Definizione di Igiene e principi di Epidemiologia 2) 23/10/07

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1 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

2 CORONARY ARTERY DISEASE MORTALITY
Figure 1: Time trends in mortality from cardiovascular disease in selected countries , men (left) and women (right), aged years. Abbreviations: Rus = Russia, Hun = Hungary, Cze = Czechoslovakia (after , 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: )

3 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.

4 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.

5 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.

6 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.

7 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.

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

9 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.

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

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

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

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

14 Fattori di Rischio Cardiovascolare

15 Rischio Cardiovascolare Globale

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

17 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

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

19 Ipertensione arteriosa
Complicanze Aterosclerosi Ipertrofia del ventricolo sx Retinopatia ipertensiva Nefropatia

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

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

22 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

23 Conclusione Modulazione dell’intervento

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

25 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

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

27 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

28 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%

29 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

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

33 Fattori di Rischio Cardiovascolare

34 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