Definizione di Igiene e principi di Epidemiologia 2) 23/10/07 Prof Gianluca Perseghin 10 lezioni Esame orale a partire da Febbraio 2008 Libro di testo: Igiene Generale della Scuola e dello Sport di A Boccia e G Ricciardi Idelson-Gnocchi Ed 1) 16/10/07 Definizione di Igiene e principi di Epidemiologia 2) 23/10/07 Epidemiologia malattie infettive 3) 30/10/07 Epidemiologia malattie cronico degenerative: Obesità 4) 6/11/07 Diabete 5) 13/11/07 Diabete e Malattie cardiovascolari 6) 20/11/07 Epidemiologia malattie cronico degenerative: Tumori 7) 27/11/07 Epidemiologia dello sport e Alimentazione e sport 8) 4/12/07 Infortuni nello sport e osso 9) 11/12/07 Igiene negli impianti sportivi Impianti natatori artificiali 10) 18/12/07 Tutela sanitaria delle attività sportive e il doping nello sport

CORONARY ARTERY DISEASE MORTALITY Figure 1: Time trends in mortality from cardiovascular disease in selected countries 1970-92, men (left) and women (right), aged 45-74 years. Abbreviations: Rus = Russia, Hun = Hungary, Cze = Czechoslovakia (after 1992, Slovakia + the Czech Republic), Fin = Finland, Por = Portugal, Den = Denmark, E&W = England and Wales, Spa = Spain, Gre = Greece (From Sans et al. European Heart Journal (1997) 18: 1231-1248)

Arterial wall: structure and function Figure 7 In order to understand AS, one must understand the structure and function of the artery. The artery has three structural components: adventitia (which carries blood and nerve supply to the artery itself); media (comprised of smooth muscle, which controls vascular tone); intima (a basement membrane covered by endothelium which regulates hemostasis, thrombosis, vascular tone and permeability). The intima is the site of AS.

Different stages of atherosclerotic plaque development Figure 8 There are six stages of development of AS: Grades I – IV: accumulation of lipids, first intracellularly, then extracellularly; Grade V: fibrosis around the lipid core forming an atherosclerotic plaque; Grade VI: complicated plaque (rupture, clot or bleed) leading to a clinical event.

Vascular endothelium modification in atherosclerosis Figure 9 During AS, the integrity of the endothelium is compromised which results in: increased permeability, which facilitates the penetration of the intima by atherogenic lipoproteins; increased adhesion, which facilitates migration of monocytes into the subendothelium; diminished vasodilation, which compromises hemodynamic control.

Plaque formation 1 — Fatty streak Figure 10 Monocytes penetrate the intima and are transformed into macrophages and eventually cholesterol-rich foam cells. These activated macrophages scavenge and ingest oxidized low-density lipoprotein (LDL) in the subendothelial space. The progressive accumulation of lipids (intra- and extracellular) forms the fatty streak.

Plaque formation 2 — Fibrous cap Figure 11 The growing fatty streak eventually forms the lipid core, which becomes isolated by the progressive formation of a fibrous cap. The fibrous cap contains collagen, proteoglycans and activated smooth muscle cells. The sturdier the cap, the less likelihood there is of plaque rupture.

Plaque formation 3 — Lipid core Figure 12 Further lipid accumulation in the lipid core results in cell death (apoptosis).

From plaque to thrombosis, key event: plaque rupture Figure 13 The key event in transformation of a stable plaque to an unstable plaque is rupture, which results in either partial or complete occlusive thrombosis.

Cardiopatia ischemica Carenza assoluta di ossigeno a livello del miocardio Angina pectoris Infarto del miocardio

Angina pectoris Temporanea carenza di ossigeno a livello del miocardio capace di determinare classica sintomatologia dolorosa No necrosi

Infarto del miocardio Prolungata carenza di ossigeno a livello del miocardio capace di determinare classica sintomatologia dolorosa in associazione a necrosi cellulare

TIA: attacco ischemico transitorio Ictus conclamato Ictus cerebri e TIA TIA: attacco ischemico transitorio Ictus conclamato potenziale residua disabilità

Fattori di Rischio Cardiovascolare

Rischio Cardiovascolare Globale

Interazione tra i fattori di rischio MRFIT Kjelsberg MO et al Am J Clin Nutr 65 (Suppl 1); 191S, 1997

Ipertensione arteriosa Sistolica ≥ 140 Diastolica ≥ 90 Sistolica: forza con la quale il ventricolo sx immette il sangue nel grande circolo Diastolica: tensione di riempimento del ventricolo sx

Ipertensione arteriosa 95% essenziale 5% nefrologica o endocrina Sintomi subdoli:cefalea, malessere, vertigini, epistassi

Ipertensione arteriosa Complicanze Aterosclerosi Ipertrofia del ventricolo sx Retinopatia ipertensiva Nefropatia

Adult Treatment Panel III (ATP III) Guidelines May 2001 National Cholesterol Education Program Adult Treatment Panel III (ATP III) Guidelines May 2001

Enfasi sulle ipercolesterolemie famigliari ATP I & ATP II MAJOR GOAL OF THERAPY LDL-CHOLESTEROL Enfasi sulle ipercolesterolemie famigliari

Focus on Multiple Risk Factors New Features of ATP III Focus on Multiple Risk Factors Framingham projections of 10-year CHD risk Identify certain patients with multiple risk factors for more intensive treatment Multiple metabolic risk factors (metabolic syndrome) Intensified therapeutic lifestyle changes Diabetes: CHD risk equivalent

Conclusione Modulazione dell’intervento

ATP III Lipid and Lipoprotein Classification (continued) Total Cholesterol (mg/dL) <200 Desirable 200–239 Borderline high 240 High

Three Categories of Risk that Modify LDL-Cholesterol Goals Risk Category CHD and CHD risk equivalents Multiple (2+) risk factors Zero to one risk factor LDL Goal (mg/dL) <100 <130 <160

ATP III Lipid and Lipoprotein Classification (continued) HDL Cholesterol (mg/dL) <40 Low 60 High

Specific Dyslipidemias: Elevated Triglycerides Classification of Serum Triglycerides Normal <150 mg/dL Borderline high 150–199 mg/dL High 200–499 mg/dL Very high 500 mg/dL

CHD Risk Equivalents Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) Diabetes Multiple risk factors that confer a 10-year risk for CHD >20%

Diabete e CVD 3 2 1 rischio relativo di mortalità CVD rischio relativo no DM no IMA no DM IMA DM no IMA DM IMA Mukamal KJ et al Diabetes Care 24; 1422, 2001

Life-Habit Risk Factors Obesity (BMI  30) Physical inactivity Atherogenic diet

Fattori di Rischio Cardiovascolare

Definizione di Sindrome Metabolica Non è univoca NCEP: ATP-III, 2001 1) Obesità addominale 102 cm uomo 88 cm donna 2) Trigliceridi > 150 mg/dl 3) HDL - col 40 mg/dl uomo 50 mg/dl donna 4) PA: > 130 mm Hg sistolica > 85 mm Hg diastolica 5) Glicemia a digiuno: >110 mg/dl