kardiovaskularne bolesti prim. mr. sc. dr. nediljko pivac interna klinika, kbc split

KARDIOVASKULARNE BOLESTIPrim. Mr. Sc. Dr. Nediljko PivacInterna klinika, KBC Split

Ukupna smrtnost u svijetu 2002WHO. The World Health Report 2003: Shaping the Future. 2003.

Uzroci smrtnosti u SAD American Heart Association. Heart and Stroke Statistical Update 2007.

Uzroci smrti u Hrvatskoj 2001. godineIzvor podataka: Dravni zavod za statistiku, Hrvatski zavod za javno zdravstvo

cirkulacijske

449.67

450.49

532.27

538.73

547.78

551.55

552.15

556.84

562.49

584.08

624.5

636.9

653.61

666.24

745.27

746.01

764.06

773.7

782.16

853.25

860.36

upanije

Stopa

Opa stopa smrtnosti od bolesti cirkulacijskog sustava po upanijama Hrvatske u 2001. godini

novotvorine

219.69

227.88

231.84

236.85

244.48

248.26

258.09

263.64

266.74

268.72

270.3

270.51

271.19

272.23

274.12

276.92

279.31

301.9

308

316.67

342.79

upanije

Stope

Opa stopa smrtnost od novotvorina po upanijama Hrvatske u 2001. godine

nasilne

47.74

54.92

55.18

56.18

58.27

58.64

61.03

62.91

68.51

69.39

77.39

82.52

85.51

96.89

100.6

upanije

Stopa

Opa stopa smrtnosti od nasilnih smrti po upanijama Hrvatske u 2001. godini

probava 6

44.76

51.22

52.04

66.71

82.75

88.88

upanije

Stopa

Opa stopa smrtnosti od bolesti probavnih organa po upanijama u Hrvatskoj u 2001. godini

podaci

upanijacirkulacijske

Splitsko-dalmantinska449.67

Zadarska450.49

Dubrovako-neretvanska532.27

Meimurska538.73

Grad Zagreb547.78

Primorsko-goranska551.55

Brodsko-posavska552.15

Istarska556.84

Zagrebaka562.49

Vukovarsko-srijemska584.08

Osjeko-baranjska624.5

ibenko-kninska636.9

Poeko-slavonska653.61

Varadinska666.24

Virovitiko-podravska745.27

Sisako-moslavaka746.01

Koprivniko-krievaka764.06

Krapinsko-zagorska773.7

Karlovaka782.16

Liko-senjska853.25

Bjelovarska-bilogorska860.36

upanijaneoplazme

Zadarska219.69




ibenko-kninska244.48

Meimurska248.26


Istarska263.64





Grad Zagreb271.19

Varadinska272.23



Zagrebaka279.31


Sisako-moslavaka308

Karlovaka316.67

Liko-senjska342.79

upanijapovredeprobavaprobava

Dubrovako-neretvanska43.9544.76Dubrovako-neretvanska44.76

Grad Zagreb47.74Zadarska51.22

Zadarska48.1351.22Osjeko-baranjska52.04

Osjeko-baranjska51.7452.04Meimurska66.71

ibenko-kninska54.92Koprivniko-krievaka82.75

Vukovarsko-srijemska55.18Virovitiko-podravska88.88

Zagrebaka56.18


Istarska58.64Dubrovako-neretvanska43.95

Splitsko-dalmantinska61.03Grad Zagreb47.74

Poeko-slavonska62.91Zadarska48.13

Meimurska65.8666.71Osjeko-baranjska51.74

Sisako-moslavaka68.51ibenko-kninska54.92

Primorsko-goranska69.39Vukovarsko-srijemska55.18

Koprivniko-krievaka70.782.75Zagrebaka56.18

Bjelovarska-bilogorska77.39Brodsko-posavska58.27

Karlovaka82.52Istarska58.64

Varadinska85.51Splitsko-dalmantinska61.03

Virovitiko-podravska87.888.88Poeko-slavonska62.91

Krapinsko-zagorska96.89Meimurska65.86

Liko-senjska100.6Sisako-moslavaka68.51



upanijapovredeprobavaBjelovarska-bilogorska77.39

Grad Zagreb47.74Karlovaka82.52

ibenko-kninska54.92Varadinska85.51

Vukovarsko-srijemska55.18Virovitiko-podravska87.8

Zagrebaka56.18Krapinsko-zagorska96.89

Brodsko-posavska58.27Liko-senjska100.6

Istarska58.64






Karlovaka82.52

Varadinska85.51


Liko-senjska100.6

ENE 3. MJESTO

PROBAVA

Grad Zagreb34.69



Varadinska56.88


Meimurska66.24

ENE 3. MJESTO

DINI SUS.

Zagrebaka34.46

Bjelovarsko-bilogorska43.66



ENE 3. MJESTO

SIMTOMI


Zadarska46.11


Karlovaka62.54


ENE 3. MJESTO

ENDOKRINA


Grad Zagreb47.74

ibenko-kninska54.92


Zagrebaka56.18


Istarska58.64






Karlovaka82.52

Varadinska85.51


Liko-senjska100.6

PET-HR-pita

26542

11779

2742

2371

1939

4179

PRVIH PET UZROKA SMRTI U HRVATSKOJ U 2001. GODINI

BOLESTI CIRKULACIJSKOG SUSTAVA53%

PET-m

11690

6965

1889

1506

1126

1901

PET PRVIH UZROKA SMRTI U HRVATSKOJ 2001. GODINI - MUKI

PET-

14852

4814

865

853

813

2278

PET PRVIH UZROKA SMRTI U HRVATSKOJ U 2001. GODINI - ENE

Grafikon1

26542

11779

2742

2371

1939

4179

podaci-2

HRVATSKA

BOLESTI CIRKULACIJSKOG SUSTAVA26542

NOVOTVORINE11779pita 2

NASILNE SMRTI2742HRVATSKA

BOLESTI PROBAVNOG SUSTAVA2371BOLESTI CIRKULACIJSKOG SUSTAVA26542

BOLESTI DINOG SUSTAVA1939NOVOTVORINE11779

OSTALO4179NASILNE SMRTI2742

49552BOLESTI PROBAVNOG SUSTAVA2371

BOLESTI DINOG SUSTAVA1939

HRVATSKA MUKIOSTALO4179


NOVOTVORINE6965

NASILNE SMRTI1889

BOLESTI PROBAVNOG SUSTAVA1506


OSTALO1901

25077

HRVATSKA ENE


NOVOTVORINE4814

BOLESTI PROBAVNOG SUSTAVA865

NASILNE SMRTI853


OSTALO2278

24475

List3

Kardiovaskularna smrtnost1980-2004American Heart Association 2007

Bolesti kardiovaskularnog sustavaAngina pektorisInfarkt miokardaZatajenje srcaNagla smrtTIAIshemijski udarHemoragijski udarRenovaskularna bolestZatajenje bubregaKlaudikacijeAneurizma aorte

Primarni imbenici rizika za razvoj KVBHipertenzijaDobObiteljska povijest KVB/ genetikaDislipidemijaPuenjeeerna bolestNepromjenjiviPromjenjiviNCEP. Circulation 1994;89:13291445. Eur Heart J 1994;15:13001331.Wood D i sur. Eur Heart J 1998;19:14341503.KVB

Chart1

60

60

60

60

60

60

East

Sheet1

1st Qtr2nd Qtr3rd Qtr4th Qtr

East606060606060

West30.638.634.631.6

North45.946.94543.9

INTERHEART: utjecaj ivotnih navika na nastanak infarkta miokardaYusuf S et al. Lancet. 2004;364:937-52.imbenikPuenjeDijabetesHipertenzijaPretilostPsihosocijalni .0.250.51.024816Odds ratio (99% CI)Voe/povreTjelovjebaAlkoholeneMukarci

Kumulativni uinak imbenika rizikau nastanku KV bolestiWilson PWF et al. Circulation. 1998;97:18371847.

Hipertenzija zdruena s ostalim KV imbenicima rizika poveava rizik nastanka IMP=puenje; B=eerna bolest, deblj=abdominalna debljina; PS=psichosocijalni imbenici, R=imbenici rizika IM=srani udar.Yusuf. Lancet. 2004; 364:937-952.

Infarkt miokardaZatajenje srcaKrajnji stadij/smrtRuptura plakaimbenici rizikaHipertenzija Hiperlipidemija DijabetesAterosklerozaDisfunkcija endotelaKoronarna bolestDilatacija/RemodeliranjeKardiovaskularni niz

Ishemijska bolest srca

Ishemijska bolest srcaIznenadna smrtInfarkt miokardaNestabilna angina pektorisStabilna angina pektorisZatajenje srca

Infarkt miokarda ili iznenadna smrt: prvi znak koronarne bolesti

Patofiziologija koronarne bolesti- neravnotea izmeu potronje i opskrbe kisikom!(Stone, 2004)

Suzbijanje imbenika rizikapuenjearterijska hipertenzijahiperkolesterolemijaeerna bolesttjelovjebapretilost

Mediteranska dijeta u bolesnika sa koronarnom bolestiParikh P et al. J Am Coll Cardiol. 2005;45:1379-87.1989Diet and Reinfarction Trial (N = 2000) 29% ukupna smrtnost 27% IM 1999Lyon Diet Heart Study (N = 605) 68% kardijalna smrt, IM 1999GISSI-Prevenzione (N = 11,324) 20% ukupna smrtnost 30% KV smrtnost 2002Indo-Mediterranean Diet Heart Study (N = 1000) 33% smrtni IM 1997Indian Experiment of Infarct Survival Trial (N = 360) 50% kardijalna smrt 48% IM

Medikamentno lijeenje koronarne bolestiantitrombocitni lijekovi (ASK, klopidogrel) blokatori (selektivni, neselektivni, vazodilatacijski)nitratikalcijski antagonisti (DHP, verapamil, diltiazem)ACEI, ARBhipolipemici (statini, fibrati, ezetimib) novi lijekovi (ivabradin, trimetazidin, ranolazin, omega 3- nezasiene masne kiseline)

Koronarna bolest- mjesta dijelovanja lijekova(Stone, 2004)

Uinak ASK-e u visokorizinih bolesnika

Patrono C et al. N Engl J Med. 2005;22:2373-2383.

Uinak razliitih doza ASK-e na KV dogaanja u visokorizinih bolesnika00,51,01,52,05001500 mg 34 19160325 mg19 2675150 mg12 32

Uinak klopidogrela u bolesnika nakon PCI-ePCI CURE*Mehta et al. Lancet 2001;358:527-533.Steinhubl S et al. JAMA. 2002; 288:2411-2420.IM, CVI ili smrt (%)Mjeseci27%RRRPlacebo*Klopidogrel*0510158.5%11.5%036912do12 mjeseci plus ASK i ostali lijekovi

Placebo Klopidogrel1510500100200300400Dani12.6%8.8%P = 0.002 N = 2658KV smrt ili IM (%)31%RRRP=0.02CREDOSlide source:Lipids onlinewww.lipidsonline.org

Nitrati: upozorenjauvanje: hladna i tamna prostorija, suha i tamna posudauzimanje: NTG u sjedeem stavu, peckanjenuspojave: glavobolja, crvenilo, halitoza, sinkopa, hipotenzija, tahikardija, methemoglobinemijainterakcije: beta blokatori (+); etanol, sildenafil (-)kontraindikacije: IHSS, hipotenzija!tolerancija (nejasni, sloeni mehanizmi)ustezanje (monday morning angina)

Utjecaj blokade na ishemijsko srceoptereenjaMVO2

Efekt blokade na smrtnost nakon infarktaKumulativna smrtnost (%) 25-30%

Uinci kalcijskih antagonistadihidropiridini:selektivni vazodilatatorinedihidropiridini: jednako uinkoviti na miokard, provodni sustav i arterije -uravnoteeni hemodinamski uinak

ubrzavaju ritam i poveavaju potronju kisikausporavaju ritamslabe inotropijuperiferni i koronarni dilatatoriSA=sino-atrijski vorAV= atrio-ventrikulski vor Ferrari R i sur., Cardiovasc Dugs Ther 1994; 8 (Suppl 3):565-575SAAVAVSAperiferni i koronarni dilatatori

kao lijek prvog izbora (DHP) u Prinzmetalovoj angini, u stabilnoj AP nakon blokatora (DHP) te u sekundarnoj prevenciji koronarne bolesti u bolesnika u kojih su blokatori kontraindicirani!Kalcijski antagonisti u koronarnoj bolesti

CAMELOT: Smanjenje primarnih ishoda uz enalapril i amlodipinNissen et al. JAMA. 2004;292:2217-26.Primarni ishod= uestalost KV dogaajaKumulativni KV dogaaji00.250.200.100.056121824Mjeseci0.150PlaceboAmlodipinEnalaprilHR (95% CI)A vs P: 0.69 (0.540.88)E vs P: 0.85 (0.671.07)A vs E: 0.81 (0.631.04)P = 0.16P = 0.1P = 0.003

Br. bolesnikaPlacebo655588558525488Enalapril673608572553529Amlodipin663623599574535

Ukupna smrtnostGodVjerojatnost dogaajaACE-I299522501617892223Placebo297121841521853138Flather MD, et al. Lancet. 2000;355:15751581OR: 0.74 (0.660.83)ACE-I: 702/2995 (23.4%)Placebo: 866/2971 (29.1%)

TRACE

AIRE

SAVE

Smrtnost i veliki KV dogaajiFlather MD, et al. Lancet. 2000;355:15751581Smrt/IM ili hospitalizacijazbog zatajenja srca n = 1049n = 1244

TRACE

AIRE

SAVE

HPS. Lancet. 2002;360:7. Downs. JAMA. 1998;279:1615.LIPID. N Engl J Med. 1998;339:1349. Sacks. N Engl J Med. 1996;335:1001. 4S. Lancet. 1995;345:1274. Shepherd. N Engl J Med. 1995;333:1301. LDL-C i koronarna bolest% sa KBdogaajemLDL-C (mmol/l))0510152025302,32,83,43,94,44,95,4PI=placebo Rx=lijeenje1,8

% ***Confidence interval (CI) not reported.95% CI, 14%-41%.95% CI, 16%-37%.95% CI, 12%-31%.Hebert PR et al. JAMA. 1997;278:313-321.LDL kolesterol i KV bolestiKBKV smrtnost

Kardiovaskularni uinci lijekova koji usporavaju uestalost bila-blokatorisrana frekvencijaprovodljivost podraljivost kontraktilnost arterijski tlak verapamil diltiazemivabradin

Sekundarna prevencija nakon AIM:GISSI-Prevenzione Trial

GISSI = Gruppo Italiano per lo Studio della Sopravvivenza nellInfarto miocardico

11.000 bolesnika s preboljelim IM, lijeeni su kroz prosjeno 3,5 godine visoko proiene omega-3 nezasiene masne kiseline(1 g/dan) znaajno su smanjile kombinirane ishode - smrtnost, nefatalni IM i CVI (p< 0,05)

znaajno je smanjena sveukupna smrtnost posebice iznenadna srana smrt!GISSI-Prevenzione Investigators. Lancet 1999;354:447-455.

Stabilna AP: PCI prema medikamentnom lijeenjubroj rizikamedikamentno1138101795983463840819230PCI1149101395283363741720035godine01234560,00,50,60,70,80,91,0PCI + OMToptimalna medikamentna terapija (OMT)relativni rizik: 1.0595% CI (0,87-1,27)p = 0,627 N Engl J Med. 2007; 356:1503-16.

Smanjenje smrtnosti nakon IM - blokatoriASK- blokatoriASK- blokatoriASK- blokatori statini1970.1980.1990.2000.100%0%smanjenje smrtnosti25%25%25%25%25%40%55%64%???20%2008.statiniACEIASK- blokatori statiniACEI

trimetazidinomega-3 ivabradin??? %RRR = 70%NNT (5g.) = 7Fonarow GC. Rev Cardiovasc Med. 2003;4(suppl 3):S37-46.

Temeljno (BASIC) medikamentno lijeenje KBbeta-blokatoristatiniASKinhibitori ACEkontrola imbenika rizikaBASIC

Snienje koronarne smrtnosti u zadnjih 20 godina: primjer SAD 9%N Engl J Med 2007;356:2388-98.

1980: 263,3/100.0002000: 134.4/100.000 49% 1980: 542.9/100.0002000: 266,8/100.000 51%

Snienje koronarne smrtnosti u zadnjih 20 godina: primjer SAD9%N Engl J Med 2007;356:2388-98.Ovi bi rezultati bili i bolji da nije malignog porasta MS i eerne bolesti: ova stanja odnose isti broj ivota koje spaava sekundarna prevencija IM, inicijalno lijeenje ACS i IM te revaskulariziranje SAP!

Kronino zatajenje srca

Kronino zatajivanje srca - vodea zloudna bolest dananjicePREVALENCIJA

1% - 2% ope populacije oko10% iznad 60 godina

PROGNOZA

Prosjek smrtnosti 50% /4 g.

Teka dekomp. Smrtnost 50% /1 g.

Prevalencija zatajenja srca(NHANES: 1999-2004).

Chart1

0.30.2

21.5

7.25.2

11.612.4

Men

Women

Percent of Population

Sheet1

HF PREVALENCECHD MortalityCVD MortalityTotal Mortality

MenWomenNo MetS or DM2.65.314.4

20-390.30.2MetS w/o DM4.37.817.1

40-592.01.5MetS w/DM4.88.621.1

60-797.25.2DM only6.311.526.1

80+11.612.4Prior CVD10.916.730.0

Prior CVD and DM17.028.144.1

Chart 7A: Prevalence of heart failure by sex and ageChart 10A: Total mortality rates in U.S. adults, ages 3075, with metabolic syndrome (MetS), with and without diabetes mellitus (DM) and pre-existing CVD

NHANES: 199904NHANES II 197680 Follow-Up Study*

Source : NCHS and NHLBI.Source: Malik et al.(10) *Average of 13 years of follow-up.

Chart 7B: Hospital discharges for heart failure by sex

United States: 19702004

Note: Hospital discharges include those inpatients discharged alive, dead or status unknown. Source: NHDS, NCHS and personal communication with NHLBI.

Hospital Discharges for HF

CHF Discharges

-----------In thousands------

MalesFemales

708074

7986

98102

107111

121113

75122131

123143

143152

157173

174203

80176224

182240

195243

208255

228303

85247310

274308

269336

277357

304339

90315386

360405

373449

394481

390484

95378494

377493

431526

438540

430532

00418581

444551

441529

471566

04524575

Chart 7C. Incidence of heart failure* by age and sex

FHS 19802003

* - HF based on physician review of medical records and strict diagnostic criteria.

Source: NHLBI.(10)

7010

7522

8057

85719

902,107

952,363

002,199

052,125

Chart 13A: Trends in heart transplants

UNOS: 19702005

Source: United Network for Organ Sharing (UNOS), scientific registry data.

est. cv oper. & proc

u.s. 1979-03 (000)

CatheterizationsOpen-HeartBypassPTCACarotid EndarterectomyPacemakers

`NH WhitesNH BlacksHispanics792991721145442

Males24.914.024.8803501971375544

Females27.011.919.28569030823010740

9010465013922666897

Chart 9A: Prevalence of high school students in grades 912 reporting current cigarette use951137722573419132136

by sex and race/ethnicity001318686519561124152

YRBS: 2005011314690516571128177

021463709515657134199

04129764642766498170

Chart 13B: Trends in cardiovascular inpatient operations and procedures

United States: 19792004

Source: MMWR.4 NH indicates non-Hispanic.

MenWomen

NH White24.120.4

NH Black23.920.2

Hispanic18.915

Asian17.811.3Source: NHDS. NCHS and NHLBI. Note: In-hospital procedures only.

American Indian or Alaska Native37.333.4

Chart 9B: Prevalence of current smoking for Americans age 18 and older by race/ethnicity and sexEST. COST OF CV DISEASES 2007

NHIS: 2004Coronary Heart Disease142.5

Stroke57.9

Hypertensive Disease63.5

Heart Failure29.6

Chart 14A: Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke

United States: 2007

Source: MMWR.1 NH indicates non-Hispanic.

1988-941999-022003-04

NH White206204202

NH Black204199197

Mexican American205202201Source: NHLBI

Chart 9C: Trends in mean total serum cholesterol among adults by race, sex and survey

NHANES: 198894, 199902 and 200304

Source: NCHS and NHLBI.

1976-801988-941999-022003-04

White Males163163155156

Black Males171165166161

White Females170166163164

Black Females172174168161

Chart 9D: Trends in mean total serum cholesterol among adolescents ages 1217 by race, sex and survey

NHANES:1976-80,1988-94, 1999-02 and 2003-04


MenWomen

Total Population32.032.0

NH Whites32.034.0

NH Blacks32.030.0

Mexican Americans39.031.0

Chart 9E: Age-adjusted prevalence of Americans age 20 and older with

LDL cholesterol of 130 mg/dL or higher by race/ethnicity and sex

NHANES: 200304


MenWomen

Total259

NH Whites269

NH Blacks167

Mexican Americans2813

Chart 9F: Age-adjusted prevalence of Americans age 20 and older with

HDL cholesterol under 40 mg/dL by race/ethnicity and sex

NHANES: 200304


NH WhiteNH BlackHispanic

Male46.938.239

Female30.221.326.5

Chart 9G: Prevalence of students in grades 912 who met currently recommended

levels of physical activity during the past 7 days by race/ethnicity and sex

YRBS: 2005

Note: Currently recommended levels is defined as activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day on 5 or more of the 7 days preceding the survey. Source: MMWR.1

Source:YRBS (4)

19942004

NH White Male26.418.4

NH Black Male34.227.0

Hispanic Male37.532.5

Asian/Pacific Islander Male25.020.4

Am. Indian/Alaska Native Male34.423.8

NH White Female28.321.6

NH Black Female45.733.9

Hispanic Female44.839.6

Asian/Pacific Islander Female31.524.0

Am. Indian/Alaska Native Female36.331.8

Chart 9H: Prevalence of leisure-time physical inactivity among adults age 18 and older by race/ethnicity and sex

BRFSS: 1994 and 2004

Source: MMWR.(11) NH indicates non-Hispanic.

MalesFemales

NH Whites15.28.2

NH Blacks15.916.1

Hispanics21.312.1

Chart 9i: Prevalence of overweight among students in grades 912 by sex and race/ethnicity

YRBS: 2005

Source: BMI 95th percentile or higher by age and sex of the CDC 2000 growth chart. MMWR.(2) NH indicates non-Hispanic.

MenWomen

65-749.24.7

75-8422.314.8

85-9443.030.7

1960-621971-741976-801988-942001-2004

Men10.712.212.820.630.2

Women15.716.817.126.034.0

Chart 9J: Age-adjusted prevalence of obesity in Americans ages 2074 by sex and survey

NHES 196062; NHANES: 197174, 197680, 198894 and 200104

Note: Obesity is defined as a BMI of 30.0 or higher. Source: Health, United States, 2006; Unpublished data, NCHS.

6-1112-19

1971-744.33.6

1976-806.66.4

1988-9411.611.0

2001-200418.716.3

Chart 9K: Trends in the prevalence of overweight among U.S. children and adolescents by age and survey

NHANES: 197174, 197680; 198894 and 200104

Source: Health, United States, 2006. Unpublished data. NCHS.

NH WhitesNH BlacksMexican Americans

Men69.89.9

Women4.512.211

Chart 9L: Prevalence of physician-diagnosed diabetes in Americans age 20 and older by race/ethnicity and sex

NHANES: 19992004

NCHS and NHLBI


Less than high school7.512.010.1

High school5.69.76.0

More than high school4.29.89.8

Chart 9M. Prevalence of Non-Insulin-Dependent (Type 2) Diabetes in Americans Age 18+

by Education, Race/Ethnicity and Years of Education

NHANES: 1999-2004


Sheet1

10.712.212.820.630.2

15.716.817.12634

1960-62

1971-74

1976-80

1988-94

2001-2004


Sheet2

4.36.611.618.7

3.66.41116.3

1971-74

1976-80

1988-94

2001-2004


Sheet3

185.303214.49

190.125240.37

194.834252.488

207.11257.35

221.391275.644

236.69317.084

258.645326.377

287.202327.978

281.616347.436

288.585374.508

312.253351.142

324.63397.288

369.68417.005

383.856455.757

403.565490.614

395.02491.788

383.917496.515

381.013496.109

436.463530.027

442.23547.189

433.785540.992

421.896585.791

446.166553.626

442.772530.311

495.774597.144

524575

Male

Female

Years

Discharges in Thousands

299172114795442

350197137805544

6903082308510740

10465013922666897

1137722573419132136

1318686519561124152

129764642766498170

Catheterizations

Open-Heart

Bypass

PCI

Carotid Endarterectomy

Pacemakers

Years

Procedures in Thousands

24.927

1411.9

24.819.2

Males

Females


24.123.918.917.837.3

20.420.21511.333.4

NH White

NH Black

Hispanic

Asian

American Indian or Alaska Native


46.938.239

30.221.326.5

NH White

NH Black

Hispanic

Sex and Race/Ethnicity


151.6

62.7

66.4

33.2

Billions of Dollars

0.30.2

21.5

7.25.2

11.612.4

Men

Women


206204202

204199197

205202201

1988-94

1999-02

2003-04

Mean Serum Total Cholesterol

2.64.34.86.310.917

5.37.88.611.516.728.1

14.417.121.126.13044.1

No MetS or DM

MetS w/o DM

MetS w/DM

DM only

Prior CVD

Prior CVD and DM

Deaths/1,000 Person Years

MBD000CD551.xls

Chart3

163163155156

171165166161

170166163164

172174168161

1976-80

1988-94

1999-02

2003-04

Mean Total Blood Cholesterol

OVERWT

1960-621971-741976-801988-942001-2004

Men10.712.212.820.630.2

Women15.716.817.126.034.0

Age-Adjusted Prevalence of Obesity* in Americans Ages 20-74 by Sex and Survey

NHES and NHANES: 1960--62, 1971--74, 1976--80, 1988--94 and 2001-2004

Source:Health US, 2004.

Obesity is defined as BMI of 30 plus.

&A

Page &P

OVERWT

1960-62

1971-74

1976-80

1988-94

2001-2004


cholchild

Estimated Percentage of Children With Serum Cholesterol of 170 mg/dl or More, United States

WhiteBlack

Males 0-9 Years2940

Females 0-9 Years3350

Males 10-19 Years2534

Females 10-19 Years2941

Estimated Percentage of Children With Serum Cholesterol of 170 mg/dL

or More, United States

Trends in Mean Total Blood Cholesterol Among Adolescents Ages 12-17 by Sex and Race and Survey

NHANES:1976-80,1988-94, 1999-02 and 2003-04

1976-801988-941999-022003-04

White Males163163155156

Black Males171165166161`

White Females170166163164

Black Females172174168161

`

cholchild

&A

Page &P

White

Black


diabetes

1976-80

1988-94

1999-02

2003-04

Mean Total Blood Cholesterol

Strokerace


Men69.89.9

Women4.512.211

Age-Adjusted Prevalence of Physician-Diagnosed Diabetes in Americans Age 20 and Older by Sex and Race/Ethnicity

NHANES: 1999-2002

WhitesBlacksMexican Americans

122.95.46.4

Prevalence of Non-Insulin-Dependent (Type 2) Diabetes in Women Ages 25-64

by Education and Race/Ethnicity

NHANES III: 1988-94

DELETE

&A

Page &P

Strokerace

NH Whites

NH Blacks

Mexican Americans


Hdl&Ldl

Whites

Blacks

Mexican Americans

Years of Education


smokhschool

Relative Risk of Deaths due to StrokeCompared to Non-Hispanic Whites, by Race/Ethnicity and Age Groups, U.S., 1997

Non-Hispanic BlacksAmerican Indians/ Alaska NativesAsian/Pacific IslandersHispanics

35-444.01.91.31.3

45-543.91.31.31.3

55-643.01.51.41.2

65-741.90.91.10.9

75-841.20.81.00.6

85+0.90.40.70.5

Risk for Stroke Mortality Among Racial/Ethnic Groups Compared With Non-Hispanic Whites,

by Age Groups

United States: 1997

smokhschool

35-44

45-54

55-64

65-74

75-84

85+

Race/Ethnicity

Relative Risk

Metsyndr.

Estiamted % of Americans Age 20 and Over with High-Risk LDL-Cholesterol of 130 mg/dL or More by Race and Sex

MenWomen

Total Population32.032.0

NH Whites32.034.0

NH Blacks32.030.0

Mexican Americans39.031.0

Age-Adjusted Prevalence of Americans Age 20 and Older With

LDL-Cholesterol of 130 mg/dL or Higher by Race/Ethnicity and Sex

United States: 2003-04

MenWomen

Total259

NH Whites269

NH Blacks167

Mexican Americans2813

Estimated Age-Adjusted (2000) Prevalence of Adults Age 20 and Over With

HDL-Cholesterol Under 40 mg/dL by Race and Sex

United States: NHANES 2003-2004

Metsyndr.

Men

Women


PhysicAct.

Men

Women


smokmf

`NH WhitesNH BlacksHispanics

Males24.914.024.8

Females27.011.919.2

Prevalence of High School Students in Grades 9-12 Reporting Current Cigarette Use

Within the last 30 days by Race/Ethnicity and Sex

YRBS: 2005

&A

Page &P

smokmf

Males

Females


NHANESrf

CHD MortalityCVD MortalityTotal Mortality

No MetS or DM2.65.314.4

MetS w/o DM4.37.817.1

MetS w/DM4.88.621.1

DM only6.311.526.1

Prior CVD10.916.730.0

Prior CVD and DM17.028.144.1

Total Mortality Rates in US Adults Age 30-75, with Metabolic Syndrome, With and Without Diabetes and Pre-Existing CVD

NHANES1976-80 Follow-Up Study

NHANESrf

No MetS or DM

MetS w/o DM

MetS w/DM

DM only

Prior CVD

Prior CVD and DM

Deaths/1,000 Person Years

oweight hs

% of high school students who participated in vigorous or moderate physical physical activity in past 7 days

NH WhiteNH BlackHispanicBMI

Predisponirajui imbenici zatajenja srca2040600HTNPAR (%)IMAnginaValv.HLKDijabetesMukarcieneLevy D at al. JAMA. 1996;275:1557-62.Framingham Heart Study

HRM2.16.31.42.52.21.83.36.01.72.12.83.7

Kumulativni rizik nastanka zatajenja srca Bibbons-Domingo K et al. Circulation.2004;110:1424-30.CrCl (ml/min) = klirens kreatinina02468101214KBKB + DMKB + DM + BMI >36KB + DM + CrCl

imbenici koji pridonose zatajenju srcaInfarkt miokardaPoveani unos soliPoveani unos tekuineNepotivanje preskripcijeAritmijeInterkurentne bolesti (infekcije npr.)Stanja sa poveanim metabolikim potrebama (trudnoa, hipertireoza npr.)Lijekovi koji djeluju negativno inotropno ili dovode do zadravanja tekuine u tijelu (kortikosteroidi, NSAR)Alkohol

Prognoza zatajivanja srca je kao u malignih bolestiBritish Heart Foundation, 2002Jednogodinje preivljavanje (%)

54-60>6050403020100Poslije IMn=196

Normalna struktura i funkcija LKHipertenzijaZatajenjesrcaManifestno zatajenje srcaPuenjeDislipidemijaDijabetesPretilostDijabetesRemodeliranje lijeve klijetkeHLKIMSistolika disfunkcijaDijastolika disfunkcijaSubklinika disfunkcija lijeve klijetkeVrijeme: decenije

Vrijeme: mjeseciKrajnjistadijNastanak zatajenja srca

Patofiziologija zatajenja srcaDisfunkcija LK Bubrezi/nadbubreziBaroreceptori(karotide i LA) Renin-angiotenzinAldosteronSimpatikiivani sustavRetencijavode i solitahikardijavazokonstrikcija

Zatajenje srca klinika slika SimptomiZapuhaUmorNepodnoenje naporaSlab apetitKaalj

ZnakoviOteano disanjeEdemiProirene vene vrataHropci na pluimaPleuralni izljevhepatomegalijaAscitesUveano srceProtodijastoliki galop

Klasifikacija zatajenja srca

Lijeenje zatajenja srca nekada ...

Ciljevi lijeenja zatajenja srcapoboljati kakvou ivota (simptomi!)

smanjiti pobol i smrtnost

usporiti progresiju bolesti (potaknuti regresiju bolesti!)

Nefarmakoloko lijeenje zatajenja srcaSmanjiti unos soli i tekuineNa+ 2-3 g/d (1g Na = 2.5g NaCl)Mjerenje tjelesne mase dnevnoTjelovjebaBlago do umjereno aerobno vjebanjeUkloniti imbenike rizikaHipertenzija, puenje, dijabetes, ...

Lijeenje ostatnih simptoma

Kontrola volumena

Smanjenje smrtnosti

Lijeenje zatajenja srca

Digitalis:kliniki uinci u zatajenju srca ublaava simptome smanjuju uestalost hospitalizacija ne poboljavaju preivljavanje

Digitalis:Indikacije u zatajenju srca tahiaritmije u sklopu fibrilacije atrija protodijastoliki galop slab odgovor na temeljno lijeenje (diuretik + BB + ACEI)

Placebon=3403Digoksinn=3397480122436Smrtnost%DIGN Engl J Med 1997;336:525Mjesecip = 0.8Digitalis u zatajenju srcaN=6800NYHA II-III

VAZOKONSTRIKCIJAVAZODILATACIJA KininogenKalikreinInaktivni fragmentiAngiotenzinogenAngiotensin IRENINKininaze IIInhibitorALDOSTERONSIMPATIKUSVAZOPRESINPROSTAGLANDINitPAANGIOTENZIN IIBRADIKININACEACE inhibitori:mehanizam djelovanja

ACE inhibitori: kliniki uinci u zatajenju srca Ublaavaju simptome Smanjuju remodeliranje/progresiju Smanjuju uestalost hospitalizacija Poboljavaju preivljavanje

PlaceboEnalapril12111098765Vjerojatnost smrtiMjeseci0.10.800.20.30.70.40.50.6p< 0.001p< 0.002CONSENSUS

N Engl J Med 1987;316:142943210ACE inhibitori u zatajenju srca

Mjeseci0612p = 0.0036%Smrtnost241830364248Enalapriln=1285Placebon=1284SOLVD (Treatment) N Engl J M 1991;325:293n = 2589CHF - NYHA II-III- EF < 35%ACE inhibitori

Smrtnost%4SAVEN Engl J Med 1992;327:669Godine3020100123PlaceboKaptopril0n=1115n=1116p=0.019-19%n = 22313 - 16 dana poslije IMEF < 40%12.5 --- 150 mg/danAsimptomatskadisfunkcija LKposlije IMACE inhibitori

Mjeseci30241218061030200PlaceboRamipril n = 2006HF after AMIp = 0.002Smrtnost%AIRE

Lancet 1993;342:821ACE inhibitori

Antagonisti angiotenzinskih receptora u zatajenju srca

Mjeseci612182430360510152025KV dogaaji (%)Losartan (n = 499 dogaaja)Kaptopril (n = 447 dogaaja)Relativni rizik = 1.13 (0.991.28); P = 0.0690ACE inhibitori vs sartaniLosartan2744250424322390234423011285Kaptopril2733253424632423237423291309

00.050.10.150.20.250.3061218243036Vjerojatnost dogaajaACE inhibitori, sartani i kombinacija u zatajenju srcaPfeffer, McMurray, Velazquez, et al. N Engl J Med 2003;349

Valsartan490944644272400726481437357MjeseciValsartan vs. Kaptopril: HR = 1.00; P = 0.982Valsartan + Kaptopril vs. Kaptopril: HR = 0.98; P = 0.726Kaptopril490944284241401826351432364Valsartan + Kap488544144265399426481435382

0,540,480122448600.750.500.2500.470.360.250.130.090.310.180.4236Mjesecip = 0.08V-HeFT II N Engl J Med 1991; 325:303EnalaprilHZ + ISDNn = 804p = 0.016Vjerojatnost smrtiZatajenje srca: nitrati + hidralazin

Beta blokatori:mehanizam uinka u zatajenju srca gustou 1 receptora kardiotoksinost katekolamina neurohumoralni uinak antiishemijski uinak antiaritmijski antioksidacijski, antiproliferacijski

Beta blokatori:kliniki uinci u zatajenju srca ublaavaju simptome remodeliranje/progresiju uestalost hospitalizacija preivljavanje uestalost nagle smrti

Beta blokatori u zatajenju srcaGodinja Smrtnost %

Chart1

93

117.2

13.28.8

16.815.1

18.511.4

Placebo

Treated

Sheet1

US CARVCIBISMERITBESTCOPERN

Placebo91113.216.818.5

Treated37.28.815.111.4

Uinak b blokade na ukupni mortalitetovisno o NYHA klasi i etiologiji

0

0.5

1

1.5

2

Relativni rizik i 95% Confidence Interval

CIBIS-II

MERIT-HF

US Carvedilol HF Study

NYHA II

NYHA III

NYHA IV

Ishemijskaetiologija

Neishemijskaetiologija

*

Uinak beta blokatora u dijabetiara sa zatajenjem srca3122335264798530063991RR (95% CI)DijabetesBez dijabetesaSviSve 3 studije0.01.0CIBIS IIMERIT-HFUkupnorandomiziraniDeedwania PC et al. Am Heart J. 2005;149:159-67.1.833/27195/129228/15661/50156/95217/145635/431Smrtnost (n)Placebo/-blokatori58917002289COPERNICUS190/130DijabetesBez dijabetesaSviDijabetesBez dijabetesaSvi188670418927DijabetesBez dijabetesaAll

Uinak beta blokatora u starijih osoba za zatajenjem srcaDulin BR et al. Am J Cardiol.2005;95:896-8.COPERNICUSCarvedilol (U.S.)CIBIS-IIMERIT-HFSviBESTPlacebo bolji1110-blokator boljiRisk ratio (95% CI)0.75 (0.580.98)0.45 (0.240.86)0.70 (0.490.99)0.70 (0.520.95)0.76 (0.640.90)0.91 (0.781.05)P = 0.002Hazard ratio

ALDOSTERON Retencija Na+ Retencija H2O

Izluivanje K+ Izluivanije Mg2+ Odlaganje kolagena

Fibroza- miokard - krvne ileSpironolakton Edemi AritmijeKompetitivni antagonist aldosteronskih receptora(miokard, krvne ile, bubrezi)

-Inhibitori aldosterona u zatajenju srca

Antagonisti aldosterona u zatajenju srca

Antikoagulacija u zatajenju srca Niska istisna frakcija (

Peroralni antikoagulansi neke vanije interakcije Pojaan uinakSmanjen uinak

amiodaron barbituratiacetilsalicilna kiselina ciklosporineritromicin karbamazepinfluoksetin kolestiraminkotrimoksazol omeprazollevotiroksin rifampicinmetromidazol tireostaticinesteroidni antireumatici alkohol

Interakcije nekih pripravaka sa varfarinomPojaavaju uinak

Bijeli lukGinko bilobaSok od grejpaGlukozamin/hondroitin

Smanjuju uinak

GinsengGospina trava

Lijekovi koje valja izbjegavati u lijeenjukroninoga zatajivanja srcaBlokatori kalcijskih kanalaAntiaritmici (osim BB i amiodarona)NSARTiazolidinedioni (rosiglitazon, pioglitazon)Metformin

Zatajenje srca i mogunosti lijeenjaJessup M, Brozena S. N Engl J Med. 2003;348:2007-18.

Faze u lijeenju zatajivanja srcaNe-farmakoloka Mirovanje Inaktivnost Ogranienje tekuine (digitalis, diuretici)FarmakolokaDigitalisDiureticiNeurohormonski zahvatiFarmakoloka Digitalis Diuretici Vazodilatatori InotropiUreaji CRT ICDs LVADs Ostali?Abraham WT, 2002Umjetno srceKsenotransplantacijaMatine staniceGenski inenjering????

prije19801980s1990s2000s2020s

*According to 2002 mortality figures compiled for the World Health Organizations (WHO) World Health Report 2003: Shaping the Future, cardiovascular diseases (CVD) (mainly ischaemic heart disease and stroke) were the leading global causes of death, accounting for approximately 16.6 million deaths, followed by cancer (7.1 million deaths), intentional and unintentional injuries (5.2 million), upper and lower respiratory infections (3.8 million), chronic obstructive pulmonary disease (COPD) and asthma (2.9 million), and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (2.8 million).

Reference1. World Health Organization. The World Health Report 2003: Shaping the Future. Geneva, Switzerland: World Health Organization; 2003.***Data recently published by American Heart Association shows almost similar trends with a much higher reduction in CHD related mortality in men all the way from 70 to 2004, whereas in women the trend has been stable and only shown a decline after around 2000. *INTERHEART is a large international study of MI risk factors with 15,152 cases (patients) and 14,820 controls. It was conducted in 52 countries and includes every inhabited continent.1 The study objective was to determine the relation of smoking, history of hypertension or diabetes, waist/hip ratio, dietary patterns, physical activity, consumption of alcohol, blood apolipoproteins (Apo), and psychosocial factors (stress, depression) to MI. Participants were followed for 4 years. Collectively, these nine risk factors accounted for 90% of the risk for a first MI in both sexes and at all ages throughout the world.As shown, INTERHEART recorded similar odds ratios in men and women for the association of acute MI with smoking, elevated lipid levels, abdominal obesity, composite of psychosocial variables, and vegetable and fruit consumption. However, the increased risk associated with hypertension and diabetes was greater in women than in men.Women seemed to benefit more than men from the protective effects of exercise and alcohol.These findings support the importance of lifestyle modification in CV risk reduction.

1. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet. 2004;364: 937-952.

*This slide illustrates the cumulative effect of risk factors and illustrates that risk factors are more than additive; the total risk is higher than just the sum of the individual risk factors.

Monitoring of a USA population cohort in the town of Framingham, Massachusetts, USA, for the period of 12 years led to the identification of the major CVD risk factors, including high blood pressure, high total blood cholesterol, smoking, obesity and diabetes. Odds ratio for each of these risk factors alone ranges from around 1.2 to 2.2. When more than one factor is present, odds ratios are increased by more than an additive rate, so that all five (BMI>27, smoking, high total cholesterol, diabetes and hypertension) led to an approximate 7-fold increased risk compared to any one risk factor alone.

1. Wilson PWF, DAgostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. May 1998;97:18371847

INTERHEART was a case-control study of acute myocardial infarction (MI) in 52 countries of 15,152 cases and 14,820 controls. The INTERHEART data show the association of risk factors with acute MI in men and women after adjustment for age, sex, and geographic region.Each of the major risk factors individually, eg, current smoking, diabetes, hypertension, and dyslipidaemia (ApoB/A1), was associated with an odds ratio of having an acute MI event of approximately 2. The effects of these risk factors are consistent across both sexes.The concomitant presence of 3 of the major risk factors increased the odds ratio to 13.1, and accounted for 53% of the attributable risk for MI. The presence of all 4 major risk factors increased the odds ratio to 42.3 and accounted for 75.8% of the attributable risk. If, in addition to the major risk factors, abdominal obesity, psychosocial factors, lack of daily consumption of fruits and vegetables, regular alcohol consumption, and lack of regular activity are considered, altogether these accounted for 90% of the attributable risk in men and 94% of the attributable risk in women.

Reference1. Yusuf S, Hawken S, unpuu S, et al, on behalf of the INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937-952.*The many pathophysiologic effects of angiotensin II, mediated by stimulation of the AT1 and AT2 receptors, have diverse consequences. It is reasonable to suggest that most of these pathophysiologic effects of angiotensin II (through the stimulation of AT1 receptors) will result in pivotal, and potentially deleterious effects throughout the cardiovascular continuum.

***The Lyon Diet Heart Study randomized 605 post-MI subjects to prudent Western-style diet or to diet rich in fruits, vegetables, and fish, and incorporating an alpha-linoleic acid (ALA)-based margarine.1 After 46 months, there was 68% risk reduction in cardiac death and nonfatal MI (P = 0.0001).The GISSI-Prevenzione study randomized 11,324 post-MI patients to placebo or 1 g/d omega-3 fatty acid fish-oil supplements.1 After 3.5 years, there was a 20% risk reduction in all-cause mortality (95% CI, 6%33%) and 30% risk reduction in CV death (95% CI, 13%44%).The Indian Experiment of Infarct Survival Trial randomized 360 post-MI patients to placebo, eicosapentaenoic acid (EPA) supplement, or ALA supplement.1 After 1 year, the EPA supplement was associated with 50% risk reduction in cardiac death (P < 0.05) and 48% risk reduction in nonfatal MI (P < 0.05). The ALA supplement was associated with 40% risk reduction in cardiac events (P < 0.05) (data not shown).The Indo-Mediterranean Diet Heart Study randomized 1000 patients with angina, MI, or multiple risk factors to a National Cholesterol Education Program Step 1 diet or to a diet rich in whole grains, fruits, vegetables, walnuts, mustard seed, and soybean oil.1 After 2 years, the Mediterranean-style diet was associated with a 33% risk reduction in MI (P < 0.001).The Diet and Reinfarction Trial randomized 2000 post-MI men to their usual diet or to a diet with fish consumption twice weekly (300 g total).1 After 2 years, there was 29% risk reduction in all-cause mortality and 27% risk reduction in fatal MI.

1. Parikh P, McDaniel MC, Ashen D, Miller JI, Sorrentino M, Chan V, et al. Diets and cardiovascular disease: An evidence-based assessment. J Am Coll Cardiol. 2005;45:1379-1387.****The Antithrombotic Trialists Collaboration compared data from 65 aspirin trials to examine the effects of aspirin dose on vascular events in high-risk patients (in some trials, the doses of aspirin used were in more than one of the comparisons).[1] Serious vascular events (the primary measure of outcome) included nonfatal MI, nonfatal stroke, death from vascular causes, and death from unknown causes. They found that all doses of aspirin studied reduced the risk for vascular events. The greatest number of trials (34) examined high aspirin doses (500 mg to 1500 mg) and revealed a proportional reduction in vascular events of 19%. Aspirin doses of 160 mg to 325 mg were associated with a 26% proportional reduction in vascular events, whereas 75 mg to 150 mg and

kardiovaskularne bolesti prim. mr. sc. dr. nediljko pivac interna klinika, kbc split

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