Document 6406

Heart Attack :
Epidemiology and Risk Factors
Epidemiology ~ u n l r r a a u
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Epidemiology n e ~ ~ a ~ n a a c i l i ~ a c i l H ' a ~ ~
d o coronary mtery ii atherosclerasis
ui&
<ihud?u~~~s:ijoinn
a n m a pain 61du
typical angina s m u i n h r u i ~ i o u r r90 uo.r<d?u
$?u acute myocardial infarction ii6n>ini>
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beta-blockers. aspirin.
ua'?Em>inistAu-Zialu
I>urrunnrr~arlb'L6omn'i~~ua:
~'"RuLQuI~~~~I~
thrombolytic
therapy
d ~ ~ ~ f ~ ~(<70
f inl ) $dii ~myocardial
u
infarction
i ~ u a : 30 n o ~ ~ 1 h ~ d ~ i i i ~ ~ 7 UR:~R'%UI
~tlmul~)
t i t u ~ 4 ~ u m u a r i j m n n(mip
~ u ~ ~ckss I) u:
mutu 6 d?~u.rucimlniioini7q:a~~m7ld~~d
% ~ " m u 1 u 6 & h & ~ i n i i f n m n t o u acute
B n l u 35 5iLHkqinfim infarction A ~ ~ A ~ ~ . ~ < Q
-
infarction, low LVEF (4.40). mngestive heart
LUBQJOUA:9.0 [NNT 441)
d ~ : T u n M o u n i ~ i n w ~ : ~ ~7~ ~uin1R'ium<i
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lvdw 7-12 d?l~qUCi: 13-24 d?~lI4&77d~V4:RA
~NL*&UR:
12.6 ( W ~ ~ D U A12.7
:
LUBQ~QUA:11.1
failure, residual ischemia left ventricular hyper-
(NNT
nophy, axrhythmas. aging (>70 years), diabetes
~DUR:
meUitus. dyslipidemia female gender
~ ~ r n r i u u ~ o ~ i t f i stroke
l i i m ~U~?.IL?AI
35
myocardd
ihTuu8iKdiiuamonn~fin
infarction
recwrent mymardial infarctim ~ i l ~ d k m s m death
la
~ ~ f u ~ : u : ~ u u ~ : ~ :d~:nouWR'?u"
u:u~~~u
UR:
large
hyper-
20 ( m i o u ~ :11.3
-
66)) u ~ r i o u a r4.7 ( q i n i o u ~ : 10.5
(NW
10.0
-
mfii im
200)) RIuA'IRIU
LU~Q
1unt-u:
tension n i ~ 5 n ~ 7i ~ dcijqr;iidil-;9'~lis~Y77na~
w
LIT-mu 4
dovascular mo~ldity ua: m o M t y 16 %mu
n n m u q u u a ~ n ~ " u ~ u a l u ' ~ & nil lR.N.
' 1966
&n5&ujlom:a~
morbidity ua: m o d t y
so.r{hu infarction 1"$i
?~fiorn?lH' long term oral
tituilu7niiinn~H'hta-blocker u k infarction u h
anticoagulant
domiinnhrnd&nmu&mrii
infarction
aiunaafi total
mortality (four: 7.9 vs i o u ~ :10.0 (number needed
to treat [NNTI
- 48)). sudden death
(ioua: 3.6
LA:
~ l i f i i Y u n i ~ % ruonqin
n~
recurrent
$JQI~RR
stroke
~
u
~
D
~
myocardial
~
~
A
n17%
R ~
anIjarrhythmcs, calcium channel blockers b n u
i i l i d ~ : l u a r i ' ~n n r i i
coronary angioplasty l u
?hi
vs iouar 5.2 (NNT-63)). nonfatal re-infarction
$?u
(ioua: 5.7 vs i o u ~ :7.5 (NNT = 56))" (NNT AD
pain
~ m ~ u ~ ~ d s i o ~ ~ ~ ? u n i 7 i n wmorbidity
i ~ r r ' o ut ~i ~u )~
QI~IYUR:LU
mortality IR'H~'.IAU)
& ~ ~ t w i i u n ~ u ~ ul uui l ~ t w
Aumuara'?udu patency rate
n.n. 1974 i i ' u i i n n ~ n w i k t h : h ~ h antiplatelets
o~
n i 7 l u 5 ~ 1 G n i - 1thrombolytic therapy udBmini7
&[email protected]
aspm (75-325 m.) fu!$hu
myocar-
acute myocardial infarction
*
M
anginal
single ua: multivessel diseases szan
exercise tolerance in'Gniinn?nwi
TIO.~URQAL~DR~
lu5u~i~~::ni~~~u~5mlub~nuiuialu'um
dial infardon dolcu&4 infarction 3:aA myocar-
n i ~ mlate elective angioplasty ~u{1I?udEqiioini7
dial infarction stroke &a: vascular death u & n n
r5uHti7~nuAj~iiminfarction W u ~ l u n i ~ ~ ~ O I A ~ i
~ r n u i ? o u ' i ~ ~ o u d ~ m d . ~ d ~ uQUA:
~ ~ u14.7
a~qin
n n d u infarction Jimiolridi left ventricular ejec-
a a u B o i o u ~ : 11.4 (NNT = 31).
nonfatal infarc-
tion fraction tud?q7:u:~?ai3 d o u m m i i u n i m i
MNT = 72).
angioplasty n i u h 18-48 d ? h n h rnfaarcti~n~~
tion q i n <QUA: 4.2 LUBQ
AR
~ O U A : 2.8
RR
all cause mortality nm'our: 9.5 n i i o i o u r : 8.0
(NNT
-
67) uornin6 antiplatelets
&RA
vascular
occlusion rates no4 coronary artery w n i o u a r
27.3
L U ~ D ~ D U A 18.8
:
arteries du 7 (NNT
-
(NNT
-
12) &a: peripheral
11P2' d o u l u n.fl. 1980
De Wood n v j i thrombosis n ' i t H ' ~ E ~ n n q ~ 6 u t u
U A Q R L ~ ~ D Racute
~U
myocardial infarctionn 5uiin-n
~do~rliuu~tuuni~inwiAuui6uni~n'i
coronary
artery bypass graft f u [ I h u coronary artery disease
~ : ~ R ' d ~ : l u a u l u n i ~ ~ ~ a i n i ~ ~ 5 ~~ uI U~ .L i Eo nR
infarction ~ i u a : n ~ ~ m i u ~ i j o ~ ~ u u ~ ~ u u n i r n
huuilun-lciid~d?uii left main coronary artery
Su > ioua:
50-60 &IW
ii three-vessel disease
i ? u ~ u i i n i ~ a c l a ~ n o . r n i ~ n ' ileft
~ i u nventricle.
~~
CI intravenous thrombolytic therapy m l f i u n i ~
(d?udi! two-vessel disease ~ n u d u d . r ~ ~ u ~ i ) u n i - d
inwi
>ioua: 75 no4 left anterior descending a r t e g
acute myocardial infarction dyinpi7lu
7 l ~ f i ccontra-indication
~ u n i Y l ~ u(d7:mt-u
6
actors
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ilss"udw 6o h"diiuarh~kknirnnju
i h j , d w h 7 am mrheart disease ti
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nuu1&lurnmmilmiiu
na'ln~uu~uumfuvn?lj~&r h n n atherosdemnio'ty
roac plaque rilunuij~nindhR'~~nnur~uolu
d>mnsuwrirnii rdu aiakrZuEqGnn
{ ~ I ~ ? U $ L ~ U ~ ~ ? R ~ ~ ~ ~ > R H A D R L a
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n s i r ' d u d w a m n i > l i i m atheroderasis d u
onrii~wnmiuumndwrm~a'o~ii
[email protected]
il<udusdhKqno.r cardiovascular diseases TRU
ii~.rnunmaiuua:Impaired glucose tolerance test
ramnohh coronary heart disease, atherothromuinrrj7r~middmiru~mhz~nfl~Zv?n'ubotic stroke H3o peripheral Mscular diseases
Risk
2
A
~ R ? ~ ~ ~ R ? I U L < I ~ ~ & ~ ~ ~S P
~ hUR W
L ~ W L H ~ W 5&bY0+
fibrinogen
r & l u d % h d r o . r " diuannflnmn~
&ua:olau~wqjiimiu8~dfiurn>tiinheart attack
iBsnaiurdus~:r6u&riluni~~miu~iuauno~~~4u> m ~ % m a & ~ Y Vfibrinogen
jl
dii>:&@.rrmdu
ddii
i1~Lrdu~ddi~~~amu'sn~~~~~~
~ U ~ D U ~ I > L ~ ~ A ~ > R U R D A L Z ~ D A G ~ ~ ~ U R ~nab$
R U D I fibrinogen m l i l i i m atherosclerosis ua:
hliir~nsrhud atherosclerosis ro.nmao~r5io~rinu
thrombosis & C & ~ ~ A L W
r $ i h n bbfmogen ii
ua'a~~rii~ni~msi?u5on1~fiurnnno~
plaque RUI
U A ~ N ~ ~ U ~ A U
hemmtasis,
~ ~ U ~ ~ blood
~ O
theology,
mhuii thrombus formation qRfi E A acute
platelet aggregation Ua: endothelial function
obtmcfion l&umouni~5~~>n1mriiu'ijih4uiuldur~o~ d 4 ~ f i ~ ~ ~ ~ u i ? u n ' h ~ ~ ~ n 7 3 1 ~ 6
ddiK~uuu1A'~h
2 ntju" 6o
1.2 ModiTmble Physiological Risk Fac1. Atherogenic lisk factors
tors d>:nmAu
2. Thrombogenic lisk factors
Elevated LDL (low density lipoprotein)
and low HDL (high density lipoprotein)
1. Atherogenic Risk Factors
ZO~~=I<"L~UP~
&un'ud6u atherosclerotic vessels uu.fibr~u3 niu
i;o
1.1 Nonmdifiable Risk Factors dlrnou
ku
luJ~quiriimin3iurilu~uouiun'~l~uh
~rin:6~diimd~n~o~l~iiulihi~~~ul
atherosclerosis uar h e m attack
Hypertension
~dau~aiu<ul~Gm$~l~ii~:~J~~nfln
Age
~untjml~rain~oi~tiounjl
60 il mflniuii
atheroderotic events d>rul~RosMimosmfluQ9
n n u u m n m i ~ & r r i o u a ~ u i ~ ~45i niluclrqrwiniu
~i~
~unjud>zain>iu70 0 & 1 d ~ ~ ~ ~
uQ~oiquindoijouiinaiurdu~~~rr?lm~~nu~
k h 6 u6
0
sudden death ii9aiurrir)lounudnl"
~ ~ ~ ~ u L ~ w L ~ ~ u R W R ? ~ U ~ U
Diabetes Mellitus
u o n ~ i n l ~ n 1 m m w r ~ ~ u i l q 4 uath~du~
Genetic prediposition
erosclerosis uci? ujnuiiiiniar$du~aiu~du~n
Davldson3' ~hu.r7uuam~Anmo~uaiunn
coronary atherosclerosis uin6u6au~o hypenn-
anwilqa.xflA'aiiou 1n'uAo @iaiu~>uuo.r$aui
liimhn myocardial bfarcfion loynrdiimq6ounii
suhnemia & h u d l ~ ~ o ~ ~ h ~ f l ~ ~ n u
ua: low HDL
45 G ~ W ~ U ~ & ~ ~ R ~ > W ~ D R G D R H ~ ~ ~ ~
~ U ~ R 'nUn~n$nY8 n m ~ ~ n i ~ h u n m m i
dmlester01~
~uumurnr6&k~u~rir)lo~ntjuu~ivu~iivu~
uar
NIDDM n u i i ~ d a & ~ u Q ~ u a r n i u i i ~ m ~ i n i ~
obesity. hypertriglyceridemia
~ Y : ~ ~ N R ~ ~ L ~ ~ I ~ ~ ~ ~ ~ ' ~ ~ L ~~IH~U$?U
uLUIH?IU"
IDDM uh~151rdu.rdoaxormy events r6&urau
4 rmlurnmiu 8 [email protected]
1.3 Modifiable Behavioral Risk F a d o n
n l 5 ~ u ~ d
uonqinrituil77irdum atherosclerosis d
s17Riyu~~Caunujiiin&lk:6~1nCuHDL asw r6u
oiglyceride. LDL uc:l fibrinogen 5 s endothelial cell
dysfunclion platelets aggregation ~ i & unnn?u?u
Sedentary lifatyle
n~:u'~~~iin~n)iud~:u~nii~n?i
no.rni~~rioonrh&niuKuni~
riis athero~clerosis
u m i i n i ~ ~ n w u i n u i u d u ~ ~ ~dluriuinoqni~
ii~n~iu
hrirfimu&
rillni~r6&oMudwdiq 7 nm
atherosclerosis R'€IY:~u~%~u~uL~IR miu6uIais
n?iuhur6&uax:ciz1
HDL &olgtero~ asa.rY
luiwrn~~iiuhu
n i ~ o o n r i i ~ j n i ~ auomin
h~u~
~iunnasih"urduwoatherosclerosis ua:r6u HDL
carcholesterol uci?kiiuu?Tu'Ujionasdm~d~~y~rl
diovascular death ~R'n"~~unq'umui;ii?~mdni~
unr
mu6uhRm~.j[(iCIa1GG d~:nirni/~uqHiiiDIRnni~
l~uil?ViLh:UIN 1.7 rkmosnjun%eu L n n i ~ r i u
gimFi?uT~nnaosrPostr;~lqiin~iu8uriu~'I~um~.15~
ndu$xtn& myocardial Infarclionm nnoonrh&
R
J%
N
R
LIU
@
IU
~n~dqu~~~do~iiu~5un~un
~ I%
U ~~~uD W R R
(regress) coronary atherosclerosis
mn'liidmini~
riis corormy artery dsease L h r u l ~
lu{ihudii symptomatic mronary atherosclerosiss5
5 L~~IUA:~~IR sudden cardiac death m m i u " dlwk
2. Thrombogenic Risk Factors
idii coronary artery disease HSD myocardial infarcnu?uni~riis thrombus tu¶?lr?ain'ii
~mn~m
WDJ
i r plaque hduna'lndh6~ds:u'i1d
tion u h r i i ~ n q s ~ u n ? i ~ ~ d ~ ~ n ~ ~ n i ~ r i u rupture
~ u n ~ o n i ~infarction
~ i i n dlasa.r**' passive smok{nisriis heart attack tUd?sr?aiRjnii?iiilqjV
ncliuau'i.m'riotH'iis thrombus ~ i ~ u ~ s u u ~ 12 r i r
ers riiia?iurd~dq:L?Imcoronary events ~6uu'u1A?i9
rnrilk*
n $ P " Ao
n15&1qsi
2.1 Local vessel wall-related Factors
twrurd&biin~qnrjinniu?nrhathero2.1.1 Rheological Factors
genic risk factor umwuiin1~6~iina~nli~~iun'u
u j r ? ~ i i i i n n b u ~ n ?local
:
shear rate
~ ~ s @ & ~ c l : ~ o n ~ s i ~ n ? i ~iincnnjiu
~ u ~ : a ~ a uindiln~
~ ~ ~ 1 ~ platelets ~zauuarriisthrombus ~ I U ~ U
qin observahonal studies nVLmi~iu1ulT~ui~d
2.1.2 Degree of Plaque Damage
a A
h n a w i i m u k ~ ~ r i u n i ~ a s a m ~ COIO~~u%ni~
ujr7nhi damage 6wiisri8~expose tuowo
nary hem disease ~ ~ ~ u ~ ~ w I : ~ ~diq~ 7 1
~ i h~ intima
~ ~ il.rn~:&ua:dqr8julH'fis
u ~ ~ R ~ I u throm~ ~ ~
u d a a n o ~ n i ~ a n w ~ ~ 1 u t ~ u n ' u o u i u n ; ? l ~ r d o ~ bus
~ini~
n i ~ ~ l n w n ' t B C ~ ~ i i ~ i n ~ n r i i u ~ n o d q : ~ ~ ~ ~ a ~2.1.3
~ i i nResidual
i ~ ~ ~ Thrombus
~ Y I ~ Udsk M ~ Dprotective
factor 'dm atheroscle-
n h q l n n l~~ ~
~ I U ~ ~ ~ ~ U L ~ D A ~ ~
LBDR ujr7~hHtjino9 thrombus da8orjuia'q
rosis
~ I ~ & ~ ~ ~ W I U S I H ~ ~ ~ ' ~ V ~ U ~huurini~riisiur'l~Rbu~nu
U ~ ~ H ~ O ~ '
cholesterol ann
2.2 Systemic factors
iin~iukuKu8riunisriiRatherosclerosis TRU
9 q i n i i n i ~ r ~ & m o s q ~ ncoronary
i ~ n ~ ~heart disease ua: peripheral vasdular disease tunq'u
2.2.1 %&VOd
a
epinephrine L W M U L
~U~U
nnrii stress, circadian Mliation n j a n i ~ @ u y n ~
2.2.2 ~Km0~InUIU1ur~srn
Tsuram:~(ii~
d ~ : ~ i n ~ d i i r ~ ~ u i ~ ~ n ~ u cholesterol
6~67ua: lu
frsmi'u bpoprotein (a) ILp(a)l
~ i n i ~ ~ ~ ~ d ~ r ~ ~ ~ r i i ~ ~ r i u n ~ ~ 6 i i l J i u i ~ a i2.2.3
n 1 ~~ZR-U
n " ~Fibrinogen
~o9
nijsd-~nii~~'
ri&u
UI::
fador HI
-4
W
~ana?.rai~S~
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mdy. Strdre 1991;22 312-8.
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