Transcript Document

Ospedale San Giovanni di Dio
Firenze
3 ottobre 2009
Una Patologia Polidistrettuale:
l’Aterotrombosi
Plinio Fabiani
What is Atherothrombosis?
• Atherothrombosis is characterized by a sudden
(unpredictable) atherosclerotic plaque disruption
(rupture or erosion) leading to platelet activation and
thrombus formation
Plaque rupture1
Plaque erosion2
• Atherothrombosis is the underlying condition that
results in events leading to myocardial infarction,
ischemic stroke, and vascular death
1. Falk E et al. Circulation 1995; 92: 657–71. 2. Arbustini E et al. Heart 1999; 82: 269–72.
La due fasi dell’atero-trombosi
Infarto Miocardico Acuto
Atherothrombosis: A Generalized
and Progressive Process
Unstable
angina ACS
MI
Ischemic stroke/TIA
Critical leg ischemia
Cardiovasculardeath
Atherosclerosis
Atherothrombosis
Stable angina
Intermittent claudication
Adapted from Stary HC et al. Circulation. 1995; 92: 1355–74, and Fuster V et al. Vasc Med.
1998; 3: 231–9.
Major Clinical Manifestations
of Atherothrombosis
Ischemic
stroke
Myocardial
infarction
Transient
ischemic attack
Angina:
• Stable
• Unstable
Peripheral arterial
disease:
•
•
•
•
Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 1–6.
Intermittent claudication
Rest Pain
Gangrene
Necrosis
The Development of Atherothrombosis –
a Generalized and Progressive Process
Acute syndrome:
• coronary
• cerebrovascular
• peripheral
Occlusive
thrombus
Plaque
rupture
Platelet activation
and aggregation
Non-occlusive
thrombus
Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 1–6.
Healing and
resolution
Plaque growth
Atherothrombosis and Microcirculation
Plaque
rupture
Embolization
Microvascular
obstruction
Adapted from: Topol EJ, Yadav JS. Circulation 2000; 101: 570–80, and Falk E et al.
Circulation 1995; 92: 657–71.
Atherothrombosis* is a
Leading Cause of Death Worldwide†1
Mortality (%)
*Cardiovascular disease, ischemic heart disease and cerebrovascular disease
†Worldwide defined as Member States by WHO Region (African, Americas, Eastern
Mediterranean, European, South-East Asia and Western Pacific)
1. The World Health Report 2002. Geneva: WHO; 2002.
Identifying Those at Risk of Atherothrombosis1,2
Local factors:
• Elevated prothrombotic factors: fibrinogen, CRP, PAI-1
• Blood flow patterns, vessel diameter, arterial wall structure
Generalised
disorders
• Obesity
• Diabetes
Atherothrombosis
manifestations
(myocardial infarction,
stroke, vascular death)
Genetic
• Genetic traits
• Gender
• Age
Lifestyle
• Smoking
• Diet
• Lack of exercise
1. Yusuf S et al. Circulation 2001; 104: 2746–53. 2. Drouet L. Cerebrovasc Dis 2002;
13(suppl 1): 1–6.
Systemic
conditions
• History of vascular
events
• Hypertension
• Hyperlipidemia
• Hypercoagulable
states
• Homocystinemia
Il fumo uccide!
Six month stroke admission rate
Atherothrombosis is a Systemic Disease:
Increased Risk of Stroke in Patients After a
Myocardial Infarction1
4.5
4.0
4.17
3.58
3.5
3.0
2.5
2.0
1.5
1.0
2.72
2.08
1.43
0.93
0.5
0.0
0
1
2
3
Number of risk factors
1. Lichtman JH et al. Circulation 2002; 105: 1082–7.
4
5 or more
Calcificazioni coronariche
L’aterosclerosi coronarica è il più comune fattore predisponenete per l’aterostrombosi
Atherothrombosis is a Systemic Disease:
Long-Term Risk Increase for Stroke As a
Function of Coronary Calcification1
x 3.3
3.5
Risk increase
3.0
2.5
2.0
1.5
1.0
1.0
0.5
0.0
0–100
101–500
Coronary calcium score
1. Vliegenthart R. Stroke 2002; 33: 462–5.
> 500
Atherothrombosis is a Systemic Disease:
Long-term Risk Increase for Myocardial Infarction as
a Function of Carotid Intima Media Thickness1
4.0
x 3.61
Risk increase
3.5
3.0
2.5
2.0
1.5
1.0
1.0
0.5
0.0
1
2
3
4
Quintiles of carotid artery media thickness
1. O’Leary DH. N Engl J Med 1999; 340: 14–22.
5
Indice di Winsor (braccio/caviglia)
Atherothrombosis is a Systemic Disease:
Increase for Myocardial Infarction and Stroke as
a Function of ABI Measurement1
2.5
Risk increase
x 2.2
2.0
1.5
1.0
1.0
0.8
0.6
Ankle-brachial index (ABI) index
1. Dormandy JA, Creager MA. Cerebrovasc Dis 1999; 9(suppl 1): 14.
0.4
0.2
Causes of Death During Different
Time Intervals after First-Ever Stroke1
100%
Proportion of deaths (%)
90%
80%
70%
Unknown
60%
Non-vascular
50%
Cardiovascular
40%
30%
Recurrent stroke
20%
Related to first stroke
10%
0%
< 30 days
30d–6m
6m–1yr
Time
1. Hankey GJ. Stroke 2000; 31: 2080–6.
1–3yr
3–5yr
Manifestations of Atherothrombosis are Commonly Found
in More than One Arterial Bed in an Individual Patient*1
Cerebrovascular
disease
Coronary
disease
7.4%
24.7%
29.9%
3.3%
11.8%
3.8%
19.2%
Peripheral arterial disease
*Data from CAPRIE study (n=19,185)
1. Coccheri S. Eur Heart J 1998; 19(suppl): P1268.
Conclusioni
• L’Aterotrombosi è caratterizzata da un’improvvisa rottura di
placca che determina attivazione piastrinica e formazione del
trombo1
• L’aterotrombosi rappresenta il legame patologico comune a tutte
le maggiori manifestazioni cliniche delle malattie vascolari:
infarto del miocardio, ictus ischemico ed ateriopatia obliterante
periferica2
• Pazienti con manifestazioni cliniche di aterotrombosi in un letto
vascolare non sono solo a rischio di un evento ricorrente nella
stessa distribuzione arteriosa, ma corrono il rischio di eventi
ischemici anche in altri letti vascolari3
• L’Aterotrombosi è la maggiore causa di mortalità nel mondo
intero4
1. Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 1–6. 2. Nenci GG. Eur Heart J 1999; 1(suppl A):
A27–A30. 3. Lichtman JH et al. Circulation 2002; 105: 1082–7. 4. The World Health Report 2002.
Geneva: WHO; 2002.