presentazione standard di powerpoint medicine - lesson 1a - … · risk factor...
TRANSCRIPT
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Cardiovascular prevention
Sergio Caravita, MD, PhD
Department of Management, Information and Production Engineering, University of Bergamo
Cardiology Unit, IRCCS Istituto Auxologico Italiano San Luca Hospital, Milano
24/02/2020
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• CVDs are the number 1 cause of death globally: more people die annually
from CVDs than from any other cause
• Cardiovascular diseases (CVDs) take the lives of 17.9 million people every
year, 31% of all global deaths. (WHO)
• Most cardiovascular diseases can be prevented by addressing behavioural
risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity
and harmful use of alcohol using population-wide strategies.
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Disparities in riskfactors across regions
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CVDs due to atherosclerosis
• Ischaemic heart disease or coronary artery disease (e.g.heart attack)
• Cerebrovascular disease (e.g. stroke)
• Diseases of the aorta and arteries
Other CVDs
• Congenital heart disease
• Rheumatic heart disease
• Cardiomyopathies
• Cardiac arrhythmia
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Biological Versus Chronological Aging
DOI: 10.1016/j.jacc.2019.11.062
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DOI: 10.1016/j.jacc.2019.11.062
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DOI: 10.1016/j.jacc.2019.11.062
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Cardiovascular disease prevention
Cardiovascular disease prevention is defined as a coordinated set of actions, at the population level or targeted at an individual, that are aimed at eliminating or minimizing the impact of CVDs and their related disabilities.
- General population level: promotion of healthy lifestyle
- Individual level: optimisation of risk factors and tackling unhealthy lifestyle in patients at moderate to high risk of CVD or patients with estabilished CVD
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When to assess total
cardiovascular risk?
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How to estimate total
cardiovascular risk?
o 12 prospective studies from 11 European countries
o 117 098 men and 88 080 women (age 40-65)
o 10-year risk of CVD mortality (CAD, stroke, aneurysm of the
abdominal aorta). Non fatal CV events (x 4 Men; x 3 Women)
o Sex, Age, total cholesterol/HDL-C ratio, SBP, smoking status
o Version for high and low risk countries
SCORE (high-risk Systemic Coronary Risk Estimation
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Low-risk SCORE chart: CVD mortality < 225/100000 in men, < 175/100000 in women
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High-risk SCORE chart: CVD mortality > 225/100000 in men, > 175/100000 in women
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Advantages and limitations
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Example of CV risk estimation
o 55 years old Italian man
o Smoker
o BP: 145/85
o Total cholesterol 230 mg/dl
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Low-risk SCORE chart: CVD mortality < 225/100000 in men, < 175/100000 in women
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Relative risk SCORE chart
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Example of CV risk estimation
o 55 years old Italian man
o Smoker
o BP: 145/85
o Total cholesterol 230 mg/dl
o 10 years risk of fatal CV events: 4%
o Relative risk: 4-fold a 55 years old
men with optimal risk factors
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Risk categories
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Modifiers with reclassification
potential
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Family History/(epigenetics)
o Familial history of premature CVD is a simple indicator
reflecting both the genetic trait and the environment shared
among household members
o Genetic screening and counselling is effective in some
conditions such as familial hypercolesterolemia (FH)
o No role of generalized use of DNA-based tests
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Psychosocial risk factors
o Low socio-economic status, lack of social support, stress at work
and in family life, hostility, depression, anxiety and other
mental disorders contribute to the risk of developing CVD and a
worse prognosis of CVD depression and chronic stress
associated with alteration of autonomic function and in
endocrine markers which affects haemostatic and inflammatory
processes, endothelial function and myocardial perfusion
o Psychosocial risk factors act as a barriers to treatment
adherence and efforts to improve lifestyle more frequent
smoking, unhealthy food and less physical activity, low
adherence to behavioural changes or CV medications.
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J Am Coll Cardiol 2019 DOI: 10.1016/j.jacc.2019.03.010
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Measurment of preclinical
vascular damage
o Routine screening with imaging modalities to predict future CV
events is generally not reccomended in clinical practice
o Imaging methods may be considered as risk modifiers in CV risk
assessment in individuals with calculated CV risk around the
decisional thresholds
o Coronary artery calcium score examined through multislice CT
(AGATSON score) has a very high negative predictive value.
o Many studies demonstrated the grater value of measures of
atherosclerotic plaques in predicting future CVD.
o Arterial stifness measured using Pulse Wave Velocity (PWV) or
arterial augmentation index (AI) improves CV risk prediction for
patients with calculated CV risk around the decisional thresholds.
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Measurment of preclinical
vascular damage
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Risk factor intervention:behaviour change
o Cognitive behavioural methods are effective in supporting persons
in adopting a healthy lifestyle. Individual and environmental
factors impede the ability to adopt a healthy lifestyle, as does
complex or confusing advice from caregivers.
o Useful tools to enhance adherence are principles of effective
communication, motivational interviews, ”ten strategic step”
strategy.
o Combining the knowledge and skills of caregivers (physician,
nurses, psychologist, expert in nutrition, cardiac rehabilitation and
sport medicine) can optimize preventive efforts
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Risk factor intervention:
physical activityo Regular physical activity (PA) is a mainstay of CV prevention;
participation decreases all-cause and CV mortality in healthy and
cardiac patients.
o Aerobic physical activity is the most studied and recommended
modality – its prescription can be adjusted in terms of frequency,
duration and intensity (absolute: MET, VO2; relative: %HR,
%VO2max)
o Isotonic PA is less studied and has less evidence of benefit in lipid
and BP control but stimulates bone formation, preserves and
enhances muscle mass, strenght, power and functional ability
o Inactive adults should start gradually: even short periods of time is
better than no PA. Sessions should include warm up, conditioning,
cool down and stretching/flexibility.
o Risk of adverse CV event during exercise is extremely low,
increased by vigorous PA. Consider exercise testing in sedentary
people who want to engage in vigorous PA.
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Risk factor intervention:
physical activity
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Risk factor intervention:
smoking cessationo Most cost effective strategy for CVD prevention
o Brief interventions with advice to stop smoking, NRT, bupropion
and varencicline are the most used strategies. New approach is e-
cigarettes (needs more study on possible harmful effects)
o Smoking enhances atheroscerosis and superimposed thrombotic
phenomena: it affects endothelial function, oxidative processes,
platelet function, fibrinolysis, inflammation, lipid oxidation and
vasomotor function fully or partially reversible.
o Stopping smoking reduces CV deaths/MI (RR 0.57 and 0.74)
compared with continued smoking.
o Professional support can increase the odds of stopping. Following
the failure of these strategies, drug interventions should be
offered (RR 1.60 for NRT; 1.62 for bupropion; > 2.0 for
varencicline)
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Risk factor intervention:
smoking cessation
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Risk factor intervention:
nutrition and body weighto Dietary habits influence CVD risk healthy diet, Mediterranean diet
o Overweight and obesity are associated with an increased CVD death
and all cause mortality. Achieving and mantaining healthy weight has
favourable effect on metabolic risk factors and lower CV risk
o BMI (20-25) and waist circumference (<94 cm in men; < 80 in women)
o Diet, exercise and behaviour modifications are the mainstay therapies
for overweight and obesity. Bariatric surgery demonstrated a reduced
risk of MI, stroke, CV events and mortality.
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Risk factor intervention:
nutrition and body weight
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Hypertension, dyslipidemia, diabetesmellitus
Treatment of hypertension, dyslipidemia and diabetes mellitusaccording to individual risk and guidelines recommendations
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Self care of chronic illness and CV riskfactors
Individuals and their families maintain health through health-promoting practices.
Of 8760 hours in a year, patients spend only around 10 hours (0.001% of their time) with healthcare providers.
All other health maintenance, monitoring, and management activities are done by individuals or patients and their families as self-care activities outside of the clinical or hospital setting
Self-care
maintenance
Adherence to
behaviors needed to
maintain physical and
emotional stability
Self-care
monitoring
Process of
observing oneself
for changes in signs
and symptoms - body
listening
Self-care
management
Respond to signs
and symptoms when
they occur
Riegel B et al JAHA 2017
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