardiovascular events, in the whole population, subclinical Atherosclerosis (p < 0.04), MetS (p = 0.0000003992), BMI (p = 0.007), high C-reactive protein serum concentration (p < 0.005).
SYNDROME METABOLIQUE, ATHÉROSCLÉROSE PRÉCLINIQUE ET
FUTURS ÉVÉNEMENTS CARDIOVASCULAIRES
Novo S. , Peritore A. , Trovato R.L. , Guarneri F.P. , Di Lisi D. , Novo G.
SYNDROME METABOLIQUE, ATHÉROSCLÉROSE PRÉCLINIQUE ET
FUTURS ÉVÉNEMENTS CARDIOVASCULAIRES
Novo S. , Peritore A. , Trovato R.L. , Guarneri F.P. , Di Lisi D. , Novo G.
MetS (n=250 patients)
Non MetS(n=277 patients)
P-value TOTAL(n=527 patients)
Normal 74 (29.6%)
118 (42.6%) P=0.0026 192 patients
Epaississement intima-média(IMT)/Plaque asymptomatique
176 (70.4%) 159 (57.4%) P=0.0026 335 patients
Répartition de la population de l'étude par rapport aux Mets et échographies carotidiennes Répartition de la population de l'étude par rapport aux Mets et échographies carotidiennes
Normal: IMT <0,9 mm; IMT: IMT> 0,9 mm et <1,5 mm; plaque asymptomatique: IMT> 1,5 mmNormal: IMT <0,9 mm; IMT: IMT> 0,9 mm et <1,5 mm; plaque asymptomatique: IMT> 1,5 mm
40,5%
25,4%
52%
33%
56%
39%
Normal IMT Plaque asymptomatique
MetS Sujets de contrôle
Répartition des patients atteints d'événements cardiovasculaires par rapport à l'athérosclérose subclinique et le syndrome métabolique
Répartition des patients atteints d'événements cardiovasculaires par rapport à l'athérosclérose subclinique et le syndrome métabolique
28
Survie sans événement,
Kaplan Meyer fonction
Survie sans événement,
Kaplan Meyer fonction
Patients avec des
événements
Infarctus aigu du
myocarde N°
Angina N°
TIA N°
Stroke N°
Décès N°
Evénements
Normal (N°192) 60 (31.2%) 27 (14%) 11 (5.7%) 13 (6.7%) 22 (11.4%) 25 (13%) 98 (51.04%)
IMT/plaqueasymptomatique
(N°335)
152 (45.4%) 59 (17.6%) 19 (5.7%) 40 (12%) 37 (11%) 74 (22.1%) 229 (68.36%)
P-value P=0.0019 P=0.01 P=0.0001
Événements survenus chez des patients avec et sans lésions échographiques carotidiens Événements survenus chez des patients avec et sans lésions échographiques carotidiens
L'athérosclérose subclinique ajouté à des facteurs de risque traditionnels peut améliorer la prédiction du risque CV. Par ailleurs, selon les dernières CES 2012 des lignes directrices sur la prévention cardio-vasculaire, la détection d'une plaque carotidienne asymptomatique mis sujets dans la catégorie de risque très élevé. Nous vous proposons de rechercher la présence de l'athérosclérose subclinique chez tous les patients,> 45 ans, par un test de la carotide écho Doppler couleur, parce que dans la prévention primaire, la mesure IMT peut donner de plus amples informations pour une meilleure stratification des GCVR (risque cardiovasculaire global).
Nous recommandons également d'éviter l'apparition d'anomalies syndrome métabolique, en encourageant l'activité physique quotidienne et le régime alimentaire méditerranéen et de commencer tôt le traitement pharmacologique des facteurs de risque modifiables
L'athérosclérose subclinique ajouté à des facteurs de risque traditionnels peut améliorer la prédiction du risque CV. Par ailleurs, selon les dernières CES 2012 des lignes directrices sur la prévention cardio-vasculaire, la détection d'une plaque carotidienne asymptomatique mis sujets dans la catégorie de risque très élevé. Nous vous proposons de rechercher la présence de l'athérosclérose subclinique chez tous les patients,> 45 ans, par un test de la carotide écho Doppler couleur, parce que dans la prévention primaire, la mesure IMT peut donner de plus amples informations pour une meilleure stratification des GCVR (risque cardiovasculaire global).
Nous recommandons également d'éviter l'apparition d'anomalies syndrome métabolique, en encourageant l'activité physique quotidienne et le régime alimentaire méditerranéen et de commencer tôt le traitement pharmacologique des facteurs de risque modifiables
Palermo - Palais Chinoise
1799 – Ferdinando I de Bourbon
Palermo - Palais Chinoise
1799 – Ferdinando I de Bourbon
Merci pour votre attention Merci pour votre attention