Propuesta de Modelo para la creación de Centros de Atención en Riesgo Cardio Vascualr

1. Centros de Evaluación/Tratamiento de Riesgo
Cardiovascular
Unidades de Detección Temprana de Riesgo Cardio-Vascular
Rev. 5 May 2012

2. Objetivo
2
“Proveer de tecnología diagnóstica de última
generación, a unidades especializado en
Medicina Preventiva”

3. Principales Causa de Mortalidad (Nacional)
Orden Causas CIE-10 Defunciones
Tasa
(1)
%
1
Enfermedades del corazón I00-I51 (excepto I46 paro
cardíaco sólo para
mortalidad) 92,679 86.9 17.2
- Enfermedades isquémicas del corazón I20-I25 59,801 56.1 11.1
2 Diabetes mellitus E10-E14 75,637 70.9 14.0
3 Tumores malignos C00-C97 67,048 62.9 12.4
4 Accidentes V01-X59, Y40-Y86 38,875 36.4 7.2
5 Enfermedades del hígado K70-K76 31,528 29.6 5.8
- Enfermedad alcohólica del hígado K70 13,361 12.5 2.5
6 Enfermedades cerebrovasculares I60-I69 30,246 28.4 5.6
7
Enfermedades pulmonares obstructivas crónicas, excepto
bronquitis, bronquiectasia, enfisema y asma J44 16,540 15.5 3.1
8 Ciertas afecciones originadas en el período perinatal A33, P00-P96 14,768 13.8 2.7
- Hipoxia intrauterina, asfixia y otros trastornos
respiratorios originados en el período perinatal P20-P28 8,172 7.7 1.5
9 Agresiones (homicidios) X85-Y09 14,006 13.1 2.6
10 Neumonía e influenza J09-J18 13,456 12.6 2.5
Paro cardíaco
Síntomas signos y hallazgos anormales clínicos y de
laboratorio no clasificados en otra parte R00-R99 521 26.7 1.8
(1) Tasa por 100,000 nacimientos estimados de CONAPO.
Fuente:INEGI/Secretaría de Salud.DGIS, 2008. Elaborado a partir de base de datos de
defunciones 2008 y CONAPO, 2006. Proyecciones de Población de México 2005-2050.

4. Antecedentes
Las enfermedades del corazón constituyen la
primera causa de muerte en todo el mundo.
Y la primera en Mexico
Fuente: ENSALUD 2006
4

5. Antecedentes (cont)
• Según la Secretaría de la Salud, en México esta patología produce,
por sí sola, más muertes que la suma de los decesos producidos por
los tumores, las enfermedades transmisibles, los accidentes, y los
asesinatos.
• A diferencia de otras enfermedades, que son incurables, las
enfermedades cardiovasculares NO son incurables sino que, si
son tratadas a tiempo, ni siquiera dejan secuelas en el paciente.
5

6. Que pasa en el Mundo
6

7. Ahora bien, si el síntoma es evidente (dolor
precordial) y la enfermedad curable...por qué
es la causa de muerte #1 en el mundo?

8. Principales Causas (según encuesta a pacientes y familiares)
• FALTA DE CONCIENTIZACIÓN DE LOS CIUDADANOS
• REQUIERE DE MEDICOS ESPECIALISTAS
• FALTA DE TECNOLOGÍA PARA UN INMEDIATO DIAGNÓSTICO
CARDIOLÓGICO
8

9. Retos existentes
• Falta de conciencia PREVENTIVA.
• Infraestructura de salud dependiente de medicina especializada.
• Serias limitaciones en el número de doctores y de personal médico.
“La NO ACCION simplemente empeora el problema”
9

10. QUE PROPONEMOS

11. Plan de Prevención CON TECNOLOGIA!!!
• En el primer nivel se contaría con una detección muy temprana del
riesgo cardio-vascular.
• Esta tecnología es altamente sensible y no requiere de medico
especialista.
• Requiere muy poco tiempo para su realización y el resultado es
individualizado al paciente.
11

12. Equipamiento de Unidades Médicas
• Se pretende dotar de Equipo de una unidad de Ultrasonido
Vascular.
• Esta unidad portátil de bajo costo y operada con baterías podrá ser
utilizada como herramienta de discriminación en pacientes.
• Contara con programas dedicados que determinaran la edad
vascular del paciente, basado en la elasticidad y grosor de la zona
vascular periférica.
• Este estudio no invasivo que se puede llevar a cabo en minutos, por
personal NO-especializado y entrenado.
12

13. Unidades de Ultrasonido Vascular MYLAB ONE
13
• Sistema de Ultrasonido
Vascular dedicado.
• Operación a corriente y
batería recargable.
• Pantalla a color LCD de 12”
sensible al tacto.
• Almacenamiento en disco
duro interno y en dispositivos
USB.
• Comunicación inalámbrica
WiFi.
• Compatibilidad en Plataforma
comercial Windows XP.

14. Prestaciones del MyLab ONE
• Operación con menus en pantalla sensible al tacto, con orientación
automática.
• Programa Automático dedicado para evaluación de la edad vascular
de la Intima Media.
• Programa Automático dedicado para evaluación de la elasticidad
vascular.
14

15. Tecnología utilizada
Ademaás de mediciones tradicionales de factores de riesgo (Framingham), utiliza
indicadores predictivos basados en: El grosor de la pared arterial (QIMT) y
Elasticidad de la pared arterial (QAS)

16. Algun datos adicionales
16
RADIOFREQUENCY-BASED ESTIMATES OF LOCAL COMMON CAROTID STIFFNESS AND INTIMA-
MEDIA THICKNESS: IMPLICATIONS FOR DETECTING EARLY VASCULAR INVOLVEMENT IN
HYPERTENSION AND DIABETES
C. Palombo1, M. Kozakova1, G. Bini1, C. Morizzo1, R. Miccoli2, G. Dell' Omo3, R. Pedrinelli3, V. Di Bello3, N. Guraschi4, A. Balbarini3
(1) Department of Internal Medicine, University of Pisa, Pisa, Italy (2) Department of Endocrinology and Metabolism, Pisa, Italy
(3) Cardiothoracic Department, University of Pisa, Pisa, Italy (4) ESAOTE SpA, Genoa, Italy
Intima-media thickness (IMT) of common
carotid artery (CCA) and carotid-femoral
pulse wave velocity (CF-PWV) are established
markers of preclinical vascular disease,
implemented in European guidelines for
cardiovascular (CV) risk prediction.
However, both are influenced mostly by age
and blood pressure (BP), and their value as
forerunner of atherosclerosis remains elusive.
New US techniques improve accuracy of IMT
measurements and provide estimates of local
stiffness in the clinical setting.
Background
was to evaluate the
association of high-resolution,
radiofrequency-based (RF) US
measurements of CCA IMT
(QIMT) and local carotid
stiffness (QAS) as well as
CF-PWV with age, BP and
early disease state.
Aim of this study
64 middle-age subjects free of
clinical CV disease
 19 healthy volunteers (NL, 9 men)
 19 subjects with BP from high normal to
mild hypertension (HT, 13 men)
 26 patients with recently diagnosed, well
controlled, type 2 diabetes (DM2, 20 men)
Study Population
CCA far-wall IMT (QIMT®, Fig. 1),
diameter and distension (QAS®, Fig. 2) were
measured by a RF-based, fully automatic
algorithm implemented in a US system
(MyLab 70, Esaote, Genova,Italy), 1.0 cm
below the flow divider.
The indices of CCA stiffness were calculated
after calibration for BP .
Carotid–femoral pulse wave velocity (CF-PWV,
Complior, Alam, France), was used as an
estimate of aortic stiffness (Fig. 3).
Methods
Fig. 3
Fig. 1 Fig. 2
NL HT DM2 p
Q-IMT
(µm)
540±72 597±50 724±110* * p<0.001 vs NL and HT
CCA B
Index
7.7±2.1 10.1±3.1t 12.6±3.5*
* p<0.001 vs NL
t p<0.05 vs NL
CF-PWV
(m/s)
8.5±1.3 9.7±1.5 10.8±2.4* * p<0.001 vs NL
Age
(years)
44±8 53±9* 61±7t
* p<0.001 vs NL
t p<0.01 vs NL and HT
BP
(mmHg)
107±12/74±8 130±13/86±8* 117±29/77±6 * p<0.001 vs NL and DM2
PP
(mmHg)
34±9 44±10* 46±12* * p<0.01 vs NL
• QIMT,CCA Beta Index, CF-PWV age, systolic BP and
pulse pressure (PP) in NL, HT and DM2 are reported in
Table 1.
• In the overall population, CF-PWV, QIMT and Beta
stiffness index were directly related each other and
increased with age as well as with systolic BP and pulse
pressure (Table 2).
• In a multivariate model adjusted for age and sex,
DM2 status resulted independent predictor of QIMT,
while variability of CF-PWV and CCA Beta stiffness
index was accounted mostly by age (Table 3).
Results
New advanced US systems provide
accurate markers of preclinical vascular
involvement. An increased local CCA
stiffness shows high sensitivity to detect
vascular ageing, while QIMT seems to
have an higher potential to discriminate
early atherosclerosis, particularly in the
evaluation of the diabetic disease
Conclusions
QIMT CCA BI CF-PWV AGE SBP PP
_
0.488 0.362 0.697 0.437 0.413
QIMT
_ 0.527 0.669 0.346 0.360
CCA BI
_ 0.569 0.438 0.492
CF PWV
_ 0.332 0.382
AGE
_ __
SBP
_
PP
Tab. 1
SE p
QIMT
Age 0.44 0.12 <0.005
Diagnosis DM2 0.38 0.14 <0.01
Cumulative R2 0.57 <0.0001
Beta index
Age 0.67 0.09 <0.0001
Cumulative R2 0.45 <0.0001
CF-PWV
Age 0.45 0.11 <0.0005
PPc 0.33 0.11 <0.001
Cumulative R2 0.41 <0.0001
PP
PWV CF 0.39 0.13 <0.01
Diagnosis HBP 0.27 0.12 <0.05
Cumulative R2 0.32 <0.0005
Multivariate Model
Tab. 2
Tab. 3

17. Algun datos adicionales (cont)
17
AVERAGE DAILY PHYSICAL ACTIVITY IS AN INDEPENDENT DETERMINANT OF
LOCAL CAROTID STIFFNESS AND MYOCARDIAL PERFORMANCE
M. Kozakova1, C. Palombo1, C. Morizzo1, E. Muscelli1, N. Guraschi2, S. Pedri2, E. Ferrannini1, B. Balkau3
(1) Department of Internal Medicine, University of Pisa, Pisa, Italy (2) ESAOTE SpA, Genoa, Italy
(3) Center for Research in Epidemiology and Public Health, Villejuif, France
It has been recently reported that vigorous physical
activity (PA) attenuates age-related increase in
common carotid artery (CCA) stiffness in young
subjects and that light PA is associated with lower
aortic stiffness in elderly subjects. The hypothesis
could be raised that a PA-induced reduction in the
stiffness of large arteries could favorably influence
LV myocardial performance.
BACKGROUND
was to evaluate, in healthy middle-age
subjects, the impact of objectively
measured daily PA on CCA and aortic
stiffness and LV myocardial performance.
AIM OF THIS STUDY
47apparently healthy subjects
• age 30-60 years (mean 43±/8 years)
• not involved in endurance exercise training
• normal glucose tolerance
• normal LV geometry (LV mass, RWT)
• normal LV global and regional function (EF and kinesis)
• free of carotid plaques
STUDY POPULATION
• Interview (family history, drugs, smoking)
• Metabolic profile, insulin sensitivity by a gold-standard
euglycemic hyperinsulinemic clamp
• LV mass, Doppler-derived stroke volume and TDI-
derived longitudinal myocardial velocities by cardiac
ultrasound (MyLab, Esaote, Italy);
• Right CCA diameter and distension by a high resolution,
radio-frequency based vascular US (QAS®, Esaote,
Italy) : Fig. 1
• Carotid-femoral pulse wave velocity used as an estimate
of aortic stiffness (PWV, Complior, Alam, France): Fig. 2
• A monitoring of daily PA (single-axis accelerometer,
Computer Science Manufacturing Technology, FL, USA;
mean monitoring time 5.6±1.2 day)
STUDY PROTOCOL
• Average intensity of daily PA was expressed as an
average number of accelerometer counts per min of
monitoring time (314±106 counts/min) and was directly
related to peak systolic myocardial longitudinal velocity and
inversely to heart rate and CCA Beta stiffness index, but
not to PWV, LV mass and diastolic longitudinal myocardial
velocities (Tab. 1).
• In multivariate analyses (Tab. 2), after adjustment for
sex, smoking and stroke volume (taken as an index of
preload), average habitual PA remained independently
related to CCA Beta stiffness index (together with age and
fasting insulin) and to systolic longitudinal myocardial
velocity (together with PWV).
RESULTS
In healthy untrained middle-age subjects, the
average PA has an independent favorable
impact on local CCA stiffness but not on
carotid-femoral PWV, that represents an
independent determinant of systolic longitudinal
myocardial performance. Average intensity of
daily PA, however, seems to influence
myocardial performance independently of load.
CONCLUSIONSCCA Beta Index PSV Longitudinal
Sex p=0.71 Sex p=0.19
Age p<0.005 CF PWV p<0.01
CCA IMT p=0.87 Average PA p<0.05
Insulin p<0.005 Smoking p=0.27
M/I p=0.92
Average PA p=0.01
Smoking p=0.57
R2= 0.66 p<0.0001 R2= 0.34 p<0.01
Avg PA HR CCA BI CF PWV LV mass PSV long PEV long
_ -0.30 -0.32 n.s. n.s. 0.46 n.s. Avg PA
_ n.s. n.s. n.s. n.s. n.s. HR
_ 0.31 0.50 n.s. -0.51 CCA BI
_ n.s. -0.41 -0.47 CF PWV
_ n.s. -0.44 LV mass
_ 0.65 PSV long
_ PEV long
Fig. 2
Fig. 1
Multivariate Analyses
Tab. 1
Tab. 2

18. Algun datos adicionales
(cont)
18
INCREASED CAROTID IMT IN EARLY HYPERTENSION REPRESENTS
AN ADAPTIVE MECHANISM TO INCREASED PULSATILE LOAD
C. PALOMBO (1), M. KOZAKOVA (2), C. MORIZZO (3), G. BINI (3), A. CORCIU (4),
AM SIRONI (5), G. DELL'OMO (4), R. PEDRINELLI (4)
(1) UNIVERSITY of PISA, DEPARTMENT of SURGERY, PISA-ITALY, (2) ESAOTE SpA, GENOVA-ITALY,
(3) DEPARTMENT OF INTERNAL MEDICINE, UNIVERSITY OF PISA, PISA-ITALY, (4) UNIVERSITY of PISA,
CARDIAC and THORACIC DEPARTMENT, PISA-ITALY, (5) CNR, INSTITUTE OF CLINICAL PHYSIOLOGY, PISA-ITALY
Background
 An increased intima-media thickness (IMT) of
common carotid artery (CCA) has been reported in
early hypertension as a marker of subclinical
atherosclerosis (1).
 However, large artery wall thickening was also
supposed to be an adaptive response to the
increased pressure load (2).
References:
1. Raiko JR et al, Eur J Cardiovasc Prev Rehabil; 2010: 17:549
2. Bots ML et al, Stroke 1997; 28: 2442
Aim of the study
To verify the presence and
predictors of subclinical large
artery involvement in early
hypertension as compared to
normotensive subjects.
Design and Methods
 Thirty-eight never treated, non diabetic subjects free of clinical
cardiovascular disease were recruited so far in a prospective study, 18
with “optimal” casual BP (NL), and 20 with high-normal or mildly
elevated BP (pre-HT) (Tab. 1), according to JNC7 Report (individuals
with a systolic BP of 120 to 139 mmHg or a diastolic BP of 80 to 89
mmHg should be considered as prehypertensive and require health-
promoting lifestyle modifications to prevent CVD)
 Right CCA IMT and local stiffness were assessed by radio-frequency
(RF) based,real-time, automatic tracking of arterial wall [Q-IMT (Fig.
1) and Q-AS (Fig. 2), respectively, MyLab70, Esaote, Italy]. CCA IMT
was also measured off-line in digitized B-mode images (Fig. 3). Carotid–
femoral pulse wave velocity (CF-PWV, Complior, Alam, France) was used
as an estimate of aortic stiffness (Fig. 4).
Study population
NL PRE-HT p
AGE (years) 47±7 50±7 p=ns
BMI (Kg/m2) 27±6 26±3 p=ns
SEX (M/F) 10/8 13/7 p=ns
SBP (mmHg) 122±14 145±18 p<0.005
DBP (mmHg) 75±9 86±9 p<0.001
PP (mmHg) 46±8 59±13 p<0.005
Fig. 4
NL PRE-HT p
Q-IMT (µm) 560±97 643±85 p<0.01
Q-AS CCA distension (µm) 352±98 368±77 p=ns
CCA Diameter (mm) 7.22±0.55 7.94±0.84 p<0.01
IMT 2D derived (µm) 694±116 746±76 p=ns
Β stiffness index 8.2±1.89 10.7±4 p<0.05
RWT 0.15±0.02 0.16±0.02 p=ns
CCA tensile stress (kPa) 109±18 118±16 p=ns
CF-PWV (m/s) 8.7±1.5 9.5±1.2 p=ns
Fig. 1 Fig. 2
Fig. 3
Results
 Pre-HT had significantly higher systolic and diastolic
BP, pulse pressure (Tab. 1), Q-IMT, CCA diameter and
Beta stiffness index (Tab. 2).
 No significant differences between the groups were
found for Q-AS CCA distension, relative wall thickness
(RWT: Q-IMT/Vessel Radius), CCA tensile stress, 2D
derived IMT, CF-PWV (Tab. 2), fasting glucose and
lipide profile.
 In the entire population, significant direct correlations
were found for Q-IMT with age (r=0.48, p<0.005), SBP
(r=0.55, p<0.001), PP (r=0.57, p<0.001), and CCA
diameter (r=0.66, p<0.0001) (Figg. 5-8). Beta index was
directly related to Q-IMT (r=0.36, p<0.05) and age
(r=0.60, p<0.001) (Figg. 9-10).
 In multivariate analysis, adjusted for diagnosis, sex
and smoking habit, independent predictors of Q-IMT
were CCA diameter and PP (R square 0.66, p<0.0001);
the only independent predictor of Beta index was age (R
square 0.39, p<0.001).
Conclusions
RF-based high resolution US system (Q-IMT and Q-AS) is capable to
detect subtle changes in carotid structure and function in absence of an
increase in aortic stiffness. In subjects with early hypertension,
increased Q-IMT appears an adaptive response to increased hemodynamic
load, mainly pulsatile presssure, and is associated with an increased local
stiffness
Tab. 1
Tab. 2
r=0.48, p<0.005
400
500
600
700
800
900
QIMTRight(µm)
30 40 50 60 70
AGE (years)
Fig. 5
400
500
600
700
800
900
QIMTDx(µm)
5 6 7 8 9 10
Right CCA Diameter (mm)
r=0.66, p<0.001
Fig. 8
400
500
600
700
800
900
QIMTRight(µm)
30 50 70 90 110
Pulse Pressure (mmHg)
r=0.57, p<0.001
Fig. 7
r=0.55, p<0.001
400
500
600
700
800
900
QIMTDx(µm)
80 100 120 140 160 180 200
Systolic Blood Pressure (mmHg)
Fig. 6
r=0.60, p<0.001
4
8
12
16
20
24
30 40 50 60 70
AGE (years)
BetaindexRight
Fig. 10
4
8
12
16
20
24
BetaindexRight
400 500 600 700 800 900
QIMT Right (µm)
r=0.36, p<0.05
Fig. 9

19. Conclusiones
• Las enfermedades del corazón SI son curables si son
tratadas a tiempo.
• Se puede educar a la población para la prevención y la
reacción inmediata ante la presencia de estas patologías.
• Los recursos humanos pueden ser entrenados para estas
emergencias.
• La tecnología de apoyo existe y su costo es mínimo
comparado con los beneficios que produce.
19

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