心血管风险(一级预防)

IntegratingAggressiveCVRiskManagementinPrimaryCareHighprevalenceofmultipleCVriskfactorsinUSadultsCDC.MMWR.2005;54:113-40.BehavioralRiskFactorSurveillanceSystem,2003≥2ofhypertension,hypercholesterolemia,diabetes,smoking,physicalinactivity,obesity40.0%–46.2%36.0%–39.9%33.0%–35.9%27.0%–32.9%INTERHEART:ExponentialriseinCVdiseasewithaddedriskfactorsOddsratiofor1stMI*(99%CI)6451216122561283284Smk(1)DM(2)HTN(3)ApoB/A1ratio(4)1+2+3All4All4+ObesAll4+PsAll9riskfactors2.92.41.93.313.042.368.5182.9333.7YusufSetal.Lancet.2004;364:937-52.Smk=smoking;DM=diabetes;HTN=hypertension;Obes=obesity;Ps=psychosocialfactors*Plottedonadoublingscale3-fold26-foldINTERHEART:AnysmokingincreasesCVriskTeoKKetal.Lancet.2006;368:647-58.*vsneversmokedN=27,098from52countries1–23–45–67–89–1011–1213–1415–1617–1819–20OddsratioforfirstMI*Cigarettessmoked(n/day)Never≥21-0.751248LifetimeCVDriskestimateandriskfactorburden70605040302010050607080906950463656050403020100Men(n=3564)Women(n=4362)AdjustedcumulativeincidenceofCVD(%)5060708090≥2MajorRFs1MajorRF≥1ElevatedRF≥1NotoptimalRFAlloptimalRFs705039278Attainedage(years)Lloyd-JonesDMetal.Circulation.2006;113:791-8.01020304050607020-2930-3940-4950-5960-6970-79≥80Age(years)Prevalence(%)MenWomen2-foldinhigheragegroupAdditiveriskofagewithhypertension+hypercholesterolemiaWongNDetal.AmJCardiol.2006;98:204-8.NHANES2001-2002;N=286426.552.743.121.4ClinicalmanifestationsofobesityInsulinresistanceGlucotoxicityLipotoxicityAdiponectinLeptinAtherosclerosisCourtesyofSelwynAP,WeissmanPN.2006.Type2diabetesandglycemicdisordersFFAsDyslipidemia•LowHDL•Small,denseLDL•HypertriglyceridemiaHypertensionEndothelialdysfunction/inflammation(hsCRP)ImpairedthrombolysisPAI-1Metabolicconsequencesofvisceralobesity•Visceral/abdominalobesityCorrelatesmorestronglywithinsulinresistancethanlowerbodyobesityIsassociatedwithplasmalevelsoffattyacidsandaccompanyingTGInsulinresistanceAlteredhepaticfataccumulationandmetabolismDyslipidemiaProinflammatoryadipokines(insulinresistance,riskforCVdisease)•VisceralfatcorrelatesmorestronglywithinsulinresistancethansubcutaneousfatGrundySMetal.Circulation.2005;112:2735-52.DesprésJ-Petal.BMJ.2001;322:716-20.VisceralobesityinCVriskCTscansfrommenmatchedforBMIandtotalbodyfatWhite=visceralfatarea(VFA);black=subcutaneousfatDesprésJ-P.EurHeartJSuppl.2006;8(supplB):B4-12.SubcutaneousobesityFatmass:19.8kgVFA:96cm2VisceralobesityFatmass:19.8kgVFA:155cm2VisceralobesitydrivesCVriskprogressionindependentofBMIMeasurementofwaistcircumferencemayofferamoreusefulsurrogatemarkerofvisceraladipositythanwaist-hipratioOptimalmarker(s)forvisceraladiposityDesprésJPetal.BMJ.2001;322:716-720.MeasuringwaistcircumferenceNHLBI.–2005to2050:Diabetesfocus2084811130200400600BlacksHispanicsWhitesNarayanKMVetal.DiabetesCare.2006;29:2114-6.*Revisedprojection“appearsmorealarmingthanpreviouslyestimated”0102030MenWomenWomen≥75yrMen≥75yr32.1millionnewdiabetespatientsby2050*174%220%470%423%606%inblacks≥75yr20502005Individualswithdiabetes(millions)Diabetes2005-2050(%)Multipleriskfactors:Undertreatedandpoorlycontrolled72.870.527.229.511.76.9020406080MenWomenPatients(%)UntreatedTreatedTreatedandcontrolledWongNDetal.AmJCardiol.2006;98:204-8.NHANES2001-2002;n=638withhypertensionandhypercholesterolemiaSuddencardiacdeath:ToooftenthefirstsignofCVdisease500204060NoCVdiseasehistorySuddendeath(%)FoxCSetal.Circulation.2004;110:522-7.50%ofsuddencardiacdeathsoccurinpersonswithnoCVdiseasehistoryCalltoactionIdentifyallriskfactorsBasetreatmentonglobalriskassessmentTreatmultipleriskfactorsaggressivelyCVeventsABCsofmultipleriskfactormanagementAAspirinACEinhibitionA1CcontrolBBPcontrol-blockadeCCholesterolmanagementControlweightDDietDon’tsmokeEExercisePlateletactivationandaggregationHypertensionHyperglycemia/InsulinresistanceDyslipidemiaAdaptedfromCohenJD.Lancet.2001;357:972-3.BeckmanJAetal.JAMA.2002;287:2570-81.AHAdietandlifestylerecommendations•Healthydiet–Fruits,vegetables,legumes,wholegrains,non-fat/low-fatdairy,fish,poultry,limitedalcoholintake•Physicalactivity–≥30minonmostdays•Nosmoking–AvoiduseofandexposuretotobaccoproductsLichtensteinAHetal.Circulation.2006;114:82-96.CVriskWeightlossimprovesCVriskfactors-25-20-15-10-50510152025WeightSBPDBPHDL-CFPGChangefrombaseline*(%)SjöströmLetal.NEnglJMed.2004;351:2683-93.Conventionaltreatment(n=1660)Gastricsurgery(n=1845)*At2yearsN=4047withobesity3-Weekdiet+exerciseregimenyieldsfavorablemetabolicchanges**†**050100150200250Total-CLDL-CHDL-CTGSerumglucosemg/dL*P0.01†P0.05RobertsCK.etal.JApplPhysiol.2006;100:1657-65.*05101520253035InsulinμU/mLN=31overweight/obesemen;weight8.4lbsBaselineFollow-upPhysicalactivityreducesCVandall-causemortalityFangJetal.AmJHypertens.2005;18:751-8.N=9791;moderatephysicalactivityvslittleornophysicalactivity0.75(0.53–1.05)0.76(0.39–1.49)0.79(0.65–0.97)All-causedeathCVdeathAll-causedeathPrehypertensionCVdeathHypertensionHazardratio1.51.00.5NormalBP02.0All-causedeathCVdeath0.79(0.58–1.09)0.88(0.80–0.98)0.84(0.73–0.97)AdjustedHR(95%CI)