无症状人群心血管病风险的评估

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,2009,年中国卫生统计提要,心脑血管疾病是我国首位死亡原因,08,年我国疾病死亡病因,疾病死亡率构成比（,%,）,50,40,30,20,10,0,城市,心脏病,脑血管病,Risk factors for the development of atherosclerotic disease,Approximately 37% of American adults reported having 2 risk factors for CVD.,90% o f patients with coronary heart disease have at least 1 atherosclerotic risk factor.,Approximately half of all coronary deaths are not preceded by cardiac symptoms or diagnoses,A Report of the American College of Cardiology2010 ACCF/AHA Guideline,for Assessment of Cardiovascular Risk in Asymptomatic Adults,一级预防,是降低心脑血管疾病危害的根本措施,脑卒中发生率,冠心病发生率,冠心病死亡率,8389%,7885%,6573%,7076%,脑卒中死亡率,Lancet 2003, 362:271,改善高危因素显著降低了心脑血管事件的发生,我国人群心血管危险因素控制现况,高血压患者,1,8,亿人,吸烟者,3,5,亿人，被动吸烟者,5,4,亿人,血脂异常患者,1,6,亿人,糖尿病患者,4000,万人,肥胖患者,6000,万人，超重者,2,亿人,目前每年新增高血压或血脂异常人数,1000,万人,我国人群心血管危险因素控制不利,2002,年调查资料显示，全国血压控制率仅为,6,1,2006,年,:,血脂控制率仅为,50,，高危、极高危人群,仅为,49,和,38,2006,年糖尿病调查表明，糖尿病患者糖化血红蛋白,(HbAIc),达标,(6,5,),仅占,25,吸烟者中只有,26,的人希望戒烟，戒烟成功率仅,为,11,5,心血管疾病一级预防中国专家共识,危险因素评估方法,Framingham,SCORE,PROCAM (Men),Reynolds (Women),Reynolds (Men),中国缺血性心血管病危险评估模,型,(KNOW your risk,),心血管病的危险因素,传统的危险因素：,年龄、性别、种族、家族史、高胆固醇血症、,吸烟、糖尿病、高血压、腹型肥胖、缺乏运动、饮食缺少蔬菜水果、精神紧张,“新”的危险因素：,C,反应蛋白、载脂蛋白,a,、纤维蛋白原、,同型半胱氨酸、尿酸,Risk factors for the development of atherosclerotic disease,CVD was mentioned on the death certificates of 56% of,decedents in 2005.,It was listed as the underlying cause of death in 35.3% (864,480) of all deaths (2,448,017) in 2005 or 1 of every 2.8 deaths in the U.S. In every year since 1900 (except 1918), CVD accounted for more deaths than any other major cause of death in the United States ( 6).,It is estimated that if all forms of major CVD were eliminated, life expectancy would rise by almost 7 years,A Report of the American College of Cardiology2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults,Assessmentof Cardiovascular Risk,CLASS I,Global risk scores (such as the Framingham Risk Score )that use multiple traditional cardiovascular risk factors should be obtained for risk assessment in all asymptomatic adults without a clinical history of CHD.,These scores are useful for combining individual risk factor measurements into a single quantitative esti-,mate of risk that can be used to target preventive interventions .,(Level of Evidence: B ),Family History,CLASS I,Family history of atherothrombotic CVD should be obtained for cardiovascular risk assessment in all asymptomatic adults .,(Level of Evidence: B ),CLASS III: NO BENEFIT,Genotype testing for CHD risk assessment in asymptomatic adults is not recommended .,(,Level of Evidence: B,),A Report of the American College of Cardiology2010 ACCF/AHA Guideline,for Assessment of Cardiovascular Risk in Asymptomatic Adults,Other Circulating Blood Markers andAssociated Conditions,CLASS III:,Measurement of,natriuretic peptides,is not recommended for CHD risk assessment in asymptomatic adults . (Level of Evidence: B),CLASS IIa,In men 50 years of age or older or women 60 years of age or older with LDL cholesterol less than 130 mg/dL; not on lipid-lowering,hormone replacement, or immunosuppressant therapy; without clinical CHD, diabetes, chronic kidney disease, severe inflammatory conditions, or contraindications to statins,measurement of,CRP canbe useful,in the selection of patients for statin therapy . (Level of Evidence: B),Hemoglobin A1C (HbA1C),CLASS IIb,1. Measurement of hemoglobin A1C (HbA1C) may be reasonable for,cardiovascular risk assessment in asymptomatic adults without a,diagnosis of diabetes . ( Level of Evidence: B ),A Report of the American College of Cardiology2010 ACCF/AHA Guideline,for Assessment of Cardiovascular Risk in Asymptomatic Adults,Microalbuminuria,CLAS,S IIa,In asymptomatic adults,with hypertension or diabetes, urinalysis to detect microalbuminuria is reasonable for cardiovascular risk as-sessment . ( Level of Evidence: B ),CLASS IIb,In asymptomatic adults at intermediate risk,without hypertension or diabetes, urinalysis to detect microalbuminuria might be reasonable for cardiovascular risk assessment .,(Level of Evidence: B,Lp-PLA2,CLASS IIb,Lipoprotein-associated phospholipase A2 (Lp-PLA2) might be reasonable for cardiovascular risk assessment in intermediate-risk,asymptomatic adults .,( Level of Evidence: B ),ECG,CLASS IIa,A resting electrocardiogram (ECG) is reasonable for cardiovascular risk assessment in asymptomatic adults with hypertension or dia-betes . ( Level of Evidence: C ),CLASS IIb,A resting ECG may be considered for cardiovascular risk assessment in asymptomatic adults without hypertension or diabetes,(Level of Evidence: C ),Resting Echocardiography Transthoracic Echocardiography,CLASS IIb,Echocardiography to detect LVH may be considered for cardiovascular risk assessment in asymptomatic adults with hypertension,(Level of Evidence: B ),CLASS III:,Echocardiography is not recommended for cardiovascular risk assessment of CHD in asymptomatic adults without hypertension.,(Level of Evidence: C ),Carotid Intima-Media Thickness on Ultrasound,CLASS IIa,Measurement of carotid artery IMT is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk,Published recommendations on,required equipment, technical approach, and operator training and experience for performance,of the test must be carefully followed to achieve high-quality results . (Level of Evidence: B ),Carotid Intima-Media Thickness on Ultrasound,Pulse Wave Velocity and Other ArterialAbnormalities: Measures of Arterial Stiffness,CLASS III:,Measures of arterial stiffness outside of research settings are not recommended forcardiovascular risk assessment in asymptomatic adults.,(Level of Evidence: C ),Recommendation for Measurement ofAnkle-Brachial Index,CLASS IIa,Measurement of ABI is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk .,(,Level of Evidence: B,),Recommendation for ExerciseElectrocardiography,CLASS IIb,An exercise ECG may be considered for cardiovascular risk assessment in intermediate-risk asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), particularly when attention is paid to non-ECG markers such as exercise capacity .,(Level of Evidence: B ),Duke Treadmill Score (DTS),The angina index had avalue of 0 if no angina occurred during exercise, 1 if nontest-limiting angina occurred, and 2 if test-limiting angina occurred. A score of 5 or greater was considered low risk; between 5 and -10, intermediate risk; and less than -10,high risk.,ELECTROCARDIOGRAPHIC STRESS TESTING FOR SILENT MYOCARDIAL ISCHEMIA,ECG stress testing has an approximate 50% sensitivity and 80% specificity .,The positive predictive value for detecting CAD using coronary angiography as the gold standard ranges between 60% and 94% and was higher in men than women .,Recommendations for exercise stress testing for risk assessment do not appear to be different in patients with diabetes and patients without diabetes.,Recommendation for Stress Echocardiography,CLASS III: NO BENEFIT,Stress echocardiography is not indicated for cardiovascular risk assessment,in low- or intermediate-risk asymptomatic adults.,(Exercise or pharmacologic stress echocardiography is primarily used for its role in advanced cardiac evaluation of symptoms suspecte of representing CHD and/or estimation of prognosis in patients with,known coronary artery disease or the assessment of patients with known or suspected valvular heart disease.),(Level of Evidence: C ),Myocardial Perfusion Imaging,CLASS IIb,Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or asymptomatic adults with a strong family history of CHD or when previous risk assessment testing suggests high risk of CHD, such as a CAC score of 400 or greater. (Level of Evidence: C ),Computed Tomography for Coronary Calcium,CLASS IIa,Measurement of CAC is reasonable for cardiovascular risk assess-ment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk) . (Level of Evidence: B ),CLASS IIb,Measurement of CAC may be reasonable for cardiovascular risk,Assessment in persons at low to intermediate risk (6% to 10% 10-year risk) . (Level of Evidence: B ),CLASS III: NO BENEFIT,Persons at low risk ( 6% 10-year risk) should not undergo CAC,measurement for cardiovascular risk assessment .,(Level of Evidence: B ),Coronary Computed Tomography Angiography,CLASS III: NO BENEFIT,Coronary computed tomography angiography is not recommended for cardiovascular risk assessment in asymptomatic adults .,(Level of Evidence: C ),Magnetic Resonance Imaging of Plaque,CLASS III:,MRI for detection of vascular plaque is not recommended for cardiovascular risk assessment in asymptomatic adults.,(Level of Evidence: C ),缺血性心血管疾病,(ICVD)10,年发病危险度评估表,(,男,),缺血性心血管疾病,(ICVD)10,年发病危险度评估表,(,女,),强调重视心血管疾病危险评估,40,岁以上个体应至少每,5,年进行一次危险评估,有,2,个以上危险因素的个体，应每年进行一次危险评估。,对绝对风险低的个体推荐使用“心血管疾病相对危险评估量表”,一级预防,改善生活方式,降压,调脂,抗栓治疗,降糖,有效的心血管事件一级预防措施,规律运动,改善生活方式,合理膳食,戒烟,控制体重,保持心理平衡,女性卒中风险下降,55,男性冠心病风险下降,27,生活方式干预,1.Arch Intern Med. 2006;166:1403-1409,2. Circulation,2006;114;160-167,改善生活方式,平衡膳食：多项研究证实，饮食中降低盐摄人，减少饱和脂肪，增加蔬菜水果、海鱼和谷类纤维素，可显著降低已知心血管危险因素的发病率。,戒烟：吸烟是心血管疾病的重要致病因素，原则上也是惟一能够完全控制的致病因素。,规律运动：主要通过 降低血压、控制血糖和体重以及改善心血管功能实现。美国疾病控制和预防中心以及国家健康学院公布的运动建议中推荐：每周至少,5 d,、每天进行,30 min,以上中等强度的有氧运动。,控制体重：控制肥胖症是减少慢性病发病率和病死率的一个关键因素，,Calle,对,100,万例健康人随访,16,年显示，超重使心血管病死亡增加,1,5,倍，肥胖使心血管病死亡增加,2,3,倍。,心理平衡：,血糖控制,空腹血糖检查,OGTT,筛查,积极干预,IGT,HbA1c,每降低,1,心梗发生率下降,14,卒中发生率下降,12,BMJ,2000;321:405-412,降压治疗,收缩压每下降,10mmHg,治疗目标值,冠心病风险下降,20,1,卒中死亡风险下降,30,2,1.European Heart Journal,(2002),23,286293,2.Lancet,; 360 : 1903-12.,普通高血压：,140/90mmHg,老年人的收缩压降至,150mmHg,以下，,有糖尿病或肾病的高血压：,130/80mmHg,调脂治疗,低危：,TC,6.22mmol/L,，,LDL,4.14mmol/L,中危：,TC,5.18mmol/L,，,LDL,3.37mmol/L,高危：,TC,4.14mmol/L,，,LDL,2.60mmol/L,冠心病发生风险下降,20,LDL-C,每降低,1mmol/L,卒中发生风险下降,20,Lancet. 2005 ;366(9493):1267-78.,治疗目标值,特殊人群：一级预防不容忽视的角落,糖尿病,无症状外周动脉狭窄,肾功能损害,肾脏疾病,高龄老年人,女性,儿童,39,谢谢！,