La presentazione è in caricamento. Aspetta per favore

La presentazione è in caricamento. Aspetta per favore

Sindrome delle apnee notturne e ipertensione arteriosa M. Scoppio Responsabile reparto di Nefrologia Ambulatorio ipertensione arteriosa Ospedale San Camillo-Forlanini.

Presentazioni simili


Presentazione sul tema: "Sindrome delle apnee notturne e ipertensione arteriosa M. Scoppio Responsabile reparto di Nefrologia Ambulatorio ipertensione arteriosa Ospedale San Camillo-Forlanini."— Transcript della presentazione:

1 Sindrome delle apnee notturne e ipertensione arteriosa M. Scoppio Responsabile reparto di Nefrologia Ambulatorio ipertensione arteriosa Ospedale San Camillo-Forlanini 26 maggio 2007

2

3 Sleep apnea and hypertension Il 96% degli uomini e il 65% delle donne con Il 96% degli uomini e il 65% delle donne con ipertensione resistente hanno OSA ipertensione resistente hanno OSA Gli ipertesi resitenti con OSA hanno livelli più alti Gli ipertesi resitenti con OSA hanno livelli più alti di aldosterone plasmatico e incidenza più elevata di aldosterone plasmatico e incidenza più elevata di aldosteronismo primario, rispetto agli ipertesi di aldosteronismo primario, rispetto agli ipertesi resistenti senza OSA resistenti senza OSA OSA E IPERTENSIONE RESISTENTE

4 Sleep Apnea and Potential Health Risks Sleep Apnea Excessive sleepiness Neurocognitive deficits Crashes (motorcar accidents Crashes (motorcar accidents) Hypertension Cardiovasculare disease (IMA,stroke,SCA,CHF) Insulin-resistance

5 OSA 50% Hypertension25% CongestiveCardiacFailure 30% AcuteCoronarySyndrome 60% Stroke Prevalence of OSA In Patients with Cardiovascular and Cerebrovascular Disease Lattimore Jl JACC 2003;41

6 two recent reports have found increased OSA in subjects with APOE ε4, a genetic factor associated with Alzheimers disease. The association of APOE ε4 with OSA has been suggested to be mediated by damage to the CNS and resulting abnormal regulation breathing during sleep Am J Respir Crit Care Med Vol 170. pp 1349–1353, 2007 OSAMorbodiAlzheimer APOE ε4 Link genetico

7 Peppard PE. N Engl J Med. 2000; 342: Obstructive sleep apnea and risk for hypertension

8 EVIDENCE ON THE ASSOCIATION BETWEEN OSA AND HYPERTENSION: Recent Human Studies General population epidemiology studiesGeneral population epidemiology studies Clinic based epidemiology studiesClinic based epidemiology studies Case control studiesCase control studies Intervention studiesIntervention studies

9 EVIDENCE ON THE ASSOCIATION BETWEEN OSA AND HYPERTENSION: Recent Human Studies Studio trasversale Studio longitudinale

10

11

12 2/3 paz. con OSA OBESI ½ paz. ipertesi OSA 2/3 paz. obesi IPERTENSIONE LINK

13 OSA and Impaired Glucose Metabolism Meslier et al 2003Meslier et al male patients referred for polysomnography underwent a 2 hour oral glucose tolerance test.595 male patients referred for polysomnography underwent a 2 hour oral glucose tolerance test. 494 pts had OSAS (AHI > 10)494 pts had OSAS (AHI > 10) Fasting and postload blood glucose increased with severity of sleep apneaFasting and postload blood glucose increased with severity of sleep apnea Insulin sensitivity decreased with increasing severity of sleep apneaInsulin sensitivity decreased with increasing severity of sleep apnea BMI, age and AHI are all have an independent effect on blood glucose and insulin sensitivityBMI, age and AHI are all have an independent effect on blood glucose and insulin sensitivity Ip et al 2002Ip et al pts with OSAS (AHI>5)185 pts with OSAS (AHI>5) Insulin resistance increased with age obesity (main determinant)Insulin resistance increased with age obesity (main determinant) Independent determinants of OSA were AHI and min 02 satIndependent determinants of OSA were AHI and min 02 sat Punjabi et al 2003 [Review]Punjabi et al 2003 [Review] –Habitual snoring is associated with abnormal fasting glucose and insulin values independent of age and BMI –Prospective data from two separate studies indicate that habitual snoring is associated with more than a 2-fold risk of developing DM type II over a ten year period independent of BMI and other confounders –Several studies have suggested that the minimum oxygen saturation and AHI are predictive of glucose intolerance and insulin resistance independent of BMI, age and waist to hip ratio

14 Cluster di fattori di rischio emodinamici e metabolici tradizionali e non tradizionali (emergenti), che associati aumentano il rischio di diabete tipo 2 e di eventi cardiovascolari Dannologaritmico

15 Central obesity Men>102 cm Women>88 cm TG TG150 mg/dL HDL cholesterol Men<40 mg/dL Women<50 mg/dL Blood pressure Blood pressure130/85mmHg Fasting glucose Fasting glucose110 mg/dL Definition of metabolic syndrome Three or more of the following five risk factors: Waist circumference

16 Despite therapeutic advances, cardiovascular disease remains the leading cause of death Number of deaths (thousands) Male Female % of all deaths (right axis) No. of deaths (left axis) % All deaths (male + female) National Center for Health Statistics 2004 Data for 2002

17 Unmet clinical needs to address in the next decade CARDIOVASCULAR DISEASE Classical Risk Factors Novel Risk Factors Major Unmet Clinical Need Metabolic syndrome Abdominal Obesity HDL-C TG TNF IL-6 PAI-1 Glu Insulin T2DM Smoking LDL-C BP

18

19

20 TWIN EPIDEMICS OBESITA DIABETE TIPO 2 DIABETE TIPO 2 GLOBESITY IPERTENSIONEARTERIOSA MALATTIECARDIO-VASCOLARI DIABESITY

21 Childhood Obesity, Inflammation, and Apnea What Is the Future for Our Children? numerous recent studies have demonstrated the presence of hypertension and increased inflammation in children with OSAS AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL

22 Insulino-resistenza IpertensioneObesità Dislipidemia aterogena OSA e SINDROME METABOLICA PCOS NASH NEFROPATIAURATICA OSA LOSA ha probabilità 9 volte superiore di sviluppare sindrome metabolica rispetto alla popolazione di controllo

23 Obesità (sindrome metabolica) OSA ?

24 Valutazione del sovrappeso e dellobesità The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH Publication, October 2000 NIH Pub No The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH Publication, October 2000 NIH Pub No Indice di massa corporea: Peso (kg)/altezza(m 2 ) Circonferenza addominale Rischio elevato: Uomini > 102 cm Donne > 88 cm GRASSO VISCERALE

25 Effetti cardiometabolici sfavorevoli dei prodotti degli adipociti Adipose tissue IL-6 Adiponectina Leptina TNF α Adipsina (Complemento D) Inibitore dellattivatore del plasminogeno-1 (PAI-1) Resistina FFA Insulina Angiotensinogeno Lipoprotein lipasi Lactato Infiammazione Diabete tipo 2 Ipertensione Dislipidemia aterogenica Trombosi Aterosclerosi Lyon 2003; Trayhurn et al 2004; Eckel et al 2005

26 OSA ipossiemia - ipercapnia ROS (radicali liberi) Ipertono simpatico Eventi cardiovascolari Insulinoresistenza Ipertensionearteriosa Ag II Sindrome Metabolica eOSA

27

28 IPERTONO SIMPATICO renale

29 Profilo pressorio caratteristico dellOSA Ipertensione arteriosa diastolica Ipertensione arteriosa diastolica Ipertensione clinica Ipertensione clinica Ritmo circadiano di tipo non-dipper Ritmo circadiano di tipo non-dipper Ipertensione secondaria e resistente Ipertensione secondaria e resistente Eccessivo rialzo pressorio al risveglio Eccessivo rialzo pressorio al risveglio Alta variabilità pressoria (DS) Alta variabilità pressoria (DS)

30 UTILITA dellABPM

31 Rilevanza clinica dei fenomeni pressori nelle 24 ore Pressione notturna più alta Minore giorno/notte Eccessivo aumento pressorio mattutino Aumento della variabilità pressoria Picchi pressori eccessivi/ numerosi Pressione notturna più alta Minore giorno/notte Eccessivo aumento pressorio mattutino Aumento della variabilità pressoria Picchi pressori eccessivi/ numerosi Danno dorgano Rischio cardiovascolare Progressione a nefropatia diabetica Progressione a nefropatia diabetica Associazione con un picco mattutino degli eventi cardiovascolari Associazione con un picco mattutino degli eventi cardiovascolari

32 Sander D. et al, Circulation 2000; 102: Analisi di Kaplan-Meier per gli eventi cardiovascolari fatali e non fatali in pazienti con variabilità pressoria aumentata (> 15 mmHg) o normale (< 15 mmHg) Analisi di Kaplan-Meier per gli eventi cardiovascolari fatali e non fatali in pazienti con variabilità pressoria aumentata (> 15 mmHg) o normale (< 15 mmHg) Variabilità 15 Variabilità > 15 Variabilità 15 Variabilità > 15

33 Variabilità della pressione sistolica come fattore di rischio per ictus e mortalità cardiovascolare negli ipertesi anziani Journal of Hypertension 2003; 21: 1-7 PAS notturna (mmHg) Variabilità notturna della PAS Rischio di ictus a 2 anni

34 Monitoraggio ambulatorio della PA 24 ore Monitoraggio ambulatorio della PA 24 oree rialzo pressorio al risveglio (morning surge pressure) OSA e IPERTENSIONE ARTERIOSA

35 Mortalità nelle prime tre ore dopo il risveglio Willich. Am J Cardiol 1992; 70: Numero di morti sonno Ore dopo il risveglio

36 Variazioni circadiane nellincidenza di morte cardiaca improvvisa - Framingham Heart Study Willich. Am J Cardiol 1987; 60: Ore del giorno

37 Gami, A. S. et al. N Engl J Med 2005;352: Sudden cardiac death and OSA

38 CortisoloRASAgIIAldosteroneCatecolamine Adesività piastrinica Viscosità ematica h 24 h 12 h 18 temporali Picchi temporali dei ritmi circadiani umani h 6 PA FC NOFibrinolisi

39 OSA e EPO

40 Circulation. 2003;107 Elevated Levels of C-Reactive Protein and Interleukin-6 in Patients With Obstructive Sleep Apnea Syndrome Are Decreased by Nasal Continuous Positive Airway Pressure early clinical signs of atherosclerosis !

41 Incidence of sleep-related disorders in 440 consecutive patients with HF Sleep-related disorder Incidence (%) Central sleep apnea 25 Obstructive sleep apnea 28 Milder sleep-related disorders 18 No sleep-related disorder 29 Lamp B. Heart Failure Society of America 2004 Annual Scientific Meeting; September 12-15, 2004; Toronto

42 Hypertension 2007;49:34-39 SO 2 e Massa Ventricolare sinistra Data supporting a possible cause and effect relationship between OSA and LVH. 6 months of nocturnal CPAP to patients with severe OSA was associated with a significant reduction in LV wall thickness. Chest 2003;124

43 JACC Vol. 47, No. 7, 2006 Correlazione tra AHI e SS e GC

44 JACC Vol. 47, No. 7, 2006 Effetto della CPAP su SS e GC

45 Nocturnal Ischemic Events in Patients With Obstructive Sleep Apnea Syndrome. Effects of Continuous Positive Air Pressure Treatment. 10/51 paz. con OSA J Am Coll Cardiol 1999;34 CPAP

46 OSA treatment in CAD Milleron et al Eur Heart J 2004

47 Treatment of heart failure Once confirmed LV dysfunction on echo (not symptoms alone), treatment is a formula:Once confirmed LV dysfunction on echo (not symptoms alone), treatment is a formula: –Diuretics –Spironolactone –ACE inhibitor/ARBs –Beta blocker And now CPAPAnd now CPAP –Drug therapy alone does not decrease severity of sleep apnea in heart failure

48 Arrhythmias associated with SDB The following have been associated with SDB: –Classically severe bradycardia (sinus arrest, AV block) –Atrial and ventricular ectopics –SVT, Atrial flutter, AF –Sustained and nonsustained VT Causality is not proven but tend to occur most with severe OSA and hypoxia

49 Gami AS Circulation 2004;110:364-7 OSA e FA

50 Recurrence of AF 12 months after cardioversion Kanagala R Circulation 2003;107:

51 Prevalence of OSA after stroke Harbison Good Parra Dyken Bassetti Harbison Wessendorf Parr a Davies >40%

52

53

54

55 Wolk et al. Hypertension, 2003; 42

56 TERAPIA ANTIPERTENSIVA CONTROLLOPRESSORIO PROTEZIONEDORGANOPROTEZIONEMETABOLICA SINDROMEMETABOLICA

57 Terapia antipertensiva nella Sindrome Metabolica ACE-inibitoriSartani Farmaci che riducono la pressione arteriosa e che migliorano il quadro metabolico BLOCCANTI IL SRA

58 Potenziale influenza di telmisartan sui recettori PPAR e sullAngiotensina II Kurtz TW et al. J Hyperten 2004; 22: SARTANI Aterosclerosi Angiotensina II PPAR –+ Insulino resistenza Dislipidemia Flogosi cellulare Proliferazione cellulare Ipertensione Stress ossidativo

59

60 treatment of aldosterone excess induces not only the improvement of the cardiac alterations, but also of the metabolic complications related to hyperaldosteronism Journal of Hypertension 2007, 25:177–186 ANTIALDOSTERONICI

61 Diuretics ACE inhibitors Calcium antagonists AT 1 -receptor blockers ß-blockers 1 -blockers 1 -blockers 2003 European Society of Hypertension - European Society of Cardiology guidelines for the management of arterial hypertension

62 Among specific sleep disorders, the most serious in terms of morbidity and mortality is obstructive sleep apnea.Among specific sleep disorders, the most serious in terms of morbidity and mortality is obstructive sleep apnea.... it is time for the nation to wake up to the staggering impact of sleep disturbances on the health and welfare of our society, an impact that rivals that of smoking.... it is time for the nation to wake up to the staggering impact of sleep disturbances on the health and welfare of our society, an impact that rivals that of smoking. Ten Years Ago - April 1993! SLEEP APNEA – A MAJOR PUBLIC HEALTH PROBLEM EDITORIAL

63 M. Scoppio


Scaricare ppt "Sindrome delle apnee notturne e ipertensione arteriosa M. Scoppio Responsabile reparto di Nefrologia Ambulatorio ipertensione arteriosa Ospedale San Camillo-Forlanini."

Presentazioni simili


Annunci Google