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Ateroscleroza
Ateroscleroza
Dr. Silviu I Dumitrescu, Medic specialist cardiolog, CCUBCVA Asistent universitar, UTM
Ce este ?
Ateroscleroza este prima cauz de mortalitate n lume, peste jumtate din decesele nregistrate datorndu-se complicaiilor ei. Efectele ei clinice se manifest prin afectarea preponderent a arterelor musculare de calibru mediu, precum coronarele, bazilarele, vertebralele, carotidele i arterele membrelor inferioare. Leziunile aterosclerotice nu sunt apananajul istoriei moderne, asociat stilului de via contemporan, ci exist nc din antichitate, fiind descrise ca entiti patologice certe la mumiile egiptene.
Teoriile aterogenezei
Primele ncercri de explicitare a ateromatozei au fost fcute n 1852 de Rudolf Virchow care considera c o leziune minimal a peretelui arterial produce o reacie inflamatorie ce determin pasajul i acumularea constituenilor plasmatici n intima arterial.
Teoriile aterogenezei
n 1856, von Rokitansky elaboreaz o nou teorie completat n 1946 de Duguid care susine c ariile lezionale sunt acoperte de mici trombi, care se organizeaz prin creterea celulelor musculare n interiorul lor, ncorporndu-i n leziune, pentru a deveni ulterior zonele de progresie ale acesteia.
O ipotez complet diferit a fost lansat n 1973 ipoteza monoclonal, ce sugereaz c leziunile aterosclerotice pot s fie considerate ca o manifestare a unei forme de neoplazie. Datele actuale explic aterogeneza prin ipoteza reaciei la leziune (response-to-injury hypothesis of atherosclerosis) elaborat tot n 1973 i revizuit prin rezultatele cercetrilor recente.
DISFUNCIA ENDOTELIAL
1983 Fudmer i colab. care au demonstrat alterarea vasodilataiei mediate de endoteliu n boala coronarian i au indicat legtura dintre endoteliul disfuncional i ateroscleroz = o afeciune sistemic ce se regsete ca un numitor comun n fiziopatologia aterosclerozei, aterotrombozei i remodelrii vasculare cu determinri coronariene, carotidiene, perferice sau multiple, a insuficienei cardiace, insuficenei renale, diabetului i hipertensiunii fundamentnd astfel conceptul actual de continuum cardiovascular. viziunea actual asupra funciei endoteliale o situeaz deasupra noiunii clasice de factor de risc cardiovascular, fiind de fapt un summum al expresiei fenotipului vascular individual i o integral a tuturor factorilor lezionali / de protecie vascular.
ENDOTELIUL NORMAL
DISFUNCIA ENDOTELIAL
Disfuncia endotelial se poate defini fiziopatologic ca un dezechilibru al activitii endoteliului n sensul creterii necompensate a reaciilor i moleculelor n sensul promovrii:
vasoconstriciei, aderrii celulare, trombozei, coagulrii, inflamaiei proliferrii celulare la nivel vascular.
NORMAL
Vasodilatie
NO, EDHF (?), PGI2 BK, C-NP
DISFUNCTIONAL
Vasoconstrictie
ET-1, ROS, TxA2, A-II
Tromboliza
tPA+anexina II, TF-I, trombomodulina, Proteina S, R-proteina C,
Tromboza
PAR 1-2, TF, PAI-1, Tx-A2, vonWF, TAFI Molecule de Adeziune CAM, Selectine Factori de crestere ET-1, A-II, PDGF, ILGF, Interleukine Inflamatie ROS
Antiproliferare
NO, PGI2, TGF-, Hep Lipoliza LPL
4 HBP NADPH
Calmodulina
L-citrulina
y+
ATP
L-argininina
(i)/eNOS
+
Ca 2+
NO
Vasodilatatie, Regalarea tonusului vascular bazal Inhib aderarea, activarea, secreia i agregarea plachetar Sade expresia P selectinei la nivelul membranei plachetare Inhib aderarea leucocitar Inhib migrarea i proliferarea celulelor musculare netede Blocheaz modificrile conformaionale la nivelulul GP IIb/IIIa B
4 HBP NADPH
Calmodulina
L-citrulina
L-argininina
eNOS
+
Ca 2+
L-ornitin, Uree
NO
ADMA LDLOXIDAT ROS
ROS
Leziunea endotelial
Leziunea endotelial este evenimentul cheie n dezvoltarea ateromatozei. Manifestrile ei sunt forme de disfuncie endotelial i includ modificri ale proprietilor membranei celulare, ale expresiei moleculelor de interaciune intercelular, ale eliberrii adecvate de mediatori vasoactivi i factori de cretere i mrirea ratei turn-over-ului. Aceasta duce la acumularea excesiv de colesterol la nivelul membranei celulare endoteliale, cu alterarea consecutiv a raportului colesterol/fofolipide, modificri de compoziie ce induc rigidizarea acesteia. Plasmalema rigid va reaciona n mod anormal la stressul mecanic la care este supus de ctre fluxul sanguin mai ales n locurile de producere a turbulenelor bifurcaii, zone n care se formeaza striuri lipidice producndu-se disjuncia legturilor dintre celulele endoteliale i retracie endotelial.
Leziunea endotelial
Celulele endoteliale au receptori membranari pentru moleculele de LDL, care sunt apoi internalizate i sufer un proces de oxidare la nivel sczut transformndu-se n LDLoxidat. n condiiile existenei unor nivele crescute, acesta este agentul agresor primordial toxic att pentru endoteliu ct i pentru alte celule ce induce cascada evenimentelor inflamatorii i posibil autoimune asociate cu iniierea i dezvoltarea aterosclerozei. LDL-ox determin expresia pe suprafaa celulelor endoteliale a unui numr crescut de molecule de adeziune intercelular n special pentru monocitele circulante.
Un numr important de leucocite (mai ales monocite) se ataeaz la moleculele de adeziune expuse de endoteliul lezat, dup care trec prin spaiile intercelulare i migreaz n spaiul subendotelial. Aici se transform n macrofage i acioneaz ca celule gunoier (scavanger), ncercnd s ndeprteze moleculele de LDL-oxidat prin preluarea acestora de la celulele endoteliale pe calea receptorilor scavenger. Macrofagele preiau i molecule de LDL pe care l transform cu ajutorul unor enzime de tipul lipooxigenazei n LDL-oxidat, se suprancarc cu acesta i se transform n celule spumoase. Macrofagele se pot replica, reprezentnd cea mai important surs de acumulare celular la nivelul leziunii i secret pe lng numeroi mediatori intercelulari cel puin 6 factori de cretere: PDGF, IL-1, FGF, EGF, TGF- i M-CSF. Acetia acioneaz i asupra celulelor musculare cu fenotip secretor din medie, determinnd migraia acestora n spaiul subintimal i transformarea lor n celule spumoase. Nu sunt complet elucidate relaiile dintre limfocitele T CD8+ i CD4+ (care au fost evideniate n toate fazele aterogenezei), macrofage i LDL-oxidat care pare antigenul ce stimuleaz interaciunea dintre acestea.
Mediatorii aterogenezei
Factorii de cretere implicai n aterogenez sunt produi de celulele endoteliale (PDGF, FGF, TGF-, IGF-1, IL-1), de macrofage (PDGF, FGF, EGF, TGF, IL-1, M-CSF) i de trombocite (PDGF, FGF, EGF i TGF-). Un rol important au i celulele musculare netede ce sintetizez un singur factor de cretere: PDGF, la care rspund autocrin. n mod normal exist un echilbru ntre TGF- (un stimulator potent al formrii de esut conjunctiv i totodat cel mai puternic inhibitor al proliferrii celulelor musculare netede) i PDGF (stimulator al migrrii n subendoteliu i al proliferrii celulelor musculare netede) care atunci cnd se pierde, nclinnd balana n favoarea PDGF, pare s reprezinte un moment critic n apariia i progresia leziunilor aterosclerotice. Cea mai important surs de PDGF este reprezentat de macrofage, la aproximativ 20% dintre acestea distribuite ubicuitar n leziune evideniindu-se prezena intracitoplasmatic a lanul proteic al acestuia. PDGF este important i datorit faptului c induce creterea numrului de receptori pentru LDL, creterea sintezei de colesterol, reorganizarea filamentelor actinice i modificarea formei celulelor.
Normal Artery
Response to Injury
Endothelial Dysfunction
Fatty Streak
Fibro-fatty Atheroma
Fig. 11.7
Fatty Streak-Aorta
Fibrous Plaques
Complicated Lesions
Complicated Lesions
Disfunctie
Endoteliala
DISFUNCTIA ENDOTELIALA
Monckeberg medial calcific sclerosis Arteriolosclerosis small arteries and arterioles (hypertension and DM)
Is Atherosclerosis Reversible
Primate experiments
High fat diet discontinued; atherosclerotic lesions regress
Humans
Decrease fat and caloric intake (wars, famine, wasting disease), atheromas decrease. Angiography after cholesterol lowering, plaque size decreases
Consequence
Ischemia, turbulence
Aneurysms, vessel rupture Narrowing, ischemia, embolization Athero-embolization Increase systolic blood pressure
Thrombosis
Loss of elasticity
Aorta
Aneurysm
Pulsatile abdominal mass Abdominal pain Bleeding
Aortic Aneurysm
Aortic Aneurysm
Coronary Arteries
Consequences of coronary artery atherosclerosis: acute and chronic ischemic heart disease
Renal Artery
Progressive ischemic atrophy of kidney leads to gradual kidney failure (nephrosclerosis) Renal hypertension due to decreased perfusion
Fig. 1 - The expected number of CVD deaths at increasing levels of predicted risk. Illustration of the fact that most events occur in low risk subjects with few deaths among high risk subjects.
80
40
20
0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
18
0 3 5 140 5 3 0
People who stay healthy tend to have certain characteristics: 0 3 5 140
No tobacco
Walk 3 km daily, or 30 mins any moderate activity Portions of fruit and vegetables a day
Blood pressure less than 140 mm Hg systolic Total blood cholesterol <5 mmol/l LDL cholesterol <3 mmol/l Avoidance of overweight and diabetes
25
5 3 0
Patients with established atherosclerotic CVD. Asymptomatic individuals who are at increased risk of CVD because of :
2.
2.1 Multiple risk factors resulting in raised total CVD risk (5% 10-year risk of CVD death); 2.2 Diabetes type 2 and type 1 with microalbuminuria; 2.3 Markedly increased single risk factors especially if associated with end-organ damage.
3
Close relatives of subjects with premature atherosclerotic CVD or of those at particularly high risk.
26
To assist those at low risk of CVD to maintain this state lifelong, and to help those at increased total CVD risk to reduce it.
2.
To achieve more rigorous risk factor control in high risk subjects, especially those with established CVD or diabetes:
3.1 Blood pressure under 130/80 mmHg if feasible; 3.2 Total cholesterol <4.5 mmol/L (~175 mg/dL) with an option of <4 mmol/L (~155 mg/dL) if feasible; 3.3 LDL cholesterol <2.5 mmol/L (~100 mg/dL) with an option of <2mmol/L (~80 mg/dL) if feasible; 3.4 Fasting blood glucose <6 mmol/L (~110 mg/dL) and HbA1c <6.5% if feasible.
4.
To consider cardioprotective drug therapy in these high risk subjects especially those with established atherosclerotic CVD.
28
Fig 2 The relationship of total cholesterol / HDL cholesterol ratio to 10 year fatal CVD events in men and women aged 60 yrs with and without risk factors, based on a risk function derived from the SCORE project.
30
25
Men, smoking, SBP=160 mmHg Men, non-smoking, SBP=120 mmHg Women, smoking, SBP=160 mmHg Women, nonsmoking, SBP=120 mmHg
20
15
10
TC/HDL ratio
31
Table 1
F F M M
60 60 60 60
8 7 6 5
NO YES NO YES
2 5 8 21
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How do I use the SCORE charts to assess total CVD risk in asymptomatic persons?
1. Use the low risk chart in Belgium*, France, Greece*, Italy, Luxembourg, Spain*, Switzerland, and Portugal; use the high risk chart in other countries of Europe * Updated, re-calibrated charts are now available for Belgium, Germany, Greece, The Netherlands, Poland, Spain, and Sweden. 2. Find the cell nearest to the persons age, cholesterol, and BP values, bearing in mind that risk will be higher as the person approaches the next age, cholesterol or BP category. 3. Check the qualifiers. 4. Establish the absolute 10-year risk for fatal CVD.
Note that a low absolute risk in a young person may conceal a high relative risk; this may be explained to the person by using the relative risk chart. As the person ages, a high relative risk will translate into a high absolute risk. More intensive lifestyle advice will be needed in such persons.
35
37
39
There are time and resources to discuss and follow up advice and treatment.
The doctor should be aware of and respect the patients own values and choices.
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Lifestyle recommendations
No smoking Weight reduction if BMI 25 kg/m2 and especially if BMI 30 kg/m2 Healthy diet Wide variety of foods Energy intake adjusted to avoid overweight Encourage: fruits, vegetables, wholegrain cereals and bread, fish (especially oily), lean meat, low fat dairy products Replace saturated fat with monounsaturated and polyunsaturated fats (vegetable and marine) Hypertensive subjects should reduce salt intake
Lifestyle advice to maintain low risk status Re-assess total risk at regular intervals
No further weight gain if WC 80-88 cm in women and WC 94-102 cm in men. Advise weight loss if WC 88 cm in women and 102 cm in men
30 min of moderately vigorous exercise on most days of the week; exercise and weight reduction can prevent diabetes
Drug treatment
More likely as SCORE risk exceeds 5% and especially as it approaches 10%, or if there is end-organ damage. In the elderly, drug treatment is generally not recommended below 10% risk unless a specific indication exists Consider BP-lowering drugs when BP 140/90 Consider statins when total cholesterol 5 or LDL 3 In patients with CVD: Aspirin. Statins for most In patients with diabetes: consider glucose-lowering drugs
43
Managing total CVD risk: Why do people find it hard to change their lifestyle?
Socio-economic status: Low SES, including
low educational level and low income, impedes the ability to adopt lifestyle change. likely to have unhealthy lifestyles.
Social isolation: People living alone are more Stress: Stress at work and at home makes it
more difficult for people to adopt and sustain a healthy lifestyle.
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A- ASK systematically identify all smokers at every opportunity. A- ASSESS: Determine the persons degree of addiction and his/her readiness to cease smoking. A- ADVISE: Unequivocally urge all smokers to quit. A- ASSIST: Agree on a smoking cessation strategy including behavioural counselling, nicotine replacement therapy, and/or pharmacological intervention. A- ARRANGE a schedule of follow-up visits.
49
Continued physician encouragement and support may help in the long term.
54
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SCORE CVD risk Low <1% Moderate 14% Increased 5-9% Markedly increased 10%
Normal <130/85 Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle advice
High Normal 130139/ 8589 Lifestyle advice Lifestyle advice +consider drug Rx +consider drug Rx
Drug Rx
Drug Rx
Drug Rx
Drug Rx
Drug Rx
57
JTF4 Lipids
Total and LDL cholesterol relate to CVD risk causally, strongly, independently and progressively and are the primary focus of management. Reduction unequivocally reduces CVD risk, including stroke. Moderately raised triglycerides (>1.7 mmol/l, ~150 mg/dl) relate to risk; may relate to particle size; inverse association with HDL cholesterol; associations with abdominal obesity & blood sugar and possible thrombogenic effects- LOOK for these! HDL cholesterol relates inversely to CVD risk. HDL is antiatherogenic, anti-inflammatory and anti-thrombotic, and is involved in reverse cholesterol transport. <1 mmol/l (~40 mg/dl) in men and <1.2 mmol/l (~45 mg/dl) in women denotes increased risk. Total cholesterol:HDL ratio relates to risk but better risk estimation may be possible if they are considered separately. Apo B/A1 ratio relates strongly to risk but it is not known if it should be a treatment goal. Lp(a) relates to risk, is genetically determined, but resistant to modification. 59
Established CVD
Diabetes as above
SCORE risk 5%
Dietary and exercise advice together with attention to all risk factors comes first. Aim to reduce total cholesterol to <4.5 mmol/L (~175 mg/dL) or <4 mmol/L (~155 mg/dL) if feasible, and LDLcholesterol to <2.5 mmol/L (~100 mg/dL) or <2 mmol/L (~80 mg/dL) if feasible. This will require statin treatment in many. Some recommend statins for all CVD and most diabetic patients regardless of baseline levels.
Lifestyle advice for 3 months, then reassess SCORE and fasting lipids
SCORE now <5%
TC <5 mmol/l and LDL-C <3 mmol/l and
Treatment goals are not defined for HDL cholesterol and triglycerides, but HDL-C <1.0 mmol/L (~40 mg/dL) for men and <1.2 mmol/L (~45 mg/dL) for women and fasting triglycerides of >1.7 mmol/L (~150 mg/dL) are markers of increased cardiovascular risk
Lifestyle advice to reduce total chol <5 mmol/L (~190 mg/dL) and LDL-C <3 mmol/L (~115 mg/dL) Regular follow-up
60
HbA (%)
1c
6.5 if feasible
<6.0 (110) if feasible
Blood pressure
Total cholesterol LDL cholesterol
mmHg
mmol/L (mg/dL) mmol/L (mg/dL) mmol/L (mg/dL) mmol/L (mg/dL)
130/80
<4.5 (175) <4.0 (155) if feasible <2.5 (100) <2.0 (80) if feasible 63
Genetic factors
A family history of CVD in a first degree relative aged <55 (male) or 65 (female) carries an independent relative risk of 1.5-1.7.
Close relatives of persons with premature CVD should have risk assessments; some will have, for example, familial hyperlipidaemia. Others will share high risk lifestyles.
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Ultimately, more women (55%) die of CVD than men (45%), particularly of stroke. Cf 3% breast cancer deaths in women. The apparent lower risk in women in SCORE reflects the fact that women develop CVD 10 years later. The evidenced base for risk factor advice, especially regarding drug treatments is hampered by under-representation of women in clinical trials. Women are disadvantaged at all stages in the evolution of CVD- they are less likely to be offered risk assessment, to have chest pain evaluated or investigated, and to be offered therapy and interventions. Mortality from acute coronary syndromes and after CABG is frequently higher in women.
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When to prescribe cardioprotective drugs in addition to those used to treat blood pressure, lipids, and diabetes
Aspirin for virtually all with established CVD, and in persons at >10% SCORE risk once blood pressure has been controlled. -blockers after myocardial infarction and, in carefully titrated doses, in those with heart failure. ACE inhibitors in those with left ventricular dysfunction and in diabetic subjects with hypertension or nephropathy. Anticoagulants in those at increased risk of thromboembolic events, particularly atrial fibrillation.
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