ATEROGENEZA

Intima
Medie
Adventice
Functiile endoteliului
 licati
• Factori infectiosi:
 Virusuri

 Bacterii

 Chlamydii

• Factori imunologici

• Factori genetici
si CMN.
1.
 A
Prima decada

T
S
R

Decada a III-a
A
V

Decada a IV-a
 Patrunderea subintimala a
lipoproteinelor aterogene
Reteaua
VLDL matricii
extracelulare

LDL

Fibrile de
colagen

Frank JF, Fogelman AM. J Lipid Res 1989;30(7):967-978.

:
aspect macroscopic aspect microscopic
 Ateroscleroza debuteaza precoce
Diagnostic prin ecografie intracoronara pe grefoane cardiace la transplant

100%

80% 70%
aterosclerozei (%)
Prevalenta

60% 47%

40%
22%

20%

0%
< 25 ani 25-35 ani >35

Nissen S. Am J Cardiol 2001:87(suppl):15A-20A.

 Lumen

Capison
fibros
Miez lipidic
Glagov et al. NEJM 1987;316:1371-5.
 Lumen cu
tromb
Cap fibros
ulcerat
Miez lipidic
Stary HC et al. Circulation 1995;92:1355-74.
 1

National Cholesterol Education Program. Adult Treatment Panel III. JAMA 2001;285:2486-97.
Fosfolipide

Trigliceride

Colesterol liber
 Lipoproteina Densitate Lipidul majoritar Apo-lipoproteina Mobilitate
(g/ml) majoritara electroforetica
Chilomicroni <0.95 Trigliceride B48 Origine
alimentare

VLDL <1.006 Trigliceride endogene B100 Pre-β

IDL 1.006 - 1.019 Esteri colesterol, TG B100, E Lent pre-β

LDL 1.019-
1.063
Esteri
colesterol
B100 β

HDL 1.063-
1.210
Esteri
colesterol,
A I, A II α

fosfolipide
Lp(a) 1.055 - 1.085 Esteri colesterol B100, (a) Lent pre-β
-
Metabolice Diabetul zaharat
Lipodistrofiile Glicogenozele

Stil de viata Sedentarismul Dieta bogata in lipide saturate

Obezitatea Abuz de alcool

Medicamentoase Cortizonice Tiazide

Estrogeni Beta-blocante
Testosteron ciclosporina
Anti-retrovirale

Renale Insuficienta renala cronica

Glomerulonefrita

Hepatice Ciroza hepatica

Hormonale Estrogeni progesteron

Hipotiroidia Hipercorticism
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.
 97
100 91 Medici nefumători
94 81 Medici fumători
80
81
fiecare vârstă (%)
Supravieţuirea la

59
60 59

10 ani
40
24
20 26
2
4
0

40 50 60 70 80 90 100
Vârsta (ani)
Doll R et al. BMJ 2004;328:1519–27.
 Miez lipidic
Miez lipidic

R
Davies MJ et al. Circulation 1996;94:2013-20.
 placii vulnerabile

Arbustini E et al. Heart 1999;82:269.

IVA
 Medicatia hipolipemianta

National Cholesterol Education Program. Adult Treatment Panel III. JAMA 2001;285:2486-97.
CARACTERISTICELE CLASELOR
TERAPEUTICE HIPOLIPEMIANTE

clasa ↓ LDL ↓ TG ↑ HDL

STATINE 18 – 55% 7 – 30% 5 – 15%

FIBRATI 5 – 20% 20 – 50% 10 – 20%

RASINI 15 – 30% - 3 – 5%

ACID
5 – 25% 20 – 50% 15 – 35%
NICOTINIC
NCEP Adult Treatment Panel III. JAMA. 2001;285:2486-2497.
 Factorii clinici ce influenteaza scopurile
medicatiei hipolipemiante

National Cholesterol Education Program. Adult Treatment Panel III. JAMA 2001;285:2486-97.
 Scopul valorilor LDL colesterolului in
functie de profilul de risc clinic

Grundy SM et al. NCEP ATP III Report. Circulation 2004;110:227-39.

CTT Collaborators. Lancet 2005, 366:1267-78.
 ↓ RR = 30%

↓ LDL-C cu 30 mg/dl

Grundy SM et al. Circulation 2004;110:227-239

Obiectivele de tratament nu sunt atinse,
indeosebi de pacientii cu risc crescut
100%

80% 70%

60%
40% 39%
40%
18%
20%

0%
Boala
Risc redus Risc inalt Intreg lotul
coronara
n= 861 1,924 1,352 4,137