Ο Ρόλος της Αρτηριακής Σκληρίας στις Καρδιαγγειακές Παθήσεις. Άρης Μπεχλιούλης Καρδιολόγος, Επιμελητής Β Β Καρδιολογική Κλινική ΠΓΝ Ιωαννίνων

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1 Ο Ρόλος της Αρτηριακής Σκληρίας στις Καρδιαγγειακές Παθήσεις Άρης Μπεχλιούλης Καρδιολόγος, Επιμελητής Β Β Καρδιολογική Κλινική ΠΓΝ Ιωαννίνων Σεμινάρια Ομάδων Εργασίας ΕΚΕ 17 Φεβρουαρίου 2017

2 Σύγκρουση Συμφερόντων Καμιά όσον αφορά τη συγκεκριμένη ομιλία

3 Λειτουργία αρτηριών και Καρδιαγγειακό σύστημα Large elastic arteries (rich in elastin and collagen) and smaller (more muscular) peripheral arteries. Arterial tone regulated by the endothelium Arterial elasticity determined by the content of elastin, collagen, and smooth muscle in the vessel wall. Collagen and elastin The relative content of these molecules is regulated by a slow but dynamic process of production and degradation. Imbalance in this process overproduction of abnormal collagen and diminished quantities of normal elastin increase in vascular stiffness. Veerasamy et al Cardiology in Review

4 Λειτουργία αρτηριών και Καρδιαγγειακό σύστημα Importance of Arterial Elasticity The distensibility of the aorta is responsible for buffering the variation in flow and pressure generated by intermittent cardiac contraction. Pressure wave travels forward, it gets reflected back along branching points The actual pressure waveform is a summation of the forward and reflected waves reach the ascending aorta in diastole. Veerasamy et al Cardiology in Review

5 Αρτηριακή Σκληρία και Καρδιαγγειακό σύστημα Arterial Stiffness and Cardiovascular system Loss of elasticity and decreased absorption of this pressure wave by the aorta reflected waves reach the ascending aorta earlier in systole, augmenting systolic pressure and decreasing diastolic pressure Increased cardiac afterload and impaired coronary blood flow Veerasamy et al Cardiology in Review

6 Αρτηριακή Σκληρία και Καρδιαγγειακό σύστημα Αrterial stiffening usually involves mainly the proximal arteries the stiffness gradient between proximal elastic arteries and more distal muscular arteries decreases This phenomenon may result in a diminution of the amplitude of wave reflection from the resistance vessels, and consequently, in an increased transmission of pressure to the microcirculation, potentially dangerous mainly for brain and kidney. Palombo et al 2015 Vasc Pharmacol

7 Ηλικία και Αρτηριακή Σκληρία - Αρτηριοσκλήρυνση «Γήρανση» Καρδιαγγειακού συστήματος Sun Z Hypertension

8 Αρτηριακή Σκληρία και Αθηροσκλήρωση ΝΟΤ the same disease Common risk factors Arterial stiffness has been shown to be determined principally by age and blood pressure (70% of its variance) whereas the contribution of other established risk factors is marginal or insignificant Chronic inflammation involved in both arterial stiffening and atherosclerosis Mechanical forces at the blood-wall interface Arterial stiffening alters the mechanical properties of the vascular wall and intraluminal blood pressure mechanotransducers stimulate reactive oxygen species (ROS) and decrease endothelial NOS activity Endothelial dysfunction key event in the initiation of atherosclerotic process leads also to functional stiffening of arteries decreased NO bioavailability Vascular aging deleterious changes within the vascular wall that are involved both in atherosclerosis and arterial stiffening Palombo et al 2015 Vasc Pharmacol

9 Αρτηριακή Σκληρία και Αθηροσκλήρωση Palombo et al 2015 Vasc Pharmacol

10 Αρτηριακή Σκληρία και Παράγοντες κινδύνου

11 Πώς γίνεται η Εκτίμηση Αρτηριακής Σκληρίας

12 Αγγειακοί Βιοδείκτες και Καρδιαγγειακός Κίνδυνος Established risk score charts account for only about 50% of the individual cardiovascular risk. Consequently, the last two decades have seen large efforts aimed to identify vascular biomarkers capable to improve cardiovascular risk stratification on top of risk scores, thus allowing to tailor personalized preventive strategies

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14 Pulse Wave Velocity The most widely used and validated techniques involve the assessment of pulse waves as they travel over a significant portion of the arterial tree Carotid-femoral pulse wave velocity (cfpwv) Brachial-ankle PWV (bapwv) Cardio-ankle vascular index (CAVI) - theoretical advantage to be less dependent on BP levels. European Society of Cardiology Working Group on peripheral circulation - Endorsed by the Association for Research into Arterial Structure and Physiology (ARTERY) Society - Atherosclerosis 2015

15 Carotid-Femoral PWV Inaccurate estimation of PWV can happen in obese patients due to inappropriate length measurements

16 Carotid-Femoral PWV Μeasure of segmental stiffness from the ascending aorta to the femoral artery It fulfills most of the stringent criteria for a biomarker to be implemented in clinical practice Expert consensus document on the measurement of aortic stiffness in daily practice using carotid-femoral pulse wave velocity Luc M. Van Bortel et al J Hypertens

17 Carotid-Femoral PWV Determinants of pulse wave velocity in healthy people and in the presence of cardiovascular risk factors: establishing normal and reference values The Reference Values for Arterial Stiffness Collaboration - Eur Heart J 2010

18 Carotid-Femoral PWV

19 Carotid-Femoral PWV Cardiovascular Health and Arterial Stiffness: The Maine Syracuse Longitudinal Study Crichton et al 2014 J Hum Hypertens

20 Carotid-Femoral PWV

21 Carotid-Femoral PWV

22 Carotid-Femoral PWV

23 Carotid-Femoral PWV Young patients High risk patients

24 Carotid-Femoral PWV

25 Carotid-Femoral PWV

26 Carotid-Femoral PWV??

27 Carotid-Femoral PWV

28 Carotid-Femoral PWV 2016

29 Carotid-Femoral PWV

30 Recommendations for Improving and Standardizing Vascular Research on Arterial Stiffness - A Scientific Statement From the American Heart Association Raymond R. Townsend et al 2015 Hypertension Εκτίμηση Αρτηριακής Σκληρίας Carotid-Femoral PWV PWV - Usefulness for primary and secondary CV disease prevention (Recommendation/Level of evidence): IIa/A. European Society of Cardiology Working Group on peripheral circulation - Endorsed by the Association for Research into Arterial Structure and Physiology (ARTERY) Society - Atherosclerosis 2015

31 Brachial Ankle PWV

32 Brachial Ankle PWV European Society of Cardiology Working Group on peripheral circulation - Endorsed by the Association for Research into Arterial Structure and Physiology (ARTERY) Society - Atherosclerosis 2015 Recommendations for Improving and Standardizing Vascular Research on Arterial Stiffness - A Scientific Statement From the American Heart Association Raymond R. Townsend et al 2015 Hypertension

33 Cardio-Ankle Vascular Index (CAVI) Clinical assessment of arterial stiffness with cardio-ankle vascular index: theory and applications Kozaburo Hayashi et al 2015 J Hypertens

34 Central Hemodynamics Augmentation Index (AIx), Central pressures Augmentation pressure difference between the first and second systolic peaks Augmentation index (AI) the ratio of the augmentation pressure to pulse pressure (PP) PP the difference between the systolic and diastolic blood pressure. AI increases with mean arterial pressure (MAP) and is inversely related to heart rate and body height. The arterial pressure waveform should be analyzed in the ascending aorta because this represents the true load imposed on the left ventricle and large central arterial walls. The central aortic pressure waveform can be estimated from the waveforms measured in the common carotid or radial arteries.

35 Central Hemodynamics Augmentation Index (AIx), Central pressures Central haemodynamics/wave reflections - Usefulness for primary and secondary CV disease prevention- (Recommendation/Level of evidence): IIb/B. European Society of Cardiology Working Group on peripheral circulation - Endorsed by the Association for Research into Arterial Structure and Physiology (ARTERY) Society - Atherosclerosis 2015

36 Local Arterial Stiffness Carotid artery Meta-analysis - van Sloten et al 2015 JACC Arteries are affected to a different degree by atheromatosis or arteriosclerosis, And they have site-specific physiological consequences. Hypothesis multiregional mapping of the human arterial system s elastic properties might provide a holistic approach to CVD event prediction.

37 ΣΥΜΠΕΡΑΣΜΑΤΑ Αρτηριακή Σκληρία Σημαντικός ρόλος στη φυσιολογία του καρδιαγγειακού συστήματος και στην παθοφυσιολογία των καρδιαγγειακών νοσημάτων Ποια είναι η πιο κατάλληλη μέθοδος εκτίμησης αρτηριακής σκληρίας? Μια μόνο? PWV Η πιο καλά μελετημένη μέθοδος εκτίμησης αρτηριακής σκληρίας Τεκμηριωμένος προγνωστικός ρόλος Κατευθυντήριες οδηγίες Ενσωμάτωση στην καθημερινή πράξη (υπερτασικοί, νεφροπαθείς, νέοι ασθενείς, υψηλού κινδύνου ασθενείς?) Λείπουν μελέτες καθοδήγησης της θεραπείας με βάση τους δείκτες αρτηριακής σκληρίας Μελέτη αρτηριακής σκληρίας σε πολλαπλά τμήματα του αγγειακού δικτύου Χαρτογράφηση αγγειακού δικτύου Βελτίωση προγνωστικής ικανότητας?