LA ATEROSCLEROSIS SUBCLINICA: DETECCION POR ULTRASONIDO Y SU VALOR PARA ESTRATIFICAR EL RIESGO CARDIOVASCULAR CURSO DE EVLUACION VASCULAR NO INVASIVA POR ECO DOPPLER

Dr Pedro Forcada Médico Cardiólogo, esp. en HTA Jefe Laboratorio Vascular No Invasivo Centro de Hipertensión Arterial Instituto de Cardiología, Hospital Universitario Austral Maestría de Mecánica Vascular e HTA FCBM, Universidad Austral Jefe Laboratorio Vascular No Invasivo DIM Cardiovascular

BLOQUE 1: BASE RACIONAL PARA LA ESTRATIFICACIÓN DEL REIESGO CARDIOVASCULAR POR EVALUACION ARTERIAL DIRECTA

TASAS DE MORTALIDAD EN LA REPUBLICA ARGENTINA 2004 – 2007

http://www.indec.mecon.ar/

PROPORCION DE LA HTA EN DIFERENTES PAISES LATINOAMERICANOS

Paises

Prevalencia de HTA (%)

Diagnostico de HTA (%)

Adaptado de Journal of Hypertension 2009; 27 (5): 905-922

HTA en tratamiento (%)

HTA controlada (%)

LA HIPERTENSION ARTERIAL A NIVEL POBLACIONAL “La regla de las mitades”

40 millones

21 millones

7 millones 3,5 millones Total

Mayores de 30

Hipertensos

Diagnosticados

1,75 millones Tratados

875 mil Controlados

REGRESAR

EVENTO

ENFERMEDAD PRECLINICA

RETRASAR ENFERMEDAD CLINICA

PREVENIR

FACTORES DE RIESGO

PREVENCION PRIMORDIAL

PREVENCION PRIMARIA

ETAPA TERMINAL MUERTE

PREVENCION SECUNDARIA

PREVENCION , EL MEJOR TRATAMIENTO

Los Los Doctores Doctores Superiores Superiores previenen previenen la la enfermedad. enfermedad. Los idente. Los Doctores Doctores Mediocres Mediocres tratan tratan la la enfermedad enfermedad antes antes de de que que sea sea ev evidente. Los Los Doctores Doctores Inferiores Inferiores tratan tratan la la enfermedad enfermedad evolucionada. evolucionada. Huang édico Chino) Huang Dee Dee Nai Nai Ching Ching (2600 (2600 AC AC Texto Texto M Médico Chino) PF 08

BUSQUEDA DE ATEROSCLEROSIS Factores de Riesgo vs. Enfermedad Más de 200 factores a la fecha:

Estudio de la Estructura Arterial

HTA DBT TBQ Obesidad Historia Familiar Estrés LDL aumentado LDL densas HDL disminuido Sindrome metabólico Lipoproteina a Homocisteina Etc.

Estudio de la Función Arterial

VASOS VULNERABLES

Envejecimiento Vascular: La Historia de EVA y ADAM

CALCULO DEL RIESGO CV GLOBAL

RIESGO RIESGO GENETICO GENETICO

RIESGO RIESGO CV CV CLINICO CLINICO

(FACTORES (FACTORES HEREDOFAMILIARES) HEREDOFAMILIARES)

(FACTORES (FACTORES DE DE RIESGO RIESGO CV) CV)

RIESGO ÚIMICO BIOQ RIESGO CV CV BIOQÚ BIOQÚIMICO

RIESGO RIESGO CV CV TISULAR TISULAR

(MARCADORES (MARCADORES DE DE RIESGO RIESGO BIOQUIMICOS) BIOQUIMICOS)

(MARCADORES (MARCADORES DE DE RIESGO RIESGO TISULAR) TISULAR)

LABORATORIO VASCULAR NO INVASIVO NUEVA GENERACION

PF 08

Estructura y función vascular

Evaluación de la función Cardiovascular

PERSPECTIVAS FUTURAS Evaluacion Vascular no Invasiva: “ Un Ejercicio Clínico Diagnóstico por Excelencia”

Gasto Cardiaco

Corazó Corazón

Distensibilidad Central

Aorta

Distensibilidad Periférica

Art. Musculares

Velocidad de Onda de Pulso Aumentació Aumentación Central

Aumentacion Perifé Periférica

Cardiografia por Impedancia

Espesor Intima Media Placas Ateroscleróticas Test de Endotelio

Resistencias Perifericas

Microcirculació Microcirculación

LABORATORIO VASCULAR NO INVASIVO INFORME FINAL

GRADO DE COMPROMISO VASCULAR

EIM

PLACAS

VOP FUNCION ENDOTELIAL

CONCEPTO DE RECLASIFICACION DE RIESGO CARDIOVASCULAR

LABORATORIO VASCULAR NO INVASIVO Base Racional (I) ENFERMEDAD PRECLINICA

ENFERMEDAD ESTABLECIDA

RIESGO CARDIOVASCULAR

Espesor Intima Media Elasticidad Arterial Disfunción Endotelial

Normal

Normal

Normal

Normal

Normal

Alterado

Normal

Alterado

Alterado

FUNCIONAL

Alterado P L A Alterado C A S Alterado

ESTRUCTURAL P. Forcada Junio 2005-modif 08

LABORATORIO VASCULAR NO INVASIVO Base Racional

ALTO RIESGO Alto Riesgo del Bajo Riesgo Complicaciones

BAJO RIESGO POBLACION DE ENFERMOS CARDIOVASCULARES P. Forcada Junio 2005

Porque no rastrear la aterosclerosis subclinica? Sillesen H, Falk E Poblacion en riesgo asintomatica

Bajo Riesgo : 6% FRS

Riesgo Intermedio: area gris

Alto Riesgo : 20% FRS

opcional Historia Familiar

Prueba de aterosclerosis

Diabetes

Reclasificación

Bajo Riesgo

Riesgo Intermedio

Alto Riesgo

Modificado de SHAPE, ACCF/AHA 2010 Guidelines

The Lancet 2011; 378: 645 - 646

CASO CLINICO: Paciente masculino, 55 años, AHF + ECV. HTA (PA 156/94 mmHg), DLP (CT 250 HDL 40 LDL 170 Tg 170), SBP; SED No TBQ, DBT, HVI o microalbuminuria. Sin complicaciones clínicas.

Riesgo Framingham 19 pts.= 16% de morbimortalidad CV a 10 años Riesgo ESH / ESC Moderado= Morbilidad CV 15-20% Mortalidad= 4-5%

EIM

y/o Placas

y/o

VOP

y/o Función Endotelial

Riesgo de morbimortalidad a 10 años > 25% ARIC investigators JACC 2010; 55: 16001600-1607 Lamina C et al, MONICA substudy European Heart Journal 2006; 27: 2580 – 2587 Hansen T, Staesen J, Torp Pedersen C Circulation 2006; 113: 664 – 670 Sciacua A et al European heart Journal 2005; 26: 921921-927

Prev PLC 37% Ev s/plc 8% Ev c/plc 15%

MEDICION DEL ESPESOR INTIMA MEDIA VALOR PRONOSTICO – ESTUDIO ARIC

IMT > percentilo 75 + Placa

Ref: N (%) R N:Numero, %:Porcentaje R: Riesgo a 10 años

LABORATORIO VASCULAR NO INVASIVO Base de Datos LVNI Edad: 50 Masc: 66% PA: 133/84 mmHg

EIM

32%

PLC

72%

VOP

66%

FMD

33%

BASE HASTA DIC 2010 – ACCESO 1111-0303-2011 06:30

LECTURAS MAS RECIENTES QUE RECOMIENDAN LA EVALUACION VASCULAR NO INVASIVA PARA ESTIMAR EL RIESGO CARDIOVASCULAR Stein J, Korcarz C , Hurst R, et al: Use of Carotid Ultrasound to Identify Subclinical Vascular Disease and Evaluate Cardiovascular Disease Risk: Risk: A Consensus Statement from the American Society of Echocardiography Carotid IntimaIntima-Media Thickness Task Force Endorsed by the Society for Vascular Medicine. Medicine. Journal of the American Society of Echocardiography 2008; 21(2): 9393-111 Urbina E, Williams R, Alpert B, et al: Noninvasive Assessment of Subclinical Atherosclerosis in Children and Adolescents. Adolescents. Recommendations for Standard Assessment for Clinical Research. Research. A Scientific Statement From the American Heart Association. Association. Hypertension 2009;54:002009;54:00-00. DOI: 10.1161/HYPERTENSIONAHA.109.192639) Mancia G, Laurent S, AgabitiAgabiti-Rosei E, et al.: Reappraisal of European guidelines on hypertension management: A European Society of Hypertension Task Force document document.. J Hypertens. Hypertens. 2009;272009;27-212121212158. Greenland P, Alpert J, Beller G, et al: 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults. Adults. J.A.C.C. J.A.C.C. 2010; 56: e50e50-e103 Brott T, Halperin J, Abbara S, et al: 2011 ASA /ACCF /AHA /AANN /AANS /ACR /ASNR /CNS /SAIP /SCAI /SIR /SNIS /SVM /SV : Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. Disease. Circulation published online Jan 31, 2011 DOI: 10.1161/CIR.0b013e31820d8c98 Peters S, M den Ruijter H, Bots M et al: Improvements in risk stratification for the occurrence of cardiovascular disease by imaging subclinical atherosclerosis: atherosclerosis: a systematic review. review. Heart 2012;98:1772012;98:177184. 184.

BIBLIOGRAFIA SUGERIDA: EIM 1-Stein J H, Korcarz C E , Hurst R T et al: Use of Carotid Ultrasound Ultrasound to Identify Subclinical Vascular Disease and Evaluate Cardiovascular Disease Risk: A Consensus Statement from the American American Society of Echocardiography Carotid IntimaIntima-Media Thickness Task Force Endorsed by the Society for Vascular Medicine. Medicine. Journal of the American Society of Echocardiography 2008; 21 (2): 93 – 111. 2-Fustinoni O, Atallah A, Cirio J J et al: Sociedad Argentina de Cardiolog Cardiologíía, Sociedad Neuroló Neurológica Argentina: Consenso de Estenosis Carotí Carotídea. Revista Argentina de Cardiologia 2006, 74(2): 160 -174. 2- Stein JH, Johnson HM. Carotid intimaintima-media thickness, plaques, and cardiovascular disease risk. J Am Coll Cardiol 2010; 55:160855:1608-1610 3-Bots M L, Evans G W, Riley W A, Grobbee D E: Carotid IntimaIntima-Media Thickness Measurements in Intervention Studies Design Options, Progression Rates, and Sample Size Considerations: A Point Point of View. Stroke. 2003;34:29852003;34:2985-2994 4-O´Leary D H, Polak J F, Kronmal R A, and Cardiovascular Health Study Study Collaborative Research Group. N Engl J Med 1999;340:1422. 1999;340:14 5- Chambless L E,Folsom A A, Clegg L E, and The Atherosclerosis Risk Risk in Communities (ARIC) Study Group: Carotid Wall Thickness is Predictive of Incident Clinical Stroke. Am J Epidemiol Epidemiol 2000; 151 (5): 478 - 487 6- Vijay Nambi V, Chambless L E, Folsom A R: and The Atherosclerosis Atherosclerosis Risk in Communities (ARIC) Study Group: Carotid IntimaIntima-Media Thickness and Presence or Absence of Plaque Improves Prediction Prediction of Coronary Heart Disease Risk The ARIC (Atherosclerosis Risk In Communities) Study. J Am Coll Cardiol 2010; 010; 55: 1600 –1607. 2 7-Polak J F, Pencina M J, Pencina K M, et al: CarotidCarotid-Wall Intima– Intima–Media Thickness and Cardiovascular Events. N Engl J Med 2011; 365: 213213-21. 8-Zanchetti A, A, Hennig M, M, Baurecht H, H, et al: Prevalence and incidence of the metabolic syndrome in the the European Lacidipine Study on Atherosclerosis (ELSA) and its relation with carotid intima intima--media thickness. J Hypertens. 2007;25(12):24632007;25(12):2463-70. 9-Gariepy J; Simon A; Chironi G; Moyse D; Levenson J : Large artery wall thickening and its determinants under antihypertensive antihypertensive treatment: The IMTIMT-INSIGHT Study. Journal of Hypertension 2004;22 (1):137(1):137-143 1010-Pitt B, Byington R P, Furberg C D, for the PREVENT Investigators: Investigators: Effect of Amlodipine on the Progression of Atherosclerosis and the Occurrence of Clinical Events Circulation. Circulation. 2000;102:15032000;102:1503-1510 1111-De Groot E, E, Jukema J W, W, Montauban van Swijndregt AD, AD, et: BB-mode ultrasound assessment of pravastatin treatment effect on carotid and femoral artery walls and its correlations with coronary coronary arteriographic findings: a report of the Regression Growth Growth Evaluation Statin Study (REGRESS). J Am Coll Cardiol. 1998 Jun;31(7):1561Jun;31(7):1561-7. 1212-Lorenz M W, W, von Kegler S, S, Steinmetz H, H, Markus HS, HS, Sitzer M. M. Carotid intimaintima-media thickening indicates a higher vascular risk across a wide age range: prospective data from the Carotid Atherosclerosis Progression Study (CAPS). Stroke. 2006 Jan;37(1):87Jan;37(1):87-92. 1313-Crouse JR 3rd, 3rd, Grobbee DE, DE, O'Leary DH, DH, et al: Measuring Effects on intima media Thickness: an Evaluation Evaluation Of Rosuvastatin in subclinical atherosclerosis.(METEOR Study). : Cardiovasc Drugs Ther. 2004 May;18(3):231May;18(3):231-238.

BIBLIOGRAFIA SUGERIDA: PLACAS 1-Stein J H, Korcarz C E , Hurst R T et al: Use of Carotid Ultrasound Ultrasound to Identify Subclinical Vascular Disease and Evaluate Cardiovascular Disease Risk: A Consensus Statement from the American American Society of Echocardiography Carotid IntimaIntima-Media Thickness Task Force Endorsed by the Society for Vascular Medicine. Medicine. Journal of the American Society of Echocardiography 2008; 21 (2): 93 – 111. 2-Fustinoni O, Atallah A, Cirio J J et al: Sociedad Argentina de Cardiolog Cardiologíía, Sociedad Neuroló Neurológica Argentina: Consenso de Estenosis Carotí í dea. Revista Argentina de Cardiologia 2006, 74(2): 160 174. Carot 2- Stein JH, Johnson HM. Carotid intimaintima-media thickness, plaques, and cardiovascular disease risk. J Am Coll Cardiol 2010; 55:160855:1608-1610. 3-Davidsson L, B. Fagerberg B, Bergströ Bergström F, C. Schmidt C: UltrasoundUltrasound-assessed plaque occurrence in the carotid and femoral arteries are independent predictors of cardiovascular events in middlemiddle-aged men during 10 years of followfollow-up. Atherosclerosis 209 (2010) 469– 469–473. 4-Lamina C, Meisinger C, Heid I M,et al :Association of ankleankle-brachial index and plaques in the carotid and femoral arteries with with cardiovascular events and total mortality in a populationpopulation-based study with 13 years of followfollow-up. European Heart Journal (2006) 27, 2580– – 2587. 2580 5-Sztajzel R, Momjian S, MomjianMomjian-Mayor I,et al:.Stratified GrayGray-Scale Median Analysis and Color Mapping of the Carotid Plaque: Correlation With Endarterectomy Specimen Histology of 28 Patients. Patients. Stroke 2005;36;7412005;36;741-745. 6-Ballantyne C M, Raichlen J S, Nicholls S J et for de ASTEROID study study Investigators: Effect of Rosuvastatin Therapy on Coronary Artery Stenoses Assessed by Quantitative Coronary Angiography Angiography A Study to Evaluate the Effect of Rosuvastatin on Intravascular UltrasoundUltrasound-Derived Coronary Atheroma Burden. Circulation. 2008;117:24582008;117:2458-2466 9-Byington RP, RP, Furberg CD, CD, Crouse JR 3rd, 3rd, et al.: Pravastatin, Lipids, and Atherosclerosis in the Carotid Carotid Arteries (PLAC(PLAC-II). Am J Cardiol. 1995 Sep 28;76(9):54C28;76(9):54C-59C. 1010-V, Smilde TJ, TJ, de Groot E, E, Hutten BA, BA, Kastelein JJ, JJ, et al:. The significance of femoral intimaintima-media thickness and plaque scoring in the Atorvastatin versus Simvastatin on Atherosclerosis Atherosclerosis Progression (ASAP) study. Eur J Cardiovasc Prev Rehabil. 2003 Dec;10(6):451Dec;10(6):451-5.

BIBLIOGRAFIA SUGERIDA: VOP Y PRESION CENTRAL 1-The Reference Values for Arterial Stiffness’ Stiffness’ Collaboration† Collaboration†Determinants of pulse wave velocity in healthy people and in the presence of cardiovascular risk factors: factors: ‘establishing normal and reference values. values. European Heart Journal 2010; 31: 2338– 2338–2350. 2-O’Rourke M F, Staessen J A, Vlachopoulos C, et al: Clinical Applications Applications of Arterial Stiffness; Definitions and Reference Values. AJH 2002; 15:426– 15:426–444. 3-Hansen T W, Staessen J A, TorpTorp-Pedersen C, et al : Prognostic Value of Aortic Pulse Wave Velocity as Index of Arterial Stiffness the General Population. Population. Circulation 2006;113;6642006;113;664-670. 4-Mitchell G F, Guo C Y, Benjamin E J, et al: CrossCross-Sectional Correlates of Increased Aortic Stiffness in the Community Community The Framingham Heart Study. Circulation. 2007;115:26282007;115:2628-2636. 2636. 5-Safar M E, Blacher J, Jankowski P: Arterial stiffness, pulse pressure, pressure, and cardiovascular disease— disease—Is it possible to break the vicious circle? Atherosclerosis 218 (2011) 263– 263–271. 6-AgabitiAgabiti-Rosei E, Mancia G, O’ O’Rourke M F, et al: Central Blood Pressure Measurements and Antihypertensive Antihypertensive Therapy. A Consensus Document. Hypertension. 2007;50:1542007;50:154-160. 7-Benetos A, Thomas F, Joly L, Blacher J, Pannier B, et al: Pulse Pressure Amplification: A Mechanical Biomarker of Cardiovascular Risk. J. Am. Coll. Cardiol. 2010;55;10322010;55;1032-1037. 8-Wilkinson I B, Franklin S S, Hall I R, et al: Pressure Amplification Amplification Explains Why Pulse Pressure Is Unrelated to Risk in Young Subjects Hypertension. 2001;38:14612001;38:1461-1466.) 9-Wassertheurer S, Kropf J, T Weber T, et al: A new oscillometric method for pulse wave analysis: comparison with a common tonometric tonometric method. Journal of Human Hypertension (2010) 24, 498– 498–504. 1010-McEniery C, Barry McDonnell Y, Munnery M, et al: Central Pressure: Pressure: Variability and Impact of Cardiovascular Risk Factors : The Anglo Anglo--Cardiff Collaborative Trial II. Hypertension 2008, 51:147651:1476-1482 1111-Williams B, Peter S. Lacy P S, Thom S M, Cruickshank K et al: (CAFE (CAFE substudy investigators): Differential Impact of Blood Pressure Pressure--Lowering Drugs on Central Aortic Pressure and Clinical Outcomes. Principal Results of the Conduit Artery Function Evaluation (CAFE) Study. Circulation Circulation 2006; 113: 121312131225. 1212-Fyhrquist F, Dahlö Dahlöf B, Devereux R, et al: Pulse Pressure and Effects of Losartan or or Atenolol in Patients With Hypertension and Left Ventricular Hypertrophy. Hypertension. 2005;45:5802005;45:580-585. 1313-Safar M E, Blacher J, Jankowski P: Arterial stiffness, pulse pressure, pressure, and cardiovascular disease— disease—Is it possible to break the vicious circle? Atherosclerosis 218 (2011) 263– 263–271.

BIBLIOGRAFIA SUGERIDA: ENDOTELIO 1-Corretti M C, Anderson T J, Benjamin E et al: Guidelines for the Ultrasound Assessment of EndothelialEndothelial-Dependent FlowFlowMediated Vasodilation of the Brachial Artery A Report of the International ernational Brachial Artery Reactivity Task Force. JACC 2002; 39 Int (2), 257257- 265. 2-Brunner H, Cockcroft J,Deanfield J, et al: Endothelial function and dysfunction. Association with cardiovascular risk factors and and diseases. A statement by the Working Group on Endothelins and Endothelial Endothelial Factors of the European Society of Hypertension. J Hypertens 23:233– – 246. 23:233 3-Harris R A, Nishiyama S K, Wray W, et al: Ultrasound Assessment of FlowFlow-Mediated Dilation. Tutorial. Hypertension. 2010;55:10752010;55:1075-1085. 4- Yeboah J, Crouse J R, Hsu F C, and teh CHS study group: Brachial Brachial FlowFlow-Mediated Dilation Predicts Incident Cardiovascular Events in Older Adults: The Cardiovascular Health Study Circulation Circulation 2007;115;23902007;115;2390-2397. 3-Anderson T J, Charbonneau F, Title L M et al : Microvascular Function Predicts Cardiovascular Events in Primary Primary Prevention LongLong-Term Results From the Firefighters and Their Endothelium (FATE) Study.Circulation. 2011;123:1632011;123:163-169. 4- Sciacqua A, Scozzafava A, Pujia A et al: Interaction between vascular vascular dysfunction and cardiac mass increases the risk of cardiovascular outcomes in essential hipertensió hipertensión. European Heart Journal (2005) 26, 921– 921–927. 5- Yeboah J, Aaron R. Folsom A R, Gregory L. Burke G L, and MESA Study Study Investigators: Predictive Value of Brachial FlowFlowMediated Dilation for Incident Cardiovascular Events in a Population Population--Based Study : The MultiMulti-Ethnic Study of Atherosclerosis. Circulation. Circulation. 2009;120:5022009;120:502-509. 509.