Download - dislipidemii2009
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Definiţie• Totalitatea tulburărilor cantitative şi calitative
ale lipidelor plasmatice (C, TG, HDLc)
• Prevalenţa >30%
• Factor major de risc pentru ATS
• “Normalul” lipidic: CT <200 mg%
TG <150 mg%
HDLc ♀ 40-45 mg%
♂ 45-50 mg%
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Clase ale lipoproteinelor
Forme circulante ale lipidelorForme circulante ale lipidelor
• ChilomicroniChilomicroni
• VLDLVLDL
• IDLIDL
• LDLLDL
• HDLHDL
• Lp Lp (a)(a)
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Structura lipoproteinelor
Strat unicde FL şi CL
Apolipoproteină
Core: CE şi TG
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Clasificarea lipoproteinelor
Clasa Conţinut lipidic (%)*
TG C FLChilomicroni 80-95 2-7 3-9
VLDL 55-80 5-15 10-20
IDL 20-50 20-40 15-25
LDL 5-15 40-50 20-25
HDL 5-10 15-25 20-30
Lp(a) 5-15 40-50 20-25
*=diferenţa până la 100% este reprezentată de Apo
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ApoB48, CII, CIII, E
TG
Receptori LDLşi LRP
Perete intestinal
ApoB48, CII,CIII, E Receptori
LDL, LRP
ReceptoriLDL
Receptori LDL
LPLLPL
TG
AGL
Colesterol
AGL
AGL AGL
TG
CE
TG
VLDL
Colesterol
Colesterol
Alimente
Chilo
TG
CE
Remn
ApoB100, CII,CIII, E
IDL
TG
CE
ApoB100
LDL
CE
TG
CEHDL
ApoAI, AII
HTGL
Lumenintestinal
TG
AGL Glicerol
TG
CE
ApoB100, CII,
CIII, E
Legendă: TG=trigliceride; CE=colesterol esterificat; FL=fosfolipide; Apo=apolipoproteine; AGL=acizi graşi liberi; chilo=chilomicroni; remn=remnanţi; LPL=lipoproteinlipaza; TGL=hipertrigliceridlipaza.
Metabolismul lipoproteinelor
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Clasificarea dislipidemiilorîn funcţie de natura anomaliei
Hipercolesterolemii (HC)
Genetice (primare, familiale) Secundare
HC familială Hipotiroidism HC prin deficit de apoB100 Sindrom nefrotic HC poligenică Colestază
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Hipertrigliceridemii (HTG
Genetice (primare, familiale) Secundare
Deficit de LPL DZ controlat nesatisfăcător,
Deficit de apo CII sindrom nefrotic, uremie,
HTG familială alcoolism, estrogeni, betablocante
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Hiperlipidemii mixte (HM)
Genetice (primare, familiale) Secundare
Disbetalipoproteinemia (HLP Sindrom nefrotic
familială tip III) Hipotiroidism
Hiperlipidemia familială combinată Boală Cushing
Diuretice
DZ controlat nesatisfăcător
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Clasficarea în funcţie de severitateHipercolesterolemii
• uşoare: 200-239 mg%
• moderate: 240-299 mg%
• severe: 300 mg%
Hipertrigliceridemii• de graniţă: 150-199 mg%
• moderate: 200-399 mg%
• severe: 400 mg%
Hiperlipidemii mixte
C TG
• moderate: 200-299 mg% 200-400 mg%
• severe: 300 mg% 400 mg%
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Diagnostic
1. Tablou clinic
2. Aspectul serului sau plasmei
3. Dozarea CT, TG, HDLc
4. Calcularea LDLc
5. Alte metode (de cercetare)
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1. Tablou clinic
Xantelasmă
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Arc cornean
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Arc cornean + xantelasmă palpebrală
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Xantoame tuberoase
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Xantoame tendinoase
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Xantoame tendinoase
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Xantoame eruptive
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Lipemia retinalis
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2. Aspectul serului sau plasmei
Tub 1: plasmă normalăTub 2: HTGTub 3: plasma cu exces de VLDL şi chilomicroni (inel cremos la suprafaţă)
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3. Dozarea lipidelor
CT: >200 mg%
TG: >150 mg%
HDLc: ♂ <40 mg%
♀ <45 mg%
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4. Calculul LDLc/non HDLc
• Formula lui Friedewald (risc mic <130 mg%)
Tg <400 mg%LDLc = C- HDLc- Tg/5 (mg%)LDLc = C- HDLc- Tg/2.2 (mmol/l)
• Calculul non-HDLc (risc mic < 160 mg%)
Tg >400 mg%Non-HDLc = C-HDLc
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5. Alte metode (folosite rar în practică)
• electroforeză
• ultracentrifugare
• dozarea apoproteinelor
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Riscul coronarian
• LDL <130 mg% fără risc semnificativ
• LDL 130-159 mg% risc mediu
• LDL >160 mg% risc mare
• raport C/HDLc >5
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Factori de risc adiţionali
• Vârsta (bărbaţi >45; femei >55 sau menopauză prematură fără tratament de substituţie estrogenică)
• Istoric familial de cardiopatie ischemică precoce• Fumatul• Hipertensiune arterială (>140/90 mmHg sau
tratament antihipertensiv)• HDL scăzut (<35 mg%)• Diabet zaharat
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Factor de protecţie
• HDL-colesterol crescut (>60 mg%)
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Tratamentul dislipidemiilorTratamentul dislipidemiilor
Obiectiv• normalizarea valorilor CT, TG, LDL şi HDL –
contribuie la prevenţia primară sau secundară a bolilor cardiovasculare
Parametrii luaţi în considerare• LDL
• HDL
• prezenţa/absenţa bolilor cardiovasculare
• alţi factori de risc
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Cu risc coronarian înalt:-CI evidentă-Cu istoric familial de CI-Cu 2 sau mai mulţi factori de risc-Adulţi cu HCF+ peste 1 factor de risc-Adulţi cu by-pass coronarian-HDLc scăzut+istoric familial de CI-Diabet zaharat
<100
(<70 mg%)
Cu risc coronarian moderat:
-Fără istoric familial de CI
-Fără alţi factori de risc
-Adulţi tineri cu hipercolesterolemie familială
-Adulţi cu HCF fără alţi factori de risc
<130
Categoria de pacienţiLDL (mg%)
Valori ale LDLc ţintite terapeutic
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Mijloace terapeutice
• Dieta
• Medicaţia hipolipemiantă
1. Fibraţi
2. Statine (± ezetimide)
3. Alte (răşini chelatoare de acizi biliari, acid nicotinic)
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Dieta
Nutrient Treapta 1 Treapta 2
Lipide totale <30% din calorii <30% din calorii
Grăsimi saturate
<10% din calorii <7% din calorii
Proteine 10-20% din calorii 10-20% din calorii
Colesterol <300 mg/zi <200 mg/zi
Glucide 50-60% din calorii 50-60% din calorii
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S t a t i n e
Doza (mg/zi)• atorvastatin (Sortis, cp 10 mg, 20 mg) 10-80
• simvastatin (Zocor, cp 10 mg, 20 mg) 10-40
• pravastatin (Elisor, cp 10 mg, 20 mg) 10-40
• lovastatin (Mevacor, cp 20 mg) 20-80
• fluvastatin (Lescol, caps 20 mg, 40 mg) 20-80
• rosuvastatin (Crestor cp 5 mg, 10 mg, 10-40
20 mg, 40 mg)
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Locul de acţiune a statinelor
Acetat Statine HMG-CoA
HMG-CoA-reductaza Acid mevalonic
Colesterol
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F i b r a ţ i
Doza (mg/zi)
• fenofibrat (Lipanthyl 100 mg/cp) 300 mg
• bezafibrat (Regadrin 200 mg/cp) 600-1200 mg
• ciprofibrat (Lipanor 100 mg/cps) 100 mg
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Strategia terapeutică(în funcţie de LDLc)
Dietă Medicaţie Scop
Fără CI
0-1 f. risc
>160 mg% >190 mg% <160 mg%
Fără CI
>2 f. risc
>130 mg% >160 mg% <130 mg%
CI >100 mg% >130 mg% <100 mg%
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Sindromul metabolic
Criteriile OMS (1998)
• hiperglicemie (AGJ/ STG/ DZ ) sau insulinorezistenţă
plus cel puţin 2 din următoarele criterii:
• TA 140 mmHg/90 mmHg
• TG >150 mg% şi/sau HDLc <35 mg% (♂) şi <38 mg% (♀)
• indice abdomino-fesier >0,85 (♀) şi >0,90 (♂)
• microalbuminurie
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Criteriile NCEP-ATP III (2001)3 dintre următoarele 5 criterii:
• obezitate androidă, definită ca circumferinţa abdominală > 102 cm (♂) şi >88 cm (♀)
• TG >150 mg%
• HDLc <40 mg% (♂) şi <50 mg% (♀)
• TA 130/ 85 mmHg
• glicemia à jeun 110 mg%
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Criteriile IDF (2005)
• Obezitate centrală (circumferinţa abdominală 94 ♂, 80♀)
Plus oricare 2 dintre următoarele 4 criterii
• TG 150 mg/% sau tratament pentru HTG
• HDLc <40 mg% ♂, >50 mg%♀ sau tratament pentru această anomalie
• TA 130/85 mmHg sau tratament pentru HTA
• glicemie à jeun 100 mg% sau diagnostic anterior de DZ