DR. ROBERTO MEDINA R3 MEDICINA INTERNA

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

TIA / STROKE

• Mas de 690 mil casos anuales de ICTUS EE.UU

• Mas de 240 mil casos anuales de TIA EE.UU

• Riesgo de ICTUS después de un TIA o ICTUS previo es 3-4% anual

historica %

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Definiciones

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Ictus

Isquemico

Aterosclerosis de grandes

vasos

cardioembólica

Causas secundarias e

indeterminadas

Enfermedad de pequeños vasos

• TIA

• vs

• ICTUS

Objetivos

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Novedades

• Nuevos factores de riesgo: Apnea del sueño, aterosclerosis arco aórtico, nutrición, pre-diabetes.

• Revisión FA, estenosis carotidea, válvulas protésicas cardiacas con relación a AHA y ACC

• Consideración del ¨infarto cerebral silente¨

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack, Stroke AHA ,May 1, 2014

Secciones• Hipertensión

• Dislipidemia

• Diabetes mellitus

• Obesidad

• Inactividad física

• Nutrición

• Apnea del sueño

• Tabaco

• Alcohol

• Enfermedad carotidea

• Embarazo

• Aterosclerosis intracraneal

• Fibrilación auricular

• Miocardiopatía

• Enfermedad valvular

• PFO

• Homocisteinemia

• Antiagregantes plaquetarios

• Hipercoagulación

• Anticuerpos antifosfolipidos

• Falcemia

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Hipertensión Arterial

78 millones de estadounidenses sufren de HTA

Objetivo preventivo mas importante

Prevalencia HTA/ICTUS reciente 70%

Walter N. Kernan et, al Guidelines for the Prevention of Strokein Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Placebo vs perindopril+indapamida

Capp Trial

Lennart Hansson, Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality inhypertension: the Captopril Prevention Project (CAPPP), THE LANCET • Vol 353 • February 20, 1999

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Dislipidemia

La “ACC/AHA Guideline on the Treatment of Blood

Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in

Adults” fue lanzada en el 2013

Reemplaza la ATP III

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Trastornos del metabolismo de la glucosa

• Notable aumento

tanto en países

desarrollados como

en vía de desarrollo

• 11.3% de adultos EEUU

Actualmente Dx.

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke

AHA ,May 1, 2014

Px. con ictus isquémico reciente uso del activo RR 45% con relacion a placebo

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

ObesidadIMC mayor 30kg/m2

Factor de riesgo asociado

a dislipidemia, SM, DM y HTA

Relacion lineal:

IMC/ACV= 1kg/m2=5% ACV

Obesidad central/ACV

Px. ACV o AIT=Dx. 18-44% obesos

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,StrokeAHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Inactividad física

2013 AHA/ACC Guideline on Lifestyle Management to ReduceCardiovascular Risk

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Nutrición

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Enfoque: Desnutrición/equilibrio de micronutrientes/dieta óptima

Prevalencia 8-13% niveles de vit D/K Pescado/hortalizas/mediterranea

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack, Stroke AHA ,May 1, 2014

• Apnea del sueño

¾ de Px. con Ictus

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Enfermedad carotidea

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Figure

Data from the North American Symptomatic Carotid Artery Trial (NASCET)

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Aterosclerosis intracraneal

Causa mas importante de AIT/ICTUSSin diferencias significativas

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke

AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Fibrilación auricular• Afecta mas de 2.7 millones en EE.UU

• A mayor edad mayor prevalencia/ arritmia mas frecuente en los ancianos

• Responsable de mas de 70 mil ictus isquémico por año en EE.UU (10%)

• Estimación riesgo

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Eficacia de la anticoagulaciónWarfarina:

EAFT

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

ACTIVE-W TRIAL

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

NUEVOS ANTICOAGULANTES?

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke

AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014