«Πατσζαρκία και Καρδιαγγειακή Νόζος»

«Πατσζαρκία και Καρδιαγγειακή Νόζος» Δημήτρης Π. Παπαδόπουλος-FESC Clinical Assist. Professor George Washington University USA Επιμελητής Καρδιολογικής Κλινικής Π.Γ.Ν.Α. «ΛΑΪΚΟ» Υπεύθυνος Αντιυπερτασικού Ιατρείου Clinical Hypertension Specialist ESH

Percent of Population Prevalence of CVD in adults age 20 and older by age and sex 100 80 71.3 75.1 83.0 92.0 60 40 39.1 39.5 20 14.8 9.4 0 20-39 40-59 60-79 80+ Males Females (NHANES: 1999-2004). Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, stroke and hypertension.

Deaths in Thousands CVD disease mortality trends for males and females 550 500 450 400 79 80 85 90 95 00 04 Years Males Females

Direct and Indirect Cost of CVD and Diabetes Cardiovascular Disease Estimated Direct Medical Costs Estimated Indirect Costs (disability, work loss, premature mortality) Diabetes TOTAL $296 billion $152 billion $116 billion $58 billion $412 billion $210 billion *Note: these figures may not account for potential overlap. Sources: 2008 statistics from the American Diabetes Association and American Heart Association.

OBESITY/OVERWEIGHT

Central obesity: a driving force for cardiovascular disease & diabetes Balzac by Rodin Front Back

Establish diagnosis: BMI BMI = weight (kg)/ [height (M)] 2 Correlates well with direct measures of adiposity Overweight child: BMI >85th and <95th percentile Obese child: BMI > 95th percentile If child < 3 years old, use weight for height

Measure BMI routinely at each regular check-up. Classifications: BMI 18.5-24.9 = normal BMI 25-29.9 = overweight BMI 30-39.9 = obesity BMI 40 = extreme obesity Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998, National Institutes of Health.

Large waist circumference (WC) can identify some at increased risk over BMI alone If BMI and other cardiometabolic risk factors are assessed, currently there is insufficient evidence to: Substitute WC for BMI Measure WC in addition to BMI Klein, et al. Waist Circumference and Cardiometabolic Risk. Diabetes Care. 2007 0: dc07-9921v1-0.

Medical Complications of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis

Complications of Childhood Obesity

Adjusted relative risk Abdominal obesity and increased risk of cardiovascular events The HOPE study 1.4 Waist circumference (cm): 1.29 Tertile 1 Tertile 2 Tertile 3 Men <95 95 103 >103 1.27 Women <87 87 98 >98 1.35 1.2 1.17 1.16 1.14 1 1 1 1 0.8 CVD death MI All-cause deaths Adjusted for BMI, age, smoking, sex, CVD disease, DM, HDL-cholesterol, total-c; CVD: cardiovascular disease; MI: myocardial infarction; BMI: body mass index; DM: diabetes mellitus; HDL: high-density lipoprotein cholesterol Dagenais GR et al, 2005

Relative risk Abdominal obesity is linked to an increased risk of coronary heart disease Waist circumference has been shown to be independently associated with increased age-adjusted risk of CHD, even after adjusting for BMI and other cardiovascular risk factors 3.0 2.5 2.0 p for trend = 0.007 2.06 2.31 2.44 1.5 1.0 0.5 0.0 1.27 <69.8 69.8 <74.2 74.2 <79.2 79.2 <86.3 86.3 <139.7 Quintiles of waist circumference (cm) CHD: coronary heart disease; BMI: body mass index Rexrode KM et al, 1998

Primary Metabolic Disturbance Intermediate Vascular Disease Risk Factor Intravascular Pathology Clinical Event Insulin Resistance Hypertension Dyslipidemia Overnutrition Hyperglycemia Hyperinsulinemia Inflammation Impaired Fibrinolysis Atherosclerosis Coronary arteries Carotid arteries Cerebral arteries Aorta Peripheral arteries Hypercoagulability CVD Endothelial Dysfunction Despres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-887.

Pathophysiology of Obesity and Cardiomyopathy Lavie, C. J. et al. J Am Coll Cardiol 2009;53:1925-1932 Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.

Overview of Leptin Resistance and Hyperleptinemia in Obesity- Related Cardiovascular Disease Lavie, C. J. et al. J Am Coll Cardiol 2009;53:1925-1932 Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.

Cardiometabolic Risk Factors Overweight/obesity Source: CDC, ADA Desired Goals for Healthy Patients Prevention of overweight/obesity as measured by measured by BMI (normal = 18.5 24.9). In those who are overweight/obese, the goal is to is to lose 5 7% of body weight. Abnormal lipid metabolism metabolism High LDL cholesterol Low HDL cholesterol High triglycerides Source: NHLBI, ATP III Guidelines, ADA Hypertension Source: NHLBI, JNC7 Fasting blood glucose Source: ADA Physical inactivity Source: CDC CDC Smoking Source: ADA Desirable levels are less than 100 mg/dl. Desirable levels are greater than 40 mg/dl in men and greater than 50 mg/dl in women. Desirable levels are less than 150 mg/dl <140/90 mm/hg or 130/80 mm/hg for people with diabetes diabetes (Ideal is less than 120/80 mm/hg) Below 100 mg/dl At least 30 minutes of moderate activity most days Quit or never start

Obesity Management in an Outpatient Office Practice 40 31 27 20 Patient BMI 37 21 33 29

Selected Medications That Can Cause Weight Gain Psychotropic medications Tricyclic antidepressants Monoamine oxidase inhibitors Specific SSRIs Atypical antipsychotics Lithium Specific SSRI=selective serotonin reuptake inhibitor Diabetes medications Insulin Sulfonylureas Thiazolidinediones Highly active antiretroviral therapy Tamoxifen Steroid hormones Glucocorticoids Progestational steroids

Lifestyle modification Reduce caloric intake by 500-1000 kcal/day (depending on starting weight) Target 1-2 pound/week weight loss Increase physical activity Healthy diet Diabetes Prevention Program DASH diet Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998, National Institutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25:2165 2171, 2002. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, NIH Publication No. 04-5230, August 2004

Consider pharmacologic treatment BMI 30 with no related risk factors or diseases, or BMI 27 with related risk factors or diseases As part of a comprehensive weight loss program incl. diet & physical activity Consider surgery BMI 40 or BMI 35 with comorbid conditions Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998, National Institutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25:2165 2171, 2002

Health Benefits of Weight Loss Decreased cardiovascular risk and events Decreased glucose and insulin levels Decreased blood pressure Decreased LDL and triglycerides, increased HDL

Body Composition and Heart Failure Prognosis Lavie, C. J. et al. J Am Coll Cardiol 2009;53:1925-1932.

Risk-Adjusted Survival Curves for the 4 Body Mass Index Categories at 5 Years in a Study of 1,203 Individuals With Moderate to Severe Heart Failure Lavie, C. J. et al. J Am Coll Cardiol 2009;53:1925-1932 Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.

Body Weight - Stroke High body mass index (BMI 25) increases risk of stroke in men and women 1 Abdominal adiposity is a risk factor for stroke in men but not women 2 A randomized trial in women found no effect of dietary interventions to reduce the incidence of stroke 3 1: Kurth T et al.: Circulation (2005) 111:1992-1998 2: Hu G et al.: Arch Intern Med (2007) 167:1420-1427 3: Howard B et al.: JAMA (2006) 295:655-666

VA & SCD Related to Specific Pathology Obesity, Dieting, and Anorexia I I I IIa IIb III IIa IIb III IIa IIb III Life-threatening ventricular arrhythmias in patients with obesity, anorexia, or when dieting should be treated in the same manner that such arrhythmias are treated in patients with other diseases, including ICD and pacemaker implantation as required. Patients receiving ICD implantation should be receiving chronic optimal medical therapy and have reasonable expectation of survival with a good functional status for more than 1 year. Programmed weight reduction in obesity and carefully controlled re-feeding in anorexia can effectively reduce the risk of ventricular arrhythmias and SCD. Prolonged, unbalanced, very low calorie, semistarvation diets are not recommended; they may be harmful and provoke life-threatening ventricular arrhythmias.

SLEEP, Vol. 30, No. 3, 2007

Health Benefits of Weight Loss Decreased cardiovascular risk Decreased glucose and insulin levels Decreased blood pressure Decreased LDL and triglycerides, increased HDL

Hypertension at age 15 Type 2 DM at age 23 Renal failure at age 32 First MI at age 35 (survives) CHF at age 37 Second MI at age 40

Percent NHANES III Prevalence of Hypertension* According to BMI 50 40 30 20 BMI <25 BMI 25-<27 BMI 27-<30 BMI >30 41.9 27 27.7 22.1 14.9 15.2 32.7 37.8 10 0 Men Women *Defined as mean systolic blood pressure 140 mm Hg, mean diastolic 90 mm Hg, or currently taking antihypertensive medication. Brown C et al. Body Mass Index and the Prevalence of Hypertension and Dyslipidemia. Obes Res. 2000; 8:605-619.

Weekly SBP in the DASH Trial mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24 132 Control Group Diet 130 128 Fruits + Vegetables 126 124 122 X=5.5 mm Hg Fruits + Vegetables + Low Fat Base 1 2 3 4 5 6 7 & 8 Intervention Week

Weekly DBP in the DASH Trial mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24 86 Control Group Diet 84 Fruits + Vegetables 82 80 X=3 mm Hg Fruits + Vegetables + Low Fat 78 Base 1 2 3 4 5 6 7 & 8 Intervention Week

Επίδραζη μεηαβολών ηοσ ηρόποσ ζωής ζηην ΑΥ Μεηαβολή Μείωζη ΣΒ Μείωζη ηης ΣΑΠ 5 20 mmhg/10 kg μείωζης ΣΒ Αποδοτή δίαιηας DASH Μείωζη άλαηος Αζκηζη Περιοριζμός αλκοόλ 8 14 mmhg 2 8 mmhg 4 9 mmhg 2 4 mmhg JNC VII ESC/ESH 2007

Other risk factors, OD or disease No other risk factors 1-2 risk factors 3 or more risk factors, MS, OD or diabetes Diabetes Established CV or renal disease Initiation of antihypertensive Normal SBP 120-129 or DBP 80-84 No BP intervention Lifestyle changes Lifestyle changes Lifestyle changes Lifestyle changes + immediate drug treatment treatment High normal SBP 130-139 or DBP 85-89 No BP intervention Lifestyle changes Lifestyle changes and consider drug treatment Lifestyle changes + drug treatment Lifestyle changes + immediate drug treatment Grade 1 HT SBP 140-159 or DBP 90-99 Lifestyle changes for several months then drug treatment if BP uncontrolled Lifestyle changes for several weeks then drug treatment if BP uncontrolled Lifestyle changes + drug treatment Lifestyle changes + immediate drug treatment Grade 2 HT SBP 160-179 or DBP 100-109 Lifestyle changes for several weeks then drug treatment if BP uncontrolled Lifestyle changes for several weeks then drug treatment if BP uncontrolled Lifestyle changes + drug treatment Lifestyle changes + immediate drug treatment Grade 3 HT SBP 180 or DBP 110 Lifestyle changes + immediate drug treatment Lifestyle changes + immediate drug treatment Lifestyle changes + immediate drug treatment Lifestyle changes + immediate drug treatment

Health Benefits of Weight Loss Decreased cardiovascular risk Decreased glucose and insulin levels Decreased blood pressure Decreased LDL and triglycerides, increased HDL

CHOLESTEROL PROFILE IMPROVEMENT STRATEGY Weight Control Loosing weight increases the HDL level. Calculate your BMI Loose weight by decreasing the caloric intake with a hypocaloric diet and/or increasing output through an aerobic exercise.

Desirable Less than 200 mg/dl Borderline high risk 200 239 mg/dl High risk 240 mg/dl and over American Diabetes Association. Understanding Cardiometabolic Risk: Broadening Risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center

Total LDL HDL Triglycerides <200 mg/dl <70 mg/dl >40 men mg/dl >50 women mg/dl < 150 mg/dl Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III); National Cholesterol Education Program, National Heart, Lung, and Blood

LDL-C-lowering Category of risk LDL-C Goal 0-1 risk factor* < 160 mg/dl or lower Multiple (2+) risk factors* People with CHD or risk equivalent (e.g., diabetes) Known CAD and DM < 130 mg/dl or lower < 100 mg/dl or lower < 70 mg/dl or lower may be ideal

Lifestyle Modifications to Prevent Cardiovascular Disease Reduce weight Increa se physic al activity Moderate consumption of: alcohol sodium saturated fat cholesterol Maintain adequate intake of dietary: potassium calcium magnesium Avoid tobacco (JNC VI. Arch Intern Med. 1997)