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10/23/2017

SINDROMUL METABOLIC

SINDROMUL METABOLIC
Obezitate de tip central
Dislipidemie
(valori crescute ale
trigliceridelor plasmatice;
valori scazute ale HDL-
colesterol)
Hipertensiune arteriala
(TA 130/ 85 mmHg)
Insulino-rezistenta sau
alterarea tolerantei la
glucoza
Sindrom protrombotic
Sindrom proinflamator

Alberti et al. Circulation 2009

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De ce este important SM?


Legat de insulinorezistenta

Creste riscul de diabet de ~ 5x

Steatoza hepatica

Cancer (san, colon, rinichi, prostata)

Creste riscul bolilor cardiovasculare de 2-3 ori

Obezitatea
Aproximativ 66% (2/3 din adulti)
sunt cu exces ponderal sau
obezitate

Prevalenta obezitatii a crescut de


la 15% la peste 30% din anii 1970
----2003

2009

CDC

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INTERVENTIA PRIMARA

IDF recomanda ca interventie primara in


cadrul managementului pacientilor cu
Sindrom Metabolic promovarea unui stil de
viata sanatos:

restrictie calorica (cu 5-10% pierdere in


greutate);
consiliere nutritionala;
cresterea moderata a activitatii fizice.

INTERVENTIA TERAPEUTIC
MULTIFACTORIAL

Pe termen scurt/mediu: optimizarea stilului de via

controlul glicemic
controlul tensional (TA<130/80 mmHg)
controlul lipidic (LDL colesterol <100 mg/dl (sub 70
mg/dl la cei cu risc cardiovascular crescut); trigliceride
<150 mg/dl, HDLcolestrol>40 mg/dl la brbai i >50
mg/dl la femei)
control ponderal (la normoponderali meninerea greutii
iar la supraponderali i obezi reducerea cu 5-10% a
greutii corporale n primul an)
control plachetar (tratamentul cu aspirin, clopidogrel,
ticlopidin)
optimizarea psihosocial
Lebovitz H et al. Therapy for diabetes mellitus and related disorders,
Fifth edition, American Diabetes Association, 2009.

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TIPURI DE DIETE
Dietary Patterns for Health and Decreased Risk of
Chronic Diseases
USDA Food Guide
MyPyramid.gov
DASH Diet

Health Benefits of Moderate Fat Diets (~30% of


calories)
Lyon Diet Heart Study
Mediterranean Style Diet Pattern

Health Benefits of Low Fat Diets (<20% of calories)


Lifestyle Heart Program
Womens Health Initiative

Mahan LK, Escott-Stump S, Krauses Food: Nutrition and Diet Therapy,


WB Saunders Company 13th Edition, 2008.

NCEP ATP III DIETARY


RECOMMENDATIONS
Nutrient Recommended Intake
Saturated fat 7% of total calories
Polyunsaturated fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Total fat 25%35% of total calories
Carbohydrate 50%60% of total calories
Fiber 2030 g/d
Protein ~15% of total calories
Cholesterol 200 mg/d
Total calories Balance energy intake and expenditure
to maintain desirable body weight/
prevent weight gain

NCEP ATP III. JAMA. 2001;285:2486-2497.

BENEFICIILE
ACTIVITATII
FIZICE

Health benefits of physical activity. CMAJ. 2006;

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Tinte
Scaderea aportului caloric/modificarea paternului alimentar

Cresterea activitatii fizice

Scaderea TA

Cresterea HDL-C

Scaderea TG serice

Controlul hiperglicemiei

Management ABCDE
A Aspirina, reducerea riscului cv
Blood presure scaderea TA
Cholesterol reducerea dislipidemiei
Diabet preventia DZ
Educatie fizica

DISLIPIDEMIILE

- se definesc prin totalitatea anomaliilor


lipidelor plasmatice att de ordin
cantitativ ct i de ordin calitativ.

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Diagnostic
Diagnosticul dislipidemie rareori poate fi confirmat ca
unul de sine statator, mai frecvent fiind asociat altor
patologii (HTA, IC, DZ, angina pectorala, IM)

Manifestari clinice:
dermatologice (xantelasma, xantoame tendinoase,
tuberoase, striate palmare si eruptive)
oftalmologice (arcul cornean, lipemia retinalis)
digestive - pentru forme de dislipidemie ce evolueaza
cu HTG severa ex deficit familial de LPL sau de apo CII
semne neuropsihice - in sdr hiperchilomicronemic
manifestari cardiovasculare

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Terapia hipolipemianta
nonfarmacologica

Recomandari comune ADA si NCEP ATP III


Nutrient Step 1 diet Step 2 diet
Total fat <30% of total calories <30%of total calories
Saturated fat <10% of total calories <7% of total calories
Polyunsaturated fat 10% of total calories 10% of total calories
Monounsaturated fat 10-15% of total calories 10-15% of total calories
Carbohydrates 50-60% of total calories 50-60% of total calories
Protein 10-20% of total calories 10-20% of total calories
Cholesterol <300 mg/l <200 mg/dl
Total calories To achieve and maintain
desirable body weight

LDL-C levels
Total CV risk < 70 mg/dl 70 to <100 mg/dl 100 to <155 155 to < 190 > 120 mg/dl
% (SCORE) < 1,8 mmol/l
1,8 to <2,5 mg/dl mg/dl > 4,9 mmol/l
mmol/l 2,5 to < 4,0 4,0 to < 4,9
mmol/l mmol/l
Lifestyle intervention,
No lipid Lifestyle Lifestyle consider drug if
<1 intervention No lipid intervention intervention intervention uncontrolled
Class/level I/C I/C I/C I/C IIa/A
Lifestyle Lifestyle
intervention, intervention, Lifestyle intervention,
Lifestyle consider drug if consider drug if consider drug if
1 to < 5 intervention Lifestyle intervention uncontrolled uncontrolled uncontrolled
Class/level I/C I/C IIa/A IIa/A I/A

Lifestyle Lifestyle
Lifestyle intervention and intervention and Lifestyle intervention
>5 to < 10, or high intervention Lifestyle intervention immediate drug immediate drug and immediate drug
risk consider drug* consider drug* intervention intervention intervention
Class/level IIa/A IIa/A IIa/A I/A I/A

Lifestyle Lifestyle
Lifestyle Lifestyle intervention intervention and intervention and Lifestyle intervention
10 or very high intervention and immediate drug immediate drug immediate drug and immediate drug
risk consider drug* intervention intervention intervention intervention
Class /level IIa/A IIa/A I/A I/A I/A

Terapia hipolipemianta farmacologica (1)


Principalele clase de medicamente hipolipemiante:
mecanisme de aciune, efecte, eficien
CLASA Mecanism de aciune i efecte Eficien hipolipemiant
LDL col. HDL col. TG

1. Inhibitori HMG-CoA inhib HMG CoA reductaza;


reductaz STATINE scad sinteza VLDL; 3060% 515% 2045%
(atorvastatin, simvastatin, cresc numrul de receptori LDL;
scad procentul de LDL mici, dense (LDLB);
provastatin, lovostatin, fluvastatin)

2. Fibrai stimuleaz activitatea LPL i HSL; *


(bezafibrat, fenofibrat, cipofibrat, scad sinteza VLDL; 1025% 1020% 2050%
gemfibrozil) cresc catabolismul VLDL, IDL, LDL;
scad procentul de LDL mici, dense;
cresc sinteza de HDL2;
scad hiperlipemia postprandial;
3. Rezine scad reabsoria acizilor biliari;
(colestiramin, colestipol) cresc conversia colesterolului hepatic n acizi 1530% 35% 015%
biliari
cresc numrul receptorilor LDL;

4. Acid nicotinic i derivai inhib lipoliza adipocitar;


(acipimox) scad sinteza VLDL; 525% 1535% 2050%
scad catabolismul HDL;
scad Lp (a);

5.Ezetimibe - inhiba sterol transferaza intestinala


- reduce cu 25% absortia colesterolului 20 5% 5-10%

6. Acizi grasi omega - modifica propietatile fizice ale membranei celulare


3(4g/zi) si capacitatea membranara de legare a proteinelor 17-21% ? 27-45%
- conversie celulara in eicosanoizi bioactivi, liganzi
ptr factori de transcriptie nucleara cu modificarea
expresiei unor gene

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Dislipidemia i insulinorezistena
Insulinorezistena (IR) se asociaz cu valori crescute
ale lipidelor intramiocelulare, stare recunoscut a
interfera cu captarea celular a glucozei de catre
miocite i cu semnalizarea insulinei de asemenea
diminuat.

S-a demonstrat c IR se accentueaz n paralel cu


sporirea masei adipoase viscerale asociat obezitii.

Tratamentul farmacologic al hipercolesterolemiei

Recomandari Clasa/Nivel
Prescrierea statinei pna la doza maxima recomandata I/ A
sau doza maxima tolerate pentru obtinerea nivelului-tinta

n cazul intolerantei la statine, trebuie luate n considerare IIa/ C


EZETIMIB sau SECHESTRANTI DE ACIZI BILIARI in
monoterapie sau combinate
Daca nu se obtine nivelul-tinta, poate fi luata n considerare IIa/ B
combinatia unei STATINE cu un INHIBITOR AL
ABSORBTIEI INTESTINALE A COLESTEROLULUI

Daca nu se obtine nivelul-tinta, poate fi luata n considerare IIb/ C


combinatia unei STATINE cu un SECHESTRANT DE ACIZI

La pacientii cu risc CV foarte inalt, cu valori LDL-C IIb/ C


persistent crescute in pofida tratamentului cu doze maxime
tolerate de statine, in combinatie cu ezetimib, sau in caz de
intoleranta la statine, poate fi luat in considerare un
INHIBITOR DE PCSK9

Managementul dislipidemiei la pacientii cu


DZ sau sindrom metabolic (SM)

Recomandari

Dislipidemia aterogena:
factor de risc major pentru BCV la pacientii cu DZ si SM.
are caracter agresiv, frecvent intalnita in DZ, SM, obezitatea centrala.
relevata mai bine prin non-HDL-C (LDL-C poate fi la valori normale); 50% din pacientii cu DZT2 au
TG sau HDL-C

Non-HDL-C:
marker-surogat util pentru identificarea TRL
obiectiv secundar al tratamentului.

Tinte terapeutice: in risc CV foarte inalt: LDL-C <70mg/dl, non-HDL-C <100 mg/dl;
in risc CV inalt; LDL-C <100mg/dl, non-HDL-C <130 mg/dl
Statinele: beneficii semnificative asupra reducerii evenimentelor CV la pacientii cu DZ

Fenofibratul: reduce semnificativ numrul de evenimente cardiovasculare la pacienii cu


dislipidemie aterogena (TG >200 mg/dl si HDL-C)

*TRL, lipoproteine bogate in TG

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