Patologie cardio-vascolari: contesto epidemiologico … dell’aterosclerosi Cellule Schiumose Strie...
Transcript of Patologie cardio-vascolari: contesto epidemiologico … dell’aterosclerosi Cellule Schiumose Strie...
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Patologie cardio -vascolari: contesto epidemiologico e meccanismi
INQUINAMENTO URBANO EPATOLOGIE CARDIO-VASCOLARI
epidemiologico e meccanismi fisiopatologici
Giancarlo CasoloDirettore UO Cardiologia, USL 12 Viareggio
Presidente Regionale ANMCO
Firenze, Palazzo Vecchio, Salone de' Dugento - 7 Febbra io 2012
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Le malattie Cardiovascolari
• Infarto del miocardio• Morte Improvvisa• Scompenso Cardiaco• Ictus Cerebrale• Arteriopatie periferiche
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Cause di Morte in Italia
• Secondo l’OMS l’Italia ha in media unamortalità più bassa per tutte le cause,incluse le malattie CV che però sonoincluse le malattie CV che però sonostate la causa del decesso nel 38% deicasi nel 2001 e del 41% nel 2010 .
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Le malattie Cardiovascolari
European Society of Cardiology HIS 2006
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Deaths attributable to diseases of the heart (United States: 1900 –2008)
Circulation 2012;125:e2-e220
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Cardiovascular disease mortality trends for males and females (United States: 1979–2008)
Circulation 2012;125:e2-e220
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Quale è la principale causa di morte Cardiovascolare?
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Percentage breakdown of deaths attributable to cardiovascular disease (United States: 2008)
Circulation 2012;125:e2-e220
35%
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Age- and Sex - Adjusted Rates of Acute Myocardial Infarction, 1999 to 2008
Yeh et Al. NEJM 2010
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ISSCNESPS
SDO nazionali 20012001--20092009
Numero di “eventi” IMA e età media al ricoveroNumero di “eventi” IMA e età media al ricovero
919.265 eventi IMA in 9 anni919.265 eventi IMA in 9 anni
Età mediana 2003Età mediana 2003--2009 : 72 anni2009 : 72 anni
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L’Infarto Miocardico in Italia
• In Italia l'infarto del miocardio ogni anno colpisce circa 200 mila persone , ma solo il 50% di esse arriva in ospedale :
meno della metà in tempo, il 10% entro 2 ore daiprimi sintomi, il 20% vi arriva dopo 12 orequando la finestra temporale utile per eseguirele terapie che ricanalizzano la coronaria ostruitasi è ormai esaurita. L’altro 50% o muore prima(44%) o ha un infarto asintomatico
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L’Infarto Miocardico in Italia
• La malattia coronarica è stata causa dimorte nel 12% dei casi sebbenel’incidenza sia crollata del 27 % dal1995 al 2001. Oggi in Italia sono circa1995 al 2001. Oggi in Italia sono circa1.500.000 le persone affette dacardiopatia ischemica, la più diffusa tra lemalattie cardiovascolari, a rischio grave disubire attacchi di angina o infarti.
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MORTALITA’: STEMI e NSTEMIDati analisi TOSCANA blitz 4 qualita’
8,710,049,69
11,02
8
10
12STEMI NSTEMI
3,89
5,49
1,68
3,65
0
2
4
6
8
UTIC/Cardiologia 30 gg Mediana 180 gg 180 gg
17/420 8/487 24/386 18/446 38/437 48/495 38/327 47/378
95% con dato disponibile
95% con dato disponibile
84% con dato disponibile
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CARDIOVASCULAR DISEASES AS A CONTINUUM OF EVENTS
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Cosa causa l’Infarto e le malattie Cardiovascolari?
• Infarto Miocardico• Morte Improvvisa• Morte Improvvisa• Ictus Cerebrale• Arteriopatia Periferica
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Sviluppo dell’aterosclerosi
Cellule Cellule Cellule Cellule
SchiumoseSchiumoseSchiumoseSchiumose
StrieStrieStrieStrie
LipidicheLipidicheLipidicheLipidiche
Lesione Lesione Lesione Lesione
IntermediaIntermediaIntermediaIntermedia AteromaAteromaAteromaAteroma
Placca Placca Placca Placca
FibrosaFibrosaFibrosaFibrosa
Lesione/rottura Lesione/rottura Lesione/rottura Lesione/rottura
complicatacomplicatacomplicatacomplicata
Adattato da Stary HC et al. Circulation 1995;92:1355-1374
Disfunzione endoteliale
Prima decadePrima decadePrima decadePrima decade Dalla terza decadeDalla terza decadeDalla terza decadeDalla terza decade Dalla quarta decadeDalla quarta decadeDalla quarta decadeDalla quarta decade
Crescita dovuta principalmente all’accumulo di lipidiCrescita dovuta principalmente all’accumulo di lipidiCrescita dovuta principalmente all’accumulo di lipidiCrescita dovuta principalmente all’accumulo di lipidiMuscolo liscioMuscolo liscioMuscolo liscioMuscolo liscio
e collagenee collagenee collagenee collagene
Trombosi,Trombosi,Trombosi,Trombosi,
ematomaematomaematomaematoma
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Aterosclerosi è una malattia multidistrettuale
Coronary artery disease
Carotid artery disease� Transient ischemic attack� Stroke
Renovascular disease
Coronary artery disease
Peripheral arterial disease
� Stable angina pectoris� Acute coronary syndromes
� Intermittent claudication� Critical limb ischemia
� Hypertension� Renal insufficiency
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Sono una malattia antica…
U.S. and Egyptian cardiologists CAT scanned 22 mummieshoused in the Egyptian National Museum. Evidence of cardiac
ANCIENT EGYPTIAN AFFLICTED WITH ATHEROSCLEROSIS 3500 YEARS AGO
Computed Tomographic Assessment of Atherosclerosis in Ancient Egyptian MummiesJama: Vol. 302 No. 19, November 18, 2009
housed in the Egyptian National Museum. Evidence of cardiactissue or blood vessels was detected in 16 of the mummies.Atherosclerosis was definitely seen in five mummies andprobably there in four more.
Atherosclerosis was significantly more commonin the mummies estimated to be at least 45when they died (87% versus 25%, P=0.029).
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Infiammazione ed Aterosclerosi
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Cardiovascular risk factors and oxidative stressCardiovascular risk factors and oxidative stress
Forstermann, U. et al. Circulation 2006
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La storia tradizionaleP
laqu
e G
row
th/ S
teno
tic A
rea
Infarto del miocardio
Pla
que
Gro
wth
/ Ste
notic
Are
a
Time/Years
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La storia rivedutaP
laqu
e G
row
th/ S
teno
tic A
rea
Infarto del miocardio
Pla
que
Gro
wth
/ Ste
notic
Are
a
Time/Years
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Due aspetti importanti
• A) Sviluppo e progressione della malattia aterosclerotica
• B) Fattori che scatenano gli eventi
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Coronary heart disease epidemics: not all the same
Mirzaei M et Al. Heart 2009
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Coronary heart disease epidemics: not all the same
Mirzaei M et Al. Heart 2009
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Mirzaei M et Al. Heart 2009
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Lancet 2011
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Fattori che hanno modificato la storia delle Malattie Cardiovascolari
• Identificazione e correzione dei principali fattori di rischio
• Terapie di dimostrata efficacia (soprattutto la terapia Medica)
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Controllo dei Fattori di Rischio
• Età, sesso• Diabete• Fumo di sigaretta• Profilo lipidico Fattori di rischio • Profilo lipidico• Pressione Arteriosa• Dieta • Attività Fisica• Profilo genetico
Fattori di rischio Modificabili
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Percentuale della riduzione di mortalità per malattia coronarica
Ford et Al. N EnJMed 2007
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Percentage of Decrease in Deaths From Coronary Disease Due to Treatments for Established Disease
and Changes in Risk Factors
Hlatky et Al. JACC 2009
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Previous Use of Medication on an Outpatient Basis
Yeh et Al. NEJM 2010
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Importance of Lowering BPImportance of Lowering BP(Data from Multiple Clinical Trials Measuring the Impact of Hypertensive
Therapy on Cardiovascular Mortality)
MRC2
MIDAS/NICS/VHAS
UKPDS C vs A
NORDIL INSIGHTHOT L vs H
HOT M vs H MRC11.00
1.25
1.50
Odd
s R
atio
(ex
perim
enta
l/ref
eren
ce) P=0.002
Cardiovascular Mortality
actively controlled trials.
placebo-controlled studies or trials with an untreated control group.
Negative values indicate tighter BP control on reference treatment.
STOP2/ACEIs
STOP2/CCBs
Greater differences in BP reduction mean greater re ductions in the risk of cardiovascular mortality.
BP, blood pressureStaessen JA et al. Hypertension Research. 2005;28:385-407.
HEPEWPHE
STOP1ATMHPART2/SCAT
CAPPP
Syst-China
0.25
0.50
0.75 Syst-EurSTONE
UKPDS L vs HRCT70-80
Odd
s R
atio
(ex
perim
enta
l/ref
eren
ce)
–5 0 5 10 15 20 25
reference treatment.
HOPE
SHEPSTOP2/CCBs
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4S - Rx
4S - Placebo
LIPID - Placebo15
20
25
30
Secondary PreventionRx - Statin therapyPRA – pravastatinATV - atorvastatin
On-Treatment LDL-C is Closely Related to CHD Events in Statin Trials – Lower is Better
Adapted from Rosensen RS. Exp Opin Emerg Drugs 2004;9(2):269-279
LaRosa JC et al. N Engl J Med 2005;352:1425-1435
LDL-C achieved mg/dL (mmol/L)
WOSCOPS – Placebo
AFCAPS - Placebo
ASCOT - Placebo
AFCAPS - Rx WOSCOPS - Rx
ASCOT - Rx
HPS - Placebo
LIPID - Rx
CARE - Rx
CARE - Placebo
HPS - Rx
0
5
10
15
40(1.0)
60(1.6)
80(2.1)
100(2.6)
120(3.1)
140(3.6)
160(4.1)
180(4.7)
6
Primary Prevention
200(5.2)
PROVE-IT - PRA
PROVE-IT – ATV
TNT – ATV10
TNT – ATV80
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Morti attribuibili ai fattori di rischio
Danaei et Al. Plos Medicine 2009
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Proiezione di scenario nel 2015
Mathers, Locars. Plos Medicine 2006
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Rischio di morte cardiovascolare nel corso della vita
Berry et Al. N Eng J Med 2012
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Carte di rischio
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Sir Winston Churchill, 91 Sir Winston Churchill, 91 � Jim Fixx, 53Jim Fixx, 53 ��♥♥Who Has More Cardiovascular Risk Factors?Who Has More Cardiovascular Risk Factors?
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INTERHEART STUDY
Mc Gorrian.Eur Heart J 2011
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Esiste un rischio residuo
• Col non-LDL/non-HDL• Livello di HDL• Pressione arteriosa (alcuni fenomeni)• Depressione/Ansia• Depressione/Ansia• Esposizione al sole• Fattori dietetici (ciccolata, fritto, polifenoli)• Fattori genetici • Polveri e particolati (inquinamento)• Altri fattori ignoti
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Circulation . 2010;121:2331-2378
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Conclusioni
• Le malattie cardiovascolari sono unaimportante causa di morte, morbilità ecosti socio-sanitari nel mondo occidentale
• Nonostante una consistente riduzione di• Nonostante una consistente riduzione dimortalità si prevede un aumento dellaprevalenza della malattia
• Nuovi fattori di rischio non utilizzati nellecarte convenzionali possono avere unimportante valore ai fini della prevenzionedella malattia e degli eventi acuti
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Inflammatory Events in Complex ComorbiditiesInflammatory Events in Complex ComorbiditiesInflammatory Events in Complex ComorbiditiesInflammatory Events in Complex ComorbiditiesInflammatory Events in Complex ComorbiditiesInflammatory Events in Complex ComorbiditiesInflammatory Events in Complex ComorbiditiesInflammatory Events in Complex Comorbidities
Ukena C et al. Int J Cardiol 2010Ukena C et al. Int J Cardiol 2010Ukena C et al. Int J Cardiol 2010Ukena C et al. Int J Cardiol 2010
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US age-standardized death rates attributable to cardiovascular diseases, 2006 and 2007
Circulation 2012;125:e2-e220
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Cardiovascular disease (CVD) and other major causes of death: total, <85 years of age, and ≥85 years of age
Circulation 2012;125:e2-e220
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Hospital discharges for the 10 leading diagnostic groups (United States: 2009)
Circulation 2012;125:e2-e220
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Trends in age-adjusted rates of coronary mortality in central European countries (dotted lines) and
comparator countries (continuous lines) from 1986 t o 2004
Capewell, o’Flaherty. Lancet 2011
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SDO malattie CV
RICOVERI REGIONALI TOSCANA
7800080000820008400086000
Num
ero
SD
O
Regionali
RICOVERI NAZIONALI
1280000
1300000
1320000
Num
ero
SD
O
Nazionali
7000072000740007600078000
1 2 3
ANNI
Num
ero
SD
O
Regionali
2000 2003 20051220000
1240000
1260000
1 2 3
ANNO
Num
ero
SD
O
Nazionali
2000 2003 2005
Dati Ministero della Salute, banca dati SDO
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Il ruolo centrale della placca vulnerabile
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Contributo delle singole azioni alla riduzione della mortalità per CAD in Svezia 1986-2002
Bjork L et Al. Eur Heart J 2009
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Percentage of Decrease in Deaths From Coronary Disease Due to Treatments for Established Disease
and Changes in Risk Factors
Hlatky et Al. JACC 2009
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