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1、Integrating Aggressive CV Risk Management in Primary Care,High prevalence of multiple CV risk factors in US adults,CDC. MMWR. 2005;54:113-40.,Behavioral Risk Factor Surveillance System, 2003,2 of hypertension, hypercholesterolemia, diabetes, smoking, physical inactivity, obesity,40.0%46.2%,36.0%39.9
2、%,33.0%35.9%,27.0%32.9%,INTERHEART: Exponential rise in CV disease with added risk factors,Odds ratio for1st MI* (99% CI),64,512,16,1,2,256,128,32,8,4,Smk(1),DM(2),HTN(3),ApoB/A1 ratio (4),1+2+3,All 4,All 4+ Obes,All 4+ Ps,All 9 riskfactors,2.9,2.4,1.9,3.3,13.0,42.3,68.5,182.9,333.7,Yusuf S et al. L
3、ancet. 2004;364:937-52.,Smk = smoking; DM = diabetes; HTN = hypertension; Obes = obesity; Ps = psychosocial factors *Plotted on a doubling scale,3-fold,26-fold,INTERHEART: Any smoking increases CV risk,Teo KK et al. Lancet. 2006;368:647-58.,*vs never smoked,N = 27,098 from 52 countries,12,34,56,78,9
4、10,1112,1314,1516,1718,1920,Odds ratio for first MI*,Cigarettes smoked (n/day),Never,21,-0.75,1,2,4,8,Lifetime CVD risk estimate and risk factor burden,70,60,50,40,30,20,10,0,50,60,70,80,90,69,50,46,36,5,60,50,40,30,20,10,0,Men(n = 3564),Women (n = 4362),Adjusted cumulative incidence of CVD(%),50,60
5、,70,80,90,2 Major RFs,1 Major RF,1 Elevated RF,1 Not optimal RF,All optimal RFs,70,50,39,27,8,Attained age (years),Lloyd-Jones DM et al. Circulation. 2006;113:791-8.,2-fold in higher age group,Additive risk of age with hypertension + hypercholesterolemia,Wong ND et al. Am J Cardiol. 2006;98:204-8.,N
6、HANES 2001-2002; N = 2864,Clinical manifestations of obesity,Insulinresistance Glucotoxicity Lipotoxicity Adiponectin Leptin,Atherosclerosis,Courtesy of Selwyn AP, Weissman PN. 2006.,Type 2 diabetes and glycemic disorders FFAs Dyslipidemia Low HDL Small, dense LDL Hypertriglyceridemia Hypertension E
7、ndothelial dysfunction/inflammation (hsCRP) Impaired thrombolysisPAI-1,Metabolic consequences of visceral obesity,Visceral/abdominal obesity Correlates more strongly with insulin resistance than lower body obesity Is associated with plasma levels of fatty acids and accompanying TG Insulin resistance
8、 Altered hepatic fat accumulation and metabolism Dyslipidemia Proinflammatory adipokines (insulin resistance, risk for CV disease) Visceral fat correlates more strongly with insulin resistance than subcutaneous fat,Grundy SM et al. Circulation. 2005;112:2735-52. Desprs J-P et al. BMJ. 2001;322:716-2
9、0.,Visceral obesity in CV risk,CT scans from men matched for BMI and total body fat White = visceral fat area (VFA); black = subcutaneous fat,Desprs J-P. Eur Heart J Suppl. 2006;8(suppl B):B4-12.,Subcutaneous obesity Fat mass: 19.8 kg VFA: 96 cm2,Visceral obesity Fat mass: 19.8 kg VFA: 155 cm2,Visce
10、ral obesitydrives CV risk progression independent of BMI,Measurement of waist circumference may offer a more useful surrogate marker of visceral adiposity than waist-hip ratio,Optimal marker(s) for visceral adiposity,Desprs JP et al. BMJ. 2001;322:716-720.,Measuring waist circumference,Iliac crest,C
11、DC Projections 2005 to 2050: Diabetes focus,Narayan KMV et al. Diabetes Care. 2006;29:2114-6.,*Revised projection “appears more alarming than previously estimated”,32.1 million new diabetes patients by 2050*,174%,220%,470%,423%,606% in blacks 75 yr,2050,2005,Individuals with diabetes (millions),Diab
12、etes2005-2050 (%),Multiple risk factors: Undertreated and poorly controlled,Wong ND et al. Am J Cardiol. 2006;98:204-8.,NHANES 2001-2002; n = 638 with hypertension and hypercholesterolemia,Sudden cardiac death: Too often the first sign of CV disease,Fox CS et al. Circulation. 2004;110:522-7.,50% of
13、sudden cardiac deaths occur in persons with no CV disease history,Call to action,Identify all risk factors,Base treatment on global risk assessment,Treat multiple risk factors aggressively,CV events,ABCs of multiple risk factor management,Platelet activationand aggregation,Hypertension,Hyperglycemia
14、/ Insulin resistance,Dyslipidemia,Adapted from Cohen JD. Lancet. 2001;357:972-3. Beckman JA et al. JAMA. 2002;287:2570-81.,AHA diet and lifestyle recommendations,Healthy diet Fruits, vegetables, legumes, whole grains, non-fat/low-fat dairy, fish, poultry, limited alcohol intake Physical activity 30
15、min on most days No smoking Avoid use of and exposure to tobacco products,Lichtenstein AH et al. Circulation. 2006;114:82-96.,CV risk,Weight loss improves CV risk factors,Sjstrm L et al. N Engl J Med. 2004;351:2683-93.,Conventional treatment (n = 1660),Gastric surgery (n = 1845),*At 2 years,N = 4047
16、 with obesity,3-Week diet + exercise regimen yields favorable metabolic changes,*P 0.01 P 0.05,Roberts CK. et al. J Appl Physiol. 2006;100:1657-65.,U/mL,N = 31 overweight/obese men; weight 8.4 lbs,Baseline,Follow-up,Physical activity reduces CV and all-cause mortality,Fang J et al. Am J Hypertens. 2005;18:751-8.,N = 9791; moderate physical activity vs little or no physical activity,0.75 (0.531.05),0.76 (
