” Tratamentul medicamentos al aterosclerozei"

1. ”Tratamentul medicamentos al aterosclerozei" Dan Gaita Institutul de Boli Cardiovasculare Fundatia CardioPrevent Timisoara

2. Conflict de intereseAm sustinut conferinte si am organizat evenimente educationale pentru: Amgen, AstraZeneca, Berlin Chemie, Boehringer Ingelheim, Galenica, GSK, MSD, Mylan, Novartis, Pfizer, Sanofi, Servier

3. Adevar sau provocare? PROVOCARE!

6. De ce?

7. Europe - SDR, diseases of circulatory systemall ages per 100,000 European Union 221.7

9. WHO Targets and WHF Goal

11. Ce?

12. ”Tratamentul medicamentos al consecinteloraterosclerozei" Dan Gaita Institutul de Boli Cardiovasculare Fundatia CardioPrevent Timisoara

13. ASCVD Prevention Pyramid and Components of Cardiac Rehabilitation/Secondary Prevention Programs

14. CHD deaths prevented or postponed by treatments and risk factor changes in the United States population, 1980–2000.

15. Therapeutic control of blood pressure*, LDL-C** and diabetes*** p=0.01 p=0.69 P<0.0001 *In patients on BP lowering drugs; **In patients on lipid-lowering drugs; *** In patients with known diabetes EUROASPIRE II EUROASPIRE III EUROASPIRE IV

16. ”Preventia aterosclerozei" Dan Gaita Institutul de Boli Cardiovasculare Fundatia CardioPrevent Timisoara

17. Total CVRisk INTERHEART 2.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 333.7 Odds Ratio (99% CI) Yusuf S. Lancet 2004; 364:937 All All 1+2+3 Smoking Diabetes 1+2+3+4 Overweight Hypertension ApoB/ApoA1 Psychosoc fact

18. ROMANIA at the glance! Calea de la Ministerul Bolilor la Ministerul Sanatatii? * ascending order of indicator’s value

19. “POPULATIONAL” • Comunitati locale • “Civilizatie” • Exemplu personal NU FUMATULUI !

20. “RISC INALT” • Program national • Cabinete de Preventie in judete • Control periodic obligator Algoritm HTA

22. “PREVENTIE SECUNDARA” • Programe nationale/ patologii • Modernizare -Tehnicizare • Registre – date reale! Statina gratis post IM?

23. British Heart Foundation Sanatate CV

24. Curr Pharm Des. 2013;19(33):5909-28 Two-year treatment with allicor (garlic powder) has a direct anti-atherosclerotic effect on carotid atherosclerosis in asymptomatic men. Inflaminat (calendula, elder, and violet), which possesses anti-cytokine activity, has been shown to cause the regression of carotid atherosclerosis following the treatment of asymptomatic men for one year. The phytoestrogen-rich drug karinat (garlic powder, extract of grape seeds, green tea leaves, hop cones, β-carotene, α-tocopherol, and ascorbic acid) prevents the development of carotid atherosclerosis in postmenopausal women.

25. Antiatherosclerotic  Cyclic AMP    Prostacyclin    Prostaglandin E2    Artificial high-density lipoprotein (HDL)   Antioxidants    Calcium antagonists    Trapidil and its derivatives    Lipoxygenase inhibitors    Lipostabil    Mushroom extracts Proatherogenic  Beta-blockers    Thromboxane А2    Phenothiazine Anti-atero-sclero-tice?

26. Polymeal ? decrease of global risk with 76% 7 main elements: • wine • fish • dark chocolate • fruits • vegetables • almonds • garlic Dutch Polymeal 1) Eat fish four times a week; 2) Drink 4-5 oz. of wine a day; 3) Eat 100g (3-4 oz.) of dark chocolate a day; 4) Eat 400g (14 oz.) of fruits & vegetables a day; 5) Eat 2.7g (a pinch) of garlic a day; 6) Eat 68g (2-3 oz.) of almonds a day.

27. Ingredients % CV risk Risk factors Source reduced reduction 32% Di Castelnuovo et al CVD Wine(150ml/day) Fish (114g 4x/week) 14% CVD Whelton et al 21% ¯ Ta ubert et al Dark Chocolate SBP – 5.1mmHg ¯ (100g/day) DBP - 1.8mmHg 21% ¯ Fruits & vegetables John et al SBP - 4mmHg (400g/day) ¯ DBP -1.5mmHg Garlic (2.7g/day) 25% TC – 17.1mg/dL ¯ Ackermann et al Almonds (68g/day) 12.5% TC - 10mg/dL ¯ Jenkins et al Polymeal efficiency

28. Continuum Cardiovascular BCV Diabet zaharat Boala cronica de rinichi Factori de risc Subiecti sanatosi Populatia generala Risc crescut Preventie secundara

29. ”PRECOCITATEA interventiei asupra aterosclerozei" Dan Gaita Institutul de Boli Cardiovasculare Fundatia CardioPrevent Timisoara

30. Total CVRisk INTERHEART 2.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 333.7 Odds Ratio (99% CI) Yusuf S. Lancet 2004; 364:937 All All 1+2+3 Smoking Diabetes 1+2+3+4 Overweight Hypertension ApoB/ApoA1 Psychosoc fact

31. Hypoglycemia as Pro-atherosclerotic factor

32. Hypoglycemia followed by Hyperglycemia! … Ceriello A et al. Diabetes 2012;61:2993-7

33. Early vs late glycemic intervention

34. Defining metabolic memory • “Epidemiological and prospective data support a long-term influence of early metabolic control on clinical outcomes” • “...early glycaemic environment is remembered in the target organs (i.e., eye, kidney, heart, extremities)” • “The concept of a metabolic memory is of diabetic vascular stresses persisting after glucose normalization” Antonio Ceriello, Michael A. Ihnat and Jessica E. Thorpe The "Metabolic Memory": Is More Than Just Tight Glucose Control Necessary to Prevent Diabetic Complications? J Clin. Endocrinol. Metab. 2009 94:410-415

35. The Metabolic Memory UKPDS VADT Del Prato S, Diabetologia 2009; 52:1219–1226 Holman Ret al. N Engl J Med. 2008 ;359:1577-89

36. The take-home message is that “good glucose control should be started as early as possible to delay or prevent serious diabetes-related complications,” said Alan D. Cherrington, PhD, president, American Diabetes Association. ADA S. Diego 2005

37. Total CVRisk INTERHEART 2.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 333.7 Odds Ratio (99% CI) Yusuf S. Lancet 2004; 364:937 All All 1+2+3 Smoking Diabetes 1+2+3+4 Overweight Hypertension ApoB/ApoA1 Psychosoc fact

38. Lowering LDL-C Levels With Statins in Patients With or Without Prior CV Events Has Been Shown to Improve CV Outcomes!!! ASCOT 4S 30 ASCOT AFCAPS Secondary prevention trials1 25 4S HPS Active treatment/Statin AFCAPS HPS WOSCOPS Placebo CARE LIPID 20 LIPID Primary prevention trials2 TNT (10mg atorvastatin) TNT (80mg atorvastatin) Active treatment/Statin CARE 15 WOSCOPS Placebo CHD Events (%) 10 5 0 1. LaRosa JC, et al. N Engl J Med. 2005;352:1425-1435. 2. O’Keefe J, et al. J Am Coll Cardiol. 2004;43:2142-2146. (mg/dL) LDL Cholesterol 50 70 90 110 130 150 170 190 210

39. 20 15 10 5 Modificarea volumului placii de aterom, mm3 0 -5 Reducerea LDL–C cu 50% -10 -15 -80 -70 -60 -50% -40 -30 -20 -10 0 10 20 Reducerea LDL colesterol (%) REVERSAL:modificareavolumuluiplacii de ateromcoronareapare la reducereaLDL-C cu ~50% Nissen S et al. JAMA 2004; 291:1071-80.

40. Program de Monitorizare Globală pentru Prevenţia şi Controlul Bolilor Cronice Netransmisibile :25X25 OBIECTIV : REDUCEREA CU 25% A RATEI MORTALITĂȚII CAUZATE DE BOLILE CRONICE NETRANSMISIBILE (IN PRNCIPAL BOLILE CARDIOVASCULARE, CANCER, DIABET SI BOLILE CRONICE RESPIRATORII) REDUCEREA CU 10% REDUCEREA CU 10% REDUCEREA CU 30% REDUCEREA CU 30% REDUCEREA CU 25% CREȘTEREA CU 0% A CONSUMULUI A SEDENTARISMULUI A CONSUMULUI A CONSUMULUI A HIPERTENSIUNII A RATEI DE DE ALCOOL DE SARE/SODIU DE TUTUN ARTERIALE DIABET/OBEZITATE MASURI DEDICATE FIECARUI FACTOR DE RISC IN PARTE MINIM 50 % DINTRE PACIENȚII LA RISC SA PRIMEASCA TRATAMENT ADECVAT ȘI CONSILIERE ÎN VEDEREA PREVENIRII APARITIEI BOLILOR MINIM 80% DINTRE PACIENȚI SA AIBA ACCES LA TEHNICI DE DIAGNOSTIC SI LA TRATAMENT MODERN NECESAR TRATĂRII BOLILOR 2025