Guia de la AHA/ACC para prevencion secundaria en paciente con ictus isquemico y AIT, publicada en la revista STROKE mayo, 2014

1. DR. ROBERTO MEDINA R3 MEDICINA INTERNA
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

2. TIA / STROKE
• Mas de 690 mil casos anuales de ICTUS EE.UU
• Mas de 240 mil casos anuales de TIA EE.UU
• Riesgo de ICTUS después de un TIA o ICTUS previo es 3-4% anual
historica %
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

3. Definiciones
Aterosclerosis
de grandes
vasos
Ictus
Isquemico
cardioembólica
Causas
secundarias e
indeterminadas
Enfermedad de
pequeños vasos
• TIA
• vs
• ICTUS
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

4. Objetivos
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

5. Novedades
• Nuevos factores de riesgo: Apnea del sueño, aterosclerosis arco
aórtico, nutrición, pre-diabetes.
• Revisión FA, estenosis carotidea, válvulas protésicas cardiacas con
relación a AHA y ACC
• Consideración del ¨infarto cerebral silente¨
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack, Stroke AHA ,May 1, 2014

6. Secciones
• Hipertensión
• Dislipidemia
• Diabetes mellitus
• Obesidad
• Inactividad física
• Nutrición
• Apnea del sueño
• Tabaco
• Alcohol
• Enfermedad carotidea
• Embarazo
• Aterosclerosis intracraneal
• Fibrilación auricular
• Miocardiopatía
• Enfermedad valvular
• PFO
• Homocisteinemia
• Antiagregantes plaquetarios
• Hipercoagulación
• Anticuerpos antifosfolipidos
• Falcemia
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

7. Hipertensión Arterial
78 millones de estadounidenses
sufren de HTA
Objetivo preventivo mas importante
Prevalencia HTA/ICTUS reciente
70%
Walter N. Kernan et, al Guidelines for the Prevention of Stroke
in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

8. Placebo vs perindopril+indapamida
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

9. Capp Trial
Lennart Hansson, Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in
hypertension: the Captopril Prevention Project (CAPPP), THE LANCET • Vol 353 • February 20, 1999

10. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA
,May 1, 2014

11. Dislipidemia
La “ACC/AHA Guideline on the Treatment of Blood
Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in
Adults” fue lanzada en el 2013
Reemplaza la ATP III
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

12. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

13. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

14. Trastornos del metabolismo de la glucosa
• Notable aumento
tanto en países
desarrollados como
en vía de desarrollo
• 11.3% de adultos EEUU
Actualmente Dx.
Walter N. Kernan et, al Guidelines for the Prevention of Stroke
in Patients With Stroke and Transient Ischemic Attack,Stroke
AHA ,May 1, 2014

15. Px. con ictus isquémico reciente uso del activo RR 45% con relacion a placebo
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

16. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

17. Obesidad
IMC mayor 30kg/m2
Factor de riesgo asociado
a dislipidemia, SM, DM y HTA
Relacion lineal:
IMC/ACV= 1kg/m2=5% ACV
Obesidad central/ACV
Px. ACV o AIT=Dx. 18-44%
obesos
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke
AHA ,May 1, 2014

18. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May
1, 2014

19. Inactividad física
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

20. 2013 AHA/ACC Guideline on Lifestyle
Management to Reduce
Cardiovascular Risk
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

22. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

23. Nutrición
Enfoque: Desnutrición/equilibrio de micronutrientes/dieta óptima
Prevalencia 8-13% niveles de vit D/K Pescado/hortalizas/mediterranea
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

24. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack, Stroke AHA ,May 1, 2014

25. • Apnea del sueño
¾ de Px. con Ictus
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

26. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

27. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

28. Enfermedad carotidea
Data from the North American Symptomatic Carotid Artery Trial
(NASCET)
Figure
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

29. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

30. Aterosclerosis intracraneal
Causa mas importante de AIT/ICTUS
Sin diferencias significativas
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

31. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

32. Walter N. Kernan et, al Guidelines for the Prevention of Stroke
in Patients With Stroke and Transient Ischemic Attack,Stroke
AHA ,May 1, 2014

33. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

34. Fibrilación auricular
• Afecta mas de 2.7 millones en EE.UU
• A mayor edad mayor prevalencia/ arritmia mas frecuente en los
ancianos
• Responsable de mas de 70 mil ictus isquémico por año en EE.UU (10%)
• Estimación riesgo
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

35. Eficacia de la anticoagulación
Warfarina:
EAFT
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

36. ACTIVE-W TRIAL
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

37. NUEVOS ANTICOAGULANTES?
Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

38. Walter N. Kernan et, al Guidelines for the Prevention of Stroke
in Patients With Stroke and Transient Ischemic Attack,Stroke
AHA ,May 1, 2014

39. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014

40. Walter N. Kernan et, al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack,Stroke AHA ,May 1, 2014