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£Âڷ›· - º¿Ú̷η O‰ËÁ›Â˜
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∆∂ÀÃ√™ 15 ñ ™∂¶∆∂ªµƒπ√™ 2007
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¶·Ú¿ÁÔÓÙ˜ ∫ÈÓ‰‡ÓÔ˘
¶ÚÔÙÂÈÓfiÌÂÓË µÈ‚ÏÈÔÁÚ·Ê›·
™YNTAKTIKH E¶ITPO¶H ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ XÂÈÌÒÓ·˜ HÏ›·˜ K·Ú‰ÈÔÏfiÁÔ˜ YÔÙ¤Ú·Ú¯Ô˜ Â.·.
M¤ÏË Õı˘ÚÔ˜ B·Û›ÏÂÈÔ˜
∫§π¡π∫∂™ ª∂§∂∆∂™ ªÔÚԇ̠ӷ ¢È·Îfi„Ô˘Ì ÙË ÃÔÚ‹ÁËÛË ™Ù·Ù›Ó˘ ÌÂÙ¿ ÙËÓ √Í›· º¿ÛË ÙÔ˘ πÛ¯·ÈÌÈÎÔ‡ ∞ÁÁÂÈ·ÎÔ‡ ∂ÁÎÂÊ·ÏÈÎÔ‡ ∂ÂÈÛÔ‰›Ô˘; µ. Õı˘ÚÔ˜, ∞. ∫·Î·Ê‹Î·, ∫. ∆˙ÈfiÌ·ÏÔ˜, ∂. ¶·ÓÎÔ˘Ú¤ÏÈ·˜, Ã. ∫Ô˘Ì·Ú¿˜, ∞. ∫·Ú·ÁÈ¿ÓÓ˘.
2
ª¤Ù·-·Ó¿Ï˘ÛË: µ·ÛÈΤ˜ ∞Ú¯¤˜ ÁÈ· ÙÔÓ ∫ÏÈÓÈÎfi Î·È ÙÔÓ ∂Ú¢ÓËÙ‹ ¢ËÌÔÛı¤Ó˘ µ. ¶·Ó·ÁȈٿÎÔ˜, FESC, MACE §¤ÎÙÔÚ·˜ µÈÔÛÙ·ÙÈÛÙÈ΋˜ - ∂ȉËÌÈÔÏÔÁ›·˜ ÷ÚÔÎfiÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ
4
AÓ·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ E™Y K·Ú‰ÈÔÏÔÁÈÎfi TÌ‹Ì· B’ ¶ÚÔ·È‰Â˘ÙÈ΋˜ KÏÈÓÈ΋˜ A¶£ IÔÎÚ¿ÙÂÈÔ NÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ ∫·Ú·ÁÈ¿ÓÓ˘ ∞ÛÙ¤ÚÈÔ˜ ∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ∞ÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢, πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢. EÏÈÛ¿Ê Mˆ˘Û‹˜
£EPA¶EIA — ºAPMAKA NÈÎÔÙÈÓÈÎfi O͇ ∂. ¡¿ÎÔ˘, ∂ÈÛÙËÌÔÓÈÎfi˜ ™˘ÓÂÚÁ¿Ù˘ ÙÔ˘ ∂Í. π·ÙÚ›Ԣ ¢È·Ù·Ú·¯ÒÓ ÙÔ˘ ªÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ §Èȉ›ˆÓ ª. ∂ÏÈÛ¿Ê, ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ ∆Ô̤·˜ ¶·ıÔÏÔÁ›·˜ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ
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T· √ʤÏË ·fi ™Ù·Ù›ÓË ÛÙËÓ ∫·Ú‰È·Î‹ ∞Ó¿ÚÎÂÈ· ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î·È ÙËÓ ¶ÚÔÛÙ·Û›· ·fi ∞ÈÊÓ›‰ÈÔ £¿Ó·ÙÔ. µ. Õı˘ÚÔ˜, ∞. ∫·Î·Ê‹Î·, ∫. ∆˙ÈfiÌ·ÏÔ˜, ∂. ¶·ÓÎÔ˘Ú¤ÏÈ·˜, Ã. ∫Ô˘Ì·Ú¿˜, ∞. ∫·Ú·ÁÈ¿ÓÓ˘.
12
AÏÏ·Á‹ ÌÈ·˜ ¶ÚˆÙfiÙ˘Ë˜ ™Ù·Ù›Ó˘ Ì ∞ÓÙ›ÁÚ·ÊÔ (Generic). Y¿Ú¯ÂÈ ŸÊÂÏÔ˜ ‹ ∫fiÛÙÔ˜; µ. Õı˘ÚÔ˜, ∫. ∆˙ÈfiÌ·ÏÔ˜, ∞. ∫·Î·Ê‹Î·, Ã. ∫Ô˘Ì·Ú¿˜, ∂. ¶·ÓÎÔ˘Ú¤ÏÈ·˜, ∞. ∫·Ú·ÁÈ¿ÓÓ˘.
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K·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜ I·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ ¶ÂÚÈÊÂÚÂÈ·Îfi ¶·ÓÂÈÛÙËÌÈ·Îfi NÔÛÔÎÔÌÂ›Ô Iˆ·ÓÓ›ÓˆÓ
O¢H°IE™ √‰ËÁ›Â˜ Ù˘ ∂˘Úˆ·˚΋˜ ∫·Ú‰ÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ (ESC) Î·È Ù˘ ∂˘Úˆ·˚΋˜ ∂Ù·ÈÚ›·˜ ªÂϤÙ˘ ÙÔ˘ ™·Î¯·ÚÒ‰Ë ¢È·‚‹ÙË (EASD) ÁÈ· ÙË ¢È¿ÁÓˆÛË, ¶ÚfiÏË„Ë Î·È ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ¢È·‚‹ÙË, ¶Úԉȷ‚‹ÙË Î·È ∫·Ú‰È·ÁÁÂÈ·ÎÒÓ ¶·ı‹ÛˆÓ. ∂È̤ÏÂÈ·: ∏Ï›·˜ ÃÂÈÌÒÓ·˜
17
KÔÏÔ‚Ô‡ °ÂÓÔ‚¤Ê· K·Ú‰ÈÔÏfiÁÔ˜ YԉȢı‡ÓÙÚÈ· A’ K·Ú‰ÈÔÏÔÁÈ΋˜ KÏÈÓÈ΋˜ Î·È Y‡ı˘ÓÔ˜ §Èȉ·ÈÌÈÎÔ‡ I·ÙÚ›Ԣ øÓ·Û›Ԣ K·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ K¤ÓÙÚÔ˘ °Ô˘‰¤‚ÂÓÔ˜ πˆ¿ÓÓ˘, ∫·ıËÁËÙ‹˜ ∫·Ú‰ÈÔÏÔÁ›·˜ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ, ¶ÂÚÈÊÂÚÂÈ·Îfi ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô πˆ·ÓÓ›ÓˆÓ. ¶›ÙÛ·‚Ô˜ XÚ‹ÛÙÔ˜ AÓ·ÏËÚˆÙ‹˜ K·ıËÁËÙ‹˜ K·Ú‰ÈÔÏÔÁ›·˜, I·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ IÔÎÚ¿ÙÂÈÔ NÔÛÔÎÔÌÂ›Ô AıËÓÒÓ
¶∞ƒ∞°√¡∆∂™ ∫π¡¢À¡√À AÓıÂÎÙÈ΋ Y¤ÚÙ·ÛË Ã·Ú¿Ï·ÌÔ˜ ªËÏÈÒÓ˘, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜, ∆Ô̤·˜ ¶·ıÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ
28
¶POTEINOMENH BIB§IO°PAºIA
32
È· 3 fiÌË Î·È Á Î · ∂ ∂ ∞ Ì ÈÌÈÎÔ‡ Û ۯ¤ÛË ÂÓfi˜ ÈÛ¯· ˜ Ë ›· Û Ú ¿ Ë Ê · · Ó ·È · ‹ÛÈÌË ÂÚÔÍ› ·Ó¿ÙÔ˘ Î ·È ÌÈ· ¯Ú ı ˜ ÛÙËÓ ˘ ›Ó Ë Â Ô Ó › Ó Ë Ù ˘ Û · ‰ ˘ Ù Ï ›Ó Û ÙÔ Î È· ÙË ‹ Ù˘ Ù·-·Ó¿ ÔÌ·ÎÙÈο ∏ ‰È·ÎÔ ‹ ÈÛ¯‡˜ Á Ô˘˜. ∏ ̤ Ú Î Ù Ù È Ù ‹ È Û Á Â È ˆ Ó Ù Á ¿ · Í · Ù ¤¯Ô˘Ó ˜ ·˘ ¿ ÙËÓ Â› Ë Û ÌfiÓÔ Ì¤Ú ÙÔ˘˜ ‰ÂÓ Ó· ·˘ÍËı Ó Î·ÓÔÓÈÎ ˘ › ˜ Ô Â Â Ó Ú ›˙ fi Ô ¯ Ì Â Ó Ì ˘ Û¤¯ÂÈ ˜ ·fi Ô˘ Û Ô›·˜ ˘˜ ¤Ú¢Ó ·ÛıÂÓ›˜ ÂÈ Ó· ÚÔ Ûˆ Ù˘ Ô Ô ¤ Ú ¤ Ì ¤ Ú Ì , È ‹ Î ˜ Â È ˆ Ó È Â›Ó·È ‹ Ù¯ ˘ fiÌ Ô˘ Ô ·Ó·ÁÓÒÛÙ ÛÙ·ÙÈÛÙÈÎ ÈÎfi Ô͇ Ôı¤ÛÂˆÓ Ó È Ô ˘ Ù , Ô Ó Ó Î Ò È ˘ Î Ó Ô È Û Ó Ë ÎÏÈ ÂÏÂÙ‹ ÂÈ Ù· Ó. ∆Ô ËÙ· Ó· Ì ‰ÈÂÚ‡ÓËÛ ÂÏÂÛÌ¿Ùˆ Ó· ÌÂÈÒÓ Ù Ù fi Ô Ó · · Ù · Ë Î È Ù Ó fi ˆ Ë Ó Ù Èη ·›ÙËÙ ÙÂÚfiÓ›· ÌÔÓ·‰È΋ ÙËÓ ··Ú DL ¯ÔÏËÛ ÛÙËÓ ÂÚÌË ∏ Ë Ù ›· ˜ Â Ë Ì È Ù Ë Â Û ¯ Ó ¤ · ÛÈο ›˙Ô˘Ó ÙË · ›‰ ÎÔ Ô˘ Ú Ù · Ô Ì È Ú Ú ¿ ÌÂÚÈο ‚·  ¿ Î È Ê Ù Ó ÛËÌ· ˜ Ôԛ˜ Èȉ·ÈÌÈÎfi ·˘Í¿ÓÂÈ È˜, ÔÈ ¤˜ ÌÂϤÙ  · Î È Á Ó Ó Ú È ¤ ¤Ó· ˘ÔÏ È Ï Ó · Î Â Î ˜ ) ÛÊ·Ù ‡ÌËÙ˜ Ù˘ Lp(a ÛË Ù˘ ∫∞ ÏϤ˜ Úfi ˜ ·ÓÂÈı · Ô ¤ ‚ ¶ Ù Î Â ¤ . Π›‰· Ë Ú Ë Í · Ú ¿ Â Ú È Î·Ï‡Ù ∏ ÈÓÈ΋ fiÛÔ, ¤¯Â ÙÂÚfiÏ˘. ‰¤ÂÙ·È ÌÂ Û Ó Ë ÛÙËÓ ÎÏ ˘ Ï Û Ï˘. øÛÙ Ô Ë ¯ ˘ Ô ›Ó · Ù Ù ‰  ÛÙ· › ¯Ú‹ÛË Ù˘ ıÓËÛÈ Âڷ›· Ì ÌË) ‹ Ù· ı Ë ‹ Û Ë Ë Â˘Ú‡ÙÂÚË ‹ È Í Î Ù ‡ È fi · Ì È (ÈÛ¯· ÈÁ› Û ÂÈ Û·ÊÒ˜ ·ÓÙ› ÛÂ Ô Ú·ÊÔ Ô‰Ë ÏÔÁ›· Ù˘ , Ô ›Á È Ë Ù ¤¯Ô˘Ó ‰Â›Í Ù Ï Ó È ¿ · · Ù · Â Ó Ì Ë È˜ È ÛÂ Û Ù›Ó˘ Ù· ·fi Ù È ‰˘Ô fi„ ÈÛfi‰È· η Ô Ù˘Ë˜ ÛÙ·  fi È Ù ·ÓÂÍ¿ÚÙË ·  ˆ Ó › Ú ¿  Π· ˜ ˜ È È·ÁÁÂ Ô˘Ó ›· ÓfiÛÔ ÛÙ·ÛË ÙË ·fi ηډ ÂÚÔ Ó· ¤¯ ÛÙÂÊ·ÓÈ· ˜ Ù Ë ·ÓÙÈηٿ · fi Ó Ù È Ë · · Ù ı Î È fi ˜ Ú ‚‹ÙË ˘˜ Â›Ó·È Î·È ÓÔÛË Ú҉˘ ‰È· ÈÛË Ì ÙÔ ˘¤ÚÙ·ÛË · Ú ¯ Î ‹ ÌfiÙËÙ·˜ Î Á Î · È ‡ Ù ™ Û Î √   ı Û ÂÌ ·Ó ‰˘ÓÔ ÚËÌ¿ÙˆÓ ·ÛıÂÓ›˜ ‚¿ÓÂÙ·È ÂÈ·Îfi Î›Ó Ì È Á · √ ÎÔÓÔÌ›· ¯ Á Ï È . · È Ú ˜  ‰ Ô Ú Ù · · ÒÓ ∆¤ÏÔ˜ ¤ÓÔ Î ‡ ÓÔÌ›ÛÌ ÈÛË ·ÛıÂÓ ÈËÙÈο.. Î·È ·˘ÍËÌ Ô Ò ÙÔ˘ ·˘ÙÔ Ó Ù Ô Â ˆ Ó Ì ¯ · È fi Î Ù Ù È Ó Û · ÙËÓ ¯ÂÙ·È ÚÁ¿ÓˆÓ EASD ÁÈ· ÙÔ˘˜ ÂϤÁ ˜ ‹ ‚Ï¿‚˜ Ô Ë Û Ù · Ù È Ú · ¤ Î ˜ ESC Ô˘ Ë ˘ ‰ËÁÈÒÓ ÙË Ô ·ÛıÂÓ›˜ ÂÈÌÒÓ·˜ Ó Ã ˆ Ù ˜ · Ê · Û › fi Ï Ú ∏ Ó fiÛÔ. Ú›ÏË„Ë Ùˆ Ê·ÓÈ·›· Ó Â ·Í˘ Ù Ù Û Ó È ‡ · Î ™ Ë ˜ Ù ‹ ‹ ‚ Ù · È Ì ‰ ¢È¢ı˘Ó
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™∂¶∆∂ªµƒπ√™ 2007
ªÔÚԇ̠ӷ ¢È·Îfi„Ô˘Ì ÙË ÃÔÚ‹ÁËÛË ™Ù·Ù›Ó˘ ÌÂÙ¿ ÙËÓ √Í›· º¿ÛË ÙÔ˘ πÛ¯·ÈÌÈÎÔ‡ ∞ÁÁÂÈ·ÎÔ‡ ∂ÁÎÂÊ·ÏÈÎÔ‡ ∂ÂÈÛÔ‰›Ô˘; µ. ’∞ı˘ÚÔ˜, ∞. ∫·Î·Ê‹Î·, ∫. ∆˙ÈfiÌ·ÏÔ˜, ∂. ¶·ÓÎÔ˘Ú¤ÏÈ·˜, Ã. ∫Ô˘Ì·Ú¿˜, ∞. ∫·Ú·ÁÈ¿ÓÓ˘. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) [1] ¤‰ÂÈÍ·Ó fiÙÈ Ë ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ Ì ·ÙÔÚ‚·ÛÙ·Ù›ÓË Â¤ÊÂÚ ÌÈ· Ì›ˆÛË Î·Ù¿ 16% (p=0.03) ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÓfi˜ ı·Ó·ÙËÊfiÚÔ˘ ‹ ÌË (‰Â˘Ù¤ÚÔ˘) ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ (∞∂∂), ÔÛÔÛÙfi Ô˘ ·Ó‹Ïı ÛÙÔ 23% (p<0.001) fiÙ·Ó ÂÚÈÏ‹ÊıËÎ·Ó Î·È Ù· ·ÚÔ‰Èο ∞∂∂. ªÂ›ˆÛ ›Û˘ ÙÔÓ Î›Ó‰˘ÓÔ ÛËÌ·ÓÙÈÎÒÓ ÛÙÂÊ·ÓÈ·›ˆÓ Û˘Ì‚·Ì¿ÙˆÓ ηٿ 35% (p=0.003), ÔÔÈÔ˘‰‹ÔÙ ÛÙÂÊ·ÓÈ·›Ô˘ Û˘Ì‚¿Ì·ÙÔ˜ ηٿ 42% (p<0.001) Î·È ÙȘ ÂÂÌ‚¿ÛÂȘ ·ӷÈÌ¿ÙˆÛ˘ ηٿ 45% (p<0.001) Û ·ÛıÂÓ›˜ Ì ÚÒÙÔ ∞∂∂ ¯ˆÚ›˜ fï˜ ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ. ∏ ·ÙÔÚ‚·ÛÙ·Ù›ÓË ¯ÔÚËÁ‹ıËΠÛÙËÓ ÔÍ›· Ê¿ÛË ÙÔ˘ ∞∂∂ Î·È ÁÈ· 5 ¯ÚfiÓÈ· ÌÂÙ¿. ¢ÂÓ Â›Ó·È fï˜ ÁÓˆÛÙfi ÙÈ Û˘Ì‚·›ÓÂÈ Â¿Ó ‰È·Îfi„Ô˘Ì ÙË ÛÙ·Ù›ÓË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ˘ÂÚÔÍ›·˜ ‹ ¯ÚfiÓÈ·˜ Ê¿Û˘ ÙÔ˘ ∞∂∂ ÁÈ· ·ÛıÂÓ›˜ Ô˘ ¤·ÈÚÓ·Ó ÛÙ·Ù›ÓË ÚÈÓ ÙËÓ ÂΉ‹ÏˆÛ‹ ÙÔ˘ ‹ Û ·˘ÙÔ‡˜ Ô˘ ‹Ú·Ó ηٿ ÙËÓ ÔÍ›· Ê¿ÛË. °È· Ó· ‰È¢ÎÚÈÓ›ÛÔ˘Ó ·ÎÚÈ‚Ò˜ ·˘Ùfi ۯ‰ȿÛÙËÎ·Ó ‰‡Ô ÎÏÈÓÈΤ˜ ÌÂϤÙ˜. [2,3] ™ÙËÓ ÚÒÙË ÌÂϤÙË [2], Ë ÔÔ›· ‹Ù·Ó ÂÏÂÁ¯fiÌÂÓË Î·È Ù˘¯·ÈÔÔÈË̤ÓË, ‰ÈÂÚ¢ӋıËÎÂ Ë Â›‰Ú·ÛË Ù˘ ıÂڷ›·˜ Ì ·ÙÔÚ‚·ÛÙ·Ù›ÓË Î·ıÒ˜ Î·È Ù˘ ·fiÛ˘Ú-
Û˘ Ù˘ ÛÙËÓ ¤Î‚·ÛË ÙˆÓ ÔÍÂÈÒÓ ÈÛ¯·ÈÌÈÎÒÓ ∞∂∂. ∞fi 215 ·ÛıÂÓ›˜ Ô˘ ‰È·ÁÓÒÛÙËÎ·Ó Ì¤Û· Û 24 ÒÚ˜ fiÙÈ ¿Û¯Ô˘Ó ·fi Ô͇ ÈÛ¯·ÈÌÈÎfi ∞∂∂, ÔÈ 89 ·ÛıÂÓ›˜ ¤·ÈÚÓ·Ó ‹‰Ë ÛÙ·Ù›ÓË Î·È Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó ‹ Ó· Ï¿‚Ô˘Ó ·ÙÔÚ‚·ÛÙ·Ù›ÓË 20 mg/Ë̤ڷ (Ë=43) ‹ Ó· ‰È·Îfi„Ô˘Ó ÙË ÛÙ·Ù›ÓË (Ë=46) ÁÈ· ÙȘ 3 ÚÒÙ˜ Ë̤Ú˜ ÌÂÙ¿ ·fi ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÔͤԘ ÈÛ¯·ÈÌÈÎÔ‡ ∞∂∂. ∆Ô ÚˆÙ‡ÔÓ ÙÂÏÈÎfi ÛËÌÂ›Ô ‹Ù·Ó ı¿Ó·ÙÔ˜ ‹ Ï‹Ú˘ ÂÍ¿ÚÙËÛË (ÙÚÔÔÔÈË̤ÓÔ ·ÔÙ¤ÏÂÛÌ· Îϛ̷η˜ Rankin [mRS] > 2) Û 3 Ì‹Ó˜. ∏ ÚfiˆÚË Ó¢ÚÔÏÔÁÈ΋ Âȉ›ӈÛË (early neurologic deterioration-END) Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÂÌÊÚ¿ÎÙÔ˘ ÛÙȘ Ë̤Ú˜ 4 ¤ˆ˜ 7 ‹Ù·Ó ‰Â˘ÙÂÚ‡ÔÓÙ· ÙÂÏÈο ÛËÌ›· Ù˘ ÌÂϤÙ˘. ™Â ÌÈ· ‰Â‡ÙÂÚË ·Ó¿Ï˘ÛË, ÔÈ ÌÂÙ·‚ÏËÙ¤˜ ¤Î‚·Û˘ (ÚˆÙ‡ÔÓÙ˜ Î·È ‰Â˘ÙÂÚ‡ÔÓÙ˜) Û˘ÁÎÚ›ıËÎ·Ó Ì ·˘Ù¤˜ ·ÛıÂÓÒÓ Ì ÈÛ¯·ÈÌÈÎfi ∞∂∂ ·ÏÏ¿ ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓË ıÂڷ›· Ì ÛÙ·Ù›Ó˜ (Ë=126). Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1 Ë ‰È·ÎÔ‹ Ù˘ ÛÙ·Ù›Ó˘ ÚÔοÏÂÛ ¿Ú· Ôχ ÛËÌ·ÓÙÈ΋ Âȉ›ӈÛË Û ۇÁÎÚÈÛË Ì ÙË ¯ÔÚ‹ÁËÛË 20 mg/Ë̤ڷ ·ÙÔÚ‚·ÛÙ·Ù›Ó˘ ·ÎfiÌË Î·È Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ¤·ÈÚÓ·Ó ÛÙ·Ù›ÓË ÚÈÓ ÙÔ ∞∂∂. ∏ ‰Â‡ÙÂÚË ÌÂϤÙË [3] ·ÚfiÏÔÓ fiÙÈ Â›¯Â ÙËÓ ›‰ÈÔ ÛÙfi¯Ô ›¯Â ‰È·-
ÊÔÚÂÙÈÎfi ۯ‰ȷÛÌfi. ∆Ô ÛÎÂÙÈÎfi ‹Ù·Ó fiÙÈ Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ Ì ÚÔËÁÔ‡ÌÂÓÔ ÈÛ¯·ÈÌÈÎfi ∞∂∂ ·Ó·Ì¤ÓÂÙ·È Ó· ˆÊÂÏËı› ÛËÌ·ÓÙÈο ·fi ÙË Ì·ÎÚÔÚfiıÂÛÌË ıÂڷ›· Ì ÛÙ·Ù›Ó˜. ∂ÓÙÔ‡ÙÔȘ, Ë ‰È·ÎÔ‹ Ù˘ ıÂڷ›·˜ Ì ÛÙ·Ù›Ó˜ ÂÌÊ·Ó›˙ÂÙ·È Û˘¯Ó¿ ÛÙËÓ ÎÏÈÓÈ΋ Ú·ÎÙÈ΋. √ ÛÙfi¯Ô˜ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ·ÍÈÔÏÔÁËı› Ë Â›‰Ú·ÛË Ù˘ ‰È·ÎÔ‹˜ Ù˘ ıÂڷ›·˜ Ì ÛÙ·Ù›Ó˜ ÛÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË ·ÛıÂÓÒÓ Ô˘ ÂÈ‚›ˆÛ·Ó ·fi Ô͇ ÈÛ¯·ÈÌÈÎfi ∞∂∂. √ ÏËı˘ÛÌfi˜ Ù˘ ÌÂϤÙ˘ ÂÚȤϷ‚ 631 ‰È·‰Ô¯ÈÎÔ‡˜ ÂÈ˙ÒÓÙ˜ ·fi ÈÛ¯·ÈÌÈÎfi ∞∂∂ (322 ¿Ó‰Ú˜ Î·È 309 Á˘Ó·›Î˜, ̤Û˘ ËÏÈΛ·˜ 70,2+/-7,6 ¤ÙË) ¯ˆÚ›˜ ÎÏÈÓÈο ÛÙÔȯ›· ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ÂÍ‹Ïı·Ó ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ÌÂÙ¿ ÙÔ Ô͇ ÈÛ¯·ÈÌÈÎfi ∞∂∂ ·›ÚÓÔÓÙ·˜ ıÂڷ›· Ì ÛÙ·Ù›Ó˜ Î·È ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 12 ÌËÓÒÓ. ª¤Û· Û 12 Ì‹Ó˜ ·fi ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô 246 ·ÛıÂÓ›˜ (38,9%) ‰È¤ÎÔ„·Ó ÙË ıÂڷ›· Ì ÛÙ·Ù›ÓË (Ô Ì¤ÛÔ˜ ¯ÚfiÓÔ˜ Ô˘ ‹Ú·Ó ÛÙ·Ù›ÓË ‹Ù·Ó 49 Ë̤Ú˜). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ 12ÌËÓ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘, ¤ı·Ó·Ó 116 ·ÛıÂÓ›˜ (Èı·ÓfiÙËÙ· ı·Ó¿ÙÔ˘ ÛÙÔÓ ¤Ó· ¯ÚfiÓÔ = 0,18, 95% ¢∂, 0,15-0,21). ¶ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË Ô˘ ÂÚȤϷ‚ fiÏÔ˘˜ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ∞∂∂ Î·È ÙȘ ÌÂٷ͇ ÙÔ˘˜ ·ÏÏËÏÔÂȉڿÛÂȘ η٤‰ÂÈÍ fiÙÈ
¶π¡∞∫∞™ 1. √Ì¿‰· Ô˘ ‰È¤ÎÔ„Â ÙË ÛÙ·Ù›ÓË ÁÈ· 3 Ë̤Ú˜
™‡ÁÎÚÈÛË Ì ÔÌ¿‰· Ô˘ ‰ÂÓ ¤·ÈÚÓ ÛÙ·Ù›ÓË
OR ÌÂÙ¿ ‰ÈfiÚıˆÛË ÁÈ· ËÏÈΛ· Î·È ‚·Ú‡ÙËÙ· = ∞‡ÍËÛË ÎÈÓ‰‡ÓÔ˘ ηٿ x ÊÔÚ¤˜
OR ÌÂÙ¿ ‰ÈfiÚıˆÛË ÁÈ· ËÏÈΛ· Î·È ‚·Ú‡ÙËÙ· = ∞‡ÍËÛË ÎÈÓ‰‡ÓÔ˘ ηٿ x ÊÔÚ¤˜
£¿Ó·ÙÔ˜ ‹ Ï‹Ú˘ ÂÍ¿ÚÙËÛË
4,66 (1,46 - 14,91)
6,92 (3,75 - 34,28)
¶ÚfiˆÚË Ó¢ÚÔÏÔÁÈ΋ Âȉ›ӈÛË
8,67 (3,05 - 24,63)
19,01 (1,96 - 184,09)
∞‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ ÂÌÊÚ¿ÎÙÔ˘
∞‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ ÂÌÊÚ¿ÎÙÔ˘
37.63 mL, p < 0.001
43.51 mL, p=0.048
’∂ÌÊÚ·ÎÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Î·Ù¿
2
™‡ÁÎÚÈÛË Ì ÔÌ¿‰· ·ÙÔÚ‚·ÛÙ·Ù›Ó˘
™∂¶∆∂ªµƒπ√™ 2007
∏ ˘ÔÏÔÁÈÛÙÈ΋, ÛÙ·ÙÈÛÙÈ΋ ‰È·‰Èηۛ· Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË Ì¤Ù·-·Ó¿Ï˘ÛË, ÂÓÒ Û˘Ó‹ıˆ˜ Ï›ÂÈ ·fi ÌÈ· Û˘ÛÙËÌ·ÙÈ΋ ·Ó·ÛÎfiËÛË. √È ÚÔÛ¿ıÂȘ Ó· Û˘ÁÎÂÓÙÚˆıÔ‡Ó ·ÔÙÂϤÛÌ·Ù· ·fi ͯˆÚÈÛÙ¤˜ ÌÂϤÙ˜ (ȉȷ›ÙÂÚ· ¤Ú¢Ó˜ ÌÈÎÚ¤˜ Û ̤ÁÂıÔ˜) Î·È Ó· ÂÚÌËÓ¢ıÔ‡Ó Û˘ÁÎÂÓÙÚˆÙÈο ‰ÂÓ Â›Ó·È Î¿ÙÈ Ó¤Ô. √ ÛÙ·ÙÈÛÙÈÎÔÏfiÁÔ˜ Karl Pearson, ‹Ù·Ó Èı·Ófiٷٷ Ô ÚÒÙÔ˜ ÂÚ¢ÓËÙ‹˜ Ô˘ ÙÔ 1904 ¯ÚËÛÈÌÔÔ›ËÛ ̷ıËÌ·ÙÈΤ˜ Ù¯ÓÈΤ˜ ÁÈ· Ó· Û˘Ó‰˘¿ÛÂÈ ‰Â‰Ô̤ӷ ·fi ‰È·ÊÔÚÂÙÈο ‰Â›ÁÌ·Ù·.
MÂϤÙ˜
Ÿˆ˜ ÛÙȘ ÂÈ̤ÚÔ˘˜ ¤Ú¢Ó˜ ıÂÛ›˙ÔÓÙ·È ÎÚÈÙ‹ÚÈ· ÂÈÛ·ÁˆÁ‹˜ Î·È ·ÔÎÏÂÈÛÌÔ‡, ¤ÙÛÈ Î·È Û ÌÈ· ̤ٷ-·Ó¿Ï˘ÛË ıÂÛ›˙ÔÓÙ·È ÎÚÈÙ‹ÚÈ· Û˘ÌÌÂÙÔ¯‹˜ Î·È ·ÔÎÏÂÈÛÌÔ‡ ÙˆÓ ÂÚ¢ÓÒÓ Ô˘ ı· Û˘ÌÂÚÈÏËÊıÔ‡Ó. ¶Ú¤ÂÈ Ó· ηٷÛÙ› ۷ʤ˜ fiÙÈ Ë ÌÔÓ¿‰· ÏËÚÔÊÔÚ›·˜ ÛÙË Ì¤Ù·-·Ó¿Ï˘ÛË ‰ÂÓ Â›Ó·È ÙÔ ¿ÙÔÌÔ, ·ÏÏ¿ Ë ›‰È· Ë ¤Ú¢ӷ ‹ ÌÈ· ˘fi-ÔÌ¿‰· ·ÙfiÌˆÓ ·fi οı ¤Ú¢ӷ. ∫ÚÈÙ‹ÚÈ· Ô˘ ÌÔÚÔ‡Ó Ó· ÏËÊıÔ‡Ó ˘fi„Ë ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ÂÚ¢ÓÒÓ Â›Ó·È Ù· ÛÙÔȯ›· ÙÔ˘ ۯ‰ȷÛÌÔ‡ ÙˆÓ ÌÂÏÂÙÒÓ (.¯. ÚÔÔÙÈÎfi˜ ‹ ·Ó·‰ÚÔÌÈÎfi˜ ۯ‰ȷÛÌfi˜, ·Ó ¤ÁÈÓÂ Ù˘¯·ÈÔÔ›ËÛË ‹ fi¯È, ·Ó Ô Û¯Â‰È·ÛÌfi˜ ‹Ù·Ó ÌÔÓ¿ ‹ ‰ÈÏ¿ Ù˘ÊÏfi˜ ÎÏ), ÙÔ ¤ÙÔ˜ ¤Ó·Ú͢ Î·È ÙÔ ¤ÙÔ˜ ÙÂÚÌ·ÙÈÛÌÔ‡ Ù˘ ¤Ú¢ӷ˜, ÛÙÔȯ›· Ù˘ ÔÈfiÙËÙ·˜ Ù˘ ÌÂϤÙ˘ Î·È Ù˘
·Ó¿Ï˘Û˘ ÙˆÓ ÛÙÔȯ›ˆÓ Ù˘, Ë ÁÏÒÛÛ· ‰ËÌÔÛ›Â˘Û˘, ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ Ù˘ οı ¤Ú¢ӷ˜, Ë ÔÌÔÈfiÙËÙ· ÙˆÓ ıÂڷ¢ÙÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ ‹ ÙˆÓ ¿ÏÏˆÓ ÌÂÙÚÔ‡ÌÂÓˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ (.¯. Ë ‰fiÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ‹ ÙÔ˘ ‰È·ÙÚÔÊÈÎÔ‡ Û˘ÌÏËÚÒÌ·ÙÔ˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠÛÙË Î¿ı ÌÂϤÙË, Ô ÙÚfiÔ˜ ̤ÙÚËÛ˘ ÙˆÓ Èı·ÓÒÓ Û˘Á¯˘ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î.·.). ¶Ú¤ÂÈ fï˜ Ó· ÛËÌÂȈı› fiÙÈ Ë ¯Ú‹ÛË ·˘ÛÙËÚÒÓ ÎÚÈÙËÚ›ˆÓ ·ÔÎÏÂÈÛÌÔ‡ ÙˆÓ ÌÂÏÂÙÒÓ Ì ÛÎÔfi Ó· ÂÍ·ÛÊ·Ï›ÛÔ˘Ó ÙËÓ ÔÌÔÈÔÁ¤ÓÂÈ· ÙˆÓ ÏËı˘ÛÌÒÓ Â›Ó·È Û˘¯Ó¿ ÚÔ‚ÏËÌ·ÙÈ΋, ηıÒ˜ ·Ê‹ÓÂÈ ÛËÌ·ÓÙÈ΋ ˘ÔÎÂÈÌÂÓÈÎfiÙËÙ· ÛÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ÂÚ¢ÓÒÓ Ì Èı·Ó¿ Û˘ÛÙËÌ·ÙÈο ÛÊ¿ÏÌ·Ù· ÂÈÏÔÁ‹˜. ∂›Ó·È ÏÔÈfiÓ ÚÔÙÈÌfiÙÂÚÔ Ù· ÎÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ Ó· Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ Î·È Ó· ÛÙÔ¯Â‡Ô˘Ó ›Ûˆ˜ ÌfiÓÔ ÛÙÔÓ ·ÔÎÏÂÈÛÌfi ÌÂÏÂÙÒÓ Ô˘ Â›Ó·È ÙÂÏ›ˆ˜ ·Ó·¯ÚÔÓÈÛÙÈΤ˜ ÁÈ· ÙË Û‡Á¯ÚÔÓË ÎÏÈÓÈ΋ Ú·ÎÙÈ΋. √È ·Ú¿ÌÂÙÚÔÈ Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ·Ú·¿Óˆ ˆ˜ ÎÚÈÙ‹ÚÈ· Û˘ÌÌÂÙÔ¯‹˜ ‹ ·ÔÎÏÂÈÛÌÔ‡ ÌÔÚÔ‡Ó Î¿ÏÏÈÛÙ· Û ¤Ó· ‰Â‡ÙÂÚÔ ÛÙ¿‰ÈÔ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÛÙË ‰ÈÂÚ‡ÓËÛË Èı·Ó‹˜ ÂÙÂÚÔÁ¤ÓÂÈ·˜ ÌÂٷ͇ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙˆÓ ‰È·ÊfiÚˆÓ ÌÂÏÂÙÒÓ. √ ·Ó·ÁÓÒÛÙ˘ ÌÈ·˜ ̤ٷ-·Ó¿Ï˘Û˘ ÌÔÚ› ̤۷ ·fi ÙÔ ‰ÂÓ‰ÚfiÁÚ·ÌÌ· (™¯‹Ì· 1) ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ó· ·ÓÙÈÏËÊı› ÔȘ ¤Ú¢Ó˜
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™¯‹Ì· 1. ¢ÂÓ‰ÚfiÁÚ·ÌÌ· ·ÚÔ˘Û›·Û˘ ̤ٷ-·Ó·Ï‡Ûˆ˜
¤¯Ô˘Ó ȉȷ›ÙÂÚË ‚·Ú‡ÙËÙ· ÛÙÔ Û˘ÓÔÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Î·È ÔȘ fi¯È. °ÂÓÈο Û ¤Ó· ‰ÂÓ‰ÚfiÁÚ·ÌÌ· ÔÈ ÔÚÈ˙fiÓÙȘ ÁÚ·Ì̤˜ ·ÚÈÛÙ¿ÓÔ˘Ó ÙÔ 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ (̤ÙÚÔ ·‚‚·ÈfiÙËÙ·˜) ÁÈ· οı ¤Ú¢ӷ, ÂÓÒ Ë ÂÎÙ›ÌËÛË ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ Ù˘ οı ÌÂϤÙ˘ Û˘Ì‚ÔÏ›˙ÂÙ·È Ì ÙÔ ÙÂÙÚ¿ÁˆÓÔ (‹ οÔÈÔ ¿ÏÏÔ Û‡Ì‚ÔÏÔ), ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÔÔ›Ô˘ Ê·ÓÂÚÒÓÂÈ ÙÔ ‘‚¿ÚÔ˜’ Ù˘ οı ÌÂϤÙ˘ ÛÙË Ì¤Ù·-·Ó¿Ï˘ÛË (fiÛÔ ÈÔ ÌÂÁ¿ÏÔ Û¯‹Ì· ÙfiÛÔ ÈÔ ÌÂÁ¿ÏÔ ÙÔ ÂȉÈÎfi ‚¿ÚÔ˜ Ù˘ ÌÂϤÙ˘). ∆Ô Û˘ÓÔÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Û˘Ì‚ÔÏ›˙ÂÙ·È Ì ÙÔ ‘‰È·Ì¿ÓÙÈ’ (‹ οÔÈÔ ¿ÏÏÔ Û‡Ì‚ÔÏÔ), Û˘Ó‹ıˆ˜ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜ ÙÔ˘ ‰ÂÓ‰ÚԉȷÁÚ¿ÌÌ·ÙÔ˜ Î·È Ë ÁÚ·ÌÌ‹ ηٿ Ì‹ÎÔ˜ ÙÔ˘ ‘‰È·Ì·ÓÙÈÔ‡’ Â›Ó·È ÙÔ 95% ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ ÁÈ· ÙÔ Û˘ÓÔÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ™˘ÌÂÚ·ÛÌ·ÙÈο Ë Ì¤Ù·-·Ó¿Ï˘ÛË Â›Ó·È ÌÈ· ¯Ú‹ÛÈÌË ÛÙ·ÙÈÛÙÈ΋ Ù¯ÓÈ΋, ̤ۈ Ù˘ ÔÔ›·˜ ÌÔÚ› Ó· ·˘ÍËı› Ë ÛÙ·ÙÈÛÙÈ΋ ÈÛ¯‡˜ ÁÈ· ÙË ‰ÈÂÚ‡ÓËÛË ÎÏÈÓÈÎÒÓ ˘Ôı¤ÛÂˆÓ Ô˘ ÔÈ ÂÈ̤ÚÔ˘˜ ¤Ú¢Ó˜ ·fi ÌfiÓ˜ ÙÔ˘˜ ‰ÂÓ ¤¯Ô˘Ó ÙËÓ ··Ú·›ÙËÙË ÈηÓfiÙËÙ· Ó· ÌÂÏÂÙ‹ÛÔ˘Ó. ∂›Û˘, ÌÈ· ̤ٷ-·Ó¿Ï˘ÛË ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙËÓ ·‚‚·ÈfiÙËÙ· ÁÈ· ÙÔ Ì¤ÁÂıÔ˜ ÂÓfi˜ ·ÔÙÂϤÛÌ·ÙÔ˜ Î·È Ó· ··ÓÙ‹ÛÂÈ Û ÂÚˆÙ‹Ì·Ù· Ô˘ ‰ÂÓ Â›¯·Ó ·Ú¯Èο ÚÔÛÂÁÁ›ÛÂÈ ÔÈ ÚˆÙÔÁÂÓ›˜ ÌÂϤÙ˜. ∞ÎfiÌ· Î·È ÛÙË Ú·ÏÈÛÙÈ΋ ÂÚ›ÙˆÛË ÛÙËÓ ÔÔ›· ÔÈ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÙÂÚÔÁ¤ÓÂÈ·, Ë Ì¤Ù·-·Ó¿Ï˘ÛË ÌÔÚ› Ó· ÙËÓ ·ÓȯÓ‡ÛÂÈ, Ó· ÙËÓ ÂÎÙÈÌ‹ÛÂÈ ÔÛÔÙÈο Î·È Ó· ÙË Û˘Ó˘ÔÏÔÁ›ÛÂÈ ÛÙȘ ÂÎÙÈÌ‹ÛÂȘ ÙÔ˘ Û˘ÓÔÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜. ªÂ ‰Â‰Ô̤ÓË ÙËÓ ÂÎıÂÙÈ΋ ·‡ÍËÛË ÙˆÓ ÏËÚÔÊÔÚÈÒÓ ÛÙȘ ÂÈÛً̘ Ù˘ ˘Á›·˜ Î·È ÙËÓ ·Ó¿ÚÎÂÈ· ÙˆÓ ·Ú·‰ÔÛÈ·ÎÒÓ ·Ó·ÛÎÔ‹ÛÂˆÓ Ó· ηχ„Ô˘Ó Â‰›· fiÔ˘ ÌÂÁ¿Ï· ÔÛ¿ ÏËÚÔÊÔÚ›·˜ Û˘ÛÛˆÚ‡ÔÓÙ·È, Ô ÚfiÏÔ˜ Ù˘ ̤ٷ·Ó¿Ï˘Û˘ Á›ÓÂÙ·È ÔÏÔ¤Ó· Î·È ÈÔ ··Ú·›ÙËÙÔ˜ ÛÙȘ Ë̤Ú˜ Ì·˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1.
4
Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 Jun 14;356(24):2457-71.
2.
Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Mortality in randomized trials of antioxidant supplements for primary and secondary prevention: sy-
stematic review and meta-analysis. JAMA. 2007;297(8):842-57.
£EPA¶EIA - ºAPMAKA
NÈÎÔÙÈÓÈÎfi O͇ ∂. ¡¿ÎÔ˘, ∂ÈÛÙËÌÔÓÈÎfi˜ ™˘ÓÂÚÁ¿Ù˘ ÙÔ˘ ∂Í. π·ÙÚ›Ԣ ¢È·Ù·Ú·¯ÒÓ ÙÔ˘ ªÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ §Èȉ›ˆÓ
ª. ∂ÏÈÛ¿Ê, ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ ∆Ô̤·˜ ¶·ıÔÏÔÁ›·˜ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ ∞fi Ôχ ÓˆÚ›˜ ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ÌÂÈÒÓÂÈ Ù· ›‰· Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ÛÙÔ Ï¿ÛÌ·, ÂÓÒ Ë ÓÈÎÔÙÈÓ·Ì›‰Ë, Ô˘ ¤¯ÂÈ ¯ËÌÈ΋ ‰ÔÌ‹ ·ÚfiÌÔÈ· Ì ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇, ‰ÂÓ ÂËÚ¿˙ÂÈ ÙÔ ÏÈȉ·ÈÌÈÎfi ÚÔÊ›Ï 1. ∞˘Ù‹ Ë ‰È·ÊÔÚ¿ Èı·Ó¿ ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ Â›Ó·È ÈÛ¯˘Úfi˜ ·Ó·ÛÙÔϤ·˜ Ù˘ ÏÈfiÏ˘Û˘, Ì ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË ÙˆÓ ÂχıÂÚˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙÔ Ï¿ÛÌ·, ÂÓÒ Ë ÓÈÎÔÙÈÓ·Ì›‰Ë ‰ÂÓ ‰È·ı¤ÙÂÈ Ù¤ÙÔÈ· ·Ó·ÛÙ·ÏÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·. ¶ÚfiÛÊ·Ù· ÂÚÈÁÚ¿ÊËÎÂ Ô ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˜ ÁÈ· ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ˘Ô‰Ô¯¤·˜, ‰È·Ì¤ÛÔ˘ ÙÔ˘ ÔÔ›Ô˘ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ·ÛΛ ÙȘ ÌÂÙ·‚ÔÏÈΤ˜ ÙÔ˘ ‰Ú¿ÛÂȘ 2-4. ∂›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ ·˘Ùfi˜ Ô ˘Ô‰Ô¯¤·˜ ‰ÂÓ ÌÔÚ› Ó· Û˘Ó‰Âı› Ì ÙË ÓÈÎÔÙÈÓ·Ì›‰Ë. ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó ÙËÓ ˘ÔÏÈȉ·ÈÌÈ΋ ‰Ú¿ÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ. ™Â Ì›· ÌÂϤÙË, ÙË ‰ÂηÂÙ›· ÙÔ˘ 50, ÂÎÙÈÌ‹ıËÎÂ Ë Â›‰Ú·ÛË Ô˘ ›¯Â ÛÙÔ ÏÈȉ·ÈÌÈÎfi ÚÔÊ›Ï Ë ¯ÔÚ‹ÁËÛË 3 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÁÈ· 12 ‚‰ÔÌ¿‰Â˜ 5. ™Â 7 ¿ÙÔÌ· Ì ÔÈÎÔÁÂÓ‹ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· Ë Û˘ÁΤÓÙÚˆÛË Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ÛÙÔ Ï¿ÛÌ· ÂÏ·ÙÙÒıËΠηٿ 16%. ∏ ÌÂϤÙË ·˘Ù‹ ¤‰ÂÈÍ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ËÏÂÎÙÚÔÊfiÚËÛ˘ fiÙÈ ·˘Ù‹ Ë Ì›ˆÛË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ÔÊÂÈÏfiÙ·Ó Û Ì›ˆÛË ÙˆÓ ‚-ÏÈÔÚˆÙÂ˚ÓÒÓ (LDL) Î·È fiÙÈ Ë ·Ó·ÏÔÁ›· LDL ¯ÔÏËÛÙÂÚfiÏË/HDL ¯ÔÏËÛÙÂÚfiÏË ÂÏ·ÙÙÒıËΠ·fi 9,0 Û 5,6. §›ÁÔ ·ÚÁfiÙÂÚ·, ÔÈ Parsons Î·È Flinn ÌÂϤÙËÛ·Ó ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Û 44 ·ÛıÂÓ›˜ 6. ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ Â›¯Â ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË >7 mmol/l Î·È ¤Ï·‚ ·ÁˆÁ‹ Ì 3-6 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÁÈ· 56 ‚‰ÔÌ¿‰Â˜. ∆· ›‰· Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ÂÏ·ÙÙÒıËÎ·Ó Î·Ù¿ 20%, Ô ·ıËڈ̷ÙÈÎfi˜ ‰Â›ÎÙ˘
LDL ¯ÔÏËÛÙÂÚfiÏË/HDL ¯ÔÏËÛÙÂÚfiÏË ÂÏ·ÙÙÒıËΠ·fi 5,0 Û 2,8 Î·È Ë HDL ¯ÔÏËÛÙÂÚfiÏË ·˘Í‹ıËΠηٿ 44%. ∞˘Ù‹ Ë ÌÂϤÙË ¤‰ÂÈÍ ÁÈ· Ì›· ·ÎfiÌË ÊÔÚ¿ fiÙÈ Ë ÓÈÎÔÙÈÓ·Ì›‰Ë Û ˘„ËϤ˜ ‰fiÛÂȘ ‰ÂÓ ÂÏ¿ÙÙˆÛ ٷ ›‰· Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ∂ÈϤÔÓ, ÔÈ Parsons Î·È Flinn ¤‰ÂÈÍ·Ó ÁÈ· ÚÒÙË ÊÔÚ¿ fiÙÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ıÂڷ›·˜ Ì ÓÈÎÔÙÈÓÈÎfi Ô͇ ˘Ô¯ÒÚËÛ·Ó Ù· ˘Ô‰fiÚÈ· Í·ÓıÒÌ·Ù· ·ÛıÂÓÒÓ Ì ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·. ∞˘Ù‹ ‹Ù·Ó Ë ÚÒÙË ·Ó·ÊÔÚ¿ Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ ÂÓfi˜ ˘ÔÏÈȉ·ÈÌÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ Ó· ÌÂÈÒÓÂÈ Ù· ˘Ô‰fiÚÈ· Í·ÓıÒÌ·Ù·, ÌÈ· ›‰Ú·ÛË Ô˘ Èı·Ó¿ ÔÊ›ÏÂÙ·È ÛÙË ÌÂÙ·ÊÔÚ¿ ¯ÔÏËÛÙÂÚfiÏ˘ ·fi ÙÔ˘˜ ÈÛÙÔ‡˜ ‰È·Ì¤ÛÔ˘ ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ Ù˘ ·Ó¿ÛÙÚÔÊ˘ ÌÂÙ·ÊÔÚ¿˜ ¯ÔÏËÛÙÂÚfiÏ˘. √ ˘Ô‰Ô¯¤·˜ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ. √ ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ ‰Ú¿Û˘ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜. º·›ÓÂÙ·È fiÙÈ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ·ÛΛ ÙËÓ ·ÓÙÈÏÈÔÏ˘ÙÈ΋ ÙÔ˘ ‰Ú¿ÛË ·Ó·ÛÙ¤ÏÏÔÓÙ·˜ ÙË Û˘ÛÛÒÚ¢ÛË ÙÔ˘ ΢ÎÏÈÎÔ‡ AMP ÛÙ· ÏÈÔ·ÙÙ·Ú· ‰È·Ì¤ÛÔ˘ ·Ó·ÛÙÔÏ‹˜ Ù˘ ·‰ÂÓ˘ÏÈ΋˜ ΢ÎÏ¿Û˘. ∏ ·Ú·¿Óˆ ‰È·‰Èηۛ· Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ÌÂÙ¿ ÙË Û‡Ó‰ÂÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ÙÔÓ ÂȉÈÎfi ˘Ô‰Ô-
¯¤· Ô˘ ÂÎÊÚ¿˙ÂÙ·È ÛÙ· ÏÈÔ·ÙÙ·Ú· 2-4,7.
¢Ú¿ÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Û ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘˜ ‰˘ÛÏÈȉ·ÈÌ›·˜. √È ‰˘ÛÏÈȉ·È̛˜ Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û‡Ìʈӷ Ì ÙËÓ Ù·ÍÈÓfiÌËÛË ÙÔ˘ Fredrickson, Ë ÔÔ›· ‚·Û›˙ÂÙ·È ÛÙË ‰È·ÊÔÚÂÙÈ΋ ËÏÂÎÙÚÔÊÔÚËÙÈ΋ ÎÈÓËÙÈÎfiÙËÙ· ÙˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ (¶›Ó·Î·˜ 1). ∆Ô ÓÈÎÔÙÈÓÈÎfi Ô͇ ‰ÂÓ ÂÏ·ÙÙÒÓÂÈ ÌfiÓÔ ÙËÓ ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË, ·ÏÏ¿ Î·È Ù· ÙÚÈÁÏ˘ÎÂÚ›‰È· Î·È Â›Ó·È È‰È·›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈÎfi Ê¿ÚÌ·ÎÔ Û ·ÛıÂÓ›˜ Ì ˘ÂÚÏÈȉ·È̛˜ Ù‡Ô˘ ππ-V 8. ∂›Ó·È ȉȷ›ÙÂÚ· ·ÍÈÔÛËÌ›ˆÙË Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Û ·ÛıÂÓ›˜ Ì ˘ÂÚÏÈȉ·È̛˜ Ù‡Ô˘ πππ Î·È πV, ÛÙȘ Ôԛ˜ ·Ú·ÙËÚÂ›Ù·È ÂÎÛÂÛËÌ·Ṳ̂ÓË ·‡ÍËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙˆÓ ÏÈȉ›ˆÓ ÛÙÔ Ï¿ÛÌ·. ∏ ›‰Ú·ÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÛÙȘ ÏÈÔÚˆÙ½Ó˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜: ∏ ·‡ÍËÛË Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ 9. ∞fi Ôχ ÓˆÚ›˜ ‰È·ÈÛÙÒıËÎÂ Ô ÚfiÏÔ˜ Î·È ¿ÏÏˆÓ ÏÈÔÚˆÙÂ˚ÓÒÓ ÛÙËÓ ÂͤÏÈÍË Ù˘ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘ (¶›Ó·Î·˜ 2). ¶Ú¿ÁÌ·ÙÈ, ÌÂ-
¶›Ó·Î·˜ 1. ∆·ÍÈÓfiÌËÛË ÙˆÓ ˘ÂÚÏÈȉ·ÈÌÈÒÓ Î·Ù¿ Fredrickson ∆À¶√™ ∞À•∏ª∂¡∞ §π¶π¢π∞
∞À•∏ª∂¡∂™ §π¶√¶ƒø∆∂´¡∂™
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TÚÈÁÏ˘ÎÂÚ›‰È·
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II A
ÃÔÏËÛÙÂÚfiÏË
LDL
II B
ÃÔÏËÛÙÂÚfiÏË Î·È ÙÚÈÁÏ˘ÎÂÚ›‰È· LDL and VLDL
III IV
ÃÔÏËÛÙÂÚfiÏË Î·È ÙÚÈÁÏ˘ÎÂÚ›‰È· ‚-VLDL (IDL Î·È Î·Ù¿ÏÔÈ· ¯˘ÏÔÌÈÎÚÒÓ) TÚÈÁÏ˘ÎÂÚ›‰È· VLDL
V
TÚÈÁÏ˘ÎÂÚ›‰È· Î·È ¯ÔÏËÛÙÂÚfiÏË Ã˘ÏÔÌÈÎÚ¿ Î·È VLDL
LDL: ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË, VLDL: Ôχ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË, IDL: ÂӉȿÌÂÛ˘ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË
5
™∂¶∆∂ªµƒπ√™ 2007
¶›Ó·Î·˜ 2. §Èȉ·ÈÌÈΤ˜ ·Ú¿ÌÂÙÚÔÈ ˆ˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ ∞˘ÍË̤ӷ ›‰· LDL ¯ÔÏËÛÙÂÚfiÏ˘ ∞˘ÍË̤ӷ ›‰· ÌÈÎÚÒÓ ˘ÎÓÒÓ LDL ۈ̷Ùȉ›ˆÓ ªÂȈ̤ӷ ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘ ÀÂÚÙÚÈÁÏ˘ÎÂÚȉ·ÈÌ›· (˘„ËÏ¿ ›‰· VLDL) À„ËÏ¿ ›‰· non HDL ¯ÔÏËÛÙÂÚfiÏ˘ À„ËÏ¿ ›‰· ÏÈÔÚˆÙ½Ó˘ Lp(a) LDL: ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË, VLDL: Ôχ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË, HDL: ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË, Lp(a): ÏÈÔÚˆÙ½ÓË (·)
ϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ù· ˘„ËÏ¿ ›‰· ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ 10-12 Î·È Ù· ¯·ÌËÏ¿ ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ 13,14 Â›Ó·È Â›Û˘ ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷο Û˘Ì‚¿Ì·Ù·. VLDL Î·È LDL. ∏ Ì›ˆÛË Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ Î·È ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙË Ì›ˆÛË ÙˆÓ LDL Î·È ÙˆÓ VLDL ·ÓÙ›ÛÙÔȯ·. ™ÙËÓ ˘ÂÚÏÈȉ·ÈÌ›· Ù‡Ô˘ IV Î·È Î˘Ú›ˆ˜ ÛÙȘ ˘ÂÚÏÈȉ·È̛˜ Ù‡Ô˘ πππ Î·È V ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ÚÔηÏ› ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙˆÓ VLDL Î·È ÙˆÓ ¯˘ÏÔÌÈÎÚÒÓ, Ë ÔÔ›· Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·Ú¿ÏÏËÏË Ì ÙË Ì›ˆÛË ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Ì›ˆÛË Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ÛÙÔ Ï¿ÛÌ·. ªÈÎÚ¿ ˘ÎÓ¿ ۈ̷ٛ‰È· LDL. ªÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ù· ÌÈÎÚ¿ ˘ÎÓ¿ LDL ۈ̷ٛ‰È· Â›Ó·È Ù· ÈÔ ·ıËÚÔÁfiÓ· ۈ̷ٛ‰È· 15 Î·È ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÚÒÈÌ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ 16. ∆Ô ÓÈÎÔÙÈÓÈÎfi Ô͇ (›Ù Ì ÙË ÌÔÚÊ‹ ‰ÈÛΛˆÓ ¿ÌÂÛ˘ ·Ô‰¤ÛÌ¢Û˘ ›Ù Ì ÙË ÌÔÚÊ‹ ‰ÈÛΛˆÓ ·Ú·ÙÂٷ̤Ó˘ ·Ô‰¤ÛÌ¢Û˘) fi¯È ÌfiÓÔ ÌÂÈÒÓÂÈ Ù· ›‰· Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘, ·ÏÏ¿ ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÌÈÎÚÒÓ ˘ÎÓÒÓ LDL ۈ̷Ùȉ›ˆÓ 17. HDL. ∆Ô 1950 ÔÈ Parsons Î·È Flinn ¤‰ÂÈÍ·Ó fiÙÈ Ë ıÂڷ›· Ì ÓÈÎÔÙÈÓÈÎfi Ô͇ ·˘Í¿ÓÂÈ Ù· ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘. ™Â Ì›· ¿ÏÏË ÌÂϤÙË, ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ·‡ÍËÛ ٷ ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 50% Î·È ÙÔ ˘ÔÎÏ¿ÛÌ· HDL 2 (Ù· ÌÂÁ·Ï‡ÙÂÚ· ‰ËÏ·‰‹ HDL ۈ̷ٛ-
6
‰È·) ηٿ 100% 18. Lp(a). H ÏÈÔÚˆÙ½ÓË Lp(a) Â›Ó·È ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ 19. ∆Ô ÓÈÎÔÙÈÓÈÎfi Ô͇ Â›Ó·È ÙÔ ÌfiÓÔ ˘ÔÏÈȉ·ÈÌÈÎfi Ê¿ÚÌ·ÎÔ Ô˘ ÚÔηÏ› ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ Lp(a). ™Â Ì›· ÌÂϤÙË, Ë ¯ÔÚ‹ÁËÛË 4 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÁÈ· 5-7 ‚‰ÔÌ¿‰Â˜ Ì›ˆÛ ٷ ›‰· Ù˘ Lp(a) ηٿ 40% 18. ∏ ›‰Ú·ÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÛÙȘ ÏÈÔÚˆÙ½Ó˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Ê·›ÓÂÙ·È Û˘ÓÔÙÈο ÛÙÔÓ ¶›Ó·Î· 3.
√ ÚfiÏÔ˜ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Û ÂȉÈΤ˜ ÌÔÚʤ˜ ‰˘ÛÏÈȉ·ÈÌ›·˜. ·) ¢˘ÛÏÈȉ·ÈÌ›· ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË. √ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷ΋ ıÓËÙfiÙËÙ·, Ë ÔÔ›· Â›Ó·È 2-4 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË ÛÙ· ¿ÙÔÌ· Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Û ۇÁÎÚÈÛË Ì ٷ ¿ÙÔÌ· ¯ˆÚ›˜ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË. ∏ ‰˘ÛÏÈȉ·ÈÌ›· ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘„ËÏ¿ ›‰· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È ¯·ÌËÏ¿ ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘, ¯ˆÚ›˜ fï˜ Ó· ˘¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙ· ›‰· Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ 20 ÌÂٷ͇ ‰È·‚ËÙÈÎÒÓ Î·È ÌË ‰È·‚ËÙÈÎÒÓ ·ÙfïÓ. ∞˘Ùfi˜ Ô Ù‡Ô˜ Ù˘ ‰˘ÛÏÈȉ·ÈÌ›·˜ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛı› ·ÔÙÂÏÂÛÌ·ÙÈο Ì ÙË ¯ÔÚ‹ÁËÛË ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ. øÛÙfiÛÔ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ì ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ ÛÙȘ Ôԛ˜ Ê·›ÓÂÙ·È fiÙÈ Ë ıÂڷ›· Ì ÓÈÎÔÙÈÓÈÎfi Ô͇ Âȉڿ ·ÚÓËÙÈο ÛÙÔ ÁÏ˘Î·ÈÌÈÎfi ¤ÏÂÁ¯Ô ÙˆÓ ‰È·-
‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ, ¤Ó· ‡ÚËÌ· fï˜ Ô˘ ‰ÂÓ ¤¯ÂÈ ÂȂ‚·Èˆı› ·fi ÌÂÁ¿Ï˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜. ™Â ÌÈ· ÌÂϤÙË (ADMIT, The Arterial Disease Multiple Intervention Trial), ÛÙËÓ ÔÔ›· Û˘ÌÌÂÙ›¯·Ó 468 ·ÛıÂÓ›˜ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ 125 ›¯·Ó ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ¯ÔÚËÁ‹ıËÎ·Ó 3 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÁÈ· 1 ¯ÚfiÓÔ 21. ∆· ›‰· ÙÔ˘ ۷ί¿ÚÔ˘ ÙÔ˘ ·›Ì·ÙÔ˜ ·˘Í‹ıËÎ·Ó ÙfiÛÔ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ fiÛÔ Î·È ÛÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ÂÓÒ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ÌÂÙ·‚ÔÏ‹ Ù˘ ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (HbA1c). ∫·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ, Ù· ›‰· ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ÌÂÈÒıËÎ·Ó Î·Ù¿ 25% Î·È Ë Û˘ÁΤÓÙÚˆÛË Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ·˘Í‹ıËΠηٿ 29%. ∆Ô Û˘Ì¤Ú·ÛÌ· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È fiÙÈ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Ì ·ÛÊ¿ÏÂÈ· Û ·ÛıÂÓ›˜ Ì ηϿ Ú˘ıÌÈṲ̂ÓÔ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË. ™Â Ì›· ¿ÏÏË ÌÂϤÙË (HATS, HDL Atherosclerosis Treatmant Study), ·ÛıÂÓ›˜ Ì ¯·ÌËÏ¿ ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘ ¤Ï·‚·Ó ·ÁˆÁ‹ Ì 2-4 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÛÙ·Ù›ÓË ÁÈ· 4 ¯ÚfiÓÈ·. ∞fi ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ 25 ›¯·Ó ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË 22. ∆Ô˘˜ ÚÒÙÔ˘˜ ÔÎÙÒ Ì‹Ó˜ ıÂڷ›·˜ ÂȉÂÈÓÒıËÎÂ Ô ÁÏ˘Î·ÈÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ, ·ÏÏ¿ ·ÚÁfiÙÂÚ· Ù· ›‰· Ù˘ ÁÏ˘Îfi˙˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ·ӋÏı·Ó ÛÙ· ·Ú¯Èο ›‰· Î·È ·Ú¤ÌÂÈÓ·Ó ÛÙ·ıÂÚ¿ ÁÈ· ÙÔ ˘fiÏÔÈÔ Ù˘ ÌÂϤÙ˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÌÂϤÙË ·˘Ù‹ ¤‰ÂÈÍ fiÙÈ Ë ¯ÔÚ‹ÁËÛË Û˘Ó‰˘·ÛÌÔ‡ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ÛÙ·Ù›ÓË Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋, ·ÛÊ·Ï‹˜ Î·È Î·Ï¿ ·ÓÂÎÙ‹ Û ·ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË. ‚) ¢˘ÛÏÈȉ·ÈÌ›· ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘. √È ·ÛıÂÓ›˜ Ì ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ Â›Ó·È ¿ÙÔÌ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘. ¶Ú¿ÁÌ·ÙÈ, Ë Â›ÙˆÛË ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ Â›Ó·È È‰È·›ÙÂÚ· ˘„ËÏ‹ (2040%) Û ¿ÙÔÌ· Ì ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, Ë ‰˘ÛÏÈȉ·ÈÌ›· ÙÔ˘ ÌÂÙ·‚ÔÏÈ-
£EPA¶EIA - ºAPMAKA ÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘„ËÏ¿ ›‰· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È ¯·ÌËÏ¿ ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘. ™˘ÓÂÒ˜, ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ı· ÌÔÚÔ‡ÛÂ Â›Ó·È È‰È·›ÙÂÚ· ·ÔÙÂÏÂÛÌ·ÙÈÎfi Ê¿ÚÌ·ÎÔ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‰˘ÛÏÈȉ·ÈÌ›·˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ 23-26. Á) ÀÂÚÏÈȉ·ÈÌ›· Ù‡Ô˘ V Î·È ·ÁÎÚ·ٛÙȉ·. ∏ ˘ÂÚÏÈȉ·ÈÌ›· Ù‡Ô˘ V, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Û˘ÁΤÓÙÚˆÛË ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ >1000 mg/dl Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ˘ÔÙÚÔÈ·˙fiÓÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·ÁÎÚ·ٛÙȉ·˜. ∏ ıÂڷ›· Ì ÓÈÎÔÙÈÓÈÎfi Ô͇ ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο Ù· ›‰· ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È ·ÔÙÚ¤ÂÈ ÙËÓ ÂΉ‹ÏˆÛË ˘ÔÙÚÔÒÓ ·ÁÎÚ·ٛÙȉ·˜ 27.
∆Ô ÓÈÎÔÙÈÓÈÎfi Ô͇ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÏÏ· ˘ÔÏÈȉ·ÈÌÈο Ê¿Ú̷η. ™ÙÔÓ ¶›Ó·Î· 4 Ê·›ÓÂÙ·È Ë Â›‰Ú·ÛË ÙÔ˘ Û˘Ó‰˘·ÛÌÔ‡ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ÛÙ·Ù›Ó˜ ‹ ÈÔÓÙÔ·ÓÙ·ÏÏ·ÎÙÈΤ˜ ÚËÙ›Ó˜ ÛÙÔ ÏÈȉ·ÈÌÈÎfi ÚÔÊ›Ï. O Û˘Ó‰˘·ÛÌfi˜ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ˘„ËϤ˜ ‰fiÛÂȘ ÈÔÓÙÔ·ÓÙ·ÏÏ·ÎÙÈ΋˜ ÚËÙ›Ó˘ ·‡ÍËÛ ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 40%, ÂÓÒ Ì›ˆÛ ٷ ›‰· Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ Î·È ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ηٿ 30%-40% Î·È 20% ·ÓÙ›ÛÙÔȯ·. √ Û˘Ó‰˘·ÛÌfi˜ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ÛÙ·Ù›Ó˜ ·‡ÍËÛ ٷ ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 30% Î·È ÂÏ¿ÙÙˆÛ ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ Î·È ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ηٿ 25-40% Î·È 20-40% ·ÓÙ›ÛÙÔȯ·. ™Â fiϘ ÙȘ ÌÂϤÙ˜ Ô Û˘Ó‰˘·ÛÌfi˜ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ¿ÏÏ· ˘ÔÏÈȉ·ÈÌÈο Ê¿Ú̷η ‹Ù·Ó ηϿ ·ÓÂÎÙfi˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜22,28-32.
√ Ì˯·ÓÈÛÌfi˜ ‰Ú¿Û˘ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ. ∏ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ VLDL Î·È ÙˆÓ LDL ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ó·ÛÙÔÏ‹ Ù˘ ÏÈfiÏ˘Û˘ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ÛÙË Ì›ˆÛË Ù˘ ·ÂÏ¢ı¤ÚˆÛ˘ ÂχıÂÚˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙÔ Ï¿ÛÌ·. Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi Ù· ÏÔ‡ÛÈ· Û ÙÚÈÁÏ˘ÎÂÚ›-
‰È· VLDL ۈ̷ٛ‰È· Û˘ÓÙ›ıÂÓÙ·È ÛÙÔ ‹·Ú. ∆· ÂχıÂÚ· ÏÈ·Ú¿ Ôͤ· Â›Ó·È ‚·ÛÈÎfi Û˘ÛÙ·ÙÈÎfi ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ 33-35. ªÂÙ¿ ÙË Û‡ÓıÂÛ‹ ÙÔ˘˜, Ù· VLDL ۈ̷ٛ‰È· ÂÈÛ¤Ú¯ÔÓÙ·È ÛÙËÓ Î˘ÎÏÔÊÔÚ›·. ªÂ ÙËÓ Â›‰Ú·ÛË Ù˘ ÏÈÔÚˆÙÂ˚ÓÈ΋˜ ÏÈ¿Û˘, ÔÈ VLDL ÌÂÙ·ÙÚ¤ÔÓÙ·È ÛÙȘ ÂӉȿÌÂÛ˘ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½Ó˜ (IDL), ÔÈ Ôԛ˜ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Î·È ˆ˜ ηٿÏÔÈ· ÙˆÓ VLDL. √È IDL Â›Ó·È Û¯ÂÙÈο ÏÔ‡ÛȘ Û ¯ÔÏËÛÙÂÚfiÏË Î·È ¤Ó· ̤ÚÔ˜ ÙÔ˘˜ ÚÔÛÏ·Ì‚¿ÓÂÙ·È ¿ÌÂÛ· ·fi Ù· Ë·ÙÔ·ÙÙ·Ú· ‰È·Ì¤ÛÔ˘ ˘Ô‰Ô¯¤ˆÓ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙËÓ ∞poE. √È ˘fiÏÔȘ IDL ˘Ê›ÛÙ·Ù·È ÙËÓ Â›‰Ú·ÛË Ù˘ Ë·ÙÈ΋˜ ÏÈ¿Û˘ Î·È ÌÂÙ·ÙÚ¤ÔÓÙ·È ÛÙȘ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½Ó˜ (LDL). ∂Ô̤ӈ˜, Â·Ó ÌÂȈı› Ë ·ÚÔ¯‹ ÂχıÂÚˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙÔ ‹·Ú ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ, ÌÂÈÒÓÂÙ·È Î·È Ë Ë·ÙÈ΋ Û‡ÓıÂÛË ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· Ë Û‡ÓıÂÛË Î·È ·ÂÏ¢ı¤ÚˆÛË ÙˆÓ VLDL, Ì ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ VLDL Î·È ÙˆÓ LDL ÛÙÔ Ï¿ÛÌ·. Ÿˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ·˘Í¿ÓÂÈ Ù· ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ÂÚ›Ô˘ ηٿ 30%, Ì›· ·‡ÍËÛË Ô˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·fi ·˘Ù‹ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ¿ÏÏˆÓ ˘ÔÏÈȉ·ÈÌÈÎÒÓ Ê·Ú̿ΈÓ. √ ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ Ì ÙÔÓ ÔÔ›Ô ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ·˘Í¿ÓÂÈ Ù· ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ‰ÂÓ Â›Ó·È Ï‹Úˆ˜ ÁÓˆÛÙfi˜. Œ¯ÂÈ ‰È·Ù˘ˆı› Ë ¿Ô„Ë fiÙÈ Ù· ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ηıÔÚ›˙ÔÓÙ·È ·fi ÙÔ Ú˘ıÌfi ηٷ‚ÔÏÈÛÌÔ‡ Ù˘ ·ÔÏÈÔÚˆÙ½Ó˘ ∞1, Ô˘ Â›Ó·È ÙÔ Î‡ÚÈÔ Û˘ÛÙ·ÙÈÎfi ÙˆÓ HDL ۈ̷Ùȉ›ˆÓ 36. MÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ÂÏ·ÙÙÒÓÂÈ ÙÔ Ú˘ıÌfi ηٷ‚ÔÏÈÛÌÔ‡ Ù˘ ·ÔÏÈÔÚˆÙ½Ó˘ A1, ÌÂÈÒÓÔÓÙ·˜ ÙË ÌÂÙ·ÊÔÚ¿ Ù˘ ÛÙÔ ‹·Ú, ¯ˆÚ›˜ fï˜ Ó· ÂËÚ¿˙ÂÈ ÙË ÌÂÙ·ÊÔÚ¿ ÂÛÙ¤ÚˆÓ ¯ÔÏËÛÙÂÚfiÏ˘ ·fi Ù· HDL ۈ̷ٛ‰È· ÛÙÔ ‹·Ú 37. ∂›Û˘ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ Èı·Ó¿ ·˘Í¿ÓÂÈ ÙËÓ ¤ÎÊÚ·ÛË Ù˘ ÚˆÙ½Ó˘ - ÌÂÙ·ÊÔÚ¤· ∞µCA1, Ë ÔÔ›· ÂÎÊÚ¿˙ÂÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ·
ÙˆÓ Î˘ÙÙ¿ÚˆÓ Î·È ‰È·Ì¤ÛÔ˘ Ù˘ ÔÔ›·˜ Á›ÓÂÙ·È Ë ÌÂÙ·ÊÔÚ¿ Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ·fi Ù· ·ÙÙ·Ú· ÛÙ· ·Ú¯¤ÁÔÓ· ÌfiÚÈ· HDL 38.
H ›‰Ú·ÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÛÙËÓ Î·Ú‰È·ÁÁÂȷ΋ ÓÔÛËÚfiÙËÙ·/ıÓËÙfiÙËÙ·. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ÂÎÙ›ÌËÛ·Ó ÙÔ ÚfiÏÔ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÛÙË ‰Â˘ÙÂÚÔÁÂÓ‹ ÚfiÏË„Ë Ù˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘. ™Â Ì›· ·fi ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜ (Coronary Drug Project, CDP) ·ÛıÂÓ›˜ Ô˘ ÂÈ‚›ˆÛ·Ó ÌÂÙ¿ ·fi ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘ Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Û ·ÁˆÁ‹ Ì 3 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ‹ ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ ÁÈ· 6,5 ¤ÙË 39. ∆· ηډȷÁÁÂȷο Û˘Ì‚¿Ì·Ù· ÌÂÈÒıËÎ·Ó Î·Ù¿ 14% (p<0,01) ÛÙËÓ ÔÌ¿‰· Ô˘ ¤Ï·‚ ÓÈÎÔÙÈÓÈÎfi Ô͇, ¯ˆÚ›˜ fï˜ η̛· ›‰Ú·ÛË ÛÙË ıÓËÙfiÙËÙ·. øÛÙfiÛÔ, Ù· ÂfiÌÂÓ· 15 ¯ÚfiÓÈ· ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ÌÂϤÙ˘ Ë ÔÏÈ΋ ıÓËÙfiÙËÙ· ÂÏ·ÙÙÒıËΠηٿ 11% ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¤Ï·‚ ·ÁˆÁ‹ Ì ÓÈÎÔÙÈÓÈÎfi Ô͇ 40. ∂›Û˘ Û ̛· ¿ÏÏË ÌÂϤÙË ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ÚfiÏ˄˘ Ù˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘, ·ÛıÂÓ›˜ ÌÂÙ¿ ·fi ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘ Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Û ·ÁˆÁ‹ ÌÂ Û˘Ó‰˘·ÛÌfi ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ (3 g/Ë̤ڷ) Î·È ÎÏÔÊÈ‚Ú¿Ù˘ (2 g/Ë̤ڷ) ‹ ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ ÁÈ· 5 ¯ÚfiÓÈ·. H ÔÏÈ΋ Î·È Ë Î·Ú‰È·ÁÁÂȷ΋ ıÓËÙfiÙËÙ· ÌÂÈÒıËÎ·Ó Î·Ù¿ 26% Î·È 36% ·ÓÙ›ÛÙÔȯ· ÛÙËÓ ÔÌ¿‰· Ô˘ ¤Ï·‚ ˘ÔÏÈȉ·ÈÌÈ΋ ·ÁˆÁ‹ Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ 41. ™ÙË ÌÂϤÙË ÚfiÏ˄˘ ηډȷÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ HATS (HDL Atherosclerosis Treatment Study) 160 ¿Ó‰Ú˜ Î·È Á˘Ó·›Î˜ Ì ¯·ÌËÏ¿ ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘ Î·È Ê˘ÛÈÔÏÔÁÈο ›‰· LDL ¯ÔÏËÛÙÂÚfiÏ˘ Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Û ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ ‹ Û˘Ó‰˘·ÛÌfi ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ÛÈÌ‚·ÛÙ·Ù›ÓË. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ›¯·Ó ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ 22. ™ÙËÓ ÔÌ¿‰· ÙÔ˘ Û˘Ó‰˘·ÛÌÔ‡ (¡+™) Ù· ›‰· Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ Î·È ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ÌÂÈÒıËÎ·Ó Î·Ù¿ 42% Î·È 36% ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Ù· ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ·˘Í‹ıËÎ·Ó Î·Ù¿ 26%. ∏ ›وÛË ÙÔ˘ ÚˆÙ·Ú¯ÈÎÔ‡ ηٷÏËÎÙÈÎÔ‡ ÛË-
7
™∂¶∆∂ªµƒπ√™ 2007
¶›Ó·Î·˜ 3. ∂›‰Ú·ÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÛÙȘ ÏÈÔÚˆÙ½Ó˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. §π¶√¶ƒø∆∂´¡∂™
∂¶π¢ƒ∞™∏
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↓
VLDL
↓
‚-VLDL
↓
IDL
↓
LDL
↓
sdLDL
↓
HDL
↑
HDL2
↑
Lp(a)
↓
VLDL: Ôχ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË, IDL: ÂӉȿÌÂÛ˘ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË, LDL: ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË, sdLDL: ÌÈÎÚ¿ ˘ÎÓ¿ LDL ۈ̷ٛ‰È·, HDL: ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ½ÓË, Lp(a): ÏÈÔÚˆÙ½ÓË (·)
Ì›Ԣ Ù˘ ÌÂϤÙ˘ (¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘, ı¿Ó·ÙÔ˜ ηډȷÁÁÂȷ΋˜ ·ÈÙÈÔÏÔÁ›·˜, ·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο ÂÂÈÛfi‰È·, ÂÂÌ‚¿ÛÂȘ ·ӷÁÁ›ˆÛ˘) ‹Ù·Ó 24% ÛÙËÓ ÔÌ¿‰· ÙÔ˘ ÂÈÎÔÓÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ Î·È 3% ÛÙËÓ ÔÌ¿‰· ¡+™. ¶·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ›وÛ˘ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ Û˘Ì‚·Ì¿ÙˆÓ ÛÙËÓ ÔÌ¿‰· ¡+™ ηٿ 90% Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ (p<0,05). ∂›Û˘ Ô ·ÁÁÂÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍ fiÙÈ Ô ‚·ıÌfi˜ ÛÙ¤ÓˆÛ˘ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ ·˘Í‹ıËΠηٿ 3,9% ÛÙËÓ ÔÌ¿‰· Ô˘ ‹Ú ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ Î·È ÂÏ·ÙÙÒıËΠηٿ 0,4% ÛÙËÓ ÔÌ¿‰· ¡+™ (p<0,001). ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙË ÌÂϤÙË ·˘Ù‹ ÙÔ fiÊÂÏÔ˜ ·fi ÙË Û˘Á¯ÔÚ‹ÁËÛË ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ÛÈÌ‚·ÛÙ·Ù›ÓË fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ Î‡ÚÈˆÓ Î·Ù·ÏËÎÙÈÎÒÓ ÛËÌ›ˆÓ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ Û ۇÁÎÚÈÛË Ì ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ÌÔÓÔıÂڷ›·˜ Ì ÛÙ·Ù›Ó˜.
¡ÈÎÔÙÈÓÈÎfi Ô͇ ·Ú·ÙÂٷ̤Ó˘ ·Ô‰¤ÛÌ¢Û˘ (prolonged-release, PR) ∆Ô ÓÈÎÔÙÈÓÈÎfi Ô͇ ·Ú¯Èο ¯ÚËÛÈÌÔÔÈ‹ıËΠ̠ÙË ÌÔÚÊ‹ ‰ÈÛΛˆÓ ¿ÌÂÛ˘ ·Ô‰¤ÛÌ¢Û˘. ŸÌˆ˜ ·˘Ù‹ Ë ÌÔÚÊ‹ ÙÔ˘ ÓÈÎÔÙÈ-
8
ÓÈÎÔ‡ ÔͤԘ ¤¯ÂÈ ·ÚÎÂÙ¤˜ ·ÚÂÓ¤ÚÁÂȘ, ·fi ÙȘ Ôԛ˜ ÈÔ Û˘¯Ó‹ Â›Ó·È Ë ¤Í·„Ë, Ë ÔÔ›· Î·È Î·ıÈÛÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ ÚÔ‚ÏËÌ·ÙÈ΋ ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ. ŒÙÛÈ ¿Ú¯ÈÛ·Ó Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ù· Û΢¿ÛÌ·Ù· ÂÈ‚Ú·‰˘ÓfiÌÂÓ˘ ·Ô‰¤ÛÌ¢Û˘ (sustained-release, SR) ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ, Ù· ÔÔ›· fï˜ ÚÔηÏÔ‡Ó ÛËÌ·ÓÙÈÎÔ‡ ‚·ıÌÔ‡ Ë·ÙÔÙÔÍÈÎfiÙËÙ· Î·È ÁÈ· ·˘Ùfi ÙÔ ÏfiÁÔ ·ÔÛ‡ÚıËÎ·Ó ·fi ÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË. ™‹ÌÂÚ·, ÛÙȘ ∏¶∞ ΢ÎÏÔÊÔÚ› ¤Ó· Û··ÛÌ· ·Ú·ÙÂٷ̤Ó˘ ·Ô‰¤ÛÌ¢Û˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ (prolonged-release PR), ÙÔ ¡iaspan 42. ∫·È ·˘Ù‹ Ë ÌÔÚÊ‹ Û‹ÌÂÚ· ÂÌÊ·Ó›˙ÂÈ ÙȘ Ù˘ÈΤ˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÙÔ˘ ·ÏÔ‡ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ. øÛÙfiÛÔ, Ë ¤Í·„Ë Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ó‹ Î·È ÏÈÁfiÙÂÚÔ ¤ÓÙÔÓË Û ۇÁÎÚÈÛË Ì ٷ Û΢¿ÛÌ·Ù· ¿ÌÂÛ˘ ·Ô‰¤ÛÌ¢Û˘. °È· Ó· ÂÏ·¯ÈÛÙÔÔÈËı› Ë Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ¤Í·„˘, ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ¯ÔÚËÁÂ›Ù·È ÛÙËÓ ·Ú¯‹ Û ¯·ÌËÏ‹ ‰ÔÛÔÏÔÁ›· (125-250 mg ‰‡Ô ÊÔÚ¤˜ ÙËÓ Ë̤ڷ ‹ 500 mg ÙÔ ‚Ú¿‰˘) Ë ÔÔ›· ÛÙ·‰È·Î¿ ·˘Í¿ÓÂÙ·È ÙÔ˘˜ ÂfiÌÂÓÔ˘˜ Ì‹Ó˜ 43.
ªÔÓÔıÂڷ›· Ì ÓÈÎÔÙÈÓÈÎfi Ô͇ ·Ú·ÙÂٷ̤Ó˘ ·Ô‰¤ÛÌ¢Û˘ (prolonged-release, PR) 1) ™Â ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜: ª›· ÌÂϤÙË Û˘Ó¤ÎÚÈÓ ÙȘ ÌÂÙ·‚ÔÏÈΤ˜ ÂȉڿÛÂȘ 1,5 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ·Ú·ÙÂٷ̤Ó˘ ·Ô‰¤ÛÌ¢Û˘ (PR) Ì ÙȘ ·ÓÙ›ÛÙÔȯ˜ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ¿ÌÂÛ˘ ·Ô‰¤ÛÌ¢Û˘ Û 200 ·ÛıÂÓ›˜ Ì ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· 44. √È ÂȉڿÛÂȘ ÛÙÔ ÏÈȉ·ÈÌÈÎfi ÚÔÊ›Ï ÙˆÓ ‰‡Ô Û΢·ÛÌ¿ÙˆÓ ‹Ù·Ó ·ÚfiÌÔȘ Ì ÂÍ·›ÚÂÛË ÙËÓ Â›‰Ú·ÛË ÛÙËÓ ÏÈÔÚˆÙ½ÓË (·) {Lp(a)}.∆Ô ÓÈÎÔÙÈÓÈÎfi Ô͇ ·Ú·ÙÂٷ̤Ó˘ ·Ô‰¤ÛÌ¢Û˘ (PR) ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÌÂÁ·Ï‡ÙÂÚË Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ Lp(a) Û ۇÁÎÚÈÛË Ì ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ¿ÌÂÛ˘ ·Ô‰¤ÛÌ¢Û˘. ∫·È Ù· ‰‡Ô Û··ÛÌ·Ù· ÚÔοÏÂÛ·Ó ÌÈÎÚ‹ ·‡ÍËÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ Ù˘ ÁÏ˘Îfi˙˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. 2) ™Â ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. √ Grundy Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘
ÌÂϤÙËÛ·Ó ÙȘ ÂȉڿÛÂȘ 1 Î·È 1,5 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ PR Û ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ 45. ∆· ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ·˘Í‹ıËÎ·Ó Î·Ù¿ 19% Î·È 24% ·ÓÙ›ÛÙÔȯ·, ÂÓÒ Ù· ›‰· ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ÌÂÈÒıËÎ·Ó Î·Ù¿ 13% Î·È 28% ·ÓÙ›ÛÙÔȯ·. ∏ Û˘ÁΤÓÙÚˆÛË Ù˘ ÁÏ˘Îfi˙˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ‰ÂÓ ÌÂÙ·‚Ï‹ıËΠηٿ ÙË ‰È¿ÚÎÂÈ· 4 ÌËÓÒÓ ıÂڷ›·˜. ∏ HbA1c ‰ÂÓ ÌÂÙ·‚Ï‹ıËΠÛÙËÓ ÔÌ¿‰· Ô˘ ¤Ï·‚ 1 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ PR, ÂÓÒ ·˘Í‹ıËΠ·fi 7,1% Û 7,5% ÛÙËÓ ÔÌ¿‰· Ô˘ Ù˘¯·ÈÔÔÈ‹ıËΠ۠·ÁˆÁ‹ Ì 1,5 g ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ. ™˘ÌÂÚ·ÛÌ·ÙÈο Ë ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ PR ÌÔÚ› Ó· ‚ÂÏÙÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙË ‰˘ÛÏÈȉ·ÈÌ›· ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2. ™˘Ó‰˘·ÛÌfi˜ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ·Ú·ÙÂٷ̤Ó˘ ·Ô‰¤ÛÌ¢Û˘ (prolonged-release, PR) Ì ÛÙ·Ù›Ó˜. ∂›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜ ·˘ÙÒÓ ÙˆÓ ‰‡Ô Ê·ÚÌ¿ÎˆÓ ‚ÂÏÙÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙÔ ·ıËÚÔÁfiÓÔ ÏÈȉ·ÈÌÈÎfi ÚÔÊ›Ï, ηıÒ˜ ÂÏ·ÙÙÒÓÂÈ Ù· ›‰· ÙfiÛÔ Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ fiÛÔ Î·È ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ÂÚ›Ô˘ ηٿ 39% Î·È 37% ·ÓÙ›ÛÙÔȯ· Î·È ÂÈϤÔÓ ·˘Í¿ÓÂÈ Ù· ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 25-40% 46-50.
∞ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ √È ‰‡Ô ÈÔ Û˘¯Ó¤˜ ·ÚÂÓ¤ÚÁÂȘ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Â›Ó·È Ë ¤Í·„Ë Î·È Ë ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ô˘ÚÈÎÔ‡ ÔͤԘ ÛÙÔ Ï¿ÛÌ·. ∏ ÚÒÙË ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· ÂΉËÏÒÓÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ ÚÒÙ˘ ‰fiÛ˘, ÂÓÒ Ë ·‡ÍËÛË ÙÔ˘ Ô˘ÚÈÎÔ‡ ÔͤԘ ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÌÂÙ¿ ·fi ·ÚÎÂÙfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ¯ÔÚ‹ÁËÛ˘. ŒÍ·„Ë (flushing). ∂›Ó·È Ë ÈÔ Û˘¯Ó‹ ·ÚÂÓ¤ÚÁÂÈ· ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ, Ë ÔÔ›· Î·È ÂÚÈÔÚ›˙ÂÈ ÙË ¯Ú‹ÛË ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË. ∏ ¯ÔÚ‹ÁËÛË 1 g/Ë̤ڷ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ·fi ÙÔ ÛÙfiÌ· ÌÔÚ› Ó· ÚÔηϤÛÂÈ ¤ÓÙÔÓË ˘Ô‰fiÚÈ· ·ÁÁÂÈԉȷÛÙÔÏ‹ Û˘¯Ó¿ Û ÔÏfiÎÏËÚÔ ÙÔ ÛÒÌ·. ∏ ¤Í·„Ë Ô˘ ¿ÓÙ· ·Ú¯›˙ÂÈ ·fi
£EPA¶EIA - ºAPMAKA ÙÔ ÚfiÛˆÔ, Û˘Óԉ‡ÂÙ·È ·fi ¤ÓÙÔÓÔ ·›ÛıËÌ· ÎÓËÛÌÔ‡ Î·È ÌÔÚ› Ó· ÂÂÎÙ·ı› ÛÙ· ¯¤ÚÈ·, ÙÔ ıÒڷη Î·È Û·ÓÈfiÙÂÚ· Ù· οو ¿ÎÚ·. ∏ ¤Í·„Ë ‰È·ÚΛ ÂÚ›Ô˘ 30 ÏÂÙ¿ Î·È Û¿ÓÈ· ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È ·fi ÌÂÁ¿ÏË ÙÒÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ∏ ¤Í·„Ë ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ D 2 Î·È Èı·ÓÒ˜ Î·È ¿ÏÏˆÓ ÂÈÎÔÛ·ÓÔÂȉÒÓ ÛÙÔ ‰¤ÚÌ· 51. ∂Âȉ‹ Ë ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Ù˘ ·ÁÁÂÈԉȷÛÙÔÏ‹˜ Ô˘ ÔÊ›ÏÂÙ·È ÛÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ Â›Ó·È ·ÚfiÌÔÈ· Ì ÂΛÓË Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ¤Á¯˘ÛË ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ 52, ÌÂÏÂÙ‹ıËÎÂ Ë ÂÌÊ¿ÓÈÛË ÂÍ¿„ÂˆÓ Î·È Ë ·‡ÍËÛË Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÛÙÔ ‚Ú·¯›ÔÓ· ÌÂÙ¿ ÙË Ï‹„Ë ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ, ·ÊÔ‡ ÚÔËÁÔ˘Ì¤Óˆ˜ ¯ÔÚËÁ‹ıËΠ·Ó·ÛÙÔϤ·˜ Ù˘ ΢ÎÏÔ͢ÁÂÓ¿Û˘ (ÈÓ‰ÔÌÂı·Î›ÓË) 53. ∏ ¤Í·„Ë Ô˘ ÚÔÎÏ‹ıËΠÌÂÙ¿ ·fi ÙË ¯ÔÚ‹ÁËÛË 1 g ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ·fi ÙÔ ÛÙfiÌ· Û˘Óԉ‡ÔÓÙ·Ó ·fi ÙÂÙÚ·Ï¿ÛÈ· ·‡ÍËÛË Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÙÔ˘ ‚Ú·¯›ÔÓ·. ŸÌˆ˜ Ë ¯ÔÚ‹ÁËÛË ÈÓ‰ÔÌÂı·Î›Ó˘ ÚÈÓ ·fi ÙË Ï‹„Ë ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì›ˆÛ ÙËÓ ¤Í·„Ë Î·È ÂÚÈfiÚÈÛ ÙËÓ ·‡ÍËÛË Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÛÙÔ ‚Ú·¯›ÔÓ·, ¤Ó· ‡ÚËÌ· Ô˘ ‰Â›¯ÓÂÈ fiÙÈ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙˆÓ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ. ∂ÈϤÔÓ Û ̛· ¿ÏÏË ÌÂϤÙË, Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Û Á˘Ó·›Î˜ ÚÔοÏÂÛ ‰ÈÏ¿ÛÈ· ·‡ÍËÛË Ù˘ ·¤ÎÎÚÈÛ˘ Ù˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ PGF1a 54. ™˘ÓÂÒ˜, Ë
¤Í·„Ë ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ì ÙË ¯ÔÚ‹ÁËÛË Î¿ÔÈÔ˘ ·Ó·ÛÙÔϤ· Ù˘ ΢ÎÏÔ͢ÁÂÓ¿Û˘ 30’- 60’ ÚÈÓ ·fi οı ‰fiÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ (.¯. ÈÓ‰ÔÌÂı·Î›ÓË, ·ÛÈÚ›ÓË). ¶ÚfiÛÊ·Ù· ‰È·ÈÛÙÒıËΠfiÙÈ Ô ·Ó·ÛÙÔϤ·˜ ÙÔ˘ ˘Ô‰Ô¯¤· Ù˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ D 2 (prostaglandin D 2 receptor 1) ·ÔÙÚ¤ÂÈ ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ¤Í·„˘ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ÛÙ· ÔÓÙ›ÎÈ· Î·È ÛÙÔÓ ¿ÓıÚˆÔ 55. ªÂÚÈΤ˜ ÊÔÚ¤˜ Ë ¤Í·„Ë Û˘Óԉ‡ÂÙ·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ‰ÂÚÌ·ÙÈÎÒÓ ÂÍ·ÓıËÌ¿ÙˆÓ, Ë ÔÔ›· Û˘Ó‹ıˆ˜ Â›Ó·È ÚÔÛˆÚÈÓ‹ 43. ∆¤ÏÔ˜, Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÌÔÚ› Ó· ÂȉÂÈÓÒÛÂÈ ‰ÂÚÌ·ÙÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ‰˘Ûȉڈۛ·, fiˆ˜ Â›Ó·È ÙÔ ¤Î˙ÂÌ·, ¯ˆÚ›˜ fï˜ Ó· ÂËÚ¿˙ÂÈ ÙËÓ ÂΉ‹ÏˆÛË ¿ÏÏˆÓ ‰ÂÚÌ·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ, fiˆ˜ Â›Ó·È Ë „ˆÚ›·ÛË 43,56 ÀÂÚÔ˘Úȯ·ÈÌ›·: º·›ÓÂÙ·È fiÙÈ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ·ÓÙ·ÁˆÓ›˙ÂÙ·È ÙÔ Ô˘ÚÈÎfi Ô͇ ÛÙË ÛˆÏËÓ·Úȷ΋ ·¤ÎÎÚÈÛË Î·È ¤ÙÛÈ ·˘Í¿ÓÂÈ Ù· ›‰· ÙÔ˘ Ô˘ÚÈÎÔ‡ ÔͤԘ ÛÙÔ Ï¿ÛÌ· ηٿ 515%57. ∏ ·‡ÍËÛË ·˘Ù‹ ·ÔÎÙ¿ ÎÏÈÓÈ΋ ÛËÌ·Û›· Û ·ÛıÂÓ›˜ Ì ԢÚÈ΋ ·ÚıÚ›Ùȉ· ηÈ/‹ ˘„ËÏ¿ ›‰· Ô˘ÚÈÎÔ‡ ÔͤԘ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜. °È· ·˘Ùfi ÙÔ ÏfiÁÔ Â›Ó·È ··Ú·›ÙËÙÔ Ó· Á›ÓÂÙ·È Û˘¯Ófi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ô˘ÚÈÎÔ‡ ÔͤԘ ÛÙÔ ·›Ì· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ Ì ÓÈÎÔÙÈÓÈÎfi Ô͇. H ˘ÂÚÔ˘Úȯ·ÈÌ›· ÌÔÚ›
Ó· ·ÓÙÈÌÂÙˆÈÛı› ·ÔÙÂÏÂÛÌ·ÙÈο Ì ÙË ¯ÔÚ‹ÁËÛË 100-300 mg ·ÏÏÔÔ˘ÚÈÓfiÏ˘ ÙËÓ Ë̤ڷ. °·ÛÙÚÂÓÙÂÚÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∆Ô ÓÈÎÔÙÈÓÈÎfi Ô͇ ÌÔÚ› Ó· ¤¯ÂÈ Ë·ÙÔÙÔÍÈ΋ ‰Ú¿ÛË, ΢ڛˆ˜ Ù· Û··ÛÌ·Ù· ¿ÌÂÛ˘ ·Ô‰¤ÛÌ¢Û˘. ∂›Û˘, ÙÔ 10-20% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï·Ì‚¿ÓÂÈ ÓÈÎÔÙÈÓÈÎfi Ô͇ ÂÌÊ·Ó›˙ÂÈ Û˘ÌÙÒÌ·Ù· Á·ÛÙÚ›Ùȉ·˜. Œ¯ÂÈ ÌÂÏÂÙËı› Ë Á·ÛÙÚÈ΋ ¤ÎÎÚÈÛË Û 10 ·ÛıÂÓ›˜ Ô˘ ¤·ÈÚÓ·Ó 500 mg ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ÙËÓ Ë̤ڷ. ™ÙÔ˘˜ 9 ·fi ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ë ¤ÎÎÚÈÛË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÔͤԘ ·˘Í‹ıËΠ·fi 10% ˆ˜ Î·È 200% 58. ∂ÈϤÔÓ, ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ó·˘Ù›· Î·È ¤ÌÂÙÔ, ·ÏÏ¿ Û¿ÓÈ· Î·È Û ˘„ËϤ˜ ‰fiÛÂȘ 43. º·›ÓÂÙ·È fiÙÈ Ë ıÂڷ›· Ì ÓÈÎÔÙÈÓÈÎfi Ô͇ ‰ÂÓ ÚÔηÏ› Ì˘Ô¿ıÂÈ·, Ú·‚‰ÔÌ˘fiÏ˘ÛË ‹ ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÎÈÓ¿Û˘ Ù˘ ÎÚ·ÙÈÓ›Ó˘ (CK). EÈϤÔÓ, Ô Û˘Ó‰˘·ÛÌfi˜ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ÛÙ·Ù›Ó˜ ‰ÂÓ ·˘Í¿ÓÂÈ ÂÚÈÛÛfiÙÂÚÔ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· Ì˘Ô¿ıÂÈ· Û ۇÁÎÚÈÛË Ì ÙË ÌÔÓÔıÂڷ›· Ì ÛÙ·Ù›Ó˜. øÛÙfiÛÔ, ÛÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ ÙËÓ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È Î·Ù¿ Û˘Ó¤ÂÈ· Î·È ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ÛÙ·ÙÈÓÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÛÙ·ÙÈÓÒÓ ÛÙÔ Ï¿ÛÌ· Î·È ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ì˘Ô¿ıÂÈ·˜ 43. ÕÏϘ Û¿ÓȘ ·ÚÂÓ¤ÚÁÂȘ ÙÔ˘ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Â›Ó·È Ë ÌÂÏ·Á¯ÚˆÌ·ÙÈ΋ ·Î¿ÓıˆÛË ÙÔ˘
¶›Ó·Î·˜ 4. ∞ÔÙÂϤÛÌ·Ù· Ù˘ ¯ÔÚ‹ÁËÛ˘ Û˘Ó‰˘·ÛÌÔ‡ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ Ì ÛÙ·Ù›Ó˜ ‹ ÎÔÏÂÛÙÈfiÏË. ª∂§∂∆∂™
Nπ∫√∆π¡π∫√ √•À (‰ÔÛÔÏÔÁ›·/Ë̤ڷ)
∫√§∂™∆π¶√§∏(C)/ ™∆∞∆π¡∏(S) (‰ÔÛÔÏÔÁ›·/Ë̤ڷ)
TG (%)
LDL-C(%)
HDL-C(%)
Blankenhorn et al. [28]
IR 3–12 g
C 30 g
–16
–39
+35
Brown et al. [29]
IR 0.25–4 g
C 1 5–30 g
–29
–32
+43
Jacobson et al. [30]
IR <3.0 g
S (ÊÏÔ˘‚·ÛÙ·Ù›ÓË) 20 mg
–30
–40
+28
O'Keefe [31]
IR 3.0 g
S (Ú·‚·ÛÙ·Ù›ÓË) 40 mg
–42
–25
+29
Gardner [32]
IR 1.5 g
S (ÏÔ‚·ÛÙ·Ù›ÓË) 20 mg
–19
–30
+27
Brown et al. [22]
SR 2 g
S (ÛÈÌ‚·ÛÙ·Ù›ÓË) 10 mg
–36
–42
+26
TG: ÙÚÈÁÏ˘ÎÂÚ›‰È·, LDL-C: ¯ÔÏËÛÙÂÚfiÏË ÙˆÓ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙÂ˚ÓÒÓ, HDL-C: ¯ÔÏËÛÙÂÚfiÏË ÙˆÓ ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙÂ˚ÓÒÓ, C: ÎÔÏÂÛÙÈfiÏË, S: ÛÙ·Ù›ÓË, IR: ¿ÌÂÛ˘ ·Ô‰¤ÛÌ¢Û˘, SR: ÂÈ‚Ú·‰˘ÓfiÌÂÓ˘ ·Ô‰¤ÛÌ¢Û˘
9
™∂¶∆∂ªµƒπ√™ 2007
¶›Ó·Î·˜ 5. ∂›‰Ú·ÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ Û˘Ó‰˘·ÛÌÔ‡ ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ·Ú·ÙÂٷ̤Ó˘ ‰Ú¿Û˘ (PR) Ì ÛÙ·Ù›Ó˜ ÛÙÔ ÏÈȉ·ÈÌÈÎfi ÚÔÊ›Ï ªÂϤÙ˜
PR ÓÈÎÔÙÈÓÈÎfi Ô͇ (g day–1)
™Ù·Ù›Ó˜ (mg day–1)
TG (%)
LDL-C(%)
HDL-C(%)
Guyton Î·È Capuzzi [46]
2
¢È¿ÊÔÚ˜1 10–20
–35
–36
+26
Kashyap et al. [47]
2
§Ô‚·ÛÙ·Ù›ÓË 40
–42
–45
+41
Bays et al. [48]
2
§Ô‚·ÛÙ·Ù›ÓË 40
–49
–42
+32
Capuzzi et al. [49]
1 2 1 2
ƒÔÛÔ˘‚·ÛÙ·Ù›ÓË 40 ƒÔÛÔ˘‚·ÛÙ·Ù›ÓË 10 §Ô‚·ÛÙ·Ù›ÓË 20 §Ô‚·ÛÙ·Ù›ÓË 40
–39 –34 –26 –43
–42 –36 –28 –42
+17 +24 +21 +30
Hunninghake et al. [50]
PR: ·Ú·ÙÂٷ̤Ó˘ ·Ô‰¤ÛÌ¢Û˘, 1:ÊÏÔ˘‚·ÛÙ·Ù›ÓË 20, ÏÔ‚·ÛÙ·Ù›ÓË 20, Ú·‚·ÛÙ·Ù›ÓË 10, ÛÈÌ‚·ÛÙ·Ù›ÓË 10, TG: ÙÚÈÁÏ˘ÎÂÚ›‰È·, LDL-C: ¯ÔÏËÛÙÂÚfiÏË ÙˆÓ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙÂ˚ÓÒÓ, HDL-C: ¯ÔÏËÛÙÂÚfiÏË ÙˆÓ ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙÂ˚ÓÒÓ
‰¤ÚÌ·ÙÔ˜, ÙÔ Ô›‰ËÌ· ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, Ë ÌÈÎÚ‹ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (ηٿ 11%), Ë ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘ Î·È Ë ÌÈÎÚ‹ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ʈÛÊfiÚÔ˘ ÛÙÔ Ï¿ÛÌ· (ηٿ 10%)43.
¡ÈÎÔÙÈÓÈÎfi Ô͇ Î·È ıÚÔÌ‚ÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜. ªÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ ÂËÚ¿˙ÂÈ ÙÔ ÈÓˆ‰ÔÏ˘ÙÈÎfi Û‡ÛÙËÌ· ›Ù ¿ÌÂÛ·, ›Ù ‰È·Ì¤ÛÔ˘ Ù˘ ›‰Ú·Û‹˜ ÙÔ˘
ÛÙ· ›‰· ÙˆÓ ÂχıÂÚˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ 59. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ô ·Ó·ÛÙÔϤ·˜ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘ (PAI) Â›Ó·È ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ Î·È Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ˘ÂÚÙÚÈÁÏ˘ÎÂÚȉ·ÈÌ›· 60-62. √ Johansson Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ ¤‰ÂÈÍ·Ó fiÙÈ Ë ıÂڷ›· Ì ÓÈÎÔÙÈÓÈÎfi Ô͇ Û ·ÛıÂÓ›˜ Ì ˘ÂÚÙÚÈÁÏ˘ÎÂÚȉ·ÈÌ›· ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ıÚÔÌ‚ˆÙÈÎÒÓ ·Ú·Áfi-
ÓÙˆÓ PAI-1, tPA, ηıÒ˜ Î·È ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘ ηٿ 31%,15% Î·È 15% ·ÓÙ›ÛÙÔȯ· 63. ™˘ÓÔ„›˙ÔÓÙ·˜, ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇ Â›Ó·È ¤Ó· ˘ÔÏÈȉ·ÈÌÈÎfi Ê¿ÚÌ·ÎÔ Ô˘ ¤¯ÂÈ ÙË ÌÔÓ·‰È΋ ÈηÓfiÙËÙ· Ó· ÌÂÈÒÓÂÈ Ù· ›‰· Ù˘ Lp(a) Î·È Ó· ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο Ù· ›‰· Ù˘ ∏DL ¯ÔÏËÛÙÂÚfiÏ˘. øÛÙfiÛÔ, ¤¯ÂÈ ·ÚÎÂÙ¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ, ÔÈ Ôԛ˜ ÂÚÈÔÚ›˙Ô˘Ó ÙËÓ Â˘Ú‡ÙÂÚË ¯Ú‹ÛË ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË.
µÈ‚ÏÈÔÁÚ·Ê›· 1.
Altschul R, Hoffer A, Stephen JD. Influence of nicotinic acid on serum cholesterol in man. Arch Biochem 1955; 54: 558-9.
2.
Lorenzen A, Stannek C, Lang H et al. Characterization of a G protein-coupled receptor for nicotinic acid. Mol Pharmacol 2001; 59: 349-57.
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Wise A, Foord SM, Fraser NJ et al. Molecular identification of high and low affinity receptors for nicotinic acid. J Biol Chem 2003; 278: 9869-74. Tunaru S, Kero J, Schaub A et al . PUMA-G and HM74 are receptors for nicotinic acid and mediate its antilypolytic effect. Nat Med 2003; 9: 352-5. Parsons WB, Achor RWP, Berge KG, McKenzie BF, Barker NW. Changes in blood lipids following prolonged administration of large doses of nicotinic acid to persons with hypercholesterolaemia. Proc Staff Meet Mayo Clin 1956; 31: 377-90. Parsons WB, Flinn JH. Reduction of serum cholesterol levels and beta-lipoprotein cholesterol levels by nicotinic acid. Arch Intern Med 1959; 103: 783-90. Karpe F, Frayn KN. The nicotinic acid receptor- a new mechanism for an old drug. Lancet 2004; 363: 1892-4.
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Carlson LA, Oro L. EEffect of treatment with nicotinic acid for one month on serum lipids in patients with different types of hyperlipidaemia. Atherosclerosis 1973; 18: 1-9.
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Third report of the National Cholesterol Education Program (NCEP). Expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III); final report. Circulation 2002; 106: 3143-421.
10. Albrink M, Man EB. Serum triglycerides in coronary artery disease. Arch Intern Med 1959; 103: 4-8. 11. Carson LA. Serum lipids in men with myocardial infarction. Acta Med Scand 1960; 167: 399-413. 12. Castelli W. Epidemiology of triglycerides: a view from Framingham. Am J Cardiol 1992; 70: 3H-9H. 13 Miller GJ, Miller NE. Plasma high-density lipoprotein concentration and development of ischaemic heart disease. Lancet 1975; I: 16-19. 14. Gordon T, Castelli WP, Hjortland MC et al. High density lipoprotein as a protectine factor against coronary heart disease. The Framingham Study. Am J Med 1977; 62: 707-14.
15. Dejager S, Bruckert E, Chapman MJ. Dense low density lipoprotein subspecies with diminished oxidative resistance predominate in combined hyperlipidaemia. J Lipid Res 1993; 34: 295308. 16. Lamarche B, Tchernof A, Dagenais GR et al. Small, dense particle and the risk of ischemic heart disease:prospective results from the Quebec Cardiovascular Study. Circulation 1997; 95: 69-75. 17. Superko HR, McGovern ME, Raul E et al. Differential effect of two nicotinic acid preparations on low-density lipoprotein subclass distribution in patients classified as low-density lipoprotein pattern A, B, or I. Am J Cardiol 2004; 94: 588–94. 18. Carlson LA, Hamsten A, Asplund A. Pronounced lowering of serum levels of lipoprotein Lp(a) in hyperlipidaemic subjects treated with nicotinic acid. J Intern Med 1989; 226: 271-6. 19. Von Eckardstein A, Assman G. Clinical implications of elevated lipoprotein (a). Curr Atheroscler Rep 2001;3: 267-70. 20. U.K.Prospective Diabetes Study Group. Prospective Diabetes Study 27 Plasma lipids and lipoproteins at diagnosis of NIDDM by age and sex. Diabetes Care 1997; 20: 1683-7.
£EPA¶EIA - ºAPMAKA 21. Elam MB, Hunninghake DB, Davis KB, Garg R, Johnson C, Egan D, Kostis JB, Sheps DS, µrinton EA. Effect of niacin on lipid and lipoprotein levels and glycemic control in patients with diabetes and peripheral arterial disease: the ADMIT study: A randomized trial. Arterial Disease Multiple Intervention Trial. JAMA. 2000; 284: 1263-70. 22. Brown BG, Zhao XQ, Chait A et al. Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease. N Engl J Med 2001; 345: 1583-92. 23. Deedwania PC, Gupta R. Management issues in the metabolic syndrome. J Assoc Physicians India 2006; 54: 797810. 24. Deedwania PC, Volkova N. Current Treatment Options for the Metabolic Syndrome. Gurr Treat Options Cardiovasc Med 2005; 7: 61-74. 25. Wagh A, Stone NJ. Treatment of metabolic syndrome. Expert Rev Cardiovasc Ther 2004; 2: 213-28. 26. Menuet R, Lavie CJ, Milani RV. Importance and management of dyslipidemia in the metabolic syndrome. Am J Med Sci 2005; 330: 295-302. 27. Carlson LA. Nicotinic acid: the broadspectrum lipid drug. A 50th anniversary review. J Intern Med. 2005; 258: 94114. 28. Blankenhorn DH, Nessim SA, Johnson RL et al. Beneficial effects of combined colestipol–niacin therapy on coronary atherosclerosis and coronary bypass grafts. JAMA 1987; 257: 3233–40. 29. Brown G, Albers J, Fisher LD et al. Regression of coronary artery disease as a result of intensive lipid-lowering therapy in men with high levels of apolipoprotein B. N Engl J Med 1990; 323: 1289–98. 30. Jacobson TA, Chin MM, Fromell GJ. Fluvastatin with and without niacin for hypercholesterolemia. Am Cardiol 1994; 74: 149–54. 31. O'Keefe JH Jr. Effects of pravastatin with niacin or magnesium on lipid levels and postprandial lipemia. Am J Cardiol 1995; 76: 480–4. 32. Gardner SF. Combination therapy with low-dose lovastatin and niacin is as effective as higher-dose lovastatin. Pharmacotherapy 1996; 16: 419–23. 33. Laurell S. Recycling of intravenously injected palmitic acid-1-C14 as esterified fatty acid in the plasma of rats and turnover rate of plasma triglycerides. Acta Physiol Scand 1959; 47: 218-23. 34. Carlson LA. Studies on the incorporation of injected palmitic acid-1-C14 into liver and plasma lipids in man. Acta Soc Med Ups 1960; 65: 85-9. 35. Haver RJ. Conversion of plasma free fatty acids into triglycerides of plasma lipoprotein fractions in man. Metab Clin Exp 1961; 10: 1031-6. 36. Brinton EA, Eisenberg S, Brteslow JL. Human HDL chgolesterol levels are determined by Apo A-I fractional catabolic rate, which correlates inversely which estimates of HDL particle size. Arterioscler Thromb 1994; 14: 707-20. 37. Jin F-Y, Kmanna VS, Kashyap ML et
al. Niacin decreases removal of highdensity lipoprotein apolipoprotein A-I but not cholesterol ester by Hep G2 cells. Arterioscler Thromb Vasc Biol 1997; 17: 2020-8. 38. Rubic T, Trottman M, Lorenz RL. Stimulation of CD 36 and the key effector of reverse cholesterol transport ATP-binding cassette A1 in monocytoid cells by niacin. Biochem Pharmacol 2004; 67: 411-9. 39. The Coronary Drug Project Research Group. Clofibrate and niacin in coronary heart disease. JAMA 1975; 231: 360-81. 40. Canner PL, Berge KG, Wenger NK et al. Fifteen year mortality in Coronary Drug Project Patients. Long-term benefits with niacin. J Am Coll Cardiol 1986; 81: 1245-55. 41. Carlson LA, Rosenhamer G. Reduction of mortality in the Stockholm Ischaemic Heart Disease Secondary Prevention Study by combined treatment with clofibrate and nicotinic acid. Acta Med Scand 1988; 223: 405–18. 42. Carlson LA. Niaspan, the prolonged release preparation of nicotinic acid (niacin), the broad-spectrum lipid drug. Int J Clin Pract 2004 ;58: 706-13. 43. Guyton JR, Bays HE. Safety considerations with niacin therapy. Am J Cardiol 2007 ;99: 22C-31C. 44. Knopp RH, Alagona P, Davidson M et al. Equivalent efficacy of a time-release form of niacin (Niaspan) given once-anight versus plain niacin in the management of hyperlipidemia. Metabolism 1998; 47: 1097-104. 45. Grundy SM, Vega GL, McGovern ME et al. Efficacy, safety, and tolerability of once-daily niacin for the treatment of dyslipidemia associated with type 2 diabetes. Results of the assessment of diabetes control and evaluation of the efficacy of niaspan trial. Arch Intern Med 2002; 162: 1568–76. 46. Guyton JR, Capuzzi DM. Treatment of hyperlipiemia with combined niacin–statin regimens. Am J Cardiol 1998; 82: 82U–6U. 47. Kashyap ML, McGovern ME, Berra K et al. Long-term safety and efficacy of a once-daily niacin/lovastatin formulation for patients with dyslipidemia. Am J Cardiol 2002; 89: 672–8. 48. Bays HE, Dujovne CA, McGovern ME et al. Comparison of once-daily niacin extended-release/lovastatin with standard doses of atorvastatin and simvastatin [the ADvicor Versus Other Cholesterolmodulating Agents Trial Evaluation (ADVOCATE)]. Am J Cardiol 2003; 91: 667–72. 49. Capuzzi DM, Morgan JM, Weiss RJ et al. Beneficial effects of rosuvastatin alone and in combination with extended-release niacin in patients with a combined hyperlipidemia and low highdensity lipoprotein cholesterol levels. Am J Cardiol 2003; 91: 1304–10.
51. Morrow JD, Awad JA, Oates A, Roberts LJ II. Identification of skin as a major site of prostaglandin D2 release following oral administration of niacin in humans. J Invest Dermatol. 1992 ;98: 812-5. 52. Carlson LA, Ekelund LG, Oro L. Clinical and metabolic effects of different doses of prostaglandin E1 in man. Acta Med Scand 1968; 183: 423-30. 53. Kaijser L, Eklund LG, Osslon AG et al .Dissociation of the effects of nicotinic acid on vasolidation and lipolysis by a prostaglandin synthesis inhibitor, indomethacin, in man. Med Biol 1979; 57: 114-7. 54. Olsson AG, Carlson LA, Anggard E et al . Prostacyclin production augmented in the short term by nicotinic acid. Lancet 1983; 2: 565-6. 55. Cheng K, Wu TJ, Wu KK, Sturino C, Metters K, Gottesdiener K, Wright SD, Wang Z, O'Neill G, Lai E, Waters MG. Antagonism of the prostaglandin D2 receptor 1 suppresses nicotinic acidinduced vasodilation in mice and humans. Proc Natl Acad Sci U S A 2006; 103: 6682-7. 56. Guyton JR. Extended-release niacin for modifying the lipoprotein profile. Expert Opin Pharmacother 2004; 5: 1385-98. 57. Gershon SL, Fox IH. Pharmacologic effects of nicotinic acid on human purine metabolism. J Lab Clin Med 1974; 84: 179-86. 58. Andersson S, Carlson LA, Orö L et al . Effect of nicotinic acid on gastric secretion of acid in human subjects and in dogs. Scand J Gastroenterol 1971; 6: 555–9. 59. Weiner M, Redisch W, Steele JM. Occurrence of fibrinolytic activity following administratin of nicotinic acid. Proc Soc Exp Biol Med 1958; 98: 755-7. 60. Hamsten A, Wiman B, de Faire U et al. Increased plasma levels of a rapid inhibitor of tissue plasminogen activator in young survivors of myocardial infarction. N Engl J Med 1985; 313: 155763. 61. Hamsten A, de Faire U, Walldius G, et al. Plasminogen activator inhibitor in plasma: risk factor for recurrent myocardial infarction. Lancet 1987; ii: 3-9. 62. Asplund-Carlson A, Hamsten A, Wiman B et al . Relationship between plasma plasminogen activator inhibitor-1 activity and VLDL-triglyceride concentration, insulin levels and insulin sensitivity: studies in randomly selected normand hypertriglyceridaemic men. Diabetologia 1993; 36: 817-25. 63. Johansson JQ, Egberg N, AsplundCarson A et al. Nicotinic acid treatment shifts the fibrinolytic balance favourably and decreases plasma fibrinogen in hypertriglyceridaemic men. J Cardiovasc Risk 1997; 4: 165-71.
50. Hunninghake DB, McGovern ME, Koren M et al . A dose-ranging study of a new, once daily, dual-component drug product containing niacin extended-release and lovastatin. Clin Cardiol 2003; 26: 112–8.
11
™∂¶∆∂ªµƒπ√™ 2007
T· √ʤÏË ·fi ™Ù·Ù›ÓË ÛÙËÓ ∫·Ú‰È·Î‹ ∞Ó¿ÚÎÂÈ· ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î·È ÙËÓ ¶ÚÔÛÙ·Û›· ·fi ∞ÈÊÓ›‰ÈÔ £¿Ó·ÙÔ. µ. Õı˘ÚÔ˜, ∞. ∫·Î·Ê‹Î·, ∫. ∆˙ÈfiÌ·ÏÔ˜, ∂. ¶·ÓÎÔ˘Ú¤ÏÈ·˜, Ã. ∫Ô˘Ì·Ú¿˜, ∞. ∫·Ú·ÁÈ¿ÓÓ˘. ∏ ›وÛË Ù˘ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ (∫∞) ·˘Í¿ÓÂÙ·È Û˘Ó¯Ҙ ·Ú¿ ÙȘ ÚÔfi‰Ô˘˜ ÛÙËÓ ÚfiÏË„Ë Î·È ıÂڷ›· Ù˘. ¶ÔÏϤ˜ ÚfiÛÊ·Ù˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ Û·ÊÒ˜ fiÙÈ Ë ıÂڷ›· Ì ÛÙ·Ù›ÓË Û˘Ó‰¤ÂÙ·È Ì ηχÙÂÚË ¤Î‚·ÛË Ù˘ ∫∞ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ (ÈÛ¯·ÈÌÈ΋ ‹ ÌË) ‹ Ù· ›‰· ¯ÔÏËÛÙÂÚfiÏ˘. [1] ¶Ú¿ÁÌ·ÙÈ, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ÌÂÁ¿Ï˜ ÌÂϤÙ˜ Ì ÛÙ·Ù›Ó˜ Î·È ·˘Ù¤˜ Ì ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ∫∞ ¤¯Ô˘Ó ηٷ‰Â›ÍÂÈ ÌÈ· ıÂÙÈ΋ ›‰Ú·ÛË ÙˆÓ ÛÙ·ÙÈÓÒÓ ÛÙËÓ ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ∫∞. ∂ÈϤÔÓ, Ë ¯Ú‹ÛË ÙˆÓ ÛÙ·ÙÈÓÒÓ ÛÙË ∫∞ Ê·›ÓÂÙ·È Ó· Â›Ó·È ·ÛÊ·Ï‹˜ ‰Â‰Ô̤ÓÔ˘ fiÙÈ Î·Ì›· ·fi ÙȘ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ‰ÂÓ ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ·ÛıÂÓ›˜ Ì ∫∞ Û Âȉ›ӈÛË. [1] √È Èı·ÓÔ› Ì˯·ÓÈÛÌÔ› ̤ۈ ÙˆÓ ÔÔ›ˆÓ ÔÈ ÛÙ·Ù›Ó˜ ı· ÌÔÚÔ‡Û·Ó Ó· ˆÊÂÏ‹ÛÔ˘Ó ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ∫∞ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î˘Ú›ˆ˜ ÙȘ ÌË ÏÈȉ·ÈÌÈΤ˜ ‰Ú¿ÛÂȘ ÙˆÓ ÛÙ·ÙÈÓÒÓ. ∏ ›‰Ú·ÛË ÛÙÔ ÓÈÙÚÈÎfi ÔÍ›‰ÈÔ, ÛÙ· ÂÓ‰ÔıËÏȷο ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘, ÛÙËÓ ·fiÙˆÛË, ÛÙË Ì˘Ôηډȷ΋ ·Ó·‰È·ÌfiÚʈÛË Î·È ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË Ó¢ÚÔÔÚÌÔÓÒÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÔÈ Èı·ÓÔ› ˆÊ¤ÏÈÌÔÈ Ì˯·ÓÈÛÌÔ› ‰Ú¿Û˘. [1] ∆· ÛÙÔȯ›· ÎÏÈÓÈÎÔ‡ ÔʤÏÔ˘˜ ÙˆÓ ÛÙ·ÙÈÓÒÓ Û ·ÛıÂÓ›˜ Ì ∫∞ ÚÔ¤Ú¯ÔÓÙ·È ·fi ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ ‹ ÌÂϤÙ˜ ·Ú·Ù‹-
ÚËÛ˘. √È ÌÂÁ¿Ï˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜ Ô˘ ‰ÈÂÓÂÚÁÔ‡ÓÙ·È ÙÒÚ· ı· ÂȂ‚·ÈÒÛÔ˘Ó Ì ۷ʋÓÂÈ· ÙÔ ÚfiÏÔ ÙˆÓ ÛÙ·ÙÈÓÒÓ ÛÙË ıÂڷ›· ·ÛıÂÓÒÓ Ì ∫∞. [2] ™ÙÔ ÚfiÛÊ·ÙÔ (1-5 ™ÂÙÂÌ‚Ú›Ô˘ 2007) Û˘Ó¤‰ÚÈÔ Ù˘ European Society of Cardiology ÛÙË µÈ¤ÓÓË ·Ó·ÎÔÈÓÒıËÎ·Ó ÛÙÔȯ›· Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ ı¤Ì· ·˘Ùfi[3]. ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ÈÏÔÙÈ΋ ÌÂϤÙË Ô˘ ÂÚȤϷ‚ 110 ¿ÙÔÌ· Ì ∫∞ Ô˘ Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Û 10 mg/Ë̤ڷ ·ÙÔÚ‚·ÛÙ·Ù›Ó˘ ‹ Û ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ. ∆· ÎÚÈÙ‹ÚÈ· ÂÈÛfi‰Ô˘ ÛÙË ÌÂϤÙ˘ ‹Ù·Ó ∫∞ NYHA-3 Î·È ÎÏ¿Ì· ÂÍÒıËÛ˘ < 30%. √È ·ÛıÂÓ›˜ ·ÔÎÏ›ÛÙËÎ·Ó Â¿Ó ‹Ù·Ó Û ÚÔËÁÔ‡ÌÂÓË ıÂڷ›· Ì ÛÙ·Ù›Ó˜ ‹ ·ÌȈ‰·ÚfiÓË ‹ ›¯·Ó ·˘ÙfiÌ·ÙÔ ÂÌÊ˘Ù‡ÛÈÌÔ ·ÈÓȉˆÙ‹. ™¯Â‰fiÓ fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ ‹Ù·Ó Û ıÂڷ›· Ì ‰ÈÔ˘ÚËÙÈο ·Á·Ï˘ Î·È ·ª∂∞, ÂÓÒ ÂÚ›Ô˘ ÙÔ 80% ‹Ù·Ó Û ıÂڷ›· Ì ‚-·ÔÎÏÂÈÛÙ¤˜. ∏ ∫∞ ‹Ù·Ó ÈÛ¯·ÈÌÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Û ÔÛÔÛÙfi ÂÚ›Ô˘ 60% ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ ÌÂϤÙ˘. ∆Ô ÔÛÔÛÙfi ı·Ó¿ÙÔ˘ ·fi ÔÔÈ·‰‹ÔÙ ·ÈÙ›· ÁÈ· ¿Óˆ ·fi 12 Ì‹Ó˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ‹Ù·Ó 16% ÁÈ· ÙÔ˘˜ 55 ·ÛıÂÓ›˜ ÛÙËÓ ÔÌ¿‰· Ù˘ ·ÙÔÚ‚·ÛÙ·Ù›Ó˘ Î·È 36% ÁÈ· ÙÔ˘˜ 55 Ô˘ ‹Ù·Ó Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÛÙÔ ÂÈÎÔÓÈÎfi Ê¿Ú-
Ì·ÎÔ (p=0,017). ∆· ÔÛÔÛÙ¿ ÙÔ˘ ·ÈÊÓ›‰ÈÔ˘ ηډȷÎÔ‡ ı·Ó¿ÙÔ˘ ‹Ù·Ó 5% Î·È 22%, ·ÓÙ›ÛÙÔȯ· (p=0,012), ÂÓÒ Ë ‰È·ÊÔÚ¿ ÛÙË ıÓËÙfiÙËÙ· ·fi ÙËÓ ·Ó¿ÚÎÂÈ· ·ÓÙÏ›·˜ ‹Ù·Ó ÏÈÁfiÙÂÚÔ ÂÎÛÂÛËÌ·Ṳ̂ÓË: 9% ÛÙËÓ ÔÌ¿‰· Ù˘ ·ÙÔÚ‚·ÛÙ·Ù›Ó˘ Î·È 15% ÛÙËÓ ÔÌ¿‰· ÙÔ˘ ÂÈÎÔÓÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ (p=0,38). ∆Ô ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ (·fi ·ÈÊÓ›‰ÈÔ Î·Ú‰È·Îfi ı¿Ó·ÙÔ ÌfiÓÔ) ‹Ù·Ó 2,3 ÊÔÚ¤˜ ˘„ËÏfiÙÂÚÔ ÛÙËÓ ÔÌ¿‰· Ù˘ ·ÙÔÚ‚·ÛÙ·Ù›Ó˘ ·' fiÙÈ ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ (p=0,01). ∏ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ¤‰ÂÈÍ fiÙÈ Ë ËÏÈΛ·, Ë ·ÈÙÈÔÏÔÁ›· Ù˘ ∫∞, Î·È Ù· ›‰· ÙÔ˘ Ó·ÙÚÈÔ˘ÚËÙÈÎÔ‡ ÂÙȉ›Ô˘ ‰ÂÓ ‹Ù·Ó ÛËÌ·ÓÙÈÎÔ› ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ÙÔ˘ ·ÈÊÓ›‰ÈÔ˘ ηډȷÎÔ‡ ı·Ó¿ÙÔ˘. ∞ÓÙÈı¤Ùˆ˜ ¤Ó·˜ QT-variability index ÛÙËÓ 75Ë ÂηÙÔÛÙÈ·›· ı¤ÛË ‹Ù·Ó ·ÓÂÍ¿ÚÙËÙÔ˜ ‰Â›ÎÙ˘ ÎÈÓ‰‡ÓÔ˘ Ì ‚·ıÌfi ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜ 1,45 (p=0,02). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ ÛÙÔ Ì¤ÏÏÔÓ Ë ÂÈÏÔÁ‹ Ù˘ ÛÙ·Ù›Ó˘ ÁÈ· ·ÛıÂÓ›˜ Ì ∫∞ ı· ÂÍ·ÚÙ¿Ù·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÙȘ ·ÓÙÈÊÏÂÁÌÔÓÒ‰ÂȘ ȉÈfiÙËÙ˜ Ù˘ Î·È ÙË ÚÔÒıËÛË Ù˘ ËÏÂÎÙÚÈ΋˜ ÛÙ·ıÂÚfiÙËÙ¿˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È fi¯È ÙfiÛÔ ·fi ÙÔ ˘ÔÏÈȉ·ÈÌÈÎfi Ù˘ ·ÔÙ¤ÏÂÛÌ·.
µÈ‚ÏÈÔÁÚ·Ê›· 1.
12
Tsouli SG, Liberopoulos EN, Goudevenos JA, Mikhailidis DP, Elisaf MS. Should a statin be prescribed to every patient with heart failure? Heart Fail Rev. 2007 Aug 12; [Epub ahead of print]
2.
Celik T, Iyisoy A, Dogru MT, Isik E. Statin use in chronic heart failure: Waiting for the results of large prospective outcome trials. Int J Cardiol. 2007 Aug 31; [Epub ahead of print]
3.
Vrtovec B, Okrajsek R, Golicnik A, et al. Atorvastatin therapy decreases sudden cardiac death in patients with advanced chronic heart failure: a prospective study. European Society of Cardiology Congress 2007; September 4, 2007; Vienna, Austria. Abstract 3195.
£EPA¶EIA - ºAPMAKA
AÏÏ·Á‹ ÌÈ·˜ ¶ÚˆÙfiÙ˘Ë˜ ™Ù·Ù›Ó˘ Ì ∞ÓÙ›ÁÚ·ÊÔ (Generic). Y¿Ú¯ÂÈ ŸÊÂÏÔ˜ ‹ ∫fiÛÙÔ˜; µ. ’∞ı˘ÚÔ˜, ∫. ∆˙ÈfiÌ·ÏÔ˜, ∞. ∫·Î·Ê‹Î·, Ã. ∫Ô˘Ì·Ú¿˜, ∂. ¶·ÓÎÔ˘Ú¤ÏÈ·˜, ∞. ∫·Ú·ÁÈ¿ÓÓ˘.
Œ¯ÂÈ ·Ô‰ÂȯÙ› fiÙÈ Ë ıÂڷ›· Ì ÛÙ·Ù›Ó˜ ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ Î·Ú‰È·ÁÁÂȷ΋ ıÓËÙfiÙËÙ· Î·È ÓÔÛËÚfiÙËÙ· ÛÙ· Ï·›ÛÈ· ÙfiÛÔ Ù˘ ÚˆÙÔÁÂÓÔ‡˜ fiÛÔ Î·È Ù˘ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ÚfiÏ˄˘ Ù˘ ·ıËÚÔÛÎÏËÚˆÙÈ΋˜ ÓfiÛÔ˘. ¶ÔÏϤ˜ ΢‚ÂÚÓ‹ÛÂȘ, ·ÛÊ·ÏÈÛÙÈο Ù·Ì›· ‹ ·ÛÊ·ÏÈÛÙÈΤ˜ ÂÙ·ÈÚ›˜ Û˘ÓÈÛÙÔ‡Ó ÙËÓ ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ ÚˆÙfiÙ˘ˆÓ ÌÔÚ›ˆÓ ÛÙ·ÙÈÓÒÓ Ì ·ÓÙ›ÁÚ·Ê· (generics) ÁÈ· Ó· ÂÏ·ÙÙÒÛÔ˘Ó Ô ÎfiÛÙÔ˜ ıÂڷ›·˜ Ì ÛÙ·Ù›Ó˜ (Ù· ·ÓÙ›ÁÚ·Ê· Â›Ó·È 20% - 30% ÊıËÓfiÙÂÚ· ·fi ÙȘ ÚˆÙfiÙ˘Â˜ ÛÙ·Ù›Ó˜). [1] ¢ÂÓ ˘¿Ú¯Ô˘Ó fï˜ ÛÙÔȯ›· Ô˘ Ó· ‰Â›¯ÓÔ˘Ó ÙËÓ Â›ÙˆÛË ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ·ÓÙÈηٷÛÙ¿ıËÎÂ Ë ÚˆÙfiÙ˘Ë ÛÙ·Ù›ÓË Ì ¤Ó· ·ÓÙ›ÁÚ·ÊÔ. ∞˘Ùfi Ô˘ ÁÓˆÚ›˙Ô˘Ì ÌfiÓÔ Â›Ó·È fiÙÈ Ë ·ÏÏ·Á‹ ·˘Ù‹ ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο ÙË Û˘ÌÌfiÚʈÛË ÙˆÓ ·ÛıÂÓÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ¤¯Ô˘Ì Û ·ÛıÂÓ›˜ Ô˘ ·›ÚÓÔ˘Ó ·ÓÙ›ÁÚ·Ê· Ôχ ÂÚÈÛÛfiÙÂÚ˜ ‰È·ÎÔ¤˜ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ·’ fiÙÈ Û ÂΛÓÔ˘˜ Ô˘ ·›ÚÓÔ˘Ó ÚˆÙfiÙ˘· Ê¿Ú̷η. [2] ™ÙÔ ÚfiÛÊ·ÙÔ (1-5 ™ÂÙÂÌ‚Ú›Ô˘ 2007) Û˘Ó¤‰ÚÈÔ Ù˘ European Society of Cardiology ÛÙË µÈ¤ÓÓË ·Ó·ÎÔÈÓÒıËÎ·Ó ÛÙÔȯ›· Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔ ı¤Ì· ·˘Ùfi. [3] ™ÙË ÌÂϤÙË Ô˘ ı· ·Ó·Ï˘ı› ·Ú·Î¿Ùˆ ‰ÈÂÚ¢ӋıËÎÂ Ë Â›‰Ú·ÛË Ù˘ ·ÏÏ·Á‹˜ Ù˘ ·ÙÔÚ‚·ÛÙ·Ù›Ó˘ Û ·ÓÙ›ÁÚ·ÊÔ ÛÈÌ‚·ÛÙ·Ù›Ó˘ Û ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ·fi ÙËÓ ÚˆÙÔ‚¿ıÌÈ· ÊÚÔÓÙ›‰· THIN (The Health Improvement Network) ÛÙÔ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ. [3] ∆· ÙÂÏÈο ÛËÌ›· ‹Ù·Ó Ë Û‡ÁÎÚÈÛË Ù˘ ηډȷÁÁÂȷ΋˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜, ÙˆÓ ÔÛÔÛÙÒÓ ‰È·ÎÔ‹˜ ÙÔ˘ Ê·Ú-
Ì¿ÎÔ˘ Î·È ÙˆÓ ÂȤ‰ˆÓ ÏÈȉ›ˆÓ ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ú¤ÌÂÈÓ·Ó Û ıÂڷ›· Ì ·ÙÔÚ‚·ÛÙ·Ù›ÓË Î·È ÂÎÂ›ÓˆÓ Ô˘ ¿ÏÏ·Í·Ó ·fi ·ÙÔÚ‚·ÛÙ·Ù›ÓË Û ·ÓÙ›ÁÚ·ÊÔ ÛÈÌ‚·ÛÙ·Ù›Ó˘, ΢ڛˆ˜ ÁÈ· ÔÈÎÔÓÔÌÈÎÔ‡˜ ÏfiÁÔ˘˜. ∞ÛıÂÓ›˜ Ô˘ ‹Ù·Ó Û ıÂڷ›· Ì ·ÙÔÚ‚·ÛÙ·Ù›ÓË ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 6 Ì‹Ó˜ ‚Ú¤ıËÎ·Ó ·fi ÙË ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ UK THIN. ∞˘Ù‹ Â›Ó·È ÌÈ· ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ ÚˆÙÔ‚¿ıÌÈ·˜ ÊÚÔÓÙ›‰·˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ 4,77 ÂηÙÔÌ̇ÚÈ· ¿ÙÔÌ· ·fi 300 ‰È·ÊÔÚÂÙÈο ÛËÌ›· ÙÔ˘ ∏ӈ̤ÓÔ˘ µ·ÛÈÏ›Ԣ. ∞ÛıÂÓ›˜ Ô˘ ¯·Ú·ÎÙËÚ›ÛÙËÎ·Ó fiÙÈ ¿ÏÏ·Í·Ó ·fi ·ÙÔÚ‚·ÛÙ·Ù›ÓË Û ÛÈÌ‚·ÛÙ·Ù›ÓË ‹Ù·Ó ·˘ÙÔ› Ô˘ ¤·ÈÚÓ·Ó ·ÙÔÚ‚·ÛÙ·Ù›ÓË ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 6 Ì‹Ó˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ‹Ú·Ó ÛÈÌ‚·ÛÙ·Ù›ÓË. √È ÙÂÏÂ˘Ù·›ÔÈ ÁÈ· Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÛÙË ÌÂϤÙË ¤Ú ӷ ‘Ù·ÈÚÈ¿˙Ô˘Ó‘ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ Ê‡ÏÔ, ÛÙÔ ÈÛÙÔÚÈÎfi ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ ‹ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ÛÙÔ ¯ÚfiÓÔ ıÂڷ›·˜ Ì ÛÙ·Ù›Ó˜ Î·È ÛÙË ÁˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹ Ì 4 ÙÔ˘Ï¿¯ÈÛÙÔÓ ·ÛıÂÓ›˜ Ô˘ ·Ú¤ÌÂÈÓ·Ó Û ·ÙÔÚ‚·ÛÙ·Ù›ÓË. ∞˘Ùfi ¤ÁÈÓ ̤¯ÚÈ Î·È ÙÔÓ πÔ‡ÓÈÔ ÙÔ˘ 2005. [3]
¤ÁÈÓ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ıÂڷ›·˜ Ì Cox proportional hazards model, Â›Â‰Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ p<0.05. ∆· ‰Â‰Ô̤ӷ ‰ÈÔÚıÒıËÎ·Ó ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ·, ÙËÓ ¯ÔÏËÛÙÂÚfiÏË ÂÎΛÓËÛ˘, ÙÔÓ ·ıÚÔÈÛÙÈÎfi ¯ÚfiÓÔ ıÂڷ›·˜ Ì ÛÙ·Ù›Ó˜, ·ÏÏ¿ ·ÎfiÌË Î·È Ù· ÛÙÔȯ›· ‘Ù·ÈÚÈ¿ÛÌ·ÙÔ˜‘ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙË ÌÂϤÙË (ʇÏÔ, ÈÛÙÔÚÈÎfi ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ ‹ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË). ∏ ·Ó¿Ï˘ÛË ·˘Ù‹ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤Ï·‚ ˘fi„Ë Î·È ÙËÓ ÚÒÈÌË ‰È·ÎÔ‹ Ù˘ ÛÙ·Ù›Ó˘, Ë ÔÔ›· ÂÔ̤ӈ˜ ‰ÂÓ Û˘ÌÌÂÙ›¯Â ÛÙË ‰È·ÌfiÚʈÛË Ù˘ ‰È·ÊÔÚ¿˜ ÛÙÔ ÚˆÙÔÁÂÓ¤˜ ÙÂÏÈÎfi ÛËÌ›Ô.
¢∂À∆∂ƒ√°∂¡∂™ ∆∂§π∫√ ™∏ª∂π√ -- ŸÏ· Ù· Û˘ÛÙ·ÙÈο ÙÔ˘ ÚˆÙÔÁÂÓÔ‡˜ ÙÂÏÈÎÔ‡ ÛËÌ›Ԣ. -- ∏ ‰È·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· ‰È·ÎÔ‹˜ Ù˘ ÛÙ·Ù›Ó˘ (ÂÚÈÛÛfiÙÂÚÔ ·fi 90 Ë̤Ú˜ ÌË Ï‹„˘). ∞˘Ù‹ ‘‘‰ÈÔÚıÒıËΑ‘ ˆ˜ ÚÔ˜ Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Ù·ÈÚÈ¿ÛÌ·ÙÔ˜ Î·È ÙÔ Û˘ÓÔÏÈÎfi ¯ÚfiÓÔ Ï‹„˘ ÛÙ·Ù›Ó˘
∆ƒπ∆√°∂¡∂™ ∆∂§π∫√ ™∏ª∂π√
∆ÂÏÈο Û˘ÌÌÂÙ›¯·Ó 11.520 ·ÛıÂÓ›˜, 9.009 ·ÛıÂÓ›˜ Ô˘ ¤·ÈÚÓ·Ó ·ÙÔÚ‚·ÛÙ·Ù›ÓË Î·È 2.511 ·ÛıÂÓ›˜ Ô˘ ¤·ÈÚÓ·Ó ·Ï·ÈfiÙÂÚ· ·ÙÔÚ‚·ÛÙ·Ù›ÓË ·ÏÏ¿ ÙÔ˘˜ ¯ÔÚËÁ‹ıËΠ·ÓÙ›ÁÚ·ÊÔ ÛÈÌ‚·ÛÙ·Ù›Ó˘ › 2 ÂÚ›Ô˘ ¯ÚfiÓÈ·. [3]
-- ∏ ‰È·ÊÔÚ¿ ÛÙ· ›‰· Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ (TC) Î·È Ù˘ LDL-Ã
¶ƒø∆√°∂¡∂™ ∆∂§π∫√ ™∏ª∂π√
∞¶√∆∂§∂™ª∞∆∞
™‡ÓıÂÙÔ: √ ¯ÚfiÓÔ˜ ¤ˆ˜ ÙÔ ı¿Ó·ÙÔ ‹ ÙÔ ÚÒÙÔ Ì›˙ÔÓ Î·Ú‰È·ÁÁÂÈ·Îfi ۇ̂·Ì· (¤ÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘, ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ Î·È ÂÂÌ‚·ÙÈ΋ ·ӷÈÌ¿ÙˆÛË). ∏ Û‡ÁÎÚÈÛË
™ÙÔÓ ¶›Ó·Î· 1 ·Ó·ÁÚ¿ÊÔÓÙ·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ ÛÙȘ 2 ÔÌ¿‰Â˜ ıÂڷ›·˜ Î·È Ë ˘fiÏÔÈË, ÏËÓ Ù˘ Ê·Ú̷΢ÙÈ΋˜, ·ÁˆÁ‹. ¢ÂÓ ˘‹Ú¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·-
-- ¶ÔÛÔÛÙfi ›Ù¢Í˘ ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ ÛÙfi¯Ô˘ ÙˆÓ ÏÈȉ›ˆÓ
13
™∂¶∆∂ªµƒπ√™ 2007
¶›Ó·Î·˜ 1. ÷ڷÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ Î·È Û˘Á¯ÔÚËÁÔ‡ÌÂÓË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜. √Ì¿‰· Ô˘ ¿ÏÏ·Í ·ÁˆÁ‹. (n=2544)
√Ì¿‰· ÂϤÁ¯Ô˘ (n=9009)
51.3 66 28.2 16.3 5.2 (210) 60.3 141/79 20.2 38.0 12.1 8.6
51.3 66 26.3 73 4.7(182) 63.5 141/79 18.9 37.5 11.6 10.0
70.5 20.6 31.1 25.8 30.8 9.9
71.9 21.1 33.7 27.7 33.5 8.7
÷ڷÎÙËÚÈÛÙÈο ηٿ ÙËÓ ¤Ó·ÚÍË. ÕÓ‰Ú˜ (%), ª¤ÛË ËÏÈΛ· (¤ÙË). ¢È·‚‹Ù˘ (%), ¶·ÏÈfi ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘ (%), ª¤ÛË ÙÈÌ‹ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ [mmol/L (mg/dL)] À¤ÚÙ·ÛË (%), ª¤ÛË ™∞¶/¢∞¶ (mmHg), ∫¿ÓÈÛÌ· (%), ™ÙËı¿Á¯Ë (%), ¶·Ï·Èfi ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi/¶∞∂ (%), πÛÙÔÚÈÎfi ∞ÁÁÂÈÔÏ·ÛÙÈ΋˜/∞ÔÚÙÔÛÙÂÊ·ÓÈ·›·˜ ·Ú¿Î·Ì„˘ (%) ™˘Á¯ÔÚËÁÔ‡ÌÂÓ· Ê¿Ú̷η, ™˘Á¯ÔÚËÁÔ‡ÌÂÓ· ηډȷÁÁÂȷο Ê¿Ú̷η, ¢ÈÔ˘ÚËÙÈο (%), ‚-·Ó·ÛÙÔÏ›˜ (%), ∞ÓÙ·ÁˆÓÈÛÙ¤˜ ∞Û‚ÂÛÙ›Ô˘ (%), AMEA (%), ∞ÓÙ·ÁˆÓÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ∞ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ (%)
ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ÙfiÛÔ ÛÙ· ‚·ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο fiÛÔ Î·È ÛÙË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹. ∏ ÌfiÓÔ ‰È·ÊÔÚ¿ ‹Ù·Ó fiÙÈ ÚÒÙË ÔÌ¿‰· (n=2.511) ¤·ÈÚÓ ·Ï·ÈfiÙÂÚ· ·ÙÔÚ‚·ÛÙ·Ù›ÓË Î·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ¯ÚfiÓÈ· ÚÈÓ ¿ÏÏ·Í Û ·ÓÙ›ÁÚ·ÊÔ ÛÈÌ‚·ÛÙ·Ù›Ó˘ Î·È Ë ‰Â‡ÙÂÚË ÔÌ¿‰· (n=9.009) Û˘Ó¤¯ÈÛ ӷ ·›ÚÓÂÈ ·ÙÔÚ‚·ÛÙ·Ù›ÓË. [3] ™ÙÔÓ ¶›Ó·Î· 2 Ê·›ÓÂÙ·È Ô Û¯ÂÙÈÎfi˜ ΛӉ‡ÓÔ˜ (HR) ÂÌÊ¿ÓÈÛ˘
ÙÔ˘ ÚˆÙÔÁÂÓÔ‡˜ Î·È ÙˆÓ ‰Â˘ÙÂÚÔÁÂÓÒÓ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ Ù˘ ÌÂϤÙ˘ ÛÙËÓ ÔÌ¿‰· 1 (·ÓÙ›ÁÚ·ÊÔ ÛÈÌ‚·ÛÙ·Ù›Ó˘) Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÌ¿‰· 2 (Û˘Ó¤¯ÈÛË ·ÙÔÚ‚·ÛÙ·Ù›Ó˘). º·›ÓÂÙ·È ÏÔÈfiÓ fiÙÈ Ô Î›Ó‰˘ÓÔ˜ ı·Ó¿ÙÔ˘ ‹ Ì›˙ÔÓÔ˜ ηډȷÁÁÂÈ·ÎÔ‡ Û˘Ì‚¿Ì·ÙÔ˜ (Û‡ÓıÂÙÔ ÚˆÙÔÁÂÓ¤˜ ÙÂÏÈÎfi ÛËÌ›Ô) ·˘Í‹ıËΠÛÙËÓ ÔÌ¿‰· ÙÔ˘ ·ÓÙÈÁÚ¿ÊÔ˘ ηٿ 30% Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÌ¿‰· Ù˘ ·ÙÔÚ‚·ÛÙ·Ù›Ó˘. ∂›Û˘, Ô Î›Ó‰˘ÓÔ˜ ÙÔ˘
Ì›˙ÔÓÔ˜ ηډȷÁÁÂÈ·ÎÔ‡ Û˘Ì‚¿Ì·ÙÔ˜ ·˘Í‹ıËΠηٿ 43%, ÙÔ˘ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ ηٿ 36%, ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ηٿ 114% Î·È Ù˘ ÂÂÌ‚·ÙÈ΋˜ ·ӷÈÌ¿ÙˆÛ˘ ηٿ 23%. [3] £· Ú¤ÂÈ Ó· ÏËÊı› ˘fi„Ë fiÙÈ Ë Î·Ù·ÁÚ·Ê‹ ·˘Ù‹ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·ÊÔÚ¿ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌfiÓÔ 2 ÂÚ›Ô˘ ÂÙÒÓ Î·È fiÙÈ Á›ÓÂÙ·È Û‡ÁÎÚÈÛË 2 ÂÓÂÚÁÒÓ ıÂÚ·ÂÈÒÓ Ì ÛÙ·Ù›Ó˜ Î·È fi¯È Û‡ÁÎÚÈÛË ÛÙ·Ù›Ó˘ Ì ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ.
¶›Ó·Î·˜ 2. ∫›Ó‰˘ÓÔ˜ ηډȷÁÁÂÈ·ÎÒÓ Â΂¿ÛÂˆÓ ÁÈ· ·ÛıÂÓ›˜ Ô˘ ¿ÏÏ·Í·Ó ·ÁˆÁ‹ Î·È ÛÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘. √Ì¿‰· ∞ÏÏ·Á‹˜ (n=2511) ¢ÈÔÚıˆÌ¤ÓÔ˜ ∏ƒ 9.5% CI)
ŒÓ·ÓÙÈ √Ì¿‰·˜ ∂ϤÁ¯Ô˘ (n=9009) P ∞Í›·
£¿Ó·ÙÔÈ ·fi fiÏ· Ù· ·›ÙÈ· ‹ ∫∞ Û˘Ì‚¿Ì·Ù·.
1.30 (1.02, 1.64)
0.030
ªÂ›˙ÔÓ· ∫∞ Û˘Ì‚¿Ì·Ù·,
1.43 (1.10. 1.87)
0.008
ŒÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘,
1.36 (0.80, 2.32)
0.258
∞ÁÁÂȷο ÂÁÎÂÊ·ÏÈο,
2.14 (1.21, 3.81)
0.009
∂ÂÌ‚¿ÛÂȘ ·ӷÁÁ›ˆÛ˘,
1.23 (0.87, 1.73)
0.240
£¿Ó·ÙÔÈ ·fi ÔÔÈ·‰‹ÔÙ ·ÈÙ›·.
0.80 (0.49, 1.30)
0.369
*¢ÈÔÚıˆÌ¤ÓÔ ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ·, ÙÔ Ê‡ÏÔ, ·Ï·Èfi ∂ª, ‰È·‚‹ÙË, ¯ÚfiÓÔ ·fi ÙËÓ ‰È·ÎÔ‹ Ù˘ ÛÙ·Ù›Ó˘, ∞ıÚÔÈÛÙÈÎfi˜ ¯ÚfiÓÔ˜ ¯ÔÚ‹ÁËÛ˘ Ù˘ ÛÙ·Ù›Ó˘ ÚÈÓ ÙËÓ ËÌÂÚÔÌËÓ›· ¤Ó·Ú͢ Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘, ÙËÓ ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË Î·Ù¿ ÙËÓ ¤Ó·ÚÍË, *∂ª, ∞∂∂ ‹ ·ӷÁÁ›ˆÛË
14
£EPA¶EIA - ºAPMAKA ∂ÈÎfiÓ· 1: ÃÚfiÓÔ˜ ̤¯ÚÈ ÙÔ ı¿Ó·ÙÔ ‹ ÙÔ ÚÒÙÔ Ì›˙ˆÓ ηډȷÁÁÂÈ·Îfi Û˘Ì‚¿Ó (∂ª, ∞∂∂ ‹ ÂÂÌ‚¿ÛÂȘ ÛÙÂÊ·ÓÈ·›·˜ ·ӷÁÁ›ˆÛ˘). ªË ‰ÈÔÚıˆÌ¤ÓÔ HR =1.29 (95% CI:1.03, 1.61) P=0.025 ∞ıÚÔÈÛÙÈ΋ ›وÛË (%)
¢ÈÔÚıˆÌ¤ÓÔ HR=1.30 (95% CI:1.02, 1.64) P=0.030
√Ì¿‰· ÂϤÁ¯Ô˘ √Ì¿‰· ·ÏÏ·Á‹˜
√Ì¿‰· ÂϤÁ¯Ô˘ √Ì¿‰· ·ÏÏ·Á‹˜ ŒÙË ·fi ÙËÓ ËÌÂÚÔÌËÓ›· ¤Ó·ÚÍË ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È ·ÛıÂÓ›˜ Û ΛӉ˘ÓÔ
™ÙËÓ ∂ÈÎfiÓ· 1 Ê·›ÓÂÙ·È ÙÔ ¯ÚÔÓԉȿÁÚ·ÌÌ· ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ Û‡ÓıÂÙÔ˘ ÚˆÙÔÁÂÓÔ‡˜ ÙÂÏÈÎÔ‡ ÛËÌ›Ԣ ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ıÂڷ›·˜. ∆Ô ÂÓÙ˘ˆÛÈ·Îfi Â›Ó·È fiÙÈ ÔÈ Î·Ì‡Ï˜ ÙˆÓ Û˘Ì‚·Ì¿ÙˆÓ ·Ú¯›˙Ô˘Ó Ó· ͯˆÚ›˙Ô˘Ó ·fi ÙÔ ÚÒÙÔ ÎÈfiÏ·˜ Ì‹Ó· ıÂڷ›·˜ (Èı·ÓÒ˜ ˘‹Ú¯Â ‰È·ÊÔÚ¿ Î·È ÛÙȘ ÏÂÈÔÙÚÔÈΤ˜ ‰Ú¿ÛÂȘ).
™ÙËÓ ∂ÈÎfiÓ· 2 Ê·›ÓÂÙ·È ÙÔ ¯ÚÔÓԉȿÁÚ·ÌÌ· ‰È·ÎÔ‹˜ Ù˘ ıÂڷ›·˜ Ì ÛÙ·Ù›ÓË ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ıÂڷ›·˜. √ ΛӉ˘ÓÔ˜ ‰È·ÎÔ‹˜ ÙÔ˘ ·ÓÙ›ÁÚ·ÊÔ˘ ÛÈÌ‚·ÛÙ·Ù›Ó˘ ‹Ù·Ó 2,15 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi ÙÔ Î›Ó‰˘ÓÔ ‰È·ÎÔ‹˜ Ù˘ ·ÙÔÚ‚·ÛÙ·Ù›Ó˘ Î·È ÙÂÏÈο ‰È¤ÎÔ„Â ÙÔ 30% ÂÚ›Ô˘ ÙˆÓ ·ÛıÂÓÒÓ. [3] º·›ÓÂÙ·È fiÙÈ ÌÂÙ¿ ÙËÓ ·ÏÏ·Á‹ ·fi
·ÙÔÚ‚·ÛÙ·Ù›ÓË Û ·ÓÙ›ÁÚ·ÊÔ ÛÈÌ‚·ÛÙ·Ù›Ó˘ ÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ıˆÚÔ‡Ó Ï¤ÔÓ ÙË ıÂڷ›· ·˘Ù‹ ÛËÌ·ÓÙÈ΋ Î·È ¤¯Ô˘Ó ÙË Ù¿ÛË Ó· ÙË ‰È·ÎfiÙÔ˘Ó Ôχ ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ Â¿Ó ¤ÌÂÓ·Ó ÛÙËÓ ·Ú¯È΋ ıÂڷ›· Ì ·ÙÔÚ‚·ÛÙ·Ù›ÓË. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ‰È·ÎÔ‹˜ ‰ÂÓ ÂËÚ¤·Û ÙËÓ ÎÏÈÓÈ΋ ¤Î‚·ÛË ÙˆÓ ·ÛıÂ-
∂ÈÎfiÓ· 2: ÃÚfiÓÔ˜ ̤¯ÚÈ ÙË ‰È·ÎÔ‹ Ù˘ ıÂڷ›·˜ Ì ÛÙ·Ù›ÓË. ªË ‰ÈÔÚıˆÌ¤ÓÔ HR =2.56 (95% CI:2.34, 2.81) P=0.001
¢È·ÎÔ‹ (>90 Ë̤Ú˜) (%)
¢ÈÔÚıˆÌ¤ÓÔ HR=2.15 (95% CI:1.96, 2.36) P=0.001
√Ì¿‰· ÂϤÁ¯Ô˘ √Ì¿‰· ·ÏÏ·Á‹˜
ª‹Ó˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘
15
™∂¶∆∂ªµƒπ√™ 2007
∞ÛıÂÓ›˜ (%)
∂ÈÎfiÓ· 3: ¶ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ô˘ ¤Ù˘¯·Ó ÙÔÓ ÛÙfi¯Ô Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ (<193 mg/dL) ÛÙËÓ ¤Ó·ÚÍË Î·È ÌÂÙ¿ 1 ¤ÙÔ˜
ŒÓ·ÚÍË
1 ŒÙÔ˜
ŒÓ·ÚÍË
1 ŒÙÔ˜
√Ì¿‰· ·ÏÏ·Á‹˜
√Ì¿‰· ÂϤÁ¯Ô˘
n=(1257)
n=(4792)
ÓÒÓ (ÚˆÙÔÁÂÓ¤˜ Î·È ‰Â˘ÙÂÚÔÁÂÓ‹ ÎÏÈÓÈο ÙÂÏÈο ÛËÌ›·) ÁÈ·Ù› ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰È¤ÎÔÙ·Ó ÙÔ Ê¿ÚÌ·ÎÔ ‰ÂÓ ˘ÔÏÔÁ›ÛÙËÎ·Ó Ù· ÎÏÈÓÈο Û˘Ì‚¿Ì·Ù· (treatment based analysis and not intention to treat). ÕÚ· Ô ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÎÏÈÓÈÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ ·ÊÔÚÔ‡Û ÌfiÓÔ Ù· ¿ÙÔÌ· Î·È ·fi ÙȘ 2 ÔÌ¿‰Â˜ Ô˘ ¤·ÈÚÓ·Ó ÂÓÂÚÁfi ıÂڷ›· Ì ÛÙ·Ù›ÓË. ™ÙËÓ ∂ÈÎfiÓ· 3 Ê·›ÓÂÙ·È ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‹Ù·Ó ÛÙÔ ÛÙfi¯Ô ıÂڷ›·˜ ÁÈ· ÙË ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Î·È ÙÔ Ù¤ÏÔ˜ Ù˘ ÌÂϤÙ˘. ∂›Ó·È ۷ʤ˜ fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ô˘ Û˘Ó¤¯ÈÛ·Ó Ì ·ÙÔÚ‚·ÛÙ·Ù›ÓË ¤Ù˘¯·Ó Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙÔ ıÂڷ¢ÙÈÎfi ÛÙfi¯Ô Û ۇÁÎÚÈÛË Ì ·˘ÙÔ‡˜ Ô˘ ¤·ÈÚÓ·Ó ·ÓÙ›ÁÚ·ÊÔ ÛÈÌ‚·ÛÙ·Ù›Ó˘. ∞˘Ùfi ÙÔ ÁÂÁÔÓfi˜ Â›Ó·È Ôχ Èı·Ófi Ó· Û˘Ó¤‚·Ï ÛÙȘ ‰È·ÊÔÚ¤˜ Ô˘ ‰È·ÈÛÙÒıËÎ·Ó ÛÙË ÎÏÈÓÈ΋ ¤Î‚·ÛË ÛÙȘ 2 ÔÌ¿‰Â˜ ıÂڷ›·˜.
™Àª¶∂ƒ∞™ª∞ ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ [3], Ô˘ Â›Ó·È Ë ÚÒÙË ÛÙÔ Â›‰Ô˜ Ù˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë
¯Ú‹ÛË ·ÓÙÈÁÚ¿ÊÔ˘ ÛÈÌ‚·ÛÙ·Ù›Ó˘ Ì ¯·ÌËÏfiÙÂÚÔ ÎfiÛÙÔ˜ ÂÌ‚·Ï·Á›Ô˘ ‹ ÌËÓÈ·›·˜ ıÂڷ›·˜ ·’ fiÙÈ Ë ÚˆÙfiÙ˘Ë ·ÙÔÚ‚·ÛÙ·Ù›ÓË fi¯È ÌfiÓÔ ‰ÂÓ Â›Ó·È Ë ÈÔ ÔÈÎÔÓÔÌÈ΋ χÛË ·ÏÏ¿ Ê·›ÓÂÙ·È fiÙÈ ÙËÓ ÏËÚÒÓÔ˘Ì Ôχ ·ÎÚÈ‚¿. √È ı¿Ó·ÙÔÈ ‰ÂÓ ·ÍÈÔÏÔÁÔ‡ÓÙ·È Ì ¯Ú‹Ì·Ù·. ∆· ηډȷÁÁÂȷο ÂÂÈÛfi‰È·, Ù· ·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο Î·È ÔÈ ÂÂÌ‚¿ÛÂȘ ·ÈÌ¿ÙˆÛ˘ ¤¯Ô˘Ó ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ ÙÂÚ¿ÛÙÈÔ ÓÔÛËÏ¢ÙÈÎfi Î·È ÎÔÈÓˆÓÈÎfi ÎfiÛÙÔ˜. ªfiÓÔ ÙËÓ ÔÈÎÔÓÔÌÈ΋ ÂÈ‚¿Ú˘ÓÛË ÙˆÓ ÓÔÛËÏ›ˆÓ, ÙˆÓ Ê·Ú̿ΈÓ, ÙˆÓ ÂÂÌ‚¿ÛÂˆÓ Î·È Ù˘ ·ÔηٿÛÙ·Û˘ Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ·‡ÍËÛË ÙˆÓ ÂÌÊÚ·ÁÌ¿ÙˆÓ ÙÔ˘ Ì˘Ôηډ›Ô˘ ηٿ 36%, ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ÂÁÎÂÊ·ÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ ηٿ 114% Î·È ÙˆÓ ÂÂÌ‚·ÙÈÎÒÓ Â·Ó·ÈÌ·ÙÒÛÂˆÓ Î·Ù¿ 23% Ó· ˘ÔÏÔÁ›ÛÔ˘Ì (ÂÈÚfiÛıÂÙ· ·fi ÙȘ ËÌÂÚ·ÚÁ›Â˜, ·Ó·ÚÚˆÙÈΤ˜ ¿‰ÂȘ, Û˘ÓÙ¿ÍÂȘ) ηٷϋÁÔ˘Ì Û ÎfiÛÙÔ˜ ÔÏÏ·Ï¿ÛÈÔ ·’ ·˘Ùfi Ô˘ ˘ÔÙ›ıÂÙ·È fiÙÈ ÁÏÈÙÒÓÔ˘Ì Ì ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ ÊıËÓfiÙÂÚÔ˘ ·fi ÙÔ ÚˆÙfiÙ˘Ô ·ÓÙÈÁÚ¿ÊÔ˘. £· Ú¤ÂÈ Â›Û˘ Ó· ˘Ôı¤ÛÔ˘Ì fiÙÈ Ô ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ Ì ٷ ·ÓÙ›ÁÚ·Ê· Ô˘ ·Ó·Ê¤ÚıËΠ·Ú·¿Óˆ Èı·-
ÓfiÓ Ó· Â›Ó·È ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚÔ˜ ÁÈ·Ù› ‰ÂÓ ˘ÔÏÔÁ›ÛÙËÎ·Ó Ù· Û˘Ì‚¿Ì·Ù· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‰È·ÎÔ‹ ÙÔ˘ ·ÓÙÈÁÚ¿ÊÔ˘ ÛÈÌ‚·ÛÙ·Ù›Ó˘ (30% ÂÚ›Ô˘ ÙˆÓ ·ÛıÂÓÒÓ, 2,15 ÊÔÚ¤˜ ÂÚÈÛÛfiÙÂÚÔ ·fi ·˘ÙÔ‡˜ Ô˘ ‰È¤ÎÔ„·Ó ÙËÓ ·ÙÔÚ‚·ÛÙ·Ù›ÓË)
2.
3.
ªÂÙ¿ Ù· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜, ÂÊfiÛÔÓ ÂȂ‚·ÈˆıÔ‡Ó Î·È ·fi ¿ÏϘ ÌÂϤÙ˜, ȉÈÒÙ˜ ÁÈ·ÙÚÔ›, ·ÛÊ·ÏÈÛÙÈο Ù·Ì›·, ·ÛÊ·ÏÈÛÙÈΤ˜ ÂÙ·ÈÚ›˜ ‹ ΢‚ÂÚÓ‹ÛÂȘ ‰ÂÓ ÌÔÚÔ‡Ó Ï¤ÔÓ Ó· ¯ÚËÛÈÌÔÔÈÔ‡Ó ÙÔ Âȯ›ÚËÌ· Î·È ÙÔ ¿ÏÏÔıÈ fiÙÈ fiϘ ÔÈ ÛÙ·Ù›Ó˜ Â›Ó·È ›‰È˜ Î·È fiÙÈ Ù· ·ÓÙ›ÁÚ·Ê· ÙÔ˘˜ Â›Ó·È ·ÍÈfiÈÛÙ·, ¿Ú· ÌÔÚÔ‡Ó Ó· οÓÔ˘Ó ÔÈÎÔÓÔÌ›·. ∆Ô ÎfiÛÙÔ˜ ÙÂÏÈο Ì ٷ ·ÓÙ›ÁÚ·Ê· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ, ·ÏÏ¿ ·˘Ùfi ›Ûˆ˜ Â›Ó·È ÙÔ ÙÂÏÂ˘Ù·›Ô Ô˘ ÂӉȷʤÚÂÈ. ∂›Ó·È Ì·ıËÌ·ÙÈο ‚¤‚·ÈÔ fiÙÈ Ë ÔÈfiÙËÙ· ˙ˆ‹˜ οÔÈˆÓ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ı· ˘Ô‚·ıÌÈÛÙ› ÌÂÙ¿ ·fi ۇ̂·Ì· Î·È Î¿ÔÈÔÈ ·ÛıÂÓ›˜ ı· Âı¿ÓÔ˘Ó ÏfiÁˆ Ù˘ ·ÏÏ·Á‹˜ ·˘Ù‹˜. £¤ÏÔ˘Ì ӷ ÂÏ›˙Ô˘Ì fiÙÈ Ë ÚÔÂȉÔÔ›ËÛË Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙË ÌÂϤÙË ·˘Ù‹ Â›Ó·È ·ÚÎÂÙ‹ ÁÈ· ·ÏÏ·Á‹ ÔÏÈÙÈ΋˜ ·fi fiÏÔ˘˜ ÙÔ˘˜ ÊÔÚ›˜ ˘Á›·˜.
µÈ‚ÏÈÔÁÚ·Ê›· 1.
16
Moon JC, Bogle RG. Switching statins. BMJ 2006;332:1344-1345.
Thiebaud P, Patel BV, Nichol MB, Berenbeim DM. The effect of switching on compliance and persistence: the case of statin treatment. Am J Manag Care 2005; 11:670-674.
Phillips B, Roberts G, Rudolph AE, Morant S, Aziz F, O’Regan CP. Switching Statins: The Impact on Patient Outcomes. European Society of Cardiology Congress, Vienna, 1-5 Sept 2007.
√¢∏°π∂™
√‰ËÁ›Â˜ Ù˘ ∂˘Úˆ·˚΋˜ ∫·Ú‰ÈÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ (ESC) Î·È Ù˘ ∂˘Úˆ·˚΋˜ ∂Ù·ÈÚ›·˜ ªÂϤÙ˘ ÙÔ˘ ™·Î¯·ÚÒ‰Ë ¢È·‚‹ÙË (EASD) ÁÈ· ÙË ¢È¿ÁÓˆÛË, ¶ÚfiÏË„Ë Î·È ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ¢È·‚‹ÙË, ¶Úԉȷ‚‹ÙË Î·È ∫·Ú‰È·ÁÁÂÈ·ÎÒÓ ¶·ı‹ÛˆÓ. ∂ÈÛ·ÁˆÁ‹ ™·Î¯·Ú҉˘ ¢È·‚‹Ù˘ (™¢) Î·È Î·Ú‰È·ÁÁÂȷΤ˜ ·ı‹ÛÂȘ Û˘¯Ó¿ ÂÌÊ·Ó›˙ÔÓÙ·È ˆ˜ ‰‡Ô Ï¢ڤ˜ ÙÔ˘ ·˘ÙÔ‡ ÓÔÌ›ÛÌ·ÙÔ˜. √ ‰È·‚‹Ù˘, ·fi ÏÂ˘Ú¿˜ ÚfiÁÓˆÛ˘, ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛı› ˆ˜ ÈÛÔ‰‡Ó·ÌÔ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ (™¡). ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿ ÔÏÏÔ› ·ÛıÂÓ›˜ Ì ¤Î‰ËÏË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ¿Û¯Ô˘Ó ·fi ™¢ ‹ ·fi ÚÔÛÙ¿‰È· ÙÔ˘. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Â›Ó·È ··Ú·›ÙËÙÔ ÔÈ Î·Ú‰ÈÔÏfiÁÔÈ Î·È ÔÈ ‰È·‚ËÙÔÏfiÁÔÈ Ó· ÂÓÒÛÔ˘Ó ÙȘ ‰˘Ó¿ÌÂȘ
ÙÔ˘˜ ÒÛÙ ӷ ‚ÂÏÙÈÒÛÔ˘Ó ÙÔÓ ÙÚfiÔ Ì ÙÔÓ ÔÔ›Ô ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÂηÙÔÌ̇ÚÈ· ·ÛıÂÓÒÓ Ô˘ ¿Û¯Ô˘Ó ·Ó¿ ÙÔÓ ÎfiÛÌÔ Ù·˘Ùfi¯ÚÔÓ· ·fi ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· Î·È Î·Ú‰È·ÁÁÂȷΤ˜ ·ı‹ÛÂȘ ∞ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ı· Ú¤ÂÈ Ó· ÂÚ¢ÓÒÓÙ·È ÁÈ· Ù˘¯fiÓ ‡·ÚÍË ÛÙÂÊ·ÓÈ·›·˜ ‹ ¿ÏÏ˘ ·ıËÚÔıÚÔÌ‚ˆÙÈ΋˜ ÓfiÛÔ˘ Î·È ·ÛıÂÓ›˜ Ì ™¡ Ú¤ÂÈ Ó· ÂÚ¢ÓÒÓÙ·È ÁÈ· Ù˘¯fiÓ ‡·ÚÍË ÌÂÙ·‚ÔÏÈ΋˜ ‰È·Ù·Ú·¯‹˜ (∂ÈÎfiÓ· 1), ÒÛÙ ӷ Ù›ıÂÙ·È Ë
‚¿ÛË ÁÈ· ÙËÓ Î·Ù¿ÏÏËÏË ·fi ÎÔÈÓÔ‡ ıÂڷ›·. ∞˘Ù‹ Ë Î·Ú‰ÈÔ-‰È·‚ËÙÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË ı· ˆÊÂÏ‹ÛÂÈ Ù· ̤ÁÈÛÙ· fi¯È ÌfiÓÔ ÛÙË ıÂڷ›· ÙˆÓ ·ÛıÂÓÒÓ ·ÏÏ¿ Î·È ÛÙËÓ ÚfiÔ‰Ô Ù˘ ηډÈÔÏÔÁ›·˜, Ù˘ ‰È·‚ËÙÔÏÔÁ›·˜ Î·È Ù˘ ÚfiÏ˄˘. √È ıÂڷ¢ÙÈÎÔ› ÛÙfi¯ÔÈ ÁÈ· ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË, ÙȘ ÙÈ̤˜ ÙˆÓ ÏÈȉ›ˆÓ, ÙËÓ Ú‡ıÌÈÛË ÙÔ˘ ۷ί¿ÚÔ˘ ·›Ì·ÙÔ˜ Î·È ÙËÓ ˘ÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘ÓÔÙÈο ÛÙÔÓ ¶›Ó·Î· 1.
∂ÈÎfiÓ· 1. ∞ÏÁfiÚÈıÌÔ˜ ‰ÈÂÚ‡ÓËÛ˘ ·ÛıÂÓÒÓ Ì ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ (™¡) ‹ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË (™¢) ™¡ Î·È ™¢
∫‡ÚÈ· ‰È¿ÁÓˆÛË ™¢±™N
ÕÁÓˆÛÙÔ ·Ó ™¡ ∏∫° ∏¯ˆÎ·Ú‰ÈÔÁÚ¿ÊËÌ· ∆ÂÛÙ ÎÔÒÛˆ˜
°ÓˆÛÙ‹ ™¡
ÕÁÓˆÛÙÔ ·Ó ™¢
°ÓˆÛÙfi˜ ™¢
∏∫° ∏¯ˆÎ·Ú‰ÈÔÁÚ¿ÊËÌ· ∆ÂÛÙ ÎÔÒÛˆ˜
¢ÔÎÈÌ·Û›· ∞ÓÔ¯‹˜ °Ï˘Îfi˙˘ §È›‰È· ·›Ì·ÙÔ˜, ™¿Î¯·ÚÔ ·›Ì·ÙÔ˜ HbA 1C
ŒÏÂÁ¯Ô˜ ÁÈ· ÓÂÊÚÔ¿ıÂÈ· ∞Ó Ùˆ¯‹ Ú‡ıÌÈÛË Û·Î¯¿ÚÔ˘ (HbA 1C>7%) ·Ú·ÔÌ‹ Û ‰È·‚ËÙÔÏfiÁÔ
∞¡ (+) Â˘Ú‹Ì·Ù· ·Ú·ÔÌ‹ Û ηډÈÔÏfiÁÔ
Î.Ê. ·Ú·ÎÔÏÔ‡ıËÛË
∫‡ÚÈ· ‰È¿ÁÓˆÛË ™¡±™¢
ªË Ê˘ÛÈÔÏÔÁÈο ¶·Ú·ÔÌ‹ Û ηډÈÔÏfiÁÔ, ıÂڷ›· ÈÛ¯·ÈÌ›·˜, ·Ó·›Ì·ÎÙÔ˜ ‹ ·ÚÂÌ‚·ÙÈ΋
Î.Ê. ·Ú·ÎÔÏÔ‡ıËÛË
¢È¿ÁÓˆÛË ™¢ ‹ ¢È·Ù·Ú·¯‹˜ √ÌÔÈÔÛÙ·Û›·˜ °Ï˘Îfi˙˘ (±ª™) ¶·Ú·ÔÌ‹ Û ‰È·‚ËÙÔÏfiÁÔ
17
™∂¶∆∂ªµƒπ√™ 2007
√ÚÈÛÌÔ›, ηٿٷÍË Î·È ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ÙˆÓ Úԉȷ‚ËÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÁÏ˘Îfi˙˘ √ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Â›Ó·È ÌÈ· ÌÂÙ·‚ÔÏÈ΋ ¿ıËÛË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¯ÚfiÓÈ· ˘ÂÚÁÏ˘Î·ÈÌ›· Î·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ˘‰·Ù·ÓıڿΈÓ, ÙˆÓ ÏÈÒÓ Î·È ÙˆÓ ÏÂ˘ÎˆÌ¿ÙˆÓ, ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÂÏ·Ùو̷ÙÈ΋˜ ¤ÎÎÚÈÛ˘ ‹ ÂÏ·Ùو̷ÙÈ΋˜ ‰Ú¿Û˘ Ù˘ ÈÓÛÔ˘Ï›Ó˘ ‹ Û˘Ó‰˘·ÛÌÔ‡ Î·È ÙˆÓ ‰‡Ô. √ Ù‡Ô˘ 1 ‰È·‚‹Ù˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ¤ÏÏÂÈ„Ë ÂÓ‰ÔÁÂÓÔ‡˜ ·Ú·ÁˆÁ‹˜ ÈÓÛÔ˘Ï›Ó˘ ·fi ÙÔ ¿ÁÎÚÂ-
·˜ ÂÓÒ Ë ˘ÂÚÁÏ˘Î·ÈÌ›· ÛÙÔÓ Ù‡Ô˘ 2 ‰È·‚‹ÙË ÚÔ¤Ú¯ÂÙ·È ·fi ÈÔ ÔχÏÔÎË ‰È·Ù·Ú·¯‹. ¶·Ú·‰ÔÛȷο, ·Ï·ÈfiÙÂÚ· Ë ‰È¿ÁÓˆÛË ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ÁÈÓfiÙ·Ó Ì ٷ Û˘ÌÙÒÌ·Ù· Ô˘ ÚÔηÏÔ‡ÛÂ Ë ˘ÂÚÁÏ˘Î·ÈÌ›·, ·ÏÏ¿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ¤¯ÂÈ ‰Ôı› ¤ÌÊ·ÛË ÛÙËÓ ·Ó¿ÁÎË ¤ÁηÈÚ˘ ‰È¿ÁÓˆÛ˘ ÙÔ˘ ‰È·‚‹ÙË Î·È ÙˆÓ ¿ÏÏˆÓ ‰È·Ù·Ú·¯ÒÓ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ ۷ί¿ÚÔ˘, ÚÈÓ ÂÌÊ·ÓÈÛıÔ‡Ó Ù· Û˘ÌÙÒÌ·Ù· √ ‰È·‚‹Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·Ó¿Ù˘ÍË ‚Ï¿‚˘ Û fiÚÁ·Ó· ÛÙfi¯Ô˘˜, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Ô ·ÌÊÈ‚ÏËÛÙÚÔÂȉ‹˜, ÔÈ ÓÂÊÚÔ›, Ù· ÂÚÈÊÂÚÈο Ó‡ڷ
Î·È ÙÔ ·˘ÙfiÓÔÌÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·. ¶¤Ú·Ó ·˘ÙÔ‡ ÔÈ ·ÛıÂÓ›˜ Ì ™¢ ¤¯Ô˘Ó ȉȷ›ÙÂÚ· ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ÂÌÊ·Ó›ÛÔ˘Ó Î·Ú‰È·Î¿ ÓÔÛ‹Ì·Ù· Î·È ·ı‹ÛÂȘ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ Î·È ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ·ÁÁ›ˆÓ. ∆¤ÛÛÂÚȘ Â›Ó·È ÔÈ Î‡ÚȘ ·ÈÙÈÔÏÔÁÈΤ˜ ηÙËÁÔڛ˜ ™¢: Ô Ù‡Ô˘ 1, Ô Ù‡Ô˘ 2, ¿ÏϘ ÂȉÈΤ˜ ÌÔÚʤ˜ fiˆ˜ Ô ÂΉËÏÔ‡ÌÂÓÔ˜ ηٿ ÙËÓ ˆÚ›Ì·ÓÛË ‰È·‚‹Ù˘ ÙˆÓ Ó¤ˆÓ (Maturity-Onset Diabetes in the Young –MODY) Î·È Ô ‰Â˘ÙÂÚÔ·ı‹˜ Û ¿ÏϘ ·ı‹ÛÂȘ ‹ ηٷÛÙ¿ÛÂȘ (¯ Ô ‰È·‚‹Ù˘ Ù˘ ·ËÛ˘ ‹ ÛÙË ‰È¿ÚÎÂÈ· ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛˆÓ).
¶›Ó·Î·˜ 1. £Âڷ¢ÙÈÎÔ› ÛÙfi¯ÔÈ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ™¢ Î·È ™¡
∞ÚÙËÚȷ΋ ›ÂÛË
ƒ‡ıÌÈÛË ™·Î¯¿ÚÔ˘
§È›‰È· (mg/dl)
ÀÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹
18
ªÂÙ·‚ÏËÙ¤˜
£Âڷ¢ÙÈÎfi˜ ÛÙfi¯Ô˜
™˘ÛÙÔÏÈ΋/‰È·ÛÙÔÏÈ΋ (mmHg) ™Â ÂÚ›ÙˆÛË ÓÂÊÚÈ΋˜ ‰È·Ù·Ú·¯‹˜ ‹ ÏÂ˘Îˆ·ÙÔ˘Ú›·˜ > 1 gr/24ˆÚÔ HbA1C ™¿Î¯·ÚÔ (ÊÏ‚ÈÎfi Ï¿ÛÌ·) mg/dl ¡ËÛÙ›·˜ ªÂÙ·ÁÂ˘Ì·ÙÈÎfi (̤ÁÈÛÙË ÙÈÌ‹) ∆‡Ô˘ 1 ∆‡Ô˘ 2
<130/80
√ÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË LDL-¯ÔÏËÛÙÂÚfiÏË HDL-¯ÔÏËÛÙÂÚfiÏË ÕÓ‰Ú˜ °˘Ó·›Î˜ ∆ÚÈÁÏ˘ÎÂÚ›‰È·* √ÏÈ΋/ HDL-¯ÔÏËÛÙÂÚfiÏË* ¢È·ÎÔ‹ ηӛÛÌ·ÙÔ˜ ∆·ÎÙÈ΋ ۈ̷ÙÈ΋ ¿ÛÎËÛË (1ã/ËÌÂÚ) ™ˆÌ·ÙÈÎfi ‚¿ÚÔ˜: ¢ª™ (kg/m2), À¤Ú‚·ÚÔÈ, Ì›ˆÛË ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ (%) ¶ÂÚ›ÌÂÙÚÔ˜ ̤Û˘ (cm) ÕÓ‰Ú˜ °˘Ó·›Î˜ ¢È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ ∞Ï¿ÙÈ ÙÚÔÊ‹˜ (gr/ËÌÂÚ) º˘ÙÈΤ˜ ›Ó˜ ™·Î¯·ÚÔ‡¯· ÔÙ¿ (ÌÔÓÔ- Î·È ‰È۷ί·Ú›Ù˜) §›Ô˜ ‰›·ÈÙ·˜ (% ÙˆÓ ıÂÚÌ›‰ˆÓ) ∫ÔÚÂṲ̂ӷ ÏÈ·Ú¿ Trans-ÏÈ·Ú¿ ¶ÔÏ˘·ÎfiÚÂÛÙ· ˆ-6 ¶ÔÏ˘·ÎfiÚÂÛÙ· ˆ-3
< 175 < 70
<125/75 ≤ 6,5 < 108 135 - 160 < 135
> 40 > 46 < 150 <3 ˘Ô¯ÚˆÙÈ΋ > 35-40 < 25 10 < 94 < 80 <6 > 30 gr/ËÌÂÚ ·ÔÊ˘Á‹ ≤ 30 - 35 < 10 <2 6-8 2 gr/ËÌÂÚ ÏÈÓÔÏÂÓÈÎÔ‡ Î·È 200 mg/ËÌÂÚ ÏÈ·ÚÒÓ ÔͤˆÓ Ì·ÎÚ¿˜ ·Ï‡ÛÛÔ˘
√¢∏°π∂™
¶›Ó·Î·˜ 2. ∫ÚÈÙ‹ÚÈ· ÁÏ˘ÎÔÌÂÙ·‚ÔÏÈ΋˜ ηٿٷ͢ ηٿ ¶√À (WHO) (1999 Î·È 2006) Î·È Î·Ù¿ ∞ÌÂÚÈηÓÈ΋ ¢È·‚ËÙÔÏÔÁÈ΋ ∂Ù·ÈÚ›· (ADA) (1997 Î·È 2003). °Ï˘ÎÔÌÂÙ·‚ÔÏÈ΋ ηÙËÁÔÚ›· º˘ÛÈÔÏÔÁÈ΋ Ú‡ıÌÈÛË ÁÏ˘Îfi˙˘ (NGR) ADA (1997) ¢È·Ù·Ú·¯‹ Ù˘ ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜ (IFG)
¶ËÁ‹
∫ÚÈÙ‹ÚÈ· ηٿٷ͢ °Ï˘Îfi˙Ë ÊÏ‚ÈÎÔ‡ Ï¿ÛÌ·ÙÔ˜ (mg/dl)
WHO
FPG < 110 + 2 h PG < 140
FPG < 110 ADA (2003) WHO ADA (1997) ADA (2003)
FPG < 100 FPG ÌÂٷ͇ 110 Î·È 126 + 2 h PG < 140 FPG ÌÂٷ͇ 110 Î·È 126 FPG ÌÂٷ͇ 100 Î·È 126
¢È·Ù·Ú·¯‹ ·ÓÔ¯‹˜ Ù˘ ÁÏ˘Îfi˙˘ (IGT)
WHO
FPG < 126 + 2 h PG ÌÂٷ͇ 140 Î·È 200
¢È·Ù·Ú·¯‹ ÔÌÔÈÔÛÙ·Û›·˜ Ù˘ ÁÏ˘Îfi˙˘ (IGH)
WHO
IFG ‹ IGT
WHO FPG ≥ 126 ADA (2003)
FPG > 126 ‹ 2 h PG ≥ 200
™·Î¯·Ú҉˘ ‰È·‚‹Ù˘ (™¢) ADA (1997)
∏ ÈÛ¯‡Ô˘Û· ηٿٷÍË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ÁÏ˘Îfi˙˘ Á›ÓÂÙ·È Ì ÎÚÈÙ‹ÚÈ· Ô˘ ¤¯Ô˘Ó ı¤ÛÂÈ Ë ¶√À (WHO) Î·È ∞ÌÂÚÈηÓÈ΋ ¢È·‚ËÙÔÏÔÁÈ΋ ∂Ù·ÈÚ›· (ADA), Ù· ÔÔ›· fï˜ ‰È·Ê¤ÚÔ˘Ó ÌÂٷ͇ ÙÔ˘˜ Û οÔÈÔ ‚·ıÌfi (¶›Ó·Î·˜ 2). ∏ ¶√À Û˘ÓÈÛÙ¿ Ó· Á›ÓÂÙ·È Ë Î·Ù¿Ù·ÍË Ì ‚¿ÛË ÙË Ì¤ÙÚËÛË fi¯È ÌfiÓÔ Ù˘ ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜ ·ÏÏ¿, fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ÂÌÊ·Ó‹˜ ˘ÂÚÁÏ˘Î·ÈÌ›·, Ì ̤ÙÚËÛË Î·È Ù˘ ÁÏ˘Îfi˙˘ ÌÂÙ¿ ÊfiÚÙÈÛË. ¶ÚÔ˜ ÙÔ‡ÙÔ, Ó· ¯ÔÚËÁÂ›Ù·È ÁÏ˘Îfi˙Ë ·fi ÙÔ ÛÙfiÌ· Û ‰fiÛË 75 ÁÚ·ÌÌ·Ú›ˆÓ, ‰È·Ï˘Ì¤ÓË Û 250 – 300 Î.Â. ÓÂÚÔ‡, Û ‰È¿ÛÙËÌ· 5 ÏÂÙÒÓ Î·È Ó· ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Ë ÁÏ˘Îfi˙Ë ·›Ì·ÙÔ˜ ÛÙȘ 2 ÒÚ˜ (¢ÔÎÈÌ·Û›·
FPG ≥ 126
·ÓÔ¯‹˜ ÁÏ˘Îfi˙˘ – Oral Glucose Tolerance Test, OGTT). H ¯Ú‹ÛË Ù˘ OGTT ıˆÚÂ›Ù·È ··Ú·›ÙËÙË ÁÈ·Ù› Ë ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ (Fasting Glucose, FG) Î·È Ô OGTT (2 h post-load Glucose, 2hPG) ÌÔÚ› ÌÂÓ Ó· Â›Ó·È Ù·˘Ùfi¯ÚÔÓ· ·ıÔÏÔÁÈΤ˜ Û ÔÚÈṲ̂ӷ ¿ÙÔÌ·, Û˘¯Ó¿ fï˜ ÌÔÚ› Ë ÌÈ· Ó· Â›Ó·È ·ıÔÏÔÁÈ΋ Î·È Ë ¿ÏÏË fi¯È. ™ÙËÓ ∂ÈÎfiÓ· 2 Ê·›ÓÂÙ·È fiÙÈ ÙÔ 1/3 ÙˆÓ ‰È·‚ËÙÈÎÒÓ ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ Î·È Ë ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Ì OGTT. H ÁÏ˘ÎÔ˙˘ÏȈ̤ÓË ·ÈÌÔÛÊ·ÈÚ›ÓË (Hb∞1C) ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ˆ˜ ‰È·ÁÓˆÛÙÈ΋ ‰ÔÎÈÌ·Û›·, ÂÂȉ‹ ¤¯ÂÈ
ÌÈÎÚ‹ ¢·ÈÛıËÛ›· Î·È Ë Â‡ÚÂÛË Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ‰ÂÓ ·ÔÎÏ›ÂÈ ÙËÓ ‡·ÚÍË ™¢ ‹ ‰È·Ù·Ú·¯‹˜ Ù˘ ÔÌÔÈÔÛÙ·Û›·˜ Ù˘ ÁÏ˘Îfi˙˘. ¢Â›¯ÓÂÈ ÙË Ì¤ÛË ÙÈÌ‹ Ù˘ ÁÏ˘Îfi˙˘ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÚÔËÁÔ‡ÌÂÓˆÓ 6 ¤ˆ˜ 8 ‚‰ÔÌ¿‰ˆÓ (‰È¿ÚÎÂÈ· ˙ˆ‹˜ ÙˆÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ) Î·È Â›Ó·È ¤Ó·˜ ηÏfi˜ ‰Â›ÎÙ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ Ú‡ıÌÈÛ˘ ÙÔ˘ ۷ί¿ÚÔ˘ Û ·ÛıÂÓ›˜ Ì ÁÓˆÛÙfi ™¢. ∏ ¤Ú¢ӷ ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi ·ÛıÂÓÒÓ Ì ™¢ Î·È ·˘ÙÒÓ Ô˘ ¤¯Ô˘Ó ÌÂÁ¿ÏË Èı·ÓfiÙËÙ· Ó· ·Ó·Ù‡ÍÔ˘Ó ™¢ ÛÙÔ ÂÁÁ‡˜ ̤ÏÏÔÓ ÌÔÚ› Ó· Á›ÓÂÈ: ·) Ì ÙË ¯Ú‹ÛË ‰ËÌÔÁÚ·ÊÈÎÒÓ Î·È ÎÏÈÓÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ Î·ıÒ˜ ηÈ
∂ÈÎfiÓ· 2. ∏ ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ Î·È Ë ÁÏ˘Îfi˙Ë ÌÂÙ¿ ÊfiÚÙÈÛË ÂÓÙÔ›˙Ô˘Ó ‰È·ÊÔÚÂÙÈο ¿ÙÔÌ· Ì ·Û˘Ìو̷ÙÈÎfi ™¢. ªÂϤÙË DECODE. FPG=ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜. 2hPG=ÁÏ˘Îfi˙Ë 2 ÒÚ˜ ÌÂÙ¿ ÊfiÚÙÈÛË. p.
ªfiÓÔ FPG ·ıÔÏÔÁÈ΋ ¡=613
FPG Î·È 2hPG ·ıÔÏÔÁÈΤ˜ ¡=431
ªfiÓÔ 2hPG ·ıÔÏÔÁÈ΋ ¡=473
19
™∂¶∆∂ªµƒπ√™ 2007
™‡ÛÙ·ÛË
∫·ÙËÁÔÚ›·
∂›Â‰Ô ¤Ó‰ÂÈ͢
∏ Û¯¤ÛË ÌÂٷ͇ ˘ÂÚÁÏ˘Î·ÈÌ›·˜ Î·È Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ (∫∞¡) Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È Â˘ı¤ˆ˜ ·Ó¿ÏÔÁË. °È· οı 1% ·‡ÍËÛË Ù˘ HbA1C ·Ú·ÙËÚÂ›Ù·È ÌÈ· ÔÚÈṲ̂ÓË ·‡ÍËÛË ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘
π
∞
√ ΛӉ˘ÓÔ˜ ∫∞¡ ·˘Í¿ÓÂÙ·È ·fi ÙÔÓ ¤Î‰ËÏÔ ™¢ ηٿ 2 Ì 3 ÊÔÚ¤˜ ÛÙÔ˘˜ ¿Ó‰Ú˜ Î·È Î·Ù¿ 3 Ì 5 ÊÔÚ¤˜ ÛÙȘ Á˘Ó·›Î˜
π
∞
∏ ÌÂÙ·ÁÂ˘Ì·ÙÈ΋ (ÌÂÙ¿ ÊfiÚÙÈÛË) ÙÈÌ‹ Ù˘ ÁÏ˘Îfi˙˘ Â›Ó·È Î·Ï‡ÙÂÚÔ˜ ‰Â›ÎÙ˘ ÎÈÓ‰‡ÓÔ˘ ÌÂÏÏÔÓÙÈÎÒÓ ∫∞¡ ·fi ÙËÓ ÙÈÌ‹ Ù˘ ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜ Î·È ·˘ÍË̤ÓË ÌÂÙ·ÁÂ˘Ì·ÙÈ΋ (ÌÂÙ¿ ÊfiÚÙÈÛË) ÁÏ˘Îfi˙Ë ÚԂϤÂÈ ·˘ÍË̤ÓÔ Î·Ú‰È·ÁÁÂÈ·Îfi ΛӉ˘ÓÔ Û ¿ÙÔÌ· ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜
π
∞
√È ÁÏ˘ÎÔÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ Û˘Ó¿ÁÔÓÙ·È È‰È·›ÙÂÚ· ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ Î·Ú‰È·ÁÁÂȷ΋˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ÛÙȘ Á˘Ó·›Î˜, ÔÈ Ôԛ˜ ÁÈ’ ·˘Ùfi ÙÔ ÏfiÁÔ ¯ÚÂÈ¿˙ÔÓÙ·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹.
ππa
B
ÚÔËÁÔ˘Ì¤ÓˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ (ËÏÈΛ·, ۈ̷ÙÈÎfi ‚¿ÚÔ˜, ÂÚ›ÌÂÙÚÔ˜ ̤Û˘, ·ıÔÏÔÁÈ΋ ÙÈÌ‹ ÁÏ˘Îfi˙˘ ÛÙË ‰È¿ÚÎÂÈ· ÓÔÛ‹ÛˆÓ, ÂÁ¯ÂÈÚ‹ÛˆÓ, ÂÁ΢ÌÔÛ‡Ó˘ ÎÏ), ‚) Ì ÙË Û˘ÏÏÔÁ‹ ÏËÚÔÊÔÚÈÒÓ Ì¤Ûˆ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ ÁÈ· ·ÈÙÈÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ·Ó¿Ù˘Í˘ ™¢ (ÎÏËÚÔÓÔÌÈÎfi ÈÛÙÔÚÈÎfi, ‰È·ÙÚÔÊ‹, ۈ̷ÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·) Î·È Á) ̤ÙÚËÛË ÙÔ˘ ۷ί¿ÚÔ˘ ·›Ì·ÙÔ˜. ∏ ‰ÔÎÈÌ·Û›· ·ÓÔ¯‹˜ Ù˘ ÁÏ˘Îfi˙˘ (OGTT) Â›Ó·È ¿ÓÙÔÙ ··Ú·›ÙËÙË ˆ˜ ‰Â‡ÙÂÚÔ ‚‹Ì· ÁÈ· ÙËÓ ·ÎÚÈ‚‹ ‰È¿ÁÓˆÛË Ù˘ ‰È·Ù·Ú·¯‹˜ Ù˘ ÔÌÔÈÔÛÙ·Û›·˜ ÁÏ˘Îfi˙˘. √È ÁÏ˘ÎÔÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ Â›Ó·È Û˘Ó‹ıÂȘ Û ·ÛıÂÓ›˜ Ì ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· Î·È ÁÈ’ ·˘Ùfi Ë OGTT ‰ÂÓ Ú¤ÂÈ Ó· ·Ú·Ï›ÂÙ·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜.
∂ȉËÌÈÔÏÔÁ›· ÙÔ˘ ™¢, ‰È·Ù·Ú·¯‹˜ Ù˘ ÔÌÔÈÔÛÙ·Û›·˜ ÁÏ˘Îfi˙˘ (impaired glucose homeostasis – IGH) Î·È Î·Ú‰È·ÁÁÂÈ·Îfi˜ ΛӉ˘ÓÔ˜. O ÂÈÔÏ·ÛÌfi˜ ÙÔ˘ ™¢ ·˘Í¿ÓÂÙ·È Ì ÙËÓ ËÏÈΛ·, ÙfiÛÔ ÛÙÔ˘˜ ¿Ó‰Ú˜ fiÛÔ Î·È ÛÙȘ Á˘Ó·›Î˜ (∂ÈÎfiÓ· 3). ™ÙÔÓ ∂˘Úˆ·˚Îfi ÏËı˘ÛÌfi Ë Èı·ÓfiÙËÙ· Ó· ·Ó·Ù‡ÍÂÈ Î·Ó›˜ ÛÙË ˙ˆ‹ ÙÔ˘ ™¢ ·Ó¤Ú¯ÂÙ·È Û 30-40%. ¶ÂÚ›Ô˘ ÔÈ ÌÈÛÔ› ·fi ÙÔ˘˜ ¿Û¯ÔÓÙ˜ ‰ÂÓ ÁÓˆÚ›˙Ô˘Ó fiÙÈ ¿Û¯Ô˘Ó. ™ÙÔÓ ∂˘Úˆ·˚Îfi ÏËı˘ÛÌfi ̤Û˘ ËÏÈΛ·˜ ÙÔ ÔÛÔÛÙfi ·˘ÙÒÓ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ‰È·Ù·Ú·¯‹ Ù˘ ·ÓÔ¯‹˜ ÁÏ˘Îfi˙˘ (IGT) ·Ó¤Ú¯ÂÙ·È Û 15% ÂÚ›Ô˘ Î·È ÙÔ ÔÛÔÛÙfi ·˘Í¿ÓÂÙ·È Û 35-40% ÛÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜.
20
∏ ÈÔ Û˘¯Ó‹ ·ÈÙ›· ı·Ó¿ÙÔ˘ ÙˆÓ ∂˘Úˆ·›ˆÓ ÂÓËÏ›ÎˆÓ ‰È·‚ËÙÈÎÒÓ Â›Ó·È Ë ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ (™¡). √ ΛӉ˘ÓÔ˜ Â›Ó·È ‰‡Ô Ì ÙÚÂȘ ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi ÙÔÓ Î›Ó‰˘ÓÔ ÙˆÓ ÌË ‰È·‚ËÙÈÎÒÓ. ∏ Û˘Ó‡·ÚÍË ™¢ Ù‡Ô˘ 2 Î·È ™¡ ‚¿˙ÂÈ ÙÔ˘˜ ·ÛıÂÓ›˜ Û ÂÍ·ÈÚÂÙÈο ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ ÛÙÂÊ·ÓÈ·›Ô˘ ı·Ó¿ÙÔ˘. √ Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙȘ Á˘Ó·›Î˜ ·fi fiÙÈ ÛÙÔ˘˜ ¿Ó‰Ú˜. √ ÏfiÁÔ˜ ÁÈ· ÙË ‰È·ÊÔÚ¿ ·˘Ù‹ ·Ó¿ÌÂÛ· ÛÙ· ‰‡Ô ʇϷ ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜. À¿Ú¯Ô˘Ó ›Û˘ ÈÛ¯˘Ú¤˜ ÂӉ›ÍÂȘ fiÙÈ Î·È Ë ‰È·Ù·Ú·¯‹ Ù˘ ·ÓÔ¯‹˜ ÛÙË ÁÏ˘Îfi˙Ë Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ™¡. ∏ ·˘ÍË̤ÓË ÌÂÙ·ÁÂ˘Ì·ÙÈ΋ ÁÏ˘Îfi˙Ë (2 ÒÚ˜ ÌÂÙ¿ ÊfiÚÙÈÛË) ÚԂϤÂÈ Î·Ï‡ÙÂÚ· ÙÔÓ Î›Ó‰˘ÓÔ Î·Ú‰È·ÁÁÂȷ΋˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜, ·ÎfiÌË Î·È ÌÂÙ¿ ‰ÈfiÚıˆÛË Ì ÙÔ˘˜ ¿ÏÏÔ˘˜ Ì›˙ÔÓ˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ÂÓÒ Ë ·˘ÍË̤ÓË ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ ‰ÂÓ ¤¯ÂÈ ÙËÓ ›‰È· ÚÔÁÓˆÛÙÈ΋ ÈηÓfiÙËÙ·.. ∏ ˘ÂÚÁÏ˘Î·ÈÌ›· ηı’ ·˘Ù‹ ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· ÁÈ· ÙËÓ ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘. ŸÌˆ˜ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› ·ÎfiÌË, ÌÔÏÔÓfiÙÈ ˘¿Ú¯Ô˘Ó οÔȘ ÂӉ›ÍÂȘ, ·Ó ÂÏ¿ÙÙˆÛË Ù˘ ÌÂÙ¿ ÊfiÚÙÈÛË ÙÈÌ‹˜ Ù˘ ÁÏ˘Îfi˙˘ ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ. √ ΛӉ˘ÓÔ˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ·fi ·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο Â›Ó·È Â›Û˘ ·˘ÍË̤ÓÔ˜ ÛÙÔ ™¢ ÂÓÒ ÔÈ ÁÓÒÛÂȘ Ì·˜ ÁÈ· ÙË Û¯¤ÛË ÙÔ˘ ·Û˘Ìو̷ÙÈÎÔ‡ ‰È·‚‹ÙË Î·È Ù˘ ‰È·Ù·Ú·¯‹˜ ·ÓÔ¯‹˜ Ù˘ ÁÏ˘Îfi˙˘ Ì ٷ ·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο
Â›Ó·È ÛËÌ·ÓÙÈο ÏÈÁfiÙÂÚ˜.
∂ÓÙÔÈÛÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ∫∞¡ ‹ ™¢ ∂ӉȷʤÚÔÓ ¤¯ÂÈ Û˘ÁÎÂÓÙÚÒÛÂÈ Ë Û˘ÛÛÒÚ¢ÛË ·Ú·ÁfiÓÙˆÓ, Ô Î·ı¤Ó·˜ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘. ∏ ηٿÛÙ·ÛË ¤¯ÂÈ ÔÓÔÌ·Ûı› «ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ» (ª™). À¿Ú¯ÂÈ ‰È·ÊˆÓ›· ÁÈ· ÙÔ ·Ó Ë Û˘ÛÛÒÚ¢ÛË ·˘Ù‹ ·ÔÙÂÏ› ͯˆÚÈÛÙ‹ ÔÓÙfiÙËÙ·, fï˜ Ë ·Ó·ÁÓÒÚÈÛË Ù˘ ‚ÔËı¿ÂÈ ÛÙÔÓ ÂÓÙÔÈÛÌfi ·ÙfiÌˆÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ ∫∞¡ Î·È ™¢ Ù‡Ô˘ 2. ∞˘Ù‹ ÙË ÛÙÈÁÌ‹ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙÔ› ÔÚÈÛÌÔ› ÙÔ˘ ª™. √ ÈÔ ÚfiÛÊ·ÙÔ˜ ¤¯ÂÈ Û˘ÓÙ·¯ı› ·fi ÙËÓ IDF (¶·ÁÎfiÛÌÈ· √ÌÔÛÔÓ‰›· ÙÔ˘ ¢È·‚‹ÙË) (¶›Ó·Î·˜ 3). ∏ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ª™ Î·È ÙˆÓ Â› ̤ÚÔ˘˜ Û˘ÓÈÛÙˆÛÒÓ ÙÔ˘ Â›Ó·È Û‡ÓıÂÙË Î·È fi¯È ·fiÏ˘Ù· ηٷÓÔËÙ‹. √ˆÛ‰‹ÔÙ fï˜ Ë ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ· Î·È Ë ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Â›Ó·È ÛËÌ·ÓÙÈÎÔ› ·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜. ∏ ÂÚ›ÌÂÙÚÔ˜ Ù˘ ÎÔÈÏÈ¿˜ Â›Ó·È ÙÔ ÎÏÈÓÈÎfi ÛËÌÂ›Ô ·Ó·˙‹ÙËÛ˘ ÙÔ˘ ª™ ÛÙÔÓ ÏËı˘ÛÌfi Î·È Û¯ÂÙ›˙ÂÙ·È Ì ·˘Ùfi ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔÓ ¢Â›ÎÙË ª¿˙·˜ ™ÒÌ·ÙÔ˜ (¢ª™). °È· ÙËÓ Úfi‚ÏÂ„Ë ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ı·Ó·ÙËÊfiÚˆÓ ‹ ÌË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÂÈÛÔ‰›ˆÓ ÂÓÙfi˜ ÔÚÈṲ̂ÓÔ˘ ¯ÚfiÓÔ˘ ¤¯Ô˘Ó ÂÈÓÔËı› ‰È¿ÊÔÚ· ۯ‰ȷÁÚ¿ÌÌ·Ù· ‹ ‚·ıÌÔÏÔÁ‹ÛÂȘ ∆Ô ∂˘Úˆ·˚Îfi Heart Score ÂÎÙÈÌ¿ ÙËÓ Èı·ÓfiÙËÙ· ı·Ó¿ÙÔ˘ ·fi
√¢∏°π∂™ ∂ÈÎfiÓ· 3. ∂ÈÔÏ·ÛÌfi˜ ÙÔ˘ ¢™ ηٿ ÔÌ¿‰Â˜ ËÏÈÎÈÒÓ Î·È Î·Ù¿ ʇÏÔ Û 13 ∂˘Úˆ·˚ÎÔ‡˜ ÏËı˘ÛÌÔ‡˜. ªÂϤÙË DECODE DMF:™¢ ‰È·ÁÓˆÛı›˜ Ì ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ ≥126 mg/dl Î·È ÁÏ˘Îfi˙Ë 2 ÒÚ˜ ÌÂÙ¿ ÊfiÚÙÈÛË<200 mg/dl. DMP:™¢ ‰È·ÁÓˆÛı›˜ Ì ÁÏ˘Îfi˙Ë 2 ÒÚ˜ ÌÂÙ¿ ÊfiÚÙÈÛË ≥200 mg/dl Î·È ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ <126 mg/dl DMF Î·È DMP:™¢ ‰È·ÁÓˆÛı›˜ Ì ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ ≥126 mg/dl Î·È ÁÏ˘Îfi˙Ë 2 ÒÚ˜ ÌÂÙ¿ ÊfiÚÙÈÛË≥200 mg/dl. Known diabetes:·Ï·ÈfiÙÂÚ· ‰È·ÁÓˆṲ̂ÓÔ˜ ™¢. *P<0,05 ∫·È ** P<0,001 ÌÂٷ͇ ·Ó‰ÚÒÓ Î·È Á˘Ó·ÈÎÒÓ ·ÓÙ›ÛÙÔȯ·
ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ˘˜ ·Ú·‰ÔÛÈ·ÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ‰ÂÓ ÂÎÙÈÌ¿ fï˜ ÙËÓ Èı·ÓfiÙËÙ· ™¢. √ FINDRISC (FINnish Diabetes Risk Score), ‰È·ı¤ÛÈÌÔ˜ ÛÙÔÓ ‰È·‰˘ÎÙÈ·Îfi ÙfiÔ HYPERLINK "http://www.diabetes.fi/english" www.diabetes.fi/english, ›ӷÈ
¤Ó· ÂÚÁ·ÏÂ›Ô Ô˘ ‚ÔËı¿ÂÈ ÛÙËÓ Úfi‚ÏÂ„Ë Ì ·ÚÎÂÙ‹ ·ÎÚ›‚ÂÈ· Ù˘¯fiÓ ÂΉ‹ÏˆÛ˘ ™¢ Ù· ÚÔÛ¯‹ 10 ¯ÚfiÓÈ·, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ ÙÔ˘ ·Û˘Ìو̷ÙÈÎÔ‡ ™¢ Î·È Ù˘ ‰È·Ù·Ú·¯‹˜ ÔÌÔÈÔÛÙ·Û›·˜ Ù˘ ÁÏ˘Îfi˙˘.
¶ÚfiÏË„Ë Ù˘ ÔÚ›·˜ ÚÔ˜ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË
¶›Ó·Î·˜ 3. √ÚÈÛÌfi˜ ÙÔ˘ ªÂÙ·‚ÔÏÈÎÔ‡ ™˘Ó‰ÚfiÌÔ˘ ηٿ IDF. ∫ÂÓÙÚÈ΋ ·¯˘Û·ÚΛ· (ÔÚÈ˙fiÌÂÓË ˆ˜ ÂÚ›ÌÂÙÚÔ˜ ̤Û˘ ≥ 94 cm ÁÈ· ÙÔ˘˜ ∂˘Úˆ·›Ô˘˜ ¿Ó‰Ú˜ Î·È ≥ 80 cm ÁÈ· ÙȘ ∂˘Úˆ·›Â˜ Á˘Ó·›Î˜, Ì ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ ÙÈÌÒÓ ·˘ÙÒÓ ÁÈ· ¿ÏϘ ÂıÓÈΤ˜ ÔÌ¿‰Â˜) ™˘Ó ÔÈÔÓ‰‹ÔÙ ‰‡Ô ·fi ÙÔ˘˜ ηو٤ڈ 4 ·Ú¿ÁÔÓÙ˜ ñ ∞˘ÍË̤ӷ ›‰· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ (≥ 150 mg/dl), ‹ ÂȉÈ΋ ıÂڷ›· ÁÈ· ·˘Ù‹ ÙË ÏÈȉ·ÈÌÈ΋ ‰È·Ù·Ú·¯‹ ñ ÷ÌËÏ‹ HDL-¯ÔÏËÛÙÂÚfiÏË (< 40 mg/dl ÛÙÔ˘˜ ¿Ó‰Ú˜ Î·È < 50 mg/dl ÛÙȘ Á˘Ó·›Î˜) ‹ ÂȉÈ΋ ıÂڷ›· ÁÈ· ·˘Ù‹ ÙË ÏÈȉ·ÈÌÈ΋ ‰È·Ù·Ú·¯‹ ñ ∞˘ÍË̤ÓË ∞ÚÙËÚȷ΋ ¶›ÂÛË: Û˘ÛÙÔÏÈ΋ ≥ 130 ‹ ‰È·ÛÙÔÏÈ΋ ≥ 85 mmHg, ‹ ·ÓÙÈ˘ÂÚÙ·ÛÈ΋ ıÂڷ›· ñ ∞˘ÍË̤ÓË ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ (FPG) ≥ 100 mg/dl, ‹ ‰È·ÁÓˆṲ̂ÓÔ˜ ™¢ Ù‡Ô˘ 2. ∞Ó Ë ÁÏ˘Îfi˙Ë ÓËÛÙ›·˜ Â›Ó·È > 100 mg/dl, Û˘ÓÈÛÙ¿Ù·È Ë ‰ÈÂÓ¤ÚÁÂÈ· OGTT, ·Ó Î·È ‰ÂÓ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ª™
∆˘ ÂΉ‹ÏˆÛ˘ ™¢ Ù‡Ô˘ 2 Û˘Ó‹ıˆ˜ ÚÔËÁÔ‡ÓÙ·È, ¯ÚfiÓÈ· ÚÈÓ, ‰È·Ù·Ú·¯¤˜ Ù˘ ÌÂÙ·‚ÔÏÈ΋˜ ηٿÛÙ·Û˘, fiˆ˜ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È ‰˘Û·ÓÂÍ›· ÛÙË ÁÏ˘Îfi˙Ë. ªÔÏÔÓfiÙÈ ‰ÂÓ Ô‰Â‡Ô˘Ó fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ٤ÙÔȘ ‰È·Ù·Ú·¯¤˜ ÚÔ˜ ÙÔÓ ™¢, Ô Î›Ó‰˘ÓÔ˜ Ó· ÂΉËÏÒÛÔ˘Ó ÙË ÓfiÛÔ Â›Ó·È ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ˜. ªË ÛˆÛÙ‹ ‰›·ÈÙ· Î·È Î·ıÈÛÙÈÎfi˜ ÙÚfiÔ˜ ˙ˆ‹˜ Û˘Ì‚¿ÏÔ˘Ó Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘. ∞ÔÙÂÏÂÛÌ·ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ÛÙÔÓ ÙÚfiÔ ˙ˆ‹˜ ÌÔÚÔ‡Ó Ó· ÚÔÏ¿‚Ô˘Ó ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ Ó· ηı˘ÛÙÂÚ‹ÛÔ˘Ó ÙËÓ ÂͤÏÈÍË ÚÔ˜ ™¢ Û ٤ÙÔÈ· ¿ÙÔÌ· (¶›Ó·Î·˜ 4). ∞Ó ·ÔÙ‡¯ÂÈ Ë ˘ÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÂÓ·ÏÏ·ÎÙÈο Ë Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹. ∞ԉ‰ÂÈÁ̤ÓË ·Í›· ¤¯Ô˘Ó Ë ·Î·Ú‚fi˙Ë, Ë ÌÂÙÊÔÚÌ›ÓË Î·È Ë ÚÔÛÈÁÏ˘Ù·˙fiÓË. ŸÌˆ˜, fiÙ·Ó Ë ÌÂÙÊÔÚÌ›ÓË Û˘ÁÎÚ›ıËΠ̠ÙËÓ ˘ÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹ Ô ·ÚÈıÌfi˜
21
™∂¶∆∂ªµƒπ√™ 2007
™‡ÛÙ·ÛË
∫·ÙËÁÔÚ›·
∂›Â‰Ô ¤Ó‰ÂÈ͢
∆Ô ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ ¯·Ú·ÎÙËÚ›˙ÂÈ ¿ÙÔÌ· Û ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ∫∞¡ Û ۇÁÎÚÈÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi, ·Ú’ fiÙÈ ÌÔÚ› Ó· ÌË ‰›ÓÂÈ Î·Ï‡ÙÂÚ˜ ‹ ·ÎfiÌË Î·È ÙÔ ›‰ÈÔ Î·Ï¤˜ ÏËÚÔÊÔڛ˜ ·fi ÙËÓ ‚·ıÌÔÏfiÁËÛË Ô˘ ‚·Û›˙ÂÙ·È ÛÙÔ˘˜ Ì›˙ÔÓ˜ ηډȷÁÁÂÈ·ÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘
ππ
µ
∂ÚÁ·Ï›· ÂÎÙ›ÌËÛ˘ ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ Î·È ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÙfiÛÔ Û ‰È·‚ËÙÈο fiÛÔ Î·È Û ÌË ‰È·‚ËÙÈο ¿ÙÔÌ·
π
∞
∏ ÂÎÙ›ÌËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ™¢ Ù‡Ô˘ 2 Ì ÙË ¯Ú‹ÛË ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÂÚÁ·Ï›ˆÓ Ú¤ÂÈ Ó· ·ÔÙÂÏ› ̤ÚÔ˜ Ù˘ ηıËÌÂÚÈÓ‹˜ ÊÚÔÓÙ›‰·˜ ˘Á›·˜
ππ
∞
√È ·ÛıÂÓ›˜ ¯ˆÚ›˜ ÁÓˆÛÙfi ™¢ ·ÏÏ¿ Ì ÂΉËψ̤ÓË ™¡ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û OGTT
π
µ
ÕÙÔÌ· Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ˘„ËÏfi ΛӉ˘ÓÔ Ó· ÂÌÊ·Ó›ÛÔ˘Ó ™¢ Ù‡Ô˘ 2 Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔ˘Ó ÙȘ ηٿÏÏËϘ ˘ÁÈÂÈÓԉȷÈÙËÙÈΤ˜ Ô‰ËÁ›Â˜ ηÈ, ÂÓ ·Ó¿ÁÎË, Ê¿Ú̷η, ÒÛÙ ӷ ÌÂȈı› ‹ Ó· ηı˘ÛÙÂÚ‹ÛÂÈ Ô Î›Ó‰˘ÓÔ˜ ÂΉ‹ÏˆÛ˘ ÙÔ˘ ™¢. ∞˘Ùfi ÌÔÚ› Ó· ÌÂÈÒÛÂÈ Â›Û˘ Î·È ÙÔÓ Î›Ó‰˘ÓÔ ∫∞¡.
π
∞
ÙˆÓ ·ÙfiÌˆÓ Ô˘ ¯ÚÂÈ¿ÛıËΠӷ ıÂڷ¢ıÔ‡Ó (¡¡∆) ÁÈ· Ó· ·ÔÊ¢¯ı› ¤Ó· ÂÚÈÛÙ·ÙÈÎfi ™¢ ‹Ù·Ó ηٿ 50% ÌÈÎÚfiÙÂÚÔ˜ Ì ÙËÓ ˘ÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹, ·fi fiÙÈ Ì ÙËÓ ÌÂÙÊÔÚÌ›ÓË. ª¿ÏÈÛÙ· Ë Û˘Ó‰˘·Ṳ̂ÓË ·ÁˆÁ‹ Î·È Ì ÙȘ ‰‡Ô ÌÂıfi‰Ô˘˜ ‰ÂÓ Â›¯Â ÚfiÛıÂÙÔ ·ÔÙ¤ÏÂÛÌ·.
£Âڷ›· ÁÈ· ÙËÓ Ì›ˆÛË ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ∏ ÌË Ê·Ú̷΢ÙÈ΋ ıÂڷ›·, fiˆ˜ ÛÎÈ·ÁÚ·ÊÂ›Ù·È ÛÙÔÓ ¶›Ó·Î· 1, Â›Ó·È Ô˘ÛÈ҉˘ ÁÈ· ÙËÓ ÂÈÙ˘¯‹ Ì›ˆÛË ÙÔ˘ ۷ί¿ÚÔ˘ ·›Ì·ÙÔ˜, ΢ڛˆ˜ ÛÙ· ·Ú¯Èο ÛÙ¿‰È· ÙÔ˘ ‰È·‚‹ÙË. ∏ ˘ÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹ Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÍ ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ì ÔÔÈÔ‰‹ÔÙ ʿÚÌ·ÎÔ ÁÈ· ÙË Ì›ˆÛË Ù˘ ÁÏ˘Îfi˙˘ Î·È ¤¯ÂÈ ‰Â›ÍÂÈ ÛÙȘ Ù˘¯·ÈÔÔÈË̤Ó˜ ÂÏÂÁ¯fiÌÂÓ˜ Ì placebo ÌÂϤÙ˜ fiÙÈ ÂÙ˘¯·›ÓÂÈ Ì¤ÛË Ì›ˆ-
ÛË Ù˘ HbA1c ηٿ 1,0-1,5%.
¯ÚˆÙÈÎfi Ó· Á›ÓÂÙ·È Î¿ı ¯ÚfiÓÔ.
∏ ıÂڷ›· Ô˘ ÛÙԯ‡ÂÈ ÛÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ HbA1c ÚÔ˜ Ù· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· ÂÙ˘¯·›ÓÂÈ Ì›ˆÛË ÙˆÓ ÌÈÎÚÔ·ÁÁÂÈ·ÎÒÓ Î·È ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ ÂÈÏÔÎÒÓ ÛÙ· ¿ÙÔÌ· Ì ™¢ Ù‡Ô˘ 1 Î·È Ù‡Ô˘ 2. ªÂ›ˆÛË Ù˘ HbA1c ηٿ 1,0% ÂÏ·ÙÙÒÓÂÈ ÙȘ ÌÈÎÚÔ·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ηٿ 25% Î·È Ô ·fiÏ˘ÙÔ˜ ΛӉ˘ÓÔ˜ Û ›‰· HbA1c οو ÙˆÓ 7,5% Ê·›ÓÂÙ·È Ó· Â›Ó·È ÌÈÎÚfi˜
∏ Û¯¤ÛË ÌÂٷ͇ Ì·ÎÚÔ·ÁÁÂÈ·ÎÒÓ ·ı‹ÛÂˆÓ Î·È ˘ÂÚÁÏ˘Î·ÈÌ›·˜ Â›Ó·È ÏÈÁfiÙÂÚÔ ÍÂοı·ÚË, ·Ó Î·È ˘¿Ú¯Ô˘Ó οÔȘ ÂӉ›ÍÂȘ.
√È ÌÈÎÚÔ·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ·fi Ù· ÓÂÊÚ¿ Î·È Ù· Ì¿ÙÈ· ·Í›˙Ô˘Ó ÚÔÛÂÎÙÈο ıÂڷ¢ÙÈο ̤ÙÚ·, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ηٿÏÏËÏ˘ Ú‡ıÌÈÛ˘ Ù˘ ∞¶ Ì ÙË ¯Ú‹ÛË ∞ª∂∞ ηÈ/‹ ·ÓÙ·ÁˆÓÈÛÙ¤˜ Ù˘ ·ÁÁÂÈÙÂÓÛ›Ó˘ ππ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi Ë ‰ÈÂÚ‡ÓËÛË ÁÈ· Ù˘¯fiÓ ‡·ÚÍË ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·˜ Î·È ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·˜ Â›Ó·È ˘Ô-
™ÙÔÓ ™¢ Ù‡Ô˘ 1 Ë ıÂڷ›· Á›ÓÂÙ·È Ì ÈÓÛÔ˘Ï›ÓË, ηٿÏÏËÏË ‰›·ÈÙ· Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ۷ί¿ÚÔ˘ ·›Ì·ÙÔ˜ ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ·ÛıÂÓ‹ (·˘ÙÔ·Ú·ÎÔÏÔ‡ıËÛË), ÒÛÙ ӷ ‰È·ÙËÚÂ›Ù·È Ë HbA1c οو ·fi 7%. µ¤‚·È· Ë ıÂڷ›· ı· Ú¤ÂÈ Ó· ·˘Í¿ÓÂÙ·È ÚÔԉ¢ÙÈο, ÒÛÙ ӷ ·ÔʇÁÔÓÙ·È Ù· ˘ÔÁÏ˘Î·ÈÌÈο ÂÂÈÛfi‰È·. ™ÙÔÓ ™¢ Ù‡Ô˘ 2 ‰ÂÓ ˘¿Ú¯ÂÈ ÌÈ· ÎÔÈÓ‹ ıÂڷ¢ÙÈ΋ ÚÔۤϷÛË ÁÈ· fiϘ ÙȘ ÂÚÈÙÒÛÂȘ. ªÂÚÈΤ˜ ·fi„ÂȘ ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ‰›‰ÔÓÙ·È ÛÙÔÓ ›Ó·Î· 5, ÂÓÒ ÔÈ ıÂڷ¢ÙÈÎÔ› ÛÙfi¯ÔÈ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1.
¶›Ó·Î·˜ 4. ¶ÂÚÈÏËÙÈο Â˘Ú‹Ì·Ù· ÌÂÚÈÎÒÓ ÌÂÏÂÙÒÓ ˘ÁÈÂÈÓԉȷÙËÙÈ΋˜ ·ÁˆÁ‹˜, Ì ÛÎÔfi ÙËÓ ÚfiÏË„Ë Û ÏËı˘ÛÌÔ‡˜Ì ‰È·Ù·Ú·¯‹ Ù˘ ·ÓÔ¯‹˜ ÁÏ˘Îfi˙˘ ªÂϤÙË
∞ÚÈıÌfi˜ ·ÙfïÓ
ª¤ÛÔ˜ ¢ª™ (kg/m 2)
¢È¿ÚÎÂÈ· (¤ÙË)
RRR (%)
ARR (%)
NNT
Malmö
217
26,6
5
63
18
28
DPS
523
31,0
3
58
12
22
DPP
2161*
34,0
3
58
15
21
Da Qing
500
25,8
6
46
27
25
RRR= ∂Ï¿ÙÙˆÛË Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘. ARR= ∞fiÏ˘ÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘/100.000 ¿ÙÔÌ·-¤ÙË. NNT = ·ÚÈıÌfi˜ ·ÙfiÌˆÓ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ó· ıÂڷ¢ı› ÁÈ· Ó· ÚÔÏËÊı› ¤Ó· ÂÚÈÛÙ·ÙÈÎfi ™¢ Û ‰È¿ÛÙËÌ· 12 ÌËÓÒÓ * ∞ıÚÔÈÛÙÈο ¿ÙÔÌ· ÙˆÓ ÔÌ¿‰ˆÓ placebo, ‰›·ÈÙ·˜ Î·È ¿ÛÎËÛ˘.
22
√¢∏°π∂™ ™‡ÛÙ·ÛË
∫·ÙËÁÔÚ›·
∂›Â‰Ô ¤Ó‰ÂÈ͢
H ‰ÔÌË̤ÓË Âη›‰Â˘ÛË ÙˆÓ ·ÛıÂÓÒÓ ‚ÂÏÙÈÒÓÂÈ ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi Î·È ‚ÔËı¿ÂÈ ÛÙË Ú‡ıÌÈÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘
I
A
ªË Ê·Ú̷΢ÙÈ΋, ˘ÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹ ‚ÂÏÙÈÒÓÂÈ ÙÔÓ ÌÂÙ·‚ÔÏÈÎfi ¤ÏÂÁ¯Ô
I
A
∏ ·˘ÙÔ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ‚ÂÏÙÈÒÓÂÈ ÙÔÓ ÁÏ˘Î·ÈÌÈÎfi ¤ÏÂÁ¯Ô
π
∞
π I
∞ A
∏ ÂÓÙ·ÙÈ΋ ÈÓÛÔ˘ÏÈÓÔıÂڷ›· ÛÙÔÓ ™¢ Ù‡Ô˘ 1 ÌÂÈÒÓÂÈ ÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ·
I
A
∏ ¤ÁηÈÚË ÂÓÙ·ÙÈÎÔÔ›ËÛË Ù˘ ıÂڷ›·˜ ÒÛÙ ӷ ÂÈÙ¢¯ıÔ‡Ó ÔÈ ÚÔηıÔÚÈṲ̂ÓÔÈ ıÂڷ¢ÙÈÎÔ› ÛÙfi¯ÔÈ ‚ÂÏÙÈÒÓÂÈ ÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ÛÙÔÓ ™¢ Ù‡Ô˘ 2.
πIa
µ
™Â ·ÛıÂÓ›˜ Ì ™¢ Ù‡Ô˘ 2 Ô˘ ·ÔÙ˘Á¯¿ÓÔ˘Ó Ó· Êı¿ÛÔ˘Ó ÙÔ˘˜ ÛÙfi¯Ô˘˜ ÛÙȘ ÙÈ̤˜ ÙÔ˘ ۷ί¿ÚÔ˘, ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛΤ„Ë ÁÈ· ÚÒÈÌË ¤Ó·ÚÍË ÈÓÛÔ˘Ï›Ó˘
πIa
C
∏ ÌÂÙÊÔÚÌ›ÓË ıˆÚÂ›Ù·È ÚÒÙ˘ ÂÈÏÔÁ‹˜ Ê¿ÚÌ·ÎÔ ÛÙÔ˘˜ ˘¤Ú‚·ÚÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ù‡Ô˘ 2
πIa
B
∏ ‰È·Ù‹ÚËÛË Ù˘ ÁÏ˘Îfi˙˘ ÎÔÓÙ¿ ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· (HbA1c ≤ 6,5%*) ªÂÈÒÓÂÈ ÙȘ ÌÈÎÚÔ·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ªÂÈÒÓÂÈ ÙȘ Ì·ÎÚÔ·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ππ∞∞
* diabetes Control and Complication Trial-standardized.
ŸÙ·Ó Ù· ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ·ÓÙȉȷ‚ËÙÈο Û ηٿÏÏËϘ ‰fiÛÂȘ ·ÔÙ˘Á¯¿ÓÔ˘Ó, Û˘ÓÈÛÙÒÓÙ·È Û˘Ó‰˘·ÛÌÔ› Ê·Ú̿ΈÓ, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ÚÒÈÌ˘ ÎÏÈ̿ΈÛ˘ ̤¯ÚÈ ÙËÓ ÈÓÛÔ˘Ï›ÓË, ÒÛÙ ӷ ÌÂÁÈÛÙÔÔÈÂ›Ù·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È Ó· ÂÏ·¯ÈÛÙÔÔÈÔ‡ÓÙ·È ÔÈ ·ÚÂÓ¤ÚÁÂȘ. ªÈ· ̤ÛË ‰fiÛË ÂÓfi˜ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ·ÓÙȉȷ‚ËÙÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ ·Ô‰›‰ÂÈ ÙÔ 80% ÂÚ›Ô˘ Ù˘ ̤ÁÈÛÙ˘ ˘ÔÁÏ˘Î·ÈÌÈ΋˜ ÙÔ˘ ‰Ú¿Û˘ ÂÓÒ ÌÂÈÒÓÂÈ ÙȘ Èı·ÓfiÙËÙ˜ ·ÚÂÓÂÚÁÂÈÒÓ (¶›Ó·Î˜ 6 Î·È 7)
¢˘ÛÏÈȉ·È̛˜ ∏ ‰˘ÛÏÈȉ·ÈÌ›· Â›Ó·È Ì¤ÚÔ˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ Î·È Ù˘ Úԉȷ‚ËÙÈ΋˜ ηٿÛÙ·Û˘. ∂È̤ÓÂÈ ·Ú¿ ÙËÓ ˘ÔÁÏ˘Î·ÈÌÈ΋ ıÂڷ›· Î·È ¯ÚÂÈ¿˙ÂÙ·È ÂȉÈ΋ ·ÁˆÁ‹ Ì ˘ÁÈÂÈÓԉȷÈÙËÙÈο ̤ÙÚ· Î·È Ê¿Ú̷η. ∆˘Èο ÛÙÔÓ ™¢ Ù‡Ô˘ 2 ˘¿Ú¯ÂÈ Ì¤ÙÚÈ· ˘ÂÚÙÚÈÁÏ˘ÎÂÚȉ·ÈÌ›·, ¯·ÌËÏ‹ HDL-¯ÔÏËÛÙÂÚfiÏË Î·È ·ıÔÏÔÁÈ΋ ÌÂÙ·ÁÂ˘Ì·ÙÈ΋ ÏÈȉ·ÈÌ›·. ∏ ÔÏÈ΋ Î·È Ë LDL-¯ÔÏËÛÙÂÚfiÏË Â›Ó·È Û ›‰È· ›‰· Ì ·˘Ù¿ ÙˆÓ ·ÙfiÌˆÓ ¯ˆÚ›˜ ™¢, fï˜ Ù· ÌfiÚÈ· Ù˘ LDL Â›Ó·È ÌÈÎÚ¿ Î·È ˘ÎÓ¿, Ú¿ÁÌ· Ô˘ Ù· ηıÈÛÙ¿ ȉȷ›ÙÂÚ· ·ıËÚÔÁfiÓ· √È ÛÙ·Ù›Ó˜, ›Ù ¯ÚËÛÈÌÔÔÈÔ‡-
ÓÙ·È ÁÈ· ÚˆÙÔ·ı‹ ›Ù ÁÈ· ‰Â˘ÙÂÚÔ·ı‹ ÚfiÏË„Ë, ÂÙ˘¯·›ÓÔ˘Ó ÙÔ ›‰ÈÔ fiÊÂÏÔ˜ ÛÙË Ì›ˆÛË ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ Û ·ÛıÂÓ›˜ Ì ‹ ¯ˆÚ›˜ ‰È·‚‹ÙË. ¢Â‰Ô̤ÓÔ˘ fiÙÈ Ô ·fiÏ˘ÙÔ˜ ΛӉ˘ÓÔ˜ Â›Ó·È ˘„ËÏfiÙÂÚÔ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‰È·‚‹ÙË, Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÙfiÌˆÓ Ô˘ ¯ÚÂÈ¿˙ÂÙ·È Ó· ıÂڷ¢ÙÔ‡Ó (¡¡∆) Â›Ó·È ÌÈÎÚfiÙÂÚÔ˜ (¶›Ó·Î·˜ 8). À¿Ú¯Ô˘Ó ÈÛ¯˘Ú¤˜ ÂӉ›ÍÂȘ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ÂÈıÂÙÈ΋ Ì›ˆÛË Ù˘ LDL¯ÔÏËÛÙÂÚfiÏ˘ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∆· ÛÙÔȯ›· Û˘ÓËÁÔÚÔ‡Ó ÁÈ· ÙË ¯ÔÚ‹ÁËÛË ÛÙ·ÙÈÓÒÓ Ì ÛÎÔfi ÙËÓ ÚˆÙÔ·ı‹ ÚfiÏË„Ë ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË > 135 mg/dL Ì ÛÙfi¯Ô Ì›ˆÛË Ù˘ LDL-¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 30-40%. °È· ÙȘ ÊÈÌÚ¿Ù˜ ˘¿Ú¯Ô˘Ó ÏÈÁfiÙÂÚ· ÛÙÔȯ›·. §fiÁˆ ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ ÁÓÒÛÂˆÓ ÔÈ Ô‰ËÁ›Â˜ Â›Ó·È ÏÈÁfiÙÂÚÔ ÂÍÂȉÈÎÂ˘Ì¤Ó˜ fiÛÔÓ ·ÊÔÚ¿ ÙÔ˘˜ ÛÙfi¯Ô˘˜ ÁÈ· ÙËÓ HDL-¯ÔÏËÛÙÂÚfiÏË Î·È Ù· ÙÚÈÁÏ˘ÎÂÚ›‰È·. √ˆÛ‰‹ÔÙ fï˜ ·Ó·ÁÓˆÚ›˙Ô˘Ó fiÙÈ Ë ¯·ÌËÏ‹ HDL- ¯ÔÏËÛÙÂÚfiÏË (<39 mg/dL ÛÙÔ˘˜ ¿Ó‰Ú˜ Î·È < 46 mg/dL ÛÙȘ Á˘Ó·›Î˜) Î·È Ù· ÙÚÈÁÏ˘ÎÂÚ›‰È· ÓËÛÙ›·˜ > 151 mg/dL Â›Ó·È ‰Â›ÎÙ˜ ·˘ÍË-
̤ÓÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘. ∞Ó Ù· ÙÚÈÁÏ˘ÎÂÚ›‰È· ·Ú·Ì¤ÓÔ˘Ó > 177 mg/dL ÌÂÙ¿ ÙËÓ Â›Ù¢ÍË ÙÔ˘ ÛÙfi¯Ô˘ Ù˘ LDL-¯ÔÏËÛÙÂÚfiÏ˘ Ì ÛÙ·Ù›ÓË, Ù›ıÂÙ·È ˆ˜ ‰Â˘ÙÂÚ‡ˆÓ ÛÙfi¯Ô˜ Ë Ì›ˆÛË Ù˘ non-HDL ÛÂ Â›Â‰Ô Î·Ù¿ 31 mg/dL ˘„ËÏfiÙÂÚÔ ·fi ÙÔÓ ÛÙfi¯Ô Ù˘ LDL-¯ÔÏËÛÙÂÚfiÏ˘. ∞˘Ùfi ÌÔÚ› Ó· ¯ÚÂÈ·Ûı› ÙËÓ ÚÔÛı‹ÎË Â˙ÂÙÈÌ›Ì˘, ÊÈÌÚ¿Ù˘ ‹ ÓÈÎÔÙÈÓÈÎÔ‡.
∞ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË ∏ Ú‡ıÌÈÛË Ù˘ ∞¶ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ȉȷ›ÙÂÚË ÊÚÔÓÙ›‰·, ÒÛÙ ӷ ÂÈÙ˘Á¯¿ÓÔÓÙ·È Ù· ›‰· Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞˘Ù‹ Ë ıÂڷ¢ÙÈ΋ ÛÙÚ·ÙËÁÈ΋ Û¯ÂÙ›˙ÂÙ·È Ì ¯·ÌËÏfiÙÂÚË Â›ÙˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ. ∏ ˘ÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹ Û˘Ó‹ıˆ˜ ‰ÂÓ ·ÚΛ Î·È ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ¯ÚÂÈ¿˙ÔÓÙ·È Û˘Ó‰˘·ÛÌfi ·ÓÙÈ˘ÂÚÙ·ÛÈÎÒÓ Ê·Ú̿ΈÓ. ∆· ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ‰ÈÔ˘ÚËÙÈÎÒÓ ¤¯Ô˘Ó ÂȂ‚·Èˆı› ·ÚÎÒ˜, fiˆ˜ Î·È ÙˆÓ ‚-·Ó·ÛÙÔϤˆÓ, ÙˆÓ ·ÓÙ·ÁˆÓÈÛÙÒÓ ÙÔ˘ Ca, ÙˆÓ ∞ª∂∞ Î·È ÙˆÓ ·ÔÎÏÂÈÛÙÒÓ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ. √ ·ÔÎÏÂÈÛÌfi˜ ÙÔ˘ ™ƒ∞∞ ¤¯ÂÈ È‰È·›ÙÂÚË ·Í›· ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. √È ∞ª∂∞ Î·È ÔÈ ·ÔÎÏÂÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô-
23
™∂¶∆∂ªµƒπ√™ 2007
¶›Ó·Î·˜ 5. ∂ÈÏÔÁ‹ ·ÓÙȉȷ‚ÈÙÈ΋˜ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜ ·Ó¿ÏÔÁ· Ì ÙË ÁÏ˘ÎÔÌÂÙ·‚ÔÏÈ΋ ηٿÛÙ·ÛË °Ï˘ÎÔÌÂÙ·‚ÔÏÈ΋ ηٿÛÙ·ÛË
∞ÓÙȉȷ‚ËÙÈο Ê¿Ú̷η
ªÂÙ·ÁÂ˘Ì·ÙÈ΋ ˘ÂÚÁÏ˘Î·ÈÌ›·
∞Ó·ÛÙÔÏ›˜ Ù˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘, ÛÔ˘ÏÊÔÓ˘ÏÔ˘Ú›Â˜ ‚Ú·¯Â›·˜ ‰Ú¿Ûˆ˜, ÁÏ˘Ó›‰Â˜, ÈÓÛÔ˘Ï›ÓË ‚Ú·¯Â›·˜ ‰Ú¿Ûˆ˜ ‹ ·Ó¿ÏÔÁ· ÈÓÛÔ˘Ï›Ó˘
ÀÂÚÁÏ˘Î·ÈÌ›· ÓËÛÙ›·˜
¢ÈÁÔ˘·Ó›‰È·, ÛÔ˘ÏÊÔÓ˘ÏÔ˘Ú›Â˜ Ì·ÎÚ¿˜ ‰Ú¿Ûˆ˜, ÁÏÈÙ·˙fiÓ˜, ÈÓÛÔ˘Ï›ÓË Ì·ÎÚ¿˜ ‰Ú¿Ûˆ˜ ‹ ·Ó¿ÏÔÁ· ÈÓÛÔ˘Ï›Ó˘.
∞ÓÙ›ÛÙ·ÛË ÛÙËÓ ÈÓÛÔ˘Ï›ÓË
¢ÈÁÔ˘·Ó›‰È·, ÁÏ˘Ù·˙fiÓ˜, ·Ó·ÛÙÔÏ›˜ Ù˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘
∞Ó¿ÚÎÂÈ· ÈÓÛÔ˘Ï›Ó˘
™Ô˘ÏÊÔÓ˘ÏÔ˘Ú›Â˜, ÁÏÈÓ›‰Â˜, ÈÓÛÔ˘Ï›ÓË
¶›Ó·Î·˜ 6. M¤ÛË ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ Ê·Ú̷΢ÙÈÎÒÓ ÂÈÏÔÁÒÓ Û ·ÛıÂÓ›˜ Ì ¢™ Ù‡Ô˘ 2 º·Ú̷΢ÙÈ΋ ηÙËÁÔÚ›·
ª¤ÛË Ì›ˆÛË ·fi ÙËÓ ·Ú¯È΋ HbA1c (%)
∞Ó·ÛÙÔÏ›˜ Ù˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ ¢ÈÁÔ˘·Ó›‰È· °Ï˘Ó›‰Â˜ °ÏÈÙ·˙fiÓ˜ πÓÛÔ˘Ï›ÓË ¶·Ú¿ÁˆÁ· ÛÔ˘ÏÊ·Ó˘ÏÔ˘Ú›·˜
0,5 – 1,0 1,0 – 1,5 0,5 – 1,5 1,0 – 1,5 1,0 – 2,0 1,0 – 1,5
¶›Ó·Î·˜ 7. ¶Èı·Ó¿ ÌÂÈÔÓÂÎÙ‹Ì·Ù· ÙˆÓ Ê·Ú̷΢ÙÈÎÒÓ ÂÈÏÔÁÒÓ Û ·ÛıÂÓ›˜ Ì ™¢ Ù‡Ô˘ 2 ¶Èı·Ó¿ ÚÔ‚Ï‹Ì·Ù·
∞ÔÊ˘Á‹ ‹ ·ÓÂÎÙ›ÌËÛË ÛÎÔÈÌfiÙËÙ·˜
∞ÓÂÈı‡ÌËÙË ·‡ÍËÛË ÛˆÌ·ÙÈÎÔ‡ ‚¿ÚÔ˘˜ °·ÛÙÚÂÓÙÂÚÈο ÂÓԯϋ̷ٷ ÀÔÁÏ˘Î·ÈÌ›· µÏ¿‚Ë ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ µÏ¿‚Ë Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜
™Ô˘ÏÊ·Ó˘ÏÔ˘Ú›Â˜, ÁÏ˘Ó›‰Â˜, ÁÏÈÙ·˙fiÓ˜, ÈÓÛÔ˘Ï›ÓË ¢ÈÁÔ˘·Ó›‰È·, ·Ó·ÛÙÔÏ›˜ Ù˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ ™Ô˘ÏÊ·Ó˘ÏÔ˘Ú›Â˜, ÁÏ˘Ó›‰Â˜, ÈÓÛÔ˘Ï›ÓË ¢ÈÁÔ˘·Ó›‰È·, ÛÔ˘ÏÊ·Ó˘ÏÔ˘Ú›Â˜, °Ï˘Ó›‰Â˜, ÁÏÈÙ·˙fiÓ˜, ‰ÈÁÔ˘·Ó›‰È·, ·Ó·ÛÙÔÏ›˜ Ù˘ ·-ÁÏ˘ÎÔ˙ȉ¿Û˘ ¢ÈÁÔ˘·Ó›‰È·, ÁÏÈÙ·˙fiÓ˜
µÏ¿‚Ë Î·Ú‰ÈÔÓ¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜
¯¤ˆÓ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ Â›Ó·È ÔÈ ÚÔÙÈÌfiÙÂÚ˜ ıÂڷ›˜ ÁÈ· ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ÌÈÎÚÔÏ¢ÎÔÌ·ÙÈÓÔ˘Ú›·˜/ÚˆÙÂ˚ÓÔ˘Ú›·˜ Î·È Ù˘ ÓÂÊÚÈ΋˜ ‚Ï¿‚˘.
ÃÂÈÚÈÛÌfi˜ ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ·ı‹ÛÂˆÓ ™ÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ √È ·ÛıÂÓ›˜ Ì √™™ Î·È ™¢ ¤¯Ô˘Ó ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ ÂÈÏÔÎÒÓ. ∏ ıÓËÛÈÌfiÙËÙ· ·Ó¤Ú¯ÂÙ·È Û 7-18% ÙȘ ÚÒÙ˜ 30 Ë̤Ú˜ Î·È Û 15-34% ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ. √ Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ· ı¿Ó·ÙÔ Î˘Ì·›ÓÂÙ·È ·fi 1,3 Û 5,4 Î·È Â›Ó·È Î¿ˆ˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙȘ Á˘Ó·›Î˜. √È Î·Ù·ÁÚ·ÊÈΤ˜ ÌÂϤÙ˜ (registries) ¤¯Ô˘Ó ·Ôηχ„ÂÈ fiÙÈ ÔÈ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ ‰ÂÓ ıÂڷ‡ÔÓÙ·È ÙfiÛÔ Î·Ï¿ fiÛÔ Î·È ÔÈ ÌË ‰È·‚ËÙÈÎÔ›
24
ÔÌÔÈÔ·ı›˜ ÙˆÓ, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ‚·ÛÈṲ̂ÓË Û ÂӉ›ÍÂȘ ıÂڷ›· Î·È ÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ÂÂÌ‚¿ÛÂȘ. ŒÓ·˜ ÏfiÁÔ˜ ÁÈ’ ·˘Ùfi ÌÔÚ› Ó· Â›Ó·È ÙÔ fiÙÈ ÔÈ ‰È·‚ËÙÈÎÔ›, ÏfiÁˆ Ù˘ Ó¢ÚÔ¿ıÂÈ·˜ ÙÔ˘ ∞¡™ ¤¯Ô˘Ó Û˘¯Ó¿ ·ÓÒ‰˘ÓË ÈÛ¯·ÈÌ›· ‹ ¿Ù˘· Û˘ÌÙÒÌ·Ù·. ÕÏÏÔ˜ ÏfiÁÔ˜ Â›Ó·È fiÙÈ ÔÈ ‰È·‚ËÙÈÎÔ› ¤¯Ô˘Ó Û˘¯Ó¿ Û¯ÂÙÈΤ˜ ·ÓÙÂӉ›ÍÂȘ ÁÈ· οÔȘ ÌÔÚʤ˜ ıÂڷ›·˜. ¶·Ú’ fiÏ· ·˘Ù¿, Ë ‚·ÛÈṲ̂ÓË Û ÂӉ›ÍÂȘ ıÂڷ›·, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ÚÒÈÌ˘ ·ÁÁÂÈÔÁÚ·Ê›·˜ ηÈ, ·Ó Â›Ó·È ‰˘Ó·Ùfi, ·ӷÁÁ›ˆÛ˘, Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙfiÛÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ fiÛÔ Î·È ÛÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜, ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ÛÙÔȯ›· ÁÈ· ·˘ÍË̤Ó˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. ŒÙÛÈ, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì √™™ ı· Ú¤ÂÈ Ó· ‰›‰ÂÙ·È ÂÍ·È-
ÚÂÙÈ΋ ÚÔÛÔ¯‹, Û‡Ìʈӷ Ì ÙȘ ˘¿Ú¯Ô˘Û˜ Ô‰ËÁ›Â˜. √È ‰È·ı¤ÛÈ̘ ıÂڷ¢ÙÈΤ˜ ÂÈÏÔÁ¤˜ (¶›Ó·Î·˜ 9) ·ÔÛÎÔÔ‡Ó ÛÙÔ Ó· Û˘ÓÙËÚ‹ÛÔ˘Ó Î·È Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙËÓ Ì˘Ôηډȷ΋ ÏÂÈÙÔ˘ÚÁ›· Ó· ÛÙ·ıÂÚÔÔÈ‹ÛÔ˘Ó ÙËÓ Â˘¿ÏˆÙË ·ıËڈ̷ÙÈ΋ Ͽη, Ó· ÚÔÏ¿‚Ô˘Ó ˘ÔÙÚÔ‹ ÙˆÓ Û˘Ì‚·Ì¿ÌˆÓ Ì ¤ÏÂÁ¯Ô Ù˘ ıÚÔÌ‚ÔÁfiÓÔ˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È Ó· ·Ó·¯·ÈÙ›ÛÔ˘Ó ÙËÓ ÚfiÔ‰Ô ÙˆÓ ·ıËÚÔÛÎÏËÚˆÙÈÎÒÓ ‚Ï·‚ÒÓ. ∆· ıÚÔÌ‚ÔÏ˘ÙÈο Ê¿Ú̷η Î·È ÔÈ ÂÂÌ‚¿ÛÂȘ ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ fiÛÔ Î·È ÛÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ·ÛıÂÓ›˜. §fiÁˆ ÙÔ˘ ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ˘ ·fiÏ˘ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÙÔ fiÊÂÏÔ˜ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Â›Ó·È ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜. √È ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ‚-·Ó·ÛÙÔÏ›˜, › ·Ô˘Û›· ·ÓÙÂӉ›ÍˆÓ, Û˘ÓÈÛÙÒÓÙ·È Û fiÏÔ˘˜ ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ì √™™. ∏ ·ÛÈÚ›ÓË ÌÂÈÒÓÂÈ ÙËÓ ıÓËÙfiÙËÙ· Î·È ÓÔÛËÚfiÙËÙ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ™¡. Œ¯ÂÈ ·Ó·ÊÂÚı› ·ÏÏ¿ ‰ÂÓ ·Ô‰Â›¯ıËΠÔÙ¤ fiÙÈ Ë ·ÛÈÚ›ÓË Â›Ó·È ÏÈÁfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Î·È fiÙÈ ·˘ÙÔ› ¯ÚÂÈ¿˙ÔÓÙ·È ÌÂÁ·Ï‡ÙÂÚ˜ ‰fiÛÂȘ. √È Ô‰ËÁ›Â˜ Û˘ÓÈÛÙÔ‡Ó Ó· ¯ÔÚËÁÂ›Ù·È Ë ·ÛÈÚ›ÓË ÛÙËÓ ›‰È· ‰fiÛË Î·È Ì ÙȘ ›‰È˜ ÂӉ›ÍÂȘ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜, fiˆ˜ Î·È ÛÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜ (∆¿ÍË ÔʤÏÔ˘˜ ππ·, ∂›Â‰Ô ¤Ó‰ÂÈ͢ µ). ∏ ÎÏÔȉÔÁÚ¤ÏË ÌÔÚ› Ó· ‰Ôı› ÂÈÚfiÛıÂÙ· Ì ÙË ·ÛÈÚ›ÓË Û ·ÛıÂÓ›˜ Ì ‰È·‚‹ÙË Î·È √™™ (∆¿ÍË ππ∞, Â›Â‰Ô ¤Ó‰ÂÈ͢ C). √È ∞ª∂∞ ÚÔÛÙ·ÙÂ‡Ô˘Ó ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂ-
√¢∏°π∂™ ™‡ÛÙ·ÛË
∫·ÙËÁÔÚ›·
∂›Â‰Ô ¤Ó‰ÂÈ͢
∏ ·˘ÍË̤ÓË LDL Î·È Ë ¯·ÌËÏ‹ HDL-¯ÔÏËÛÙÂÚfiÏË Â›Ó·È ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· Û ¿ÙÔÌ· Ì ™¢
I
A
√È ÛÙ·Ù›Ó˜ Â›Ó·È Ê¿Ú̷η ÚÒÙ˘ ÂÈÏÔÁ‹˜ ÁÈ· ÙË Ì›ˆÛË Ù˘ LDL-¯ÔÏËÛÙÂÚfiÏ˘ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜
I
A
™ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ηډȷÁÁÂȷ΋ ÓfiÛÔ, Ë ıÂڷ›· Ì ÛÙ·Ù›ÓË Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·Ú¯È΋ ÙÈÌ‹ Ù˘ LDL-¯ÔÏËÛÙÂÚfiÏ˘, Ì ÛÙfi¯Ô < 70-77 mg/dL
π
B
™Â ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ù‡Ô˘ 2 ¯ˆÚ›˜ ™¡, Â¿Ó Ë ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË Â›Ó·È > 135 mg/dL, ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛΤ„Ë ÁÈ· ¤Ó·ÚÍË ÛÙ·Ù›Ó˘ Ì ÛÙfi¯Ô ÙË Ì›ˆÛË Ù˘ LDL-¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 30-40%
πIb
B
√È ‰È·‚ËÙÈÎÔ› Ù‡Ô˘ 1 ı· Ú¤ÂÈ Ó· ıˆÚÔ‡ÓÙ·È ˘Ô„‹ÊÈÔÈ ÁÈ· ıÂڷ›· Ì ÛÙ·Ù›ÓË, ÏfiÁˆ ÙÔ˘ ÛÔ‚·ÚÔ‡ ÎÈÓ‰‡ÓÔ˘ Ó· ·Ó·Ù‡ÍÔ˘Ó ∫∞¡ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘˜. ™Â ·ÛıÂÓ›˜ 18-39 ÂÙÒÓ Ì ™¢ Ù‡Ô˘ 1 ‹ 2 Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛΤ„Ë ÁÈ· ÛÙ·Ù›ÓË fiÙ·Ó ˘¿Ú¯Ô˘Ó ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ ÓÂÊÚÔ¿ıÂÈ·, η΋ Ú‡ıÌÈÛË Û·Î¯¿ÚÔ˘, ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·, ˘¤ÚÙ·ÛË, ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·, ¯·Ú·ÎÙËÚÈÛÙÈο ª™, ‹ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÚÒÈÌ˘ ™¡
πIb
C
™Â ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ˘ÂÚÙÚÈÁÏ˘ÎÂÚȉ·ÈÌ›·, Ô˘ ÌÂÙ¿ ÙËÓ Â›Ù¢ÍË ÙÔ˘ ÛÙfi¯Ô˘ Ù˘ LDL-¯ÔÏËÛÙÂÚfiÏ˘ Ì ÛÙ·Ù›ÓË ·Ú·Ì¤ÓÔ˘Ó ÙÚÈÁÏ˘ÎÂÚ›‰È· ÛÂ Â›Â‰Ô > 177 mg% Ú¤ÂÈ Ë ‰fiÛË Ù˘ ÛÙ·Ù›Ó˘ Ó· ·˘Í¿ÓÂÙ·È ÒÛÙ ӷ ÂÈÙ¢¯ı› Ô ‰Â˘ÙÂÚ‡ˆÓ ÛÙfi¯Ô˜ ÁÈ· ÙËÓ non-HDL-¯ÔÏËÛÙÂÚfiÏË. ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· Â›Ó·È ·Ó·Áη›· Û˘Ó‰˘·Ṳ̂ÓË ·ÁˆÁ‹ Ì ÚÔÛı‹ÎË Â˙ÂÙÈÌ›Ì˘, ÓÈÎÔÙÈÓÈÎÔ‡ ÔͤԘ ‹ ÊÈÌÚ¿Ù˘.
πIb
B
Ó›˜ ·fi ÌÂÏÏÔÓÙÈο ÂÂÈÛfi‰È· Î·È ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÛΤ„Ë ÁÈ· ¯ÔÚ‹ÁËÛË ÙÔ˘˜ ÂȉÈο Â¿Ó Ô ·ÛıÂÓ‹˜ Â›Ó·È ˘ÂÚÙ·ÛÈÎfi˜ Î·È ¤¯ÂÈ ÛËÌ›· ÓÂÊÚÈ΋˜ ‚Ï¿‚˘. ∆Ô Û¿Î¯·ÚÔ ·›Ì·ÙÔ˜, Â¿Ó Â›Ó·È ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ, Ú¤ÂÈ Ó· Ú˘ıÌ›˙ÂÙ·È ·Ì¤Ûˆ˜ Ì ÈÓÛÔ˘Ï›ÓË Û ‰È·‚ËÙÈÎÔ‡˜ Ô˘ ÂÈÛ¿ÁÔÓÙ·È ÛÙË ÛÙÂÊ·ÓÈ·›· ÌÔÓ¿‰· Ì √∂ª. ∂¿Ó Â›Ó·È ÏÈÁfiÙÂÚÔ ·˘ÍË̤ÓÔ (ÎÔÓÙ¿ ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·) ÌÔÚ› Ó·
·ÓÙÈÌÂÙˆÈÛı› Ì ·ÓÙȉȷ‚ËÙÈο ‰ÈÛΛ· ·fi ÙÔ ÛÙfiÌ·. ∏ ·˘ÛÙËÚ‹ Ú‡ıÌÈÛË ÙÔ˘ ۷ί¿ÚÔ˘ Ú¤ÂÈ Ó· Û˘Ó¯›˙ÂÙ·È Ì ˘ÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹ Î·È fiÙ·Ó ¯ÚÂÈ¿˙ÂÙ·È Ì ‰ÈÛΛ· ‹ Î·È ÈÓÛÔ˘Ï›ÓË. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· Ú‡ıÌÈÛË Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÛÙÂÓ¿, ÒÛÙ ÔÈ ÙÈ̤˜ Ù˘ ÁÏ˘Îfi˙˘ Ó· Â›Ó·È fiÛÔ ÈÔ ÎÔÓÙ¿ ÛÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ Â›Ó·È ‰˘Ó·ÙfiÓ.
™‡ÛÙ·ÛË
√È Û˘ÛÙ¿ÛÂȘ ÁÈ· ÙËÓ ‰Â˘ÙÂÚÔÁÂÓ‹ ÚfiÏË„Ë Â›Ó·È ›‰È˜ Ì ·˘Ù¤˜ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ¯ˆÚ›˜ ‰È·‚‹ÙË, ÔÈ ıÂڷ¢ÙÈÎÔ› ÛÙfi¯ÔÈ fï˜ Â›Ó·È ÈÔ ÊÈÏfi‰ÔÍÔÈ, fiˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ¶›Ó·Î· 1. °ÂÓÈο Ê·›ÓÂÙ·È fiÙÈ ÔÏÏÔ› ‰È·‚ËÙÈÎÔ‡ ̤¯ÚÈ ÙÒÚ· ˘ÔıÂڷ‡ÔÓÙ·È Î·È ¯ÚÂÈ¿˙ÂÙ·È ÌÂÁ¿ÏË ÚÔÛ¿ıÂÈ· ÁÈ· Ó· ‚ÂÏÙȈı› Ë Î·Ù¿ÛÙ·ÛË ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÌÂÁ¿ÏÔ Î·Ú‰È·ÁÁÂÈ·Îfi ΛӉ˘ÓÔ.
∫·ÙËÁÔÚ›·
∂›Â‰Ô ¤Ó‰ÂÈ͢
™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘¤ÚÙ·ÛË Î·È ™¢ Ë ∞¶ Ú¤ÂÈ Ó· Ú˘ıÌ›˙ÂÙ·È Û ‡„Ô˜ < 130/80 mmHg
I
B
O ηډȷÁÁÂÈ·Îfi˜ ΛӉ˘ÓÔ˜ Û ·ÛıÂÓ›˜ Ì ‰È·‚‹ÙË Î·È ˘¤ÚÙ·ÛË Â›Ó·È Ô˘ÛÈ·ÛÙÈο ·˘ÍË̤ÓÔ˜. √ ΛӉ˘ÓÔ˜ ÌÔÚ› Ó· ÌÂȈı› ·ÔÙÂÏÂÛÌ·ÙÈο Ì ÙËÓ ·ÓÙÈ˘ÂÚÙ·ÛÈ΋ ıÂڷ›·
I
A
√È ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ Û˘Ó‹ıˆ˜ ¯ÚÂÈ¿˙ÔÓÙ·È Û˘Ó‰˘·ÛÌfi ‰È·ÊfiÚˆÓ ·ÓÙÈ˘ÂÚÙ·ÛÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÁÈ· ÈηÓÔÔÈËÙÈ΋ Ú‡ıÌÈÛË Ù˘ ∞¶
π
A
√È ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔ˘Ó ¤Ó·Ó ·Ó·ÛÙÔϤ· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÚÂÓ›Ó˘-·ÁÁÂÈÔÙÂÓÛ›Ó˘-·Ï‰ÔÛÙÂÚfiÓ˘ (™ƒ∞∞) ˆ˜ ̤ÚÔ˜ Ù˘ ·ÓÙÈ˘ÂÚÙ·ÛÈ΋˜ ·ÁˆÁ‹˜
π
A
π
A
¢ÈÂÚ‡ÓËÛË ÁÈ· ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· Î·È Â·Ú΋˜ ·ÓÙÈ˘ÂÚÙÛÈ΋ ·ÁˆÁ‹, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ¯Ú‹Û˘ ∞ª∂∞ Î·È ·ÓÙ·ÁˆÓÈÛÙ‹ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ ÌÂÈÒÓÂÈ ÙËÓ ÌÈÎÚÔ- Î·È Ì·ÎÚÔ·ÁÁÂȷ΋ ÓÔÛËÚfiÙËÙ· ÛÙÔÓ Ù‡Ô 1 Î·È ÛÙÔÓ Ù‡Ô 2 ÙÔ˘ ™¢
25
™∂¶∆∂ªµƒπ√™ 2007
¶›Ó·Î·˜ 8. YÔÔÌ¿‰· ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ì ™¢ ÛÙȘ ÌÂÁ¿Ï˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ÛÙ·ÙÈÓÒÓ, ‰Â˘ÙÂÚÔ·ıÔ‡˜ ÚfiÏ˄˘ Î·È ÔÛÔÛÙfi Ì›ˆÛ˘ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Û ·ÛıÂÓ›˜ ÌÂ Î·È ¯ˆÚ›˜ ‰È·‚‹ÙË. ªÂÙ·‚ÏËÙ¤˜
ªÂϤÙË
∆‡Ô˜ Û˘Ì‚·Ì¿ÙˆÓ
£Âڷ›·
⁄·ÚÍË ‰È·‚‹ÙË
™¯ÂÙÈ΋ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ (%) ∆‡Ô˜ ·ÛıÂÓÒÓ
Ÿ¯È
¡·È
ŸÏÔÈ
¢È·‚ËÙÈÎÔ›
4S ‰È·‚ËÙÈÎÔ› n=202
™ÙÂÊ·ÓÈ·›Ô˜ ı¿Ó·ÙÔ˜ Ë ÌË ı·Ó·ÙËÊfiÚÔ ∂ª
™ÈÌ‚·ÛÙ·Ù›ÓË Placebo
19 27
23 45
32
55
4S ‰È·‚ËÙÈÎÔ› ·ӷ-·Ó¿Ï˘ÛË n=483
™ÙÂÊ·ÓÈ·›Ô˜ ı¿Ó·ÙÔ˜ Ë ÌË ı·Ó·ÙËÊfiÚÔ ∂ª
™ÈÌ‚·ÛÙ·Ù›ÓË Placebo
19 26
24 38
32
42
HPS ‰È·‚ËÙÈÎÔ›
ªÂ›˙ÔÓ ÛÙÂÊ·ÓÈ·›Ô n=3050 ‹ ·ӷÁÁ›ˆÛË
™ÈÌ‚·ÛÙ·Ù›ÓË Placebo ÂÂÈÛfi‰ÈÔ, ÂÁÎÂÊ·ÏÈÎfi
20
31 25
24 36
18
CARE ‰È·‚ËÙÈÎÔ› n=586
™ÙÂÊ·ÓÈ·›Ô˜ ı¿Ó·ÙÔ˜ Ë ÌË ı·Ó·ÙËÊfiÚÔ ∂ª
¶Ú·‚·ÛÙ·Ù›ÓË Placebo
12 15
19 23
23
25
LIPID ‰È·‚ËÙÈÎÔ› n=782
™ÙÂÊ·ÓÈ·›Ô˜ ı¿Ó·ÙÔ˜, ÌË ı·Ó·ÙËÊfiÚÔ ∂ª, ·ӷÁÁ›ˆÛË
¶Ú·‚·ÛÙ·Ù›ÓË Placebo
19 25
29 37
24
19
LIPS ‰È·‚‹Ù˘ n=202
™ÙÂÊ·ÓÈ·›Ô˜ ı¿Ó·ÙÔ˜, ÌË ı·Ó·ÙËÊfiÚÔ ∂ª, ·ӷÁÁ›ˆÛË
ºÏÔ˘‚·ÛÙ·Ù›ÓË Placebo
21 25
22 38
22
47
GREACE ‰È·‚ËÙÈÎÔ› n=313
™ÙÂÊ·ÓÈ·›Ô˜ ı¿Ó·ÙÔ˜, ÌË ı·Ó·ÙËÊfiÚÔ ∂ª, ·ÛÙ·ı‹˜ ÛÙËı¿Á¯Ë, ηډȷ΋ ·Ó¿ÚÎÂÈ·, ·ӷÁÁ›ˆÛË, ÂÁÎÂÊ·ÏÈο
∞ÙÔÚ‚·ÛÙ·Ù›ÓË Placebo
12 25
13 30
51
58
¢È·‚‹Ù˘ Î·È ÛÙÂÊ·ÓÈ·›· ·ӷÁÁ›ˆÛË √È ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ ¤¯Ô˘Ó ˘„ËÏfiÙÂÚË ıÓËÛÈÌfiÙËÙ· Î·È ÓÔÛËÚfiÙËÙ· ÌÂÙ¿ ÂÁ¯Â›ÚËÛË bypass (GABG) Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜. ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ Î·È ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÁÁÂÈÔÏ·ÛÙÈ΋ (PCI). ∏ ›‰Ú·ÛË ÙÔ˘ ÁÏ˘ÎÔÌÂÙ·‚ÔÏÈÎÔ‡ ÂϤÁ¯Ô˘ ÛÙËÓ ¤Î‚·ÛË ÌÂÙ¿ ·ӷÁÁ›ˆÛË Â›Ó·È ·ÎfiÌË ·Û·Ê‹˜. √È ·ÛıÂÓ›˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÈÓÛÔ˘Ï›ÓË ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚ· ‰˘ÛÌÂÓ‹ Û˘Ì‚¿Ì·Ù·, ·ÏÏ¿ ·˘Ùfi ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ‹ ÌÂÁ·Ï‡ÙÂÚË ‚·Ú‡ÙËÙ· ÙÔ˘ ‰È·‚‹ÙË ‹ ›Ûˆ˜ Ì ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ Â›Ó·È ¿ÁÓˆÛÙ˜ ̤¯ÚÈ ÙÒÚ·.
∂Á¯Â›ÚËÛË ¤Ó·ÓÙÈ ·ÁÁÂÈÔÏ·ÛÙÈ΋˜ ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ PCI ¤¯ÂÈ Û˘ÁÎÚÈı› ÛÂ Ù˘¯·ÈÔÔÈË-
26
¶ÔÛÔÛÙfi Û˘Ì‚·Ì¿ÙˆÓ (%)
̤Ó˜ ÌÂϤÙ˜ Ì ÙËÓ GABG. ∞Ú¯Èο ˘‹ÚÍ·Ó ·ÓËÛ˘¯›Â˜, fiÙ·Ó ÌÈ· post-hoc ·Ó¿Ï˘ÛË ˘ÔÔÌ¿‰ˆÓ ¤‰ÂÈÍ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÔÏ˘·ÁÁÂȷ΋ ÓfiÛÔ ÏÈÁfiÙÂÚÔ Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· Ì ÙËÓ PCI ·fi ÙÔ by-pass. ÕÏϘ ÌÂϤÙ˜ fï˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ·˘ÙÒÓ Ì stent ‰ÂÓ ÂȂ‚·›ˆÛ·Ó ·˘Ùfi ÙÔ Â‡ÚËÌ·. ™ÙË ÌÂϤÙË BARI ‰È·ÊÔÚ¿ ÛÙËÓ ÂÈ‚›ˆÛË ·Ú·ÙËÚ‹ıËΠÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÈ· ¤Ûˆ Ì·ÛÙÈ΋. ∆· ÂÂÓ‰˘Ì¤Ó· Ì ʿÚ̷η stents (DES) ¯·ÈÚÂÙ›ÛÙËηÓ, fiÙÈ ‚ÂÏÙÈÒÓÔ˘Ó ÙËÓ ¤Î‚·ÛË Ù˘ PCI ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ªÈ·˜ ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË Ô˘ Û˘Ó¤ÎÚÈÓ ٷ DES Ì ٷ Á˘ÌÓ¿ stents Û ‰È·‚ËÙÈÎÔ‡˜ ¤‰ÂÈÍ fiÙÈ Ù· DES ÌÂÈÒÓÔ˘Ó ÙËÓ Â·Ó·ÛÙ¤ÓˆÛË Î·Ù¿ 80% ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘. ŸÌˆ˜ ÁÈ· Ó· ÂȂ‚·Èˆı› ÔÈ· ̤ıÔ‰Ô˜ ·ӷÁÁ›ˆÛ˘ Â›Ó·È Î·Ï‡ÙÂÚË ¯ÚÂÈ-
¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜. √È ·ÓÙ·ÁˆÓÈÛÙ¤˜ Ù˘ ÁÏ˘ÎÔÚˆÙ½Ó˘ IIb/IIIa ‚ÂÏÙÈÒÓÔ˘Ó ÙËÓ ¤Î‚·ÛË Ù˘ ·ÁÁÂÈÔÏ·ÛÙÈ΋˜ fiÙ·Ó ‰›‰ÔÓÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤̂·Û˘ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ∞ÎfiÌË ÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ADP, fiˆ˜ Ë ÎÏÔȉÔÁÚ¤ÏË, ÚÔÏ·Ì‚¿ÓÔ˘Ó ÙfiÛÔ ÙȘ ÚÒÈ̘ fiÛÔ Î·È ÙȘ ηı˘ÛÙÂÚË̤Ó˜ ıÚÔÌ‚ˆÙÈΤ˜ ÂÈÏÔΤ˜, ÌÂÙ¿ ÙËÓ ÂÌʇÙ¢ÛË stents, ȉ›ˆ˜ Û ·ÛıÂÓ›˜ Ì ™¢.
∂·Ó·ÁÁ›ˆÛË Î·È Â·Ó·ÈÌ¿ÙˆÛË ÛÙÔ Ô͇ ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘. ªÈ· ·Ó¿Ï˘ÛË ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ô˘ Û˘ÌÂÚÈÏ‹ÊıËÎ·Ó ÛÂ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó Î·Ï‡ÙÂÚË ÂÈ‚›ˆÛË Û ·˘ÙÔ‡˜ Ô˘ ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Ì ڈÙÔÁÂÓ‹ PCI Û˘ÁÎÚÈÙÈο Ì ·˘ÙÔ‡˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ıÚÔÌ‚fiÏ˘ÛË.
√¢∏°π∂™ ¶›Ó·Î·˜ 9. £Âڷ¢ÙÈΤ˜ ÂÈÏÔÁ¤˜ ‚·ÛÈṲ̂Ó˜ ÛÂ Û˘ÛÛˆÚÂ˘Ì¤Ó˜ ÂӉ›ÍÂȘ ∂·Ó·ÁÁ›ˆÛË ∞ÓÙÈ-ÈÛ¯·ÈÌÈο Ê¿Ú̷η ∞ÓÙÈ·ÈÌÔÂÙ·ÏÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜ ∞ÓÙÈıÚÔÌ‚ˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¢Â˘ÙÂÚÔÁÂÓ‹˜ ÚfiÏË„Ë Ì¤Ûˆ ÙˆÓ ñ ÀÁÈÂÈÓԉȷÈÙËÙÈ΋ ·ÁˆÁ‹ (‰›·ÈÙ· Î·È Ê˘ÛÈ΋ ¿ÛÎËÛË) ñ ¢È·ÎÔ‹ ηӛÛÌ·ÙÔ˜ ñ ∞ÔÎÏÂÈÛÌfi˜ ÙÔ˘ ™ƒ∞∞ ñ ƒ‡ıÌÈÛË Ù˘ ∞¶ ñ ÀÔÏÈȉ·ÈÌÈο Ê¿Ú̷η ƒ‡ıÌÈÛË Ù˘ ÁÏ˘Îfi˙˘ ·›Ì·ÙÔ˜ ñ ÕÌÂÛË, Â¿Ó ¯ÚÂÈ¿˙ÂÙ·È, Ì ¤Á¯˘ÛË ÈÓÛÔ˘Ï›Ó˘
∫·Ú‰È·Î‹ ·Ó¿ÚÎÂÈ· Î·È Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ À¿Ú¯ÂÈ ÈÛ¯˘Ú‹ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ‰È·‚‹ÙË Î·È Î·Ú‰È·Î‹˜ ·Ó¿ÚÎÂÈ·˜ Î·È Ë Û˘Ó‡·ÚÍË ÙˆÓ ‰‡Ô ηٷÛÙ¿ÛÂˆÓ Û˘Ó¿ÁÂÙ·È Ôχ η΋ ÚfiÁÓˆÛË. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ Ô˘ Ó· ¤¯Ô˘Ó ÂȉÈο ÂÍÂÙ¿ÛÂÈ ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ŒÙÛÈ ÔÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ıÂڷ¢ÙÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ‰È·ÊfiÚˆÓ Ê·ÚÌ¿ÎˆÓ ‚·Û›˙ÂÙ·È ÛÙȘ ˘ÔÔÌ¿‰Â˜ ‰È·‚ËÙÈÎÒÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙȘ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ∆· ÂÚÈÛÛfiÙÂÚ· ‰Â‰Ô̤ӷ Û˘ÓËÁÔÚÔ‡Ó fiÙÈ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Â›Ó·È Ë ›‰È· ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Î·È ÌË, Ú¿ÁÌ· Ô˘ ÛËÌ·›ÓÂÈ fiÙÈ ÔÈ ‰È·‚ËÙÈÎÔ›, ÂÂȉ‹ ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ, ˆÊÂÏÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚÔ. ∏ ıÂڷ›· Ú¤ÂÈ Ó· ‚·Û›˙ÂÙ·È ÛÙ· ‰ÈÔ˘ÚËÙÈο, ÙÔ˘˜ ∞ª∂∞ Î·È ÙÔ˘˜ ‚-·Ó·ÛÙÔÏ›˜. ∂ÈϤÔÓ ÈÛÙ‡ÂÙ·È fiÙÈ Ô ÏÂÙÔÌÂÚ‹˜ ÌÂÙ·‚ÔÏÈÎfi˜ ¤ÏÂÁ¯Ô˜ Â›Ó·È ˆÊ¤ÏÈÌÔ˜ Û ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ηډȷ΋ ·Ó¿ÚÎÂÈ·.
∞ÚÚ˘ı̛˜, ÎÔÏÈ΋ Ì·ÚÌ·Ú˘Á‹ Î·È ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ º·›ÓÂÙ·È fiÙÈ Ô ™¢ Úԉȷı¤ÙÂÈ ÁÈ· ÎÔÏÈ΋ Ì·ÚÌ·Ú˘Á‹ (∫ª), ·Ó Î·È Ô Ì˯·ÓÈÛÌfi˜ ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜. √ ™¢ ıˆÚÂ›Ù·È Ì¤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ıÚÔÌ‚ÔÂÌ‚ÔÏÈο ÂÂÈÛfi‰È· ÛÙËÓ ∫ª. ™Â ·ÛıÂÓ›˜ Ì ÌfiÓÈÌË ‹ ·ÚÔ͢ÛÌÈ΋ ∫ª Û˘ÓÈÛÙ¿Ù·È ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ ·fi ÙÔ ÛÙfiÌ·, Ì ÛÙfi¯Ô INR 2,0-3,0, Â¿Ó ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ (·ÎfiÌË Î·È ·ÚÔ‰ÈÎÔ‡) ‹ ·Ó ¤¯Ô˘Ó Î·È ¿ÏÏÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘, fiˆ˜ ËÏÈΛ· > 75 ÂÙÒÓ, ˘¤ÚÙ·ÛË, ηډȷ΋ ·Ó¿ÚÎÂÈ· Î·È ∫∂ <35%. ∂› ·ÓÙ¤Ó‰ÂÈ͢ Ù˘ ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜ Û˘ÓÈÛÙ¿Ù·È ·ÛÈÚ›ÓË Û ‰fiÛË 325 mg/ËÌÂÚËÛ›ˆ˜. ŸÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ¿ÏÏÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÏËÓ ÙÔ˘ ™¢ ÌÔÚ› Ó· ¯ÔÚËÁËı› ·ÛÈÚ›ÓË 81-325 mg/ËÌÂÚ.
ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ· Î·È Ë ÓÂÊÚÔ¿ıÂÈ· Â›Ó·È ‰Â›ÎÙ˜ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘.
¶ÂÚÈÊÂÚÈ΋ ·ÚÙËÚÈÔ¿ıÂÈ· Î·È ÓfiÛÔ˜ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ·ÁÁ›ˆÓ ÕÙÔÌ· Ì ™¢ ¤¯Ô˘Ó ‰ÈÏ¿ÛÈÔ ¤ˆ˜ ÙÂÙÚ·Ï¿ÛÈÔ Î›Ó‰˘ÓÔ ÂÚÈÊÂÚÈ΋˜ ·ÚÙËÚÈÔ¿ıÂÈ·˜ Î·È ·ıÔÏÔÁÈÎfi˜ ÛÊ˘ÚÔ‚Ú·¯ÈfiÓÈÔ˜ ‰Â›ÎÙ˘ ··ÓÙ¿Ù·È ÛÙÔ 15% ÙˆÓ ·ÛıÂÓÒÓ. ∆· Û˘ÌÙÒÌ·Ù· ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÛΤÏÔ˘˜ Û ‰È·‚ËÙÈÎÔ‡˜ ÌÔÚ› Ó· Â›Ó·È ¿Ù˘· Î·È ·Ì‚Ï˯ڿ, ÏfiÁˆ Ù˘ ÂÚÈÊÂÚÈ΋˜ Ó¢ÚÔ¿ıÂÈ·˜. ∞ÓÙ› ÁÈ· fiÓÔ ÔÈ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ·ÈÛı¿ÓÔÓÙ·È ÎfiˆÛË ‹ ÌfiÓÔ ·‰˘Ó·Ì›· Ó· ‚·‰›ÛÔ˘Ó Ì ηÓÔÓÈÎfi ‚ËÌ·ÙÈÛÌfi. ∏ Ê˘ÛÈ΋ ÂͤٷÛË Â›Ó·È ÎÚ›ÛÈÌ˘ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ‰È¿ÁÓˆÛË. ∏ ̤ÙÚËÛË ÙÔ˘ ÛÊ˘ÚÔ‚Ú·¯ÈfiÓÈÔ˘ ‰Â›ÎÙË Â›Ó·È È‰È·›ÙÂÚ· ¯Ú‹ÛÈÌË ÁÈ· ÙËÓ ÚÒÈÌË ‰È¿ÁÓˆÛË Ù˘ ÂÚÈÊÂÚÈ΋˜ ·ÚÙËÚÈÔ¿ıÂÈ·˜. √ ™¢ Â›Ó·È ÈÛ¯˘Úfi˜, ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο ÂÂÈÛfi‰È·. ∆· ̤ÙÚ· ÁÈ· ÙËÓ ÚfiÏË„Ë ÂÁÎÂÊ·ÏÈÎÒÓ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË ıÂڷ›· Ù˘ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘, Ù˘ ˘ÂÚÏÈȉ·ÈÌ›·˜, Ù˘ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·˜, Ù˘ ˘ÂÚÁÏ˘Î·ÈÌ›·˜ Î·È ÙË ¯Ú‹ÛË ·ÓÙÈ·ÈÌÔÂÙ·ÏÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∂È̤ÏÂÈ·: ∏Ï›·˜ ÃÂÈÌÒÓ·˜
∏ ›وÛË Î·Ú‰È·ÎÒÓ ·ÚÚ˘ıÌÈÒÓ, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ Ë ÎÔÈÏȷ΋ Ì·ÚÌ·Ú˘Á‹ Î·È ÙÔ˘ ·ÈÊÓȉ›Ô˘ ı·Ó¿ÙÔ˘ Â›Ó·È ·˘ÍË̤ÓË
™‡ÛÙ·ÛË
∫·ÙËÁÔÚ›·
∂›Â‰Ô ¤Ó‰ÂÈ͢
√È ıÂڷ¢ÙÈΤ˜ ·ÔÊ¿ÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ Â·Ó·ÁÁ›ˆÛË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ™¢ Ú¤ÂÈ Ó· ÎÏ›ÓÔ˘Ó ˘¤Ú ÙÔ˘ by-pass ¤Ó·ÓÙÈ Ù˘ PCI
IIa
A
™ÙËÓ ÂÎÏÂÎÙÈ΋ PCI Û ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÂӉ›ÎÓ˘Ù·È Ë ¯ÔÚ‹ÁËÛË ·Ó·ÛÙÔϤˆÓ Ù˘ GP IIb/IIIa
I
B
ŸÙ·Ó ‰ÈÂÓÂÚÁÂ›Ù·È PCI Ì ÂÌʇÙ¢ÛË stent Û ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È DES
πIa
B
π
A
∏ Ì˯·ÓÈ΋ ·ӷÈÌ¿ÙˆÛË Ì ڈÙÔÁÂÓ‹ PCI Â›Ó·È Ë Ì¤ıÔ‰Ô˜ ÂÎÏÔÁ‹˜ ·ӷÁÁ›ˆÛ˘ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì √∂ª
27
™∂¶∆∂ªµƒπ√™ 2007
AÓıÂÎÙÈ΋ Y¤ÚÙ·ÛË Ã·Ú¿Ï·ÌÔ˜ ªËÏÈÒÓ˘, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜, ∆Ô̤·˜ ¶·ıÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ ¶ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ÌÂÏÂÙÒÓ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ˘¤ÚÙ·ÛË ·ÔÙÂÏ› ¤Ó· ȉȷ›ÙÂÚ· Û˘ÓËıÈṲ̂ÓÔ Úfi‚ÏËÌ·, ηıÒ˜ Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ ÚÔÛÂÁÁ›˙ÂÈ ÙÔ 25% ÛÙÔ˘˜ ¿Ó‰Ú˜ ÌÂٷ͇ 30 Î·È 40 ÂÙÒÓ Î·È ˘ÂÚ‚·›ÓÂÈ ÙÔ 60% Û ¿ÙÔÌ· ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 60 (1). ∫·Ù¿ Û˘Ó¤ÂÈ·, ı¤Ì·Ù· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ‹ ÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘¤ÚÙ·Û˘ ÂӉȷʤÚÔ˘Ó ¿ÌÂÛ· ÙÔÓ ÎÏÈÓÈÎfi ÁÈ·ÙÚfi. ™ËÌ·ÓÙÈÎfiÙ·ÙÔ ÔÛÔÛÙfi ·ÛıÂÓÒÓ (Ô˘ ·ÁÁ›˙ÂÈ ÙÔ 70% ·ÁÎÔÛÌ›ˆ˜) ·Ú·Ì¤ÓÂÈ ¯ˆÚ›˜ ıÂڷ›·, ÂÓÒ ÙÔ ›‰ÈÔ ÛËÌ·ÓÙÈο ÔÛÔÛÙ¿ ·ÛıÂÓÒÓ ‰ÂÓ ÂÈÙ˘Á¯¿ÓÔ˘Ó ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ıÂڷ›·˜ (2). ∆· ·ÔÙÂϤÛÌ·Ù· ÌÂÁ¿ÏˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ ·Ú¤Ì‚·Û˘ Û ‰È·ÊÔÚÂÙÈΤ˜ ÔÌ¿‰Â˜ ˘ÂÚÙ·ÛÈÎÒÓ, ‰Â›¯ÓÔ˘Ó fiÙÈ ¯ÚÂÈ¿˙ÔÓÙ·È Û˘Ó‰˘·ÛÌÔ› ÂÚÈÛÛfiÙÂÚˆÓ ·fi ‰‡Ô ηÙËÁÔÚÈÒÓ Ê·ÚÌ¿ÎˆÓ ÁÈ· Ó· ÂÈÙ¢¯ıÔ‡Ó ÔÈ ıÂڷ¢ÙÈÎÔ› ÛÙfi¯ÔÈ (3,4).
√ÚÈÛÌfi˜ Ù˘ ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ - ∂ȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ ø˜ ÂÚÈÙÒÛÂȘ ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ ÔÚ›˙ÔÓÙ·È ÂΛӘ Ô˘ ·ÊÔÚÔ‡Ó ·ÛıÂÓ›˜, ÔÈ ÔÔ›ÔÈ ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ï·Ì‚¿ÓÔ˘Ó Î·Ù¿ÏÏËÏÔ˘˜ Û˘Ó‰˘·ÛÌÔ‡˜ ·fi 3 Ê¿Ú̷η ‰È·ÊÔÚÂÙÈÎÒÓ Î·ÙËÁÔÚÈÒÓ Û ϋÚË ‰fiÛË, ÂÎ ÙˆÓ ÔÔ›ˆÓ ÙÔ ¤Ó· Â›Ó·È ‰ÈÔ˘ÚËÙÈÎfi, ¤¯Ô˘Ó ÙÈ̤˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (∞¶) ÛÙ·ıÂÚ¿ >140/90 mmHg (‹ >130/80
mmHg fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ‰È·‚ËÙÈÎÔ‡˜ ‹ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ) (¶›Ó·Î·˜ 1) (5).
¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ·ÛıÂÓÒÓ Ì ·ÓıÂÎÙÈ΋ ˘¤ÚÙ·ÛË
∞ÎfiÌË Î·È ÛÙȘ ÌÂÁ¿Ï˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Û·Ó ·ÛıÂÓ›˜ ˘fi ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË, ÔÈ ÔÔ›ÔÈ ·ÎÔÏÔ˘ıÔ‡Û·Ó Û¯‹Ì·Ù· ÙÈÙÏÔÔ›ËÛ˘ Ù˘ ‰fiÛ˘ ÙˆÓ Ê·Ú̿ΈÓ, Ô ÛÙfi¯Ô˜ ÙˆÓ 140 mmHg ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙË Û˘ÛÙÔÏÈ΋ ∞¶ (™∞¶) ‹Ù·Ó ÂÊÈÎÙfi˜ ÛÙÔ 60% ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ Ô ÛÙfi¯Ô˜ Ù˘ ‰È·ÛÙÔÏÈ΋˜ (¢∞¶) ‹Ù·Ó ‰˘Ó·ÙfiÓ Ó· ÂÈÙ¢¯ı› ۯ‰fiÓ ÛÙÔ 90% ÙˆÓ ·ÛıÂÓÒÓ (5-7). ™‡Ìʈӷ Ì ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ, ·ÓıÂÎÙÈ΋ ‹ ˘¤ÚÙ·ÛË Ô˘ ÂϤÁ¯ÂÙ·È ‰‡ÛÎÔÏ· ·Ú·ÙËÚÂ›Ù·È Û˘ÓËı¤ÛÙÂÚ· ÛÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ (>65) Î·È Ì¿ÏÈÛÙ· ÛÙÔ˘˜ ¿Ó‰Ú˜ (8). ∏ ̤ÛË ÙÈÌ‹ Ù˘ ™∞¶ Û ·˘ÙÔ‡˜ ÙÔ˘ ·ÛıÂÓ›˜ Û˘Ó‹ıˆ˜ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 145 Î·È 160 mmHg, ÂÓÒ Ë ¢∞¶ ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ Û˘Ó‹ıˆ˜ Ù· 100 mmHg (8).
º·ÈÓÔÌÂÓÈο ·ÓıÂÎÙÈ΋ ˘¤ÚÙ·ÛË
∆· ÂÚÈÛÛfiÙÂÚ· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙËÓ ·ÓıÂÎÙÈ΋ ˘¤ÚÙ·ÛË ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙȘ ÌÂÁ¿Ï˜ ÌÂϤÙ˜ ·Ú¤Ì‚·Û˘. √ ÂÈÔÏ·ÛÌfi˜ Ù˘ ÂÎÙÈÌ¿Ù·È fiÙÈ ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ ÙÔ 5% ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi, ÊÙ¿ÓÂÈ ÙÔ 13% ÛÙ· ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ· ·Ó·ÊÔÚ¿˜, ÂÓÒ ÚÔÛÂÁÁ›˙ÂÈ ÙÔ 50% ÛÙ· Â͈ÙÂÚÈο È·ÙÚ›· ÓÂÊÚÔÏÔÁÈÎÒÓ Î¤ÓÙÚˆÓ ÂÍ·ÈÙ›·˜ ÙÔ˘ ÛËÌ·ÓÙÈÎÔ‡ ÔÛÔÛÙÔ‡ ˘ÂÚÙ·ÛÈÎÒÓ ·ÛıÂÓÒÓ Ì ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜, ÏÂÈÙÔ˘ÚÁ›·˜ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û ٤ÙÔÈÔ˘ ›‰Ô˘˜ ΤÓÙÚ· (9).
¶›Ó·Î·˜ 1. OÚÈÛÌfi˜ Ù˘ AÓıÂÎÙÈ΋˜ Y¤ÚÙ·Û˘ TÈ̤˜ ™A¶/¢A¶: >140/90 mmHg
>130//80 mmHg
–AÛıÂÓ›˜ Ì ™. ¢È·‚‹ÙË –AÛıÂÓ›˜ Ì XÚ. NÂÊÚÈ΋ NfiÛÔ (ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ >1.5 mg/dl ‹ ÚˆÙ½ÓË Ô‡ÚˆÓ 300 mg/24h)
™Â ·ÁˆÁ‹ ÌÂ: – ≥ 3 Ê¿Ú̷η, ‰È·ÊÔÚÂÙÈÎÒÓ Î·ÙËÁÔÚÈÒÓ – ¤Ó· ‰ÈÔ˘ÚËÙÈÎfi
28
∂›Ó·È ÙÂÎÌËÚȈ̤ÓÔ fiÙÈ ·˘Í‹ÛÂȘ Ù˘ ∞¶ ηٿ 20/10 mmHg ¿Óˆ ·fi Ù· 115/75 mmHg (‰ËÏ·‰‹ ÙÈ̤˜ ∞¶ Û ›‰· 135/85 mmHg) ‰ÈÏ·ÛÈ¿˙Ô˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ıÓËÛÈÌfiÙËÙ·˜ ·fi ηډȷÁÁÂÈο Û˘Ì‚¿Ì·Ù· (10). ∂ÎÙÈÌ¿Ù·È fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ·ÓıÂÎÙÈ΋ ˘¤ÚÙ·ÛË Â›Ó·È Èı·ÓfiÙÂÚÔ Ó· ¤¯Ô˘Ó ‚Ï¿‚˜ ÔÚÁ¿ÓˆÓ ÛÙfi¯ˆÓ Î·È ·˘ÍË̤ÓÔ Î·Ú‰È·ÁÁÂÈ·Îfi ΛӉ˘ÓÔ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ Ë ˘¤ÚÙ·Û‹ ÙÔ˘˜ ÂϤÁ¯ÂÙ·È ÈηÓÔÔÈËÙÈο (11). √È ÛÙÚ·ÙËÁÈΤ˜ ·Ú¤Ì‚·Û˘ ÂÎÙÈÌ¿Ù·È fiÙÈ ÌÔÚÔ‡Ó Ó· ÌÂÈÒÛÔ˘Ó Ù· ηډȷÁÁÂȷο Û˘Ì‚¿Ì·Ù· (·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο ÂÂÈÛfi‰È· Î·È ÛÙÂÊ·ÓÈ·›· Û‡Ó‰ÚÔÌ·) ηٿ ÙÚfiÔ Ô˘ Â›Ó·È ·Ó¿ÏÔÁÔ˜ Ì ÙË Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ∞¶ (12,13). ∏ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ‰‡ÛÎÔÏ· ÂÏÂÁ¯fiÌÂÓË ˘¤ÚÙ·ÛË Î·È Ë Ù·˘ÙÔÔ›ËÛË Ù˘ ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ Ô˘ÛÈ·ÛÙÈο ·Ú¯›˙ÂÈ Ì ÙË ‰È¿ÎÚÈÛË ÌÂٷ͇ Ù˘ ·ÏËıÒ˜ Î·È Ù˘ Ê·ÈÓÔÌÂÓÈο ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ (¶›Ó·Î·˜ 2) (9). ∏ ÂÊ·ÚÌÔÁ‹ ÂÛÊ·Ï̤Ó˘ Ù¯ÓÈ΋˜ ÛÙË Ì¤ÙÚËÛ˘ Ù˘ ∞¶, ÙÔ ÌÈÎÚfi ̤ÁÂıÔ˜ Ù˘ ÂÚȯÂÈÚ›‰·˜ Û ۯ¤ÛË Ì ÙËÓ ÂÚ›ÌÂÙÚÔ ÙÔ˘ ‚Ú·¯›ÔÓ· ÙÔ˘ ·ÛıÂÓÔ‡˜, Ë ·ÚÔ˘Û›· „¢‰Ô¸¤ÚÙ·Û˘ Î·È Ë ˘¤ÚÙ·ÛË Ù˘ Ï¢΋˜ ÌÏÔ‡˙·˜ ·ÔÙÂÏÔ‡Ó ·Èٛ˜ Ê·ÈÓÔÌÂÓÈο ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ ‹ „¢‰Ô-·ÓÙ›ÛÙ·Û˘ ÛÙË ıÂڷ›· (¶›Ó·Î·˜ 2). ∏ ·Ó·ÁÓÒÚÈÛË Ù˘ „¢‰Ô¸¤ÚÙ·Û˘ ·ÊÔÚ¿ ÂȉÈο ÂÚÈÙÒÛÂȘ ËÏÈÎÈˆÌ¤ÓˆÓ ·ÛıÂÓÒÓ Ì ›ÌÔÓ· ·˘ÍË̤Ó˜ ÙÈ̤˜ ∞¶ ¯ˆÚ›˜ ÙËÓ Ù·˘ÙÔÔ›ËÛË ‚Ï·‚ÒÓ Û fiÚÁ·Ó· ÛÙfi¯Ô˘˜ ‹ ÙËÓ ÂÌÊ¿ÓÈÛË ÛËÌ›ˆÓ ÔÚıÔÛÙ·ÙÈ΋˜ ˘fiÙ·Û˘ ·Ú¿ ÙËÓ Î·Ù·ÁÚ·Ê‹ ˘„ËÏ‹˜ ∞¶ (14). ÷ڷÎÙËÚÈÛÙÈο ÛÙȘ ·Ï¤˜ ·ÎÙÈÓÔÁڷʛ˜
¶APA°0NTE™ KIN¢YNOY ¶›Ó·Î·˜ 2. A›ÙÈ· Ê·ÈÓÔÌÂÓÈο ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ / „¢‰Ô·ÓÙ›ÛÙ·Û˘ – EÛÊ·Ï̤ÓË Ù¯ÓÈ΋ ̤ÙÚËÛ˘ Ù˘ A¶ – MÈÎÚfi ̤ÁÂıÔ˜ ÂÚȯÂÈÚ›‰·˜ – 梉Ը¤ÚÙ·ÛË – Y¤ÚÙ·ÛË ‘Ï¢΋˜ ÌÏÔ‡˙·˜
ÌÔÚÔ‡Ó Ó· ÂÈÛËÌ·ÓıÔ‡Ó Â·Û‚ÂÛÙÒÛÂȘ ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ Ô˘ ·Ú·ÎˆÏ‡Ô˘Ó ÁÈ· ÏfiÁÔ˘˜ Ì˯·ÓÈÎÔ‡˜ ÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÂÚȯÂÈÚ›‰·˜ (14). √ ¯ÂÈÚÈÛÌfi˜ Osler, ‰ËÏ·‰‹ Ë „ËÏ¿ÊËÛË ÙÔ˘ ÎÂÚÎȉÈÎÔ‡ ÛÊ˘ÁÌÔ‡ ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÂÚȯÂÈÚ›‰· ÊÔ˘ÛÎÒÓÂÈ Û ÙÈ̤˜ ÌÂÁ·Ï‡ÙÂÚ˜ Ù˘ ™∞¶, ¤¯ÂÈ ÌÈÎÚ‹ ÂȉÈÎfiÙËÙ· ·ÏÏ¿ ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙË ‰È¿ÁÓˆÛË. √È Ù¯ÓÈΤ˜ Ù˘ ÂÓ‰·ÚÙËÚȷ΋˜ ̤ÙÚËÛ˘ Ù˘ ∞¶ ÁÈ· ÙËÓ ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ „¢‰Ô¸¤ÚÙ·Û˘ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ÚÔ˘Ù›Ó· (14). ∏ ˘¤ÚÙ·ÛË Ù˘ Ï¢΋˜ ÌÏÔ‡˙·˜, ‰ËÏ·‰‹ Ë ·Ó‡ÚÂÛË ·˘ÍËÌ¤ÓˆÓ ÙÈÌÒÓ ∞¶ ÛÙÔ È·ÙÚÂ›Ô Î·È fi¯È ÂÎÙfi˜ È·ÙÚ›Ԣ, ÌÔÚ› Ó· ¢ı‡ÓÂÙ·È ÂÚ›Ô˘ ÁÈ· 20-30% ÙˆÓ ÂÚÈÙÒÛÂˆÓ '·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘' (9,15,16). ªÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Î·È ÔÈ ·ÛıÂÓ›˜ Ì ˘¤ÚÙ·ÛË Ù˘ Ï¢΋˜ ÌÏÔ‡˙·˜ ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ, ÂÓÒ ÌÔÚ› Ó· ÂÌÊ·Ó›˙Ô˘Ó ‚Ï¿‚˜ ÙˆÓ ÔÚÁ¿ÓˆÓ ÛÙfi¯ˆÓ (9,15,16). ∏ ÌÂϤÙË Ù˘ 24ˆÚ˘ ηٷÁÚ·Ê‹˜ Ù˘ ∞¶ Î·È ÔÈ ÌÂÙÚ‹ÛÂȘ Ù˘ ∞¶ ÛÙÔ Û›ÙÈ ÌÔÚÔ‡Ó ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË (16,17).
∞ÏËıÒ˜ ·ÓıÂÎÙÈ΋ ˘¤ÚÙ·ÛË ø˜ ·›ÙÈ· Ù˘ ·ÏËıÒ˜ ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘, ·Ó·˙ËÙÔ‡ÓÙ·È fiÛ· Û¯ÂÙ›˙ÔÓÙ·È (i) Ì ÙË ¯ÔÚËÁÔ‡ÌÂÓË ·ÓÙÈ˘ÂÚÙ·ÛÈ΋ ıÂڷ›·, (ii) Ì ÙȘ ‰Ú¿ÛÂȘ Î·È ÙȘ ·ÏÏËÏÂȉڿÛÂȘ Ê·Ú̿ΈÓ, (iii) Ì ÙȘ Û˘Ó˘¿Ú¯Ô˘Û˜ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, (iv) Ì ٷ ‰Â˘ÙÂÚÔ·ı‹ ·›ÙÈ· ˘¤ÚÙ·Û˘ Î·È (v) Ì ÙËÓ ˘ÂÚÊfiÚÙˆÛË fiÁÎÔ˘ (¶›Ó·Î·˜ 3) (9,15). ∆· ·ÔÙÂϤÛÌ·Ù· ÌÈ·˜ ·Ó·‰ÚÔÌÈ΋˜ ÌÂϤÙ˘ ‰È¿ÚÎÂÈ·˜ 4 ¯ÚfiÓˆÓ ¤‰ÂÈÍ·Ó fiÙÈ Ô ¤ÏÂÁ¯Ô˜ Ù˘ ˘¤ÚÙ·Û˘ Â›Ó·È È‰È·›ÙÂÚ· ‰‡-
ÛÎÔÏÔ˜ Û ·ÛıÂÓ›˜ Ì ÊÙˆ¯‹ Û˘ÌÌfiÚʈÛË (18). ∏ ¤ÏÏÂÈ„Ë Û˘ÌÌfiÚʈÛ˘ ÛÙË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ·ÔÙÂÏ› ȉȷ›ÙÂÚ· ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ Î·È Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ·ÓÂÈı‡ÌËÙˆÓ ¶›Ó·Î·˜ 3. A›ÙÈ· ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ – ‘梉ԷÓÙ›ÛÙ·ÛË’
ÌÔÓÒ‰Ë Î·È ÔÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ΢ÎÏÔ͢ÁÂÓ¿Û˘-2 (COX-2) ÂÍ·ÈÙ›·˜ Ù˘ ηٷÎÚ¿ÙËÛ˘ Ó·ÙÚ›Ô˘ Î·È ‡‰·ÙÔ˜ Î·È Ù˘ Ì›ˆÛ˘ Ù˘ ·Ú·ÁˆÁ‹˜ ·ÁÁÂȉȷÛÙ·ÏÙÈÎÒÓ Î·È ÙˆÓ Ó·ÙÚÈÔ˘ÚËÙÈÎÒÓ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ ÛÙÔ Â›Â‰Ô ÙÔ˘ ÓÂÊÚÔ‡ (9). ∂›Û˘, ·Ú¿ÁÔÓÙ˜ fiˆ˜ Ë ÎÏÔÓȉ›ÓË ÌÂÙ¿ ÙËÓ ·fiÙÔÌË ‰È·ÎÔ‹ ÙÔ˘˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ∞¶ (9).
– AÈٛ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ʿÚ̷η – ¢Ú¿ÛÂȘ Î·È ·ÏÏËÏÂȉڿÛÂȘ Ê·ÚÌ¿ÎˆÓ – ™˘Ó˘¿Ú¯Ô˘Û˜ ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ – ¢Â˘ÙÂÚÔ·ı‹ ·›ÙÈ· ˘¤ÚÙ·Û˘ – YÂÚÊfiÚÙˆÛË fiÁÎÔ˘
ÂÓÂÚÁÂÈÒÓ, ÙÔ ÎfiÛÙÔ˜ Ù˘ ıÂڷ›·˜, ÙËÓ ÔÏ˘ÏÔÎfiÙËÙ· ÙˆÓ Û¯ËÌ¿ÙˆÓ, ÙËÓ ¤ÏÏÂÈ„Ë Î·Ù·ÓfiËÛ˘ ·fi ÙËÓ ÏÂ˘Ú¿ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÎÔÈÓˆÓÈÎÔ‡˜ Î·È ·ÙÔÌÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (9). ∏ ¯ÔÚ‹ÁËÛË ÌË ‰fiÎÈÌˆÓ Û˘Ó‰˘·ÛÌÒÓ Ì ʿÚ̷η Û ˘ÔıÂڷ¢ÙÈΤ˜ ‰fiÛÂȘ ·Ó·ÁÓˆÚ›˙ÂÙ·È fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ ÛÙȘ ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ Ì ·ÓıÂÎÙÈ΋ ˘¤ÚÙ·ÛË (43-58% ÙˆÓ ÂÚÈÙÒÛˆÓ) (9). ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› ȉȷ›ÙÂÚ· Ë ÂÈÏÔÁ‹ ¯ÔÚ‹ÁËÛ˘ ‰ÈÔ˘ÚËÙÈÎÔ‡ Û ·Ú΋ ‰fiÛË ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ˘¤ÚÙ·Û˘ Î·È ÙÔ˘ ηٿÏÏËÏÔ˘ Ù‡Ô˘ ‰ÈÔ˘ÚËÙÈÎÔ‡ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ‰ËÏ·‰‹ ‰ÈÔ˘ÚËÙÈο Ù˘ ·Á·Ï˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÛËÌ·ÓÙÈο ·˘ÍË̤ÓË ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ (ÂÚÈÛÛfiÙÂÚ˜ ·fi Ì›· ÊÔÚ¿ ÙËÓ Ë̤ڷ Â¿Ó ÚfiÎÂÈÙ·È ÁÈ· ÙË ÊÔ˘ÚÔÛÂÌ›‰Ë) (5,15). ¶ÚÈÓ ·fi οı ·Ú¤Ì‚·ÛË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘, ηٿ ÙË Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Ú¤ÂÈ Ó· ηٷÁÚ¿ÊÂÙ·È Ë ¯ÔÚ‹ÁËÛË Ê·ÚÌ¿ÎˆÓ Ô˘ ·˘Í¿ÓÔ˘Ó ÙËÓ ∞¶ Î·È ÂȉÂÈÓÒÓÔ˘Ó ÙËÓ ˘¤ÚÙ·ÛË, fiˆ˜ Ù· ·Ó·‚ÔÏÈο ÛÙÂÚÔÂȉ‹, ÔÈ Û˘Ì·ıËÙÈÎÔÌÈÌËÙÈΤ˜ ·Ì›Ó˜ (Ê·ÈÓ˘ÏÂÊÚ›ÓË), Ë ÎÔη˝ÓË, Ë ÓÈÎÔÙ›ÓË, (19), Ë ·Èı·ÓfiÏË (˘ÂÚ‚ÔÏÈ΋ ηٷӿψÛË), Ù· ÎÔÚÙÈÎÔÂȉ‹, Ë Î˘ÎÏÔÛÔÚ›ÓË, Ë ÂÚ˘ıÚÔÔÈËÙ›ÓË, Ù· ·ÓÔÚÂÍÈÔÁfiÓ· Î·È ‚¤‚·È· Ù· ÌË ÛÙÂÚÔÂȉ‹ ·ÓÙÈÊÏÂÁ-
ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ 5-10% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ ÔÊ›ÏÔÓÙ·È Û ‰Â˘ÙÂÚÔ·ı‹ ·›ÙÈ· ˘¤ÚÙ·Û˘ (5,9,15). ∆· Û˘ÓËı¤ÛÙÂÚ· ·fi ·˘Ù¿ ·ÊÔÚÔ‡Ó (i) ÙËÓ ·ıËÚÔÛÎÏËÚˆÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ ÛÙ¤ÓˆÛË Ù˘ ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ (ȉȷ›ÙÂÚ· Û ËÏÈÎȈ̤ӷ ¿ÙÔÌ·), (ii) ÓÂÊÚÔ·ÚÂÁ¯˘Ì·ÙÈ΋ ÓfiÛÔ (Ô˘ ÌÔÚ› Ó· ·Ó·‰Âȯı› ÛÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Î·È Ì ÙËÓ ÂͤٷÛË ÙÔ˘ È˙‹Ì·ÙÔ˜ ÙˆÓ Ô‡ÚˆÓ), (iii) ÙÔ Ê·ÈÔ¯ÚˆÌÔ·Ùو̷, (iv) ÙoÓ ÚˆÙÔ·ı‹ ·Ï‰ÔÛÙÂÚÔÓÈÛÌfi, (v) ÙÔ Û‡Ó‰ÚÔÌÔ Cushing, (vi) ÙÔÓ ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi Î·È ÙÔÓ ˘Ôı˘ÚÂÔÂȉÈÛÌfi, (vii) ÙÔÓ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi Î·È (viii) ÙËÓ ÈÛıÌÈ΋ ÛÙ¤ÓˆÛË Ù˘ ·ÔÚÙ‹˜ (9,15). ™·ÓÈfiÙÂÚ· ·›ÙÈ·, fiˆ˜ ·Ó‡ڢÛÌ· ÙÔ˘ ‰È¯·ÛÌÔ‡ Ù˘ ‰ÂÍÈ¿˜ ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜, ·ÚÙËÚȷ΋ ıÚfiÌ‚ˆÛË ·fi ÙËÓ ÎÔÈÏȷ΋ ·ÔÚÙ‹ ÛÙȘ ‰‡Ô ÎÔÈÓ¤˜ Ï·ÁfiÓȘ ·ÚÙËڛ˜, ·fiÊÚ·ÍË Ù˘ ·ÚÈÛÙÂÚ‹˜ ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜, ηÚÎÈÓÔÂȉ¤˜, fiÁÎÔÈ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ÓÂÊÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÚÔÂÌÌËÓÔÚÚ˘ÛÈ·Îfi Û‡Ó‰ÚÔÌÔ, ·Ó·˙ËÙÔ‡ÓÙ·È Û ÂÚÈÙÒÛÂȘ ˘„ËÏ‹˜ ÎÏÈÓÈ΋˜ ˘Ô„›·˜ (9). ∏ ˘ÂÚÊfiÚÙˆÛË Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÂÍ·ÈÙ›·˜ ÂÓfi˜ Û˘Ó‰˘·ÛÌÔ‡ ·Ú·ÁfiÓÙˆÓ ÌÔÚ› Ó· ·˘Í‹ÛÂÈ ÙËÓ ∞¶ Î·È Ó· ÂËÚ¿ÛÂÈ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ·ÓÙÈ˘ÂÚÙ·ÛÈ΋˜ ıÂڷ›·˜ (15). ∫·Ù·ÎÚ¿ÙËÛË ‡‰·ÙÔ˜ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛı› ÂÍ·ÈÙ›·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ ‹ ·Ó·ÚÎÔ‡˜ ‰ÈÔ˘ÚËÙÈ΋˜ ·ÁˆÁ‹˜. ∏ ·˘ÍË̤ÓË ÚfiÛÏË„Ë ¿Ï·ÙÔ˜ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÌÊ¿ÓÈÛË ·ÓÙ›ÛÙ·Û˘ ÛÙË ‰Ú¿ÛË ·ÓÙÈ˘ÂÚÙ·ÛÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙÔ˘˜ ·Ï·ÙÔ¢·›ÛıËÙÔ˘˜ ·ÛıÂÓ›˜ (5,15). ™ËÌ·ÓÙÈ΋ ηٷÎÚ¿ÙËÛË ‡‰·ÙÔ˜, Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ôȉ‹Ì·ÙÔ˜, ÂÚÈÁÚ¿-
29
™∂¶∆∂ªµƒπ√™ 2007
ÊÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ·ÓÙ·ÁˆÓÈÛÙÒÓ ÙˆÓ ‰È·‡ÏˆÓ ·Û‚ÂÛÙ›Ô˘ Î·È ¿ÌÂÛˆÓ ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÒÓ, fiˆ˜ Ù· ÓÈÙÚÒ‰Ë (9,15).
™˘Ó˘¿Ú¯Ô˘Û˜ ηٷÛÙ¿ÛÂȘ ∏ ·‡ÍËÛË Ù˘ ∞¶ Ô˘ ÔÊ›ÏÂÙ·È ÛÙÔ Î¿ÓÈÛÌ· ÎÚ·Ù¿ÂÈ Û˘Ó‹ıˆ˜ 30 ÏÂÙ¿. øÛÙfiÛÔ, ·˘Ùfi Â›Ó·È ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ Û˘ÛÙËÌ·ÙÈÎÒÓ Î·ÓÈÛÙÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È ˘fiÙËÓ Â‹ÚÂÈ· Ù˘ ÓÈÎÔÙ›Ó˘ Û fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜. ™Â fiÙÈ ·ÊÔÚ¿ ÙÔ ·ÏÎÔfiÏ, Ê·›ÓÂÙ·È fiÙÈ Ë Î·Ù·Ó¿ÏˆÛË ÂÚÈÛÛfiÙÂÚÔ ·fi 30 ml/Ë̤ڷ Âȉڿ ‰˘ÛÌÂÓÒ˜ ÛÙ· ›‰· Ù˘ ∞¶. À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ 65-78% ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ˘¤ÚÙ·Û˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·¯˘Û·ÚΛ· Î·È ·˘Ùfi ·Ô‰›‰ÂÙ·È (i) ÛÙËÓ Ì›ˆÛË Ù˘ ¢·ÈÛıËÛ›·˜ ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ÈÛÙÒÓ ÛÙË ‰Ú¿ÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘, (ii) ÛÙËÓ ÂÌÊ¿ÓÈÛË ·ÓÙ›ÛÙ·Û˘ ÛÙË ‰Ú¿ÛË ÙˆÓ ·ÓÙÈ˘ÂÚÙ·ÛÈÎÒÓ Î·È (iii) ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÚÂÓ›Ó˘-·ÁÁÂÈÔÙÂÓÛ›Ó˘-·Ï‰ÔÛÙÂÚfiÓ˘ Î·È ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (20). Œ¯ÂÈ ‚ÚÂı› fiÙÈ Û ·¯‡Û·Úη ¿ÙÔÌ· Ë ÂΉ‹ÏˆÛË Î·È Ë ÛÔ‚·ÚfiÙËÙ· Ù˘ ¿ÓÔÈ·˜ ÙÔ˘ ‡ÓÔ˘ Û˘Û¯ÂÙ›˙ÂÙ·È ÙfiÛÔ Ì ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ˘¤ÚÙ·Û˘ fiÛÔ Î·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ·ÓıÂÎÙÈ΋˜ ˘¤ÚÙ·Û˘ (21). ªÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¿ÓÔÈ·˜ ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÂÈ ÛÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ˘¤ÚÙ·Û˘ (21).
∞ÓÙÈÌÂÙÒÈÛË ·ÛıÂÓÒÓ Ì ·ÓıÂÎÙÈ΋ ˘¤ÚÙ·ÛË ™ÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ Ô‰ËÁ›Â˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘¤ÚÙ·-
Û˘ ‰ÂÓ ˘¿Ú¯Ô˘Ó Û·Ê›˜ Û˘ÛÙ¿ÛÂȘ ÁÈ· ÙËÓ ÚÔÛ¤ÁÁÈÛË Î·È ÙË ıÂڷ›· ·ÛıÂÓÒÓ Ì ·ÓıÂÎÙÈ΋ ˘¤ÚÙ·ÛË (12,13). ™ÙËÓ ÚÔÛ¤ÁÁÈÛË ·ÛıÂÓÒÓ Ì ·ÓıÂÎÙÈ΋ ˘¤ÚÙ·ÛË Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚÈÛıÔ‡Ó ·›ÙÈ· „¢‰Ô·ÓÙ›ÛÙ·Û˘, ·›ÙÈ· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË Û˘ÌÌfiÚʈÛË ÛÙË ıÂڷ›·, ÙȘ ‰fiÛÂȘ Î·È ÙËÓ ·ÏÏËÏ›‰Ú·ÛË ÙˆÓ Ê·Ú̿ΈÓ, ÂÓÒ ÁÈ· ÙËÓ Ù·˘ÙÔÔ›ËÛË ÙˆÓ ‰Â˘ÙÂÚÔ·ıÒÓ ·ÈÙ›ˆÓ ˘¤ÚÙ·Û˘ ÌÔÚÔ‡Ó Ó· Ì·˜ ηıÔ‰ËÁ‹ÛÔ˘Ó Ù· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· Î·È ÛËÌ›· Î·È ÌÈ· ÛÂÈÚ¿ ·fi ÂȉÈΤ˜ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ. ∏ ÚÔÙÂÈÓfiÌÂÓË ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË, ÂÎÙfi˜ ÙÔ˘ Û˘ÓËıÈṲ̂ÓÔ˘ ÂϤÁ¯Ô˘, ÂÚÈÏ·Ì‚¿ÓÂÈ (i) ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ÚÂÓ›Ó˘ Î·È Ù˘ ·Ï‰ÔÛÙÂÚfiÓ˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜, (ii) ÙË Ì¤ÙÚËÛË ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ Î·È Ù˘ ·Ú·ıÔÚÌfiÓ˘, (iii) ÙˆÓ ÌÂÙ·ÓÂÊÚÈÓÒÓ ÙˆÓ Ô‡ÚˆÓ Î·È Â› ˘Ô„›·˜ (iv) ÙË ‰ÈÂÓ¤ÚÁÂÈ· Ì·ÁÓËÙÈ΋˜ ·ÁÁÂÈÔÁÚ·Ê›·˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ. ∏ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË ··ÈÙ› ÙË ‰È¿ÁÓˆÛË Î·È ÙËÓ ·ÔηٿÛÙ·ÛË Èı·ÓÒÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ‰Â˘ÙÂÚÔ·ıÒÓ ·ÈÙ›ˆÓ ˘¤ÚÙ·Û˘. ∏ Ê·Ú̷΢ÙÈ΋ ıÂڷ›· Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÂÙ·È Û‡Ìʈӷ Ì ÙÔ ÚÔÊ›Ï ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙȘ Û˘Ó˘¿Ú¯Ô˘Û˜ ηٷÛÙ¿ÛÂȘ. ŒÓ· Ù˘ÈÎfi ıÂڷ¢ÙÈÎfi Û¯‹Ì· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÔÚ‹ÁËÛË ÂÓfi˜ ıÂÈ·˙ȉÈÎÔ‡ ‰ÈÔ˘ÚËÙÈÎÔ‡ (‹ ‰ÈÔ˘ÚËÙÈÎÔ‡ Ù˘ ·Á·Ï˘ Û ÂÚÈÙÒÛÂȘ ¤ÎÙˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜), ÂÓfi˜ ‚-·ÔÎÏÂÈÛÙ‹, ÂÓfi˜
·ÓÙ·ÁˆÓÈÛÙ‹ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ ‹ ·ÓÙ·ÁˆÓÈÛÙ‹ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ Î·È ÂÓfi˜ ·ÓÙ·ÁˆÓÈÛÙ‹ ·Û‚ÂÛÙ›Ô˘ (9). ∏ ÂÈÏÔÁ‹ ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ÙËÓ 24ˆÚË Î¿Ï˘„Ë ÙÔ˘ ·ÛıÂÓÔ‡˜. ∂ÓÈÛ¯˘ÙÈο ÛÙËÓ ·ÁˆÁ‹ ‰ÚÔ˘Ó Ë ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Î·È Ë Ì›ˆÛË Ù˘ ÚfiÛÏ˄˘ ¿Ï·ÙÔ˜ ÁÈ· ÙË ‰ÈfiÚıˆÛË ÙÔ˘ fiÁÎÔ˘, Ô ÂÚÈÔÚÈÛÌfi˜ ÙÔ˘ ·ÏÎÔfiÏ, Ë ‰È·ÎÔ‹ ÙÔ˘ ηӛÛÌ·ÙÔ˜, Ë Ì›ˆÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ Î·È Ë ·‡ÍËÛË Ù˘ ۈ̷ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜. ™Â ·ÛıÂÓ›˜ Ô˘ ·ÔÙ˘Á¯¿ÓÔ˘Ó Ó· Ú˘ıÌÈÛÙÔ‡Ó ÈηÓÔÔÈËÙÈο, Ë ¯ÔÚ‹ÁËÛË ÛÂÈÚÔÓÔÏ·ÎÙfiÓ˘ Û ‰fiÛË 25 ‹ 50 mg/Ë̤ڷ ‹ ÓÂfiÙÂÚˆÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ Ë ÂÏÂÚÂÓfiÓË ÌÔÚ› Ó· Â›Ó·È È‰È·›ÙÂÚ· ¯Ú‹ÛÈÌË (22,23). À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÛÂÈÚÔÓÔÏ·ÎÙfiÓ˘ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙËÓ ∞¶ >20/10 Û ·ÛıÂÓ›˜ ÌÂ Î·È ¯ˆÚ›˜ ÚˆÙÔ·ı‹ ·Ï‰ÔÛÙÂÚÔÓÈÛÌfi (22,23). ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ ÂÚ·ÈÙ¤Úˆ Ì›ˆÛË Ù˘ ∞¶ Â›Ó·È Ë ÌÈÓÔÍȉ›ÏË Î·È Ë ˘‰Ú·Ï·˙›ÓË, Ë ÎÏÔÓȉ›ÓË Î·È Ë ÚÂ˙ÂÚ›ÓË (Û ¯·ÌËÏ‹ ‰fiÛË). ™ÙÔ Ì¤ÏÏÔÓ ·Ó·Ì¤ÓÂÙ·È Ó· ‰È¢ÎÚÈÓÈÛı› Ô ÚfiÏÔ˜ ÓÂfiÙÂÚˆÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ ÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜ Ù˘ ÚÂÓ›Ó˘ Î·È Ù˘ ÂÓ‰ÔıËÏ›Ó˘-1, ηıÒ˜ Î·È ÌË Ê·Ú̷΢ÙÈÎÒÓ Ì¤ÙÚˆÓ fiˆ˜ ÔÈ Û˘Û΢¤˜ Ô˘ ‰ÈÂÁ›ÚÔ˘Ó ÙÔ˘˜ ÈÂÛԸԉԯ›˜ ÁÈ· ÙËÓ Î·Ï‡ÙÂÚË Ú‡ıÌÈÛË Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ›ÂÛ˘ (9).
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