Avances en Arterioesclerosis Dr César Morcillo Serra

Medicina Interna, Hospital CIMA Sanitas

8 de mayo de 2015

Sanitas

Sanitas

Iceberg de las enfermedades cardiovasculares en España

Rev Esp Cardiol 2007; 60:470

Diagnóstico

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• Personas asintomáticas con: • SCORE >5% • Diabetes mellitus • Síndrome metabólico • Hipertrofia ventricular izquierda • Enfermedad renal: microalbuminuria o insuficiencia renal crónica

• Personas con arteriosclerosis (con o sin síntomas): • Coronaria • Arterial periférica • Cerebrovascular

Enfermos de alto riesgo cardiovascular

Diagnóstico

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Diagnóstico

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Diagnóstico

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Diagnóstico

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Diagnóstico

1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use:

-High-sensitivity C-reactive protein

-Albuminuria

-Coronary artery calcium (CAC) score

-Measurement of carotid intima-media thickness

-Ankle-brachial index (ABI)

Sanitas

Diagnóstico

1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use:

-High-sensitivity C-reactive protein,

-Albuminuria,

-Coronary artery calcium (CAC) score,

-Measurement of carotid intima-media thickness,

-Ankle-brachial index (ABI).

Sanitas

Diagnóstico

1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use:

-High-sensitivity C-reactive protein

-Albuminuria

-Coronary artery calcium (CAC) score

-Measurement of carotid intima-media thickness

-Ankle-brachial index (ABI)

Sanitas

Diagnóstico

Sanitas

Diagnóstico

1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use:

-High-sensitivity C-reactive protein

-Albuminuria

-Coronary artery calcium (CAC) score

-Measurement of carotid intima-media thickness

-Ankle-brachial index (ABI)

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• Cuantificación del calcio coronario

• Coronariografía por TAC

Diagnóstico

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• Aporta algo hacer una Coronariografía por TAC?

Diagnóstico

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• 243 patients without known atherosclerosis. 54% patients had coronary atherosclerosis. • Detection of silent coronary atherosclerosis increases the risk of having an event 7,2 times. • 76% low-intermediate SCORE risk patients should be reclassified to high risk.

Diagnóstico

Sanitas

Diagnóstico

1º. Assessment of 10-Year Risk of a First Cardiovascular Event. 2º. If, after risk assessment, risk is intermediate or treatment decision is uncertain, use:

-High-sensitivity C-reactive protein

-Albuminuria

-Coronary artery calcium (CAC) score

-Measurement of carotid intima-media thickness

-Ankle-brachial index (ABI)

Sanitas

Eco doppler arterial: Permite:

– Medir grosor de la íntima – Definir tipo de placa y grado de estenosis. – Sensibilidad: 92-100%, Especificidad: 93-100%.

Diagnóstico

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Diagnóstico

Sanitas

Possibly beneficial: Stanol/sterol ester margarines (2 g per day) [IID]

Not recommended: Vitamin C, vitamin E, and beta-carotene supplementation in patients with ischemic heart disease [IIIA] Treatment of elevated homocysteine with folate or vitamins B6 & B12 in patients with ischemic heart disease [IIIA] Garlic, coenzyme Q10, selenium and chromium [IIID] Chelating therapy [IIID]

Not recommended and possibly harmful: Estrogen therapy in post-menopausal women with stable IHD and or history of stroke [IIIA] Testosterone in men with ischemic vascular disease (IVD) [IIIB]

Tratamiento

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Tratamiento

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Following non-cardioembolic stroke: - Antiplatelets are recommended over anticoagulation. Acceptable options are: aspirin 50 mg

to 325 mg daily, aspirin 25 mg plus dipyridamole 200mg twice daily, and clopidogrel 75 mg daily [IA].

- Not recommended for long term prevention of stroke: combination of aspirin and clopidogrel This combination increases the risk of hemorrhage [IIIA].

- If stroke occurs on an antiplatelet agent: No evidence exists for the effectiveness of changing the dose or switching to a different antiplatelet agent [IIID].

Tratamiento

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Tratamiento

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• Do not offer omega-3 fatty acid compounds for the prevention of CVD

• Do not offer a bile acid sequestrant for the prevention of CVD (Resincolesteramina, Colestid)

• Do not exclude from statin therapy people who have liver transaminase levels less than 3 times the upper limit of normal

• Do not stop statins because of an increase in blood glucose level or HbA1c

Tratamiento

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• Adults ≥21 years of age with primary LDL-C ≥190 mg/dL should be treated with statin therapy • Adults with LDL-C >70 mg/dL, with clinical ASCVD or diabetes or with an estimated 10-year risk ≥7.5% should

be treated with statin. • Decreasing the statin dose may be considered when 2 consecutive values of LDL-C levels are <40 mg/dL • It may be harmful to increase the dose of simvastatin to 80 mg daily. • If unexplained muscle symptoms or fatigue develop during statin therapy:

• 1º: Discontinue the statin. • 2º: If muscle symptoms resolve, give the patient the original dose of the same statin to establish a causal

relationship between the muscle symptoms and statin therapy. • 3º: If a causal relationship exists, discontinue the original statin. Once muscle symptoms resolve, use a low

dose of a different statin.

Tratamiento

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Tratamiento

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Tratamiento

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Tratamiento

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Tratamiento

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PCSK9 inhibitors:  

•ODYSSEY (Alirocumab 1 iny/2 semanas) and the OSLER (Evolocumab 1 iny/2 ó 4 semanas) trials included patients with elevated LDL cholesterol values despite statin use.

•As compared with placebo or standard therapy, both reduced LDL cholesterol levels by an average of 62%.

•Both studies showed 50% reductions in cardiovascular events at 12 to 18 months.

•Both studies showed no adverse effects overall or in those who had an LDL cholesterol level of less than 25 mg per deciliter, but more follow-up and specific assessment of neurocognitive function is needed.

Tratamiento

Sanitas

Conclusiones

• DIAGNÓSTICO: • 1º estratificar riesgo: SCORE • 2º si riesgo intermedio o dudas hacer: PCR, albuminuria, Doppler TSA,

Calcio coronario o ITB. • También tienen alto riesgo: DM, HVI, sd metabólico, esteatosis, genes.

• TRATAMIENTO: • Usar fitoesteroles. • Prediabetes: metformina si IMC>35 y <60 años • Evitar AAS + sintrom • Hipercolesterolemia:

• Estatinas en LDL ≥190 o alto riesgo + LDL >70 mg/dL

• Si aparace DM pasar a estatina menos diabetogénica (pitavastatina)

• Ezetimiba si LDL >70

• Fenofibrato si TG >150 y HDL<40