Πρόληψη και αντιμετϊπιςη των Δυςλιπιδαιμιϊν Βασίλειος ΑΘΥΡΟΣ, MD, FESC, FRSPH, FASA, FACS, FESB Μονάδα Αθηροζκλήρωζης, Β Προπ. Παθολογική Κλινική ΑΠΘ, Ιπποκράηειο Νοζοκομείο, Θεζζαλονίκη.
Diet Poor Nutrition Elevated glucose levels and obesity With almost 40% of the nation being obese, this has resulted in hypertension (HTN), high BP, high cholesterol and other chronic diseases such as diabetes Only 27% of women and 19% of men eat the proper foods during day One would expect that saturated (animal) fat consumption would be a major cause
Primary Prevention Rx: Therapeutic Lifestyle Changes (TLC) Therapeutic diet to lower LDL-C Physically active on a daily basis Weight control Expert Panel. JAMA. 2001;285:2486-2497.
Primary Prevention Rx: TLC Measures to Lower LDL-C Saturated fats (<7% total calories) and cholesterol (<200 mg/d) Also therapeutic options: Plant stanols/sterols (2 g/d) Increased viscous fiber (10 25 g/d) Expert Panel. JAMA. 2001;285:2486-2497.
Nutrient Saturated fat* Polyunsaturated fat Monounsaturated fat Total fat Carbohydrate Fiber Protein Cholesterol Total calories (energy) Therapeutic Lifestyle Changes: Nutrient Composition of TLC Diet Recommended Intake Less than 7% of total calories Up to 10% of total calories Up to 20% of total calories 25 35% of total calories 50 60% of total calories 20 30 grams per day Approximately 15% of total calories Less than 200 mg/day * Lower trans fatty acids; Emphasize complex sources Balance energy intake and output to maintain expenditure healthy body weight/prevent weight gain Slide Source: Lipids Online Slide Library www.lipidsonline.org
Μεςογειακή διατροφή Η μεςογειακή διατροφή είναι το πρότυπο διατροφήσ που ςυναντάει κανείσ ςτισ ελαιοπαραγωγικζσ περιοχζσ τησ περιοχήσ τησ Μεςογείου ςτα τζλη τησ δεκαετίασ του 1950 και αρχζσ τησ δεκαετίασ του 1960, όπου οι ςυνζπειεσ του 2ου παγκοςμίου πολζμου είχαν ξεπεραςτεί, ενϊ ο πολιτιςμόσ των «fast food» δεν είχε ακόμη ειςβάλει.
Η μελζτη των 7 Χωρϊν Μεταξφ 12.763 ανδρϊν (40-59 ετϊν) που ςυμμετείχαν ςτη μελζτη οι μεςογειακοί λαοί, και οι Ζλληνεσ ειδικότερα, είχαν το μεγαλφτερο προςδόκιμο επιβίωςησ και ανάμεςα ςτα χαμηλότερα ςυνολικά ποςοςτά θνηςιμότητασ. Menotti A, et al. Int J Epidemiol 1999
Οι κλινικζσ ενδείξεισ: The Lyon Heart Study Η κλινική-δοκιμή Lyon Heart Study ςυμπεριζλαβε 605 εμφραγματίεσ Συχαιοποίηςη ςε ΜΔ & Step I AHA diet Μετά από 27 μήνεσ παρακολοφθηςησ παρατηρήθηκε μείωςη των ςυμβαμάτων κατά 70% ςτην ομάδα τησ ΜΔ. Ο αποδοτζοσ ςτη Μεςογειακή διατροφή ΚΑΝ κίνδυνοσ ανζρχεται ςε 244%! Η μελέηη ζηαμάηηζε πρόωρα De Lorgeril M et al. Circulation 1999
Μεζογειακή διαηροθή και μεηαβολικό ζύνδρομο ζε πατύζαρκοσς Η προζκόλληζη ζηη ΜΔ ζσζτεηίζηηκε με μείωζη 27% - 60% πιθανόηηηας εμθάνιζης Μεηαβολικού Σσνδρόμοσ, ζε 226 πατσζάρκοσς αζθενείς. Paletas K. et al., J Am Col Nutr 2010
METABOLIC SYNDROME Common complications : Cardiovascular diseases Diabetes type II Non-alcoholic fatty liver disease (NAFLD) Non-alcoholic steatohepatitis (NASH)
ΠΟΟΣΑ ΠΑΧΤΑΡΚΙΑ Ε ΔΙΑΦΟΡΕ ΕΤΡΩΠΑΙΚΕ ΧΩΡΕ Γσναίκες Ανδρες Από ζηοιτεία ηοσ IOTF (International Obesity task Force) Ελλάδα Ροσμανία Σζετία Αγγλία Φιλανδία Γερμανία κωηία λοβακία Πορηογαλία Ιζπανία Δανία Bέλγιο οσηδία Γαλλία Iηαλία Ολλανδία Noρβηγία Οσγγαρία Ελβεηία % BMI >30 40 30 20 10 0 10 20 30 40
Υιοθέηηζη Μεζογειακής Γιαηροθής Διαηροθικές ζσνήθειες ηων Ελλήνων και καρδιαγγειακή νοζηρόηηηα Καρδιαγγειακή Νοζηρόηηηα 1960 1980 2000 2010
Physical Activity: Recommendations l lla llb lll B GOAL 30 minutes/day, 7 days/week; Minimum 5 days/week Assess risk with a physical activity history and/or an exercise test, to guide prescription l lla llb lll B Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all days of the week, supplemented by an increase in daily lifestyle activities B l lla llb lll Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, HF) Smith SC Jr et al. Circulation 2006;113:2363 2372.
Οι ςτρατηγικζσ παρζμβαςησ
European Guidelines 2011
Lipid Management: Goal l lla llb lll A LDL-C should be less than 100 mg/dl l lla llb lll A Further reduction of LDL-C to <70 mg/dl is reasonable If it is not possible to attain LDL-C <70 mg/dl because of a high baseline LDL-C, it generally is possible to achieve LDL-C reductions of >50% with more intensive LDL-C lowering therapy, including drug combinations If TG 200 mg/dl, non-hdl-c should be <130 mg/dl* *Non-HDL-C = total cholesterol minus HDL-C Smith SC Jr et al. Circulation 2006;113:2363 2372.
Total cardiovascular risk should not be shaped by LDL-C levels only but it should define the LDL-C target
Lipid Management: Recommendations (continued) l lla llb lll B If TG are 200 499 mg/dl, non-hdl-c should be <130 mg/dl l lla llb lll B Further reduction of non-hdl-c to <100 mg/dl is reasonable Therapeutic options to reduce non-hdl-c: More intense LDL-C lowering therapy I (B) or Niacin (after LDL-C lowering therapy) IIa (B) or Fibrate (after LDL-C lowering therapy) IIa (B) C l lla llb lll If TG are >500 mg/dl, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL lowering therapy; and treat LDL-C to goal after TG-lowering therapy, Achieve non-hdl-c <130 mg/dl, if possible TG=Triglycerides; HDL-C=high-density lipoprotein cholesterol Smith SC Jr et al. Circulation 2006;113:2363 2372.
Treatment of Mixed Hyperlipidemia (Residual Cardiovascular Risk Reduction) High LDL-C and TGs Therapeutic Lifestyle Change Drug Therapy STEP STEP 1 2 Achieve the LDL-C goal Achieve the non-hdl-c goal Increase LDL-C lowering or Add a fibrate, niacin or fish oils Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.
HMG-CoA Reductase Inhibitor: Secondary Prevention Heart Protection Study (HPS) 20,536 patients with CAD, other occlusive arterial disease, or DM randomized to simvastatin (40 mg) or placebo for 5.5 years Baseline LDL-C (mg/dl) Statin (n = 10,269) Placebo (n = 10,267) Event Rate Ratio (95% CI) <100 282 (16.4%) 358 (21.0%) 100 129 668 (18.9%) 871 (24.7%) >130 1083 (21.6%) 1356 (26.9%) All patients 2033 (19.8%) 2585 (25.2%) 0.76 (0.72-0.81) P<0.0001 CAD=Coronary artery disease, CI=Confidence interval, DM=Diabetes mellitus HPS Collaborative Group. Lancet 2002;360:7 22. 0.4 0.6 0.8 1.0 1.2 1.4 Better Worse Statin
Proportion of Patients Experiencing Major Cardiovascular Event Treating to New Targets (TNT): Primary Efficacy Outcome Measure First Major Cardiovascular Event* 0,15 0,10 HR = 0.78 (95% CI 0.69, 0.89) P=0.0002 Atorvastatin 10 mg Atorvastatin 80 mg Relative Risk Reduction = 22% 0,05 0,00 0 1 2 3 4 5 6 Time (years) * Coronary heart disease death, nonfatal non-procedure-related myocardial infarction, resuscitated cardiac arrest, fatal or nonfatal stroke LaRosa et al. N Engl J Med 2005;352:1425 1435.
Event (%) HMG-CoA Reductase Inhibitor: Secondary Prevention Relationship between LDL-C Levels and Event Rates in Secondary Prevention Trials of Patients with Stable CHD 30 25 20 Statin Placebo 4S 4S 15 10 5 LIPID LIPID CARE CARE HPS HPS TNT (atorvastatin 10 mg/d) TNT (atorvastatin 80 mg/d) 0 3 70 90 110 130 150 170 190 LDL-C (mg/dl) 210 LDL-C=low-density lipoprotein cholesterol; CHD=coronary heart disease; TNT=Treating to New Targets; HPS=Heart Protection Study; CARE=Cholesterol and Recurrent Events Trial; LIPID=Long-term Intervention with Pravastatin in Ischaemic Disease; 4S=Scandinavian Simvastatin Survival Study. LaRosa et al. N Engl J Med 2005;352:1425 1435.
Care Gap
τόχοι LDL-C κατά τισ Καναδικζσ κατευθυντήριεσ οδηγίεσ Risk Level Initiate treatment if: Primary Primary LDL-C Alternate High patients CAD,PVD Atherosclerosis Most Pts with Diabetes FRS 20%, RRS 20% Consider treatment in all Moderate (strive towards ) FRS 10-19% LDL-C>3.5 mmol/l TC/HDL >5.0 hscrp >2 men 50+, women 60+ Family history and hscrp modulate risk <2 mmol/l Or 50% LDL-C Class I Level A A <2 mmol/l Or 50% LDL-C Class IIA Level A A ApoB<0.80 Class I Level A A ApoB<0.80 Class IIA Level A A Low FRS<10% LDL-C>5.0mmol/L 50% LDL-C A Genest J et al. Can J Cardiol 2009 Oct;25(10):567-79
Greek Guidelines for the Treatment of Dyslipidaemia Level of risk for statin treatment initiation LDL-C target High CHD Stroke PAD Type 2 DM or Type 1 > 40 years CKD with GFR <60 ml/min Framingham score >20% Medium At leas 2 CVD risk factors Framingham score 10%-20% Low 0-1 CVD risk factors without CVD Framingham score <10% <70 mg/dl or LDL CHOL κατά 50% <100 mg/dl < 130 mg/dl Greek Atherosclerosis Society 2011
Age-standardized event rate (per 100 person-yr) Relationship Between Estimated GFR (egfr) and Clinical Outcomes Death from any cause Cardiovascular events Any hospitalization Total events = 51,424 Total events = 139,011 Total events = 554,651 egfr (ml/min/1.73 m 2 ) Kaiser Permanente Renal Registry, n=1,120,295 adults aged 20 years Median follow-up = 2.84 years Go AS, et al. N Engl J Med 2004;351:1296-305
Greek Guidelines for the Treatment of Dyslipidaemia Greek Atherosclerosis Society 2011
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Επεμβατική αντιμετώπιση Coronary artery bypass surgery (CABG) Artery Stent and/or balloon angioplasty
Guidelines that aren t implemented don t work
2012 Κάθε 10 τρόνια μπορεί να ζωθεί μία πόλη ζηο μέγεθος ηης Λάριζας εάν τρηζιμοποιήζοσμε ζηαηίνες ζηοσς αζθενείς με ζηεθανιαία νόζο.